Adolescent Presents With Altered Mental Status and Elevated Anion Gap After Suicide Attempt by Ethylene Glycol Ingestion

Abstract

We report the case of a 16-year-old healthy adolescent male who presented to the local emergency department with altered mental status. En route to a tertiary care facility, he began to decompensate and was found to be markedly acidotic. Further investigation revealed an elevated anion gap, and physical examination showed only abdominal pain and decreased level of consciousness. A broad differential diagnosis was considered at the time of the patient's presentation at the tertiary care center including ingestion of a volatile alcohol, sepsis, and an abdominal catastrophe. Although fomepizole and emergent dialysis were being initiated, laboratory tests confirmed ethylene glycol poisoning. This case demonstrates the importance of early recognition of potential ingestions in patients with altered mental status and supportive laboratory findings.

Etiologies and Yield of Diagnostic Testing in Children Presenting to the Emergency Department with Altered Mental Status

“…1,2,[4][5][6][7][8][9][10][11][12] Bowker et al highlighted the lack of evidence regarding recommendations for initial diagnostic testing in these patients, as well as the lack of specificity of presenting symptoms in children with altered mental status. 32 Case reports in the literature of children presenting to the ED with altered mental status have demonstrated widely varying etiologies such as acute disseminated encephalomyelitis, 6 central ,3,9,15 nervous system arteriovenous malformation, 7 ingestion, 3,9,15 hypoglycemia, 10 pericardial tamponade, 13 stroke, 18 and metabolic disorders such as ornithine transcarbamylase deficiency. 14 These case reports underscore the broad differential diagnosis facing clinicians caring for these patients as well as the often extensive initial diagnostic testing that may be performed including blood tests, urine studies, lumbar puncture, and imaging studies such as head CT, brain magnetic resonance imaging, and chest radiograph to elucidate the underlying etiology.…”

Acute Kidney Injury with Hyperlactatemia: Clues to a Hidden Problem

“…3 Whenever there is renal failure, severe metabolic acidosis, severe electrolyte imbalance, very high ethylene glycol concentrations (> 50 mg/ dL) and an osmolar gap above 10 mOsm/L, acute renal replacement therapy (hemodyalisis or hemofiltration) must be initiated. 1,2,4 In our case, continuous veno-venous hemodiafiltration was the more readily available treatment option when intoxication was confirmed, given the time of inges-tion. Therefore, it is extremely important to promptly initiate adequate treatment to achieve a favourable outcome.…”

“…On day 19, he was transferred to a psychiatric centre, where he remained for three weeks, with complete recovery of renal function and suspension of antihypertensive therapy after one month. Few cases of suicidal attempt in the pediatric age are reported, 1 especially with ethylene glycol, used as antifreeze fluid, deicing solutions and windshield wiper fluids. 2,3 Toxicity is mostly due to its metabolites (glycolic, glyoxylic and oxalic acids) which cause a false-positive elevation in lactic acid and promote calcium oxalate crystal deposits in different tissues.…”

“…Therefore, clinical and analytical clues, such as an increased anion gap acidosis and hyperlactatemia should raise the suspicion of poisoning. 1,4 When available, the first treatment option would be fomepizole, which blocks alcohol dehydrogenase, which is responsible for the metabolism of ethylene glycol (half-life of three to nine hours). 3,4 Another option would be ethanol, whose affinity is 100 times higher for alcohol dehydrogenase compared to ethylene glycol.…”

Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup

“…No data exist on intermittent hemodiafiltration, but it is expected to perform as well as hemodialysis, based on achievable urea clearance. In the rare scenario in which no antidote is available, high-efficiency hemodialysis would increase endogenous clearance at least 100% [ 278 ], i.e., “moderate” dialyzability.…”