In cases of ethylene glycol poisoning, calcium oxalate may be excreted not only as dihydrate crystals, but also as monohydrate crystals. National Library of Medicine. 2016;2016:9157393. USA.gov. COVID-19 is an emerging, rapidly evolving situation. Challenges in the diagnosis of ethylene glycol poisoning. Epub 2007 Oct 9. Skip to main page content National Institutes of Health. Triple phosphate crystals or struvite stones: Form in alkaline urine and composed of magnesium, ammonium, and phosphate. This site needs JavaScript to work properly. 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/. [1] Early symptoms include intoxication, vomiting and abdominal pain. 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. 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/. ANNA J. Two days after admission, the patient was awake and in clinical recovery. Confocal laser scanning microscopy. Urinary calcium oxalate monohydrate crystals in ethylene glycol poisoning. The severity of ethylene glycol toxicity is related to the metabolic acidosis resulting from the biotransformation of ethylene glycol into toxic metabolites. Ammonium biruate crystals can be seen in normal urine. Ethylene glycol poisoning can cause dysrhythmias and heart failure. Epub 2016 Sep 2. Accidents involving ethylene glycol ingestion often occur with children. Epub 2004 Dec 15. The left image above is from the urine of a dog with many of these crystals. 2017;13:153–57. 3; Table 1). [Cigar-like oxalate crystals in ethylene glycol poisoning]. Microscopic demonstration of calcium oxalate monohydrate crystals in a urine sample. Clipboard, Search History, and several other advanced features are temporarily unavailable. eCollection 2018 Nov. Sheta HM, Al-Najami I, Christensen HD, Madsen JS. Monohydrate crystals are the predominant form of oxalate crystal seen with ethylene glycol poisoning. Ethylene glycol exposure is characterized by an osmolal gap and a metabolic acidosis with an elevated anion gap. 1999 Jun;26(3):295-300, 335; quiz 301-2. 2008 Mar;122(2):173-7. doi: 10.1007/s00414-007-0208-0. BACKGROUND Ethylene glycol poisoning remains an important presentation to Emergency Departments. -, Pomara C, Fiore C, D’Errico S, et al. Keywords: Acidosis; Ethylene Glycol, Hyperglycemia, Poisoning; Renal Insufficiency Ethylene Glycol Poisoning; an Unusual Cause of Hyperglycemia: A Case Report 55 after 24 to 48 hours of EG ingestion. Envelope-like dihydrate calcium oxalate crystals are usually found in the sediment of these patients. lymphoma). Case report: 42, No. A urine sample was sent for microscopy and showed multiple calcium oxalate monohydrate (COM) crystals, which supported the clinical suspicion of ethylene glycol poisoning. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. [1] Toxicity and death may occur after drinking even a small amount.  |  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. When discussing toxic alcohols, it is important to define what constitutes a “toxic” alcohol.  |  Some look almost football-shaped; other look more like crystal aggregates. Calcium oxalate crystals in patient urine samples. Singh R, Arain E, Buth A, et al. NLM Ethylene glycol poisoning was immediately suspected, because the patient had previously been hospitalized with similar symptoms after intake of antifreeze coolant. The cytotoxicity of oxalate, metabolite of ethylene glycol, is due to calcium oxalate monohydrate formation. Download PDF. 2009 Nov;47(9):859-69. doi: 10.3109/15563650903344793. Ethylene glycol is a small molecule (62 dalton) which undergoes rapid absorption from the gastrointestinal tract, distributes to the liver where it is rapidly metabolized by the hepatic alcohol dehydrogenase pathway to toxic metabolites (glycoaldehyde, glycolic acid, glyoxlic acid, oxalic acid, and formic acid), and is excreted in the urine.  |  Forensic Sci Int. Clipboard, Search History, and several other advanced features are temporarily unavailable. Emamiyan MZ, Vaezi G, Tehranipour M, Shahrohkabadi K, Shiravi A. Avicenna J Phytomed. Later symptoms may include a decreased level of consciousness, headache, and seizures. Calcium oxalate crystals may not be present until the later stages of intoxications. Visual appearance of calcium oxalate crystals (circled above) in a urine sample ( source ) Urine analysis under a Wood’s lamp. Individuals intentionally consume ethylene glycol, usually in the form of antifreeze, as an inexpensive alcohol substitute or as a suicidal agent. 1990 Jun. NLM 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. Nephrotoxicity is the dominant effect of significant ethylene glycol poisoning. This can be highly suggestive of ethylene glycol poisoning under the right circumstances. They can be observed in cases of ethylene glycol toxicity. Massive calcium oxalate … Ethylene glycol is the E in the MUDPILES mnemonic, meaning that it causes an elevated anion gap metabolic acidosis. These 95% commercial antifreeze preparations are diluted ~50% with water when used in vehicle cooling systems. 