Ethylene Glycol Intoxication: Case Report and Pharmacokinetic Perspectives

Nina Vasavada, M.D.; Craig Williams, Pharm.D.; Richard N. Hellman, M.D.

Disclosures

Pharmacotherapy. 2003;23(12) 

In This Article

Case Report

A 42-year-old Caucasian man was found intoxicated under a bridge and was brought to a local emergency department. The patient admitted to consuming approximately 1 pint of vodka followed by approximately 1 pint of antifreeze in a suicide attempt 1 hour before coming to the emergency department. He denied other toxic ingestions, nausea, or vomiting and voiced no other physical complaints. His medical history revealed hepatitis C, depression, anxiety, and polysubstance abuse including tobacco, ethanol, and cocaine (in the past). His only routine drug therapy was buspirone. Initial vital signs revealed a temperature of 97.5°F, heart rate 94 beats/minute, blood pressure 139/81 mm Hg, and respiratory rate 16 breaths/minute. The patient's height was 70 inches and weight was 85 kg. Physical examination was significant for rotary nystagmus and mild hepatomegaly. Kussmaul respirations, fruity odor, rash, cardiac gallops, pericardial rub, pulmonary rales, abdominal tenderness, peripheral edema, and tetanic contractions were absent.

Initial laboratory data obtained from serum revealed the following: ethanol concentration 181 mg/dl, ethylene glycol concentration 284 mg/dl, sodium 143 mEq/L (normal range 137-145 mEq/L), potassium 3.7 mEq/L (3.5-5.5 mEq/L), carbon dioxide 23 mEq/L (22-27 mEq/L), urea nitrogen 8 mg/dl (5-20 mg/dl), creatinine 1.0 mg/dl (0.8-1.4 mg/dl), calcium 7.9 mg/dl (8.4-10.6 mg/dl), albumin 3.8 g/dl (3.5-5.0 g/dl), and glucose 153 mg/dl (65-110 mg/dl). Neither an arterial nor a venous blood gas measurement was performed. Calculated serum osmolarity was 297 mOsm/L and measured serum osmolality 425 mOsm/kg, yielding an osmol gap of 128. Serum and urine toxicology screens were negative for cocaine, salicylates, barbiturates, benzodiazepines, and other volatile alcohols. Microscopic examination of the urine did not reveal calcium oxalate crystals. An electrocardiogram demonstrated sinus tachycardia at 105 beats/minute with a corrected QT interval of 387 msec.

On arrival to the emergency department, the patient received fomepizole 15 mg/kg as an intravenous loading dose, followed by 10-mg/kg maintenance doses every 12 hours for a total of four doses, then one additional 15-mg/kg dose 12 hours later. The patient did not receive any intravenous infusions such as lorazepam, which contain propylene glycol as an additive. The patient was administered isotonic saline on hospital days 2 and 3, and each day produced a minimum urine output of 90 ml/hour. Other therapies consisted of multivitamins. At no point did the patient receive any form of dialysis. His serum creatinine level consistently remained from 0.8-1.0 mg/dl, and serum bicarbonate remained 22-24 mEq/L. Relevant laboratory values during the patient's hospitalization are shown in Table 1 . Elimination of ethylene glycol from the blood followed first-order pharmacokinetics, as shown in Figure 1. On hospital day 4, the patient was discharged to an inpatient psychiatric facility for further care.

Pharmacokinetic evaluation of ethylene glycol in the observed patient. Elimination of ethylene glycol follows first-order pharmacokinetics in the presence of alcohol dehydrogenase inhibition. The horizontal bar represents the time of fomepizole administration in reference to the time of arrival at the emergency department.

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