Acute ingestions present with altered sensorium and an osmolal gap. [1] Long term outcomes may include kidney failure and brain damage. CONCLUSIONS Demonstration of COM crystals using microscopy of a urine sample adds valuable information supporting the clinical suspicion of ethylene glycol poisoning, and may serve as an easy, quick, and cheap method that can be performed in any emergency setting. 2017 Aug;21(4):741-742. doi: 10.1007/s10157-016-1332-2. Stage 1 (0.5 to 12 hours) consists of neurological and gastrointestinal symptoms; people may appear to be intoxicated, exhibiting symptoms such as Toxicity and death may occur after drinking even a small amount. 2005 Dec 20;155(2-3):179-84. doi: 10.1016/j.forsciint.2004.11.012. eCollection 2018 Nov. Sheta HM, Al-Najami I, Christensen HD, Madsen JS. The classic laboratory profile of ethylene glycol ingestion is an early osmolar gap (the ethylene glycol serves as an unmeasured osmole) that disappears as an anion gap metabolic acidosis develops (as the ethylene glycol is converted into its acidic derivatives). 2016;2016:9157393. Emamiyan MZ, Vaezi G, Tehranipour M, Shahrohkabadi K, Shiravi A. Avicenna J Phytomed. Ethylene glycol poisoning is poisoning caused by drinking ethylene glycol. Discussion: In cases of ethylene glycol poisoning, calcium oxalate may be excreted not only as dihydrate crystals, but also as monohydrate crystals. The presence of crystals in the urine is called Crystalluria. Monohydrate crystals are the predominant form of oxalate crystal seen with ethylene glycol poisoning. National Library of Medicine. Blood glucose imbalances lymphoma). Ethylene glycol poisoning was immediately suspected, because the patient had previously been hospitalized with similar symptoms after intake of antifreeze coolant. Some look almost football-shaped; other look more like crystal aggregates. Accidents involving ethylene glycol ingestion often occur with children.  |  Ethylene glycol exposure is characterized by an osmolal gap and a metabolic acidosis with an elevated anion gap. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Clin Toxicol (Phila). They can be observed in cases of ethylene glycol toxicity. CASE REPORT In this case report, we present a patient who was admitted unconscious to the hospital. 3, pp. Singh R, Arain E, Buth A, et al. Clipboard, Search History, and several other advanced features are temporarily unavailable. 231-234. The dog did not have ethylene glycol poisoning and the crystals are assumed to be secondary to supersaturation of the urine with calcium and oxalates, which precipitated in the acidic urine. Urine sediments of dogs with experimentally induced ethylene glycol poisoning were examined by light microscopy and X-ray diffraction. Calcium oxalate crystals in the urine are the most common constituent of human kidney stones, and calcium oxalate crystal formation is also one of the toxic effects of ethylene glycol poisoning. Clinical Toxicology, 2008. USA.gov. Ethylene glycol is the E in the MUDPILES mnemonic, meaning that it causes an elevated anion gap metabolic acidosis. Ethylene glycol is a colorless, odorless, sweet-tasting chemical. The presence of crystals in the urine is called Crystalluria. Microscopic demonstration of calcium oxalate monohydrate crystals in a urine sample. Conclusions: Later symptoms may include a decreased level of consciousness, headache, and seizures. The true toxicity of ethylene glycol is mediated by its metabolites, which are responsible for the increased anion gap metabolic acidosis, renal tubular damage, and crystalluria seen later in ingestions. National Library of Medicine. It is this acid that combines with serum calcium to form the classic calcium oxalate crystals found in the urine of patients who have consumed ethylene glycol. Urinary crystals … A urinalysis may also confirm ethylene glycol poisoning and underlying kidney damage by the presence of dilute urine containing blood, protein, cellular casts (plugs of cells which have taken the shape of dying tubules in the kidneys), and calcium oxalate crystals (which are seen with ethylene glycol poisoning). Envelope-like dihydrate calcium oxalate crystals are usually found in the sediment of these patients. Coma with grave metabolic acidosis, increased anion and osmolal gap, oxalate crystals in urine sediment and increased ultrasound density of the renal parenchyma are essential clues to the diagnosis of ethylene glycol poisoning. Visual appearance of calcium oxalate crystals (circled above) in a urine sample ( source ) Urine analysis under a Wood’s lamp. Calcium oxalate crystals in patient urine samples. Ethylene glycol is found in many household products and is a common toxic ingestion. 2017;54(4):501–3. Forensic Sci Med Pathol. Urine fluorescence using a Wood's lamp to detect the antifreeze additive sodium fluorescein: a qualitative adjunctive test in suspected ethylene glycol ingestions. Chemical properties. PDF. HHS The cytotoxicity of oxalate, metabolite of ethylene glycol, is due to calcium oxalate monohydrate formation. It is poisonous if swallowed. [1] Early symptoms include intoxication, vomiting and abdominal pain. Ethylene glycol poisoning can cause dysrhythmias and heart failure. Toxicology. 2014;51:167–78. PDF. Nephrotoxicity is the dominant effect of significant ethylene glycol poisoning. 2014 Sep;10(3):401-12. doi: 10.1007/s12024-014-9536-9. Tidsskr Nor Laegeforen. Clipboard, Search History, and several other advanced features are temporarily unavailable. Most ethylene glycol poisonings occur due to the ingestion of antifreeze. Acute ingestions present with altered sensorium and an osmolal gap. Some look almost football-shaped; other look more like crystal aggregates. Calcium oxalate crystals in acute ethylene glycol poisoning: a confocal laser scanning microscope study in a fatal case. Calcium oxalate crystals in acute ethylene glycol poisoning: A confocal laser scanning microscope study in a fatal case. Common w/ kidney stones, also toxic effects of ethylene glycol poisoning. -, Pomara C, Fiore C, D’Errico S, et al. They generally only form in an acidic urine. ... Monohydrate crystals are seen in the ethylene glycol (antifreeze) poisoning. Since calcium oxalate monohydrate crystals are transported intracellularly by kidney cells, the renal toxicity of ethylene glycol may result from inhibition of mitochondrial respiratory function in proximal tubular cells by calcium oxalate monohydrate crystals. Forensic Sci Int. 1999 Jun;26(3):295-300, 335; quiz 301-2. This site needs JavaScript to work properly. Quick diagnosis and treatment are essential to prevent renal failure and life-threating complications. 2009 Nov;47(9):859-69. doi: 10.3109/15563650903344793. Ann Emerg Med . Individuals intentionally consume ethylene glycol, usually in the form of antifreeze, as an inexpensive alcohol substitute or as a suicidal agent. Introduction: Ethylene glycol, the predominant constituent of automotive products such as antifreeze and deicers, is an important but uncommon toxicological problem in current medical practice (1)(2). Glycolic acid causes severe acidosis and oxalate precipitates as calcium oxalate in the kidneys and other tissues. Uric acid crystals in the urine are more tricky because they are pleimorphic–they can have many shapes. NIH Symptoms of ethylene glycol poisoning usually follow a three-step progression, although poisoned individuals will not always develop each stage. The patient was treated with continuous intravenous ethyl alcohol infusion and hemodialysis. Assessment of a semi-quantitative screening method for diagnosis of ethylene glycol poisoning. The left image above is from the urine of a dog with many of these crystals. Any alcohol when consumed in enough of a quantity can be toxic; however, we will not discuss ethanol as it is not one of the classic “toxic alcohols.” These typically include methanol, ethylene glycol, propylene glycol, and isopropanol (isopropyl alcohol). Calcium oxalate is a combination of calcium ions and the conjugate base of oxalic acid, the oxalate anion. 2017;13:153–57. PDF. Massive calcium oxalate … Direct toxicity, cortical edema, and inhibition of mitochondrial activity, as evidenced by decreased succinate dehydrogenase activity, are possible mechanisms of crystal damage. -, McQuade DJ, Dargan PI, Wood DM. Epub 2007 Oct 9. Early symptoms include intoxication, vomiting and abdominal pain. -, Hodgman M, Marraffa JM, Wojcik S, Grant W. Serum calcium concentration in ethylene glycol poisoning. See this image and copyright information in PMC. Ethylene glycol (C2H6O2 Ethylene glycol is an odorless, colorless, sweet-tasting syrupy substance with a molecular weight of 62.07, freezing point of -13°C and a boiling point of 197.6°C. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Challenges in the diagnosis of ethylene glycol poisoning. Ethylene glycol intoxication: pathophysiology, diagnosis, and emergency management. Triple phosphate crystals or struvite stones: Form in alkaline urine and composed of magnesium, ammonium, and phosphate. [1] Toxicity and death may occur after drinking even a small amount. Clin Toxicol (Phila). They can be observed in cases of ethylene glycol toxicity. Luqman A, Stanifer J, Asif Siddiqui OM, Naseer A, Wall BM. Calcium Oxalate Monohydrate Crystals: A Clue to Ethylene Glycol Poisoning. Skip to main page content National Institutes of Health. The histologic diagnosis of acute renal failure secondary to ethylene glycol poisoning depends on the recognitions of the changes of acute tubular damage in association with calcium oxalate crystals deposition within the tubular epithelial cells and the widespread necrosis of the tubular epithelium in the proximal tubules. This site needs JavaScript to work properly. Uric acid crystals in the urine are more tricky because they are pleimorphic–they can have many shapes. Oval, spindle or dumb-bell forms are infrequently seen in urine from healthy dogs and cats but can be seen in hypercalciuric conditions and ethylene glycol toxicity.Picket fence form (arrow) are commonly observed in ethylene glycol toxicity in dogs and cats, but can also be seen in animals with hypercalciuria due to other causes (e.g. Also, we will not be discussing propylene glycol due to the rarity of its consumption. Ethylene glycol poisoning is poisoning caused by drinking ethylene glycol. 2, Fig. Clipboard, Search History, and several other advanced features are temporarily unavailable. COVID-19 is an emerging, rapidly evolving situation. When urine left at room temperature or refrigerated then urine becomes cloudy because of the precipitation of crystals or amorphous material. Calcium oxalate crystals in the urine are the most common constituent of human kidney stones, and calcium oxalate crystal formation is also one of the toxic effects of ethylene glycol poisoning. Premium PDF Package. Turillazzi E, Karch SB, Neri M, Pomara C, Riezzo I, Fineschi V. Int J Legal Med. Download PDF. Presence in the urine of either fluorescein or calcium oxalate crystals indicates ethylene glycol exposure, but their absence does not exclude this poisoning.  |  Ann Clin Biochem. According to the annual report of the American Association of Poison Control Centers, ethylene glycol … NIH Am J Med Sci. Pomara C, Fiore C, D'Errico S, Riezzo I, Fineschi V. Clin Toxicol (Phila). The severity of ethylene glycol toxicity is related to the metabolic acidosis resulting from the biotransformation of ethylene glycol into toxic metabolites. The true toxicity of ethylene glycol is mediated by its metabolites, which are responsible for the increased anion gap metabolic acidosis, renal tubular damage, and crystalluria seen later in ingestions. A urine sample was sent for microscopy and showed multiple calcium oxalate monohydrate (COM) crystals, which supported the clinical suspicion of ethylene glycol poisoning. Images in Clinical Medicine from The New England Journal of Medicine — Urinary Calcium Oxalate Crystals in Ethylene Glycol Intoxication Calcium oxalate monohydrate crystals: a clue to ethylene glycol poisoning. Urine sediments of dogs with experimentally induced ethylene glycol poisoning were examined by light microscopy and X-ray diffraction. Epub 2016 Sep 2. Acidic urine. Ethylene glycol is found in many household products and is a common toxic ingestion. It is most commonly encountered as automotive antifreeze.Diethylene glycol behaves similarly to ethylene glycol in an overdose. NLM [Cigar-like oxalate crystals in ethylene glycol poisoning]. Please enable it to take advantage of the complete set of features! Microscopic demonstration of calcium oxalate…. Rapid Diagnosis of Ethylene Glycol Poisoning by Urine Microscopy. -. 2018 Mar-Apr;8(2):170-178. Massive calcium oxalate … COVID-19 is an emerging, rapidly evolving situation. Envelope-shaped crystals of calcium oxalate may be seen in the urine except in case of significant renal failure (8). Long term outcomes may include kidney failure and brain damage. (Anti-freeze) Acidic urine. Are calcium oxalate crystals involved in the mechanism of acute renal failure in ethylene glycol poisoning? 1990 Jun. This can be highly suggestive of ethylene glycol poisoning under the right circumstances. Using new technology to answer old questions in forensic practice: an overview,. Absence does not exclude this poisoning scanning microscopy demonstrated oxalate crystals in glycol. X-Ray diffraction OM, Naseer a, et al urine microscopy 155 ( 2-3 ):179-84. doi:.. Mar ; 122 ( 2 ):173-7. doi: 10.12659/AJCR.908569 method for diagnosis of glycol! 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