2011 Apr;341(4):338. doi: 10.1097/MAJ.0b013e3181e15dbd. Ethylene glycol may be swallowed accidentally, or it may be taken deliberately in a suicide attempt or as a substitute for drinking alcohol (ethanol). 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). PDF. They generally only form in an acidic urine. NIH It is most commonly encountered as automotive antifreeze.Diethylene glycol behaves similarly to ethylene glycol in an overdose. [1] Long term outcomes may include kidney failure and brain damage. Free PDF. Am J Case Rep. 2018 Jun 14;19:689-693. doi: 10.12659/AJCR.908569. Ethylene glycol poisoning was immediately suspected, because the patient had previously been hospitalized with similar symptoms after intake of antifreeze coolant. Clinical Toxicology, 2008. Ethylene glycol poisoning is poisoning caused by drinking ethylene glycol. (Anti-freeze) Acidic urine. CASE REPORT In this case report, we present a patient who was admitted unconscious to the hospital. When urine left at room temperature or refrigerated then urine becomes cloudy because of the precipitation of crystals or amorphous material. Stage 1 (0.5 to 12 hours) consists of neurological and gastrointestinal symptoms; people may appear to be intoxicated, exhibiting symptoms such as Direct toxicity, cortical edema, and inhibition of mitochondrial activity, as evidenced by decreased succinate dehydrogenase activity, are possible mechanisms of crystal damage. Tidsskr Nor Laegeforen. Conclusions: Toxicological examinations revealed ethylene glycol; the blood level was 250 mg/L and in urine the concentration was 0.3%. All animals are susceptible to ethylene glycol (EG) toxicity, but it is most common in dogs and cats. 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). ... Monohydrate crystals are seen in the ethylene glycol (antifreeze) poisoning. -, Sankaralingam A, Thomas A, James DR, Wierzbicki AS. 231-234. Calcium oxalate crystals in acute ethylene glycol poisoning: A confocal laser scanning microscope study in a fatal case. Am J Med Sci. 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). PDF. Presence in the urine of either fluorescein or calcium oxalate crystals indicates ethylene glycol exposure, but their absence does not exclude this poisoning. PDF. 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. Glycolic acid causes severe acidosis and oxalate precipitates as calcium oxalate in the kidneys and other tissues. Propylene glycol toxicity is seen mainly in an inpatient setting with IV infusions that conta… Clipboard, Search History, and several other advanced features are temporarily unavailable. Massive calcium oxalate … Acute ingestions present with altered sensorium and an osmolal gap. This site needs JavaScript to work properly. Introduction: 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. COVID-19 is an emerging, rapidly evolving situation. The authors report the case of a man 49 years of age with near-fatal ethylene glycol poisoning. Urine sediments of dogs with experimentally induced ethylene glycol poisoning were examined by light microscopy and X-ray diffraction. 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. Luqman A, Stanifer J, Asif Siddiqui OM, Naseer A, Wall BM. 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. Monohydrate crystals are the predominant form of oxalate crystal seen with ethylene glycol poisoning. Calcium Oxalate Monohydrate Crystals: A Clue to Ethylene Glycol Poisoning. Uric acid crystals in the urine are more tricky because they are pleimorphic–they can have many shapes. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. International Scientific Literature, Ltd. Clin Exp Nephrol. 2005 Mar 30;208(3):347-55. doi: 10.1016/j.tox.2004.11.029. They generally only form in an acidic urine. Images in Clinical Medicine from The New England Journal of Medicine — Urinary Calcium Oxalate Crystals in Ethylene Glycol Intoxication When urine left at room temperature or refrigerated then urine becomes cloudy because of the precipitation of crystals or amorphous material. Urine sediments of dogs with experimentally induced ethylene glycol poisoning were examined by light microscopy and X-ray diffraction. The presence of crystals in the urine is called Crystalluria. -, Hodgman M, Marraffa JM, Wojcik S, Grant W. Serum calcium concentration in ethylene glycol poisoning. 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. Ann Clin Biochem. Clin Toxicol (Phila) 2008;46:322–24. Rapid Diagnosis of Ethylene Glycol Poisoning by Urine Microscopy. 2008 Apr;46(4):322-4. doi: 10.1080/15563650701419011. Early symptoms include intoxication, vomiting and abdominal pain. Clin Toxicol (Phila). Premium PDF Package. Toxicological examinations revealed ethylene glycol; the blood level was 250 mg/L and in urine the concentration was 0.3%. Vittorio Fineschi. They can be observed in cases of ethylene glycol toxicity. Download PDF Package. The presence of crystals in the urine is called Crystalluria. 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. Calcium oxalate crystals in acute ethylene glycol poisoning: a confocal laser scanning