Ethylene glycol intoxication presenting as a mimic of acute stroke: report of three cases

Abstract

Background: Stroke is a major cause of death and disability presenting with acute focal neurological symptoms of vascular origin. Several other disorders may cause symptoms similar to a stroke, referred as stroke mimics. Misdiagnosis of stroke mimics may lead to potentially harmful treatments, including thrombolysis. Intoxication is a rare, but possible cause of stroke mimic. We present three cases of ethylene glycol poisoning presenting as acute stroke mimic within the time window of thrombolytic therapy. Case presentations: The first patient (54-year-old, male) had nystagmus, dysarthria and truncal ataxia on admission. Cerebral CT and CT-angiography were negative. Vertebrobasilar stroke was suspected and intravenous thrombolysis was performed. A few hours later confusion, somnolence and hyperventilation developed. Arterial blood gas analysis showed metabolic acidosis. Toxicology screening revealed the presence of ethylene glycol in a toxic range. Due to the prompt treatment the patient was discharged 9 days later in a symptom-free state. The second patient (78-year-old, male) was admitted with central type of nystagmus, gaze palsy, dysarthria and ataxia. In the absence of exclusion criteria, thrombolysis was performed. A few hours later his condition deteriorated, he became comatose and tetraplegic with partially absent brainstem reflexes. Arterial blood gas analysis revealed severe metabolic acidosis. The ethylene glycol level was 159 mg/dL. Despite the appropriate treatment, he died. The third patient (54-year-old, male) with a history of chronic alcoholism was presented after an epileptic seizure with mixed aphasia and confusion. Stroke could not be excluded, therefore thrombolysis was performed. Arterial blood gases were normal, however toxicological screening revealed a serum etyhlene-glycol concentration of 16,54 mg/dL. Six days after admission he became symptom-free and was discharged home. Conclusions: Our cases show that ethylene glycol intoxication in its early phase may mimic acute stroke resulting in an unnecessary thrombolytic therapy. Symptoms not characteristic of a stroke, such as hyperventilation, agitation, and disturbance of consciousness, may appear later and warn of intoxication. The final diagnosis of ethylene-glycol intoxication can be established by a severe metabolic acidosis and toxicological screening. Close monitoring of symptoms might contribute to early recognition of ethylene-glycol intoxication and its effective treatment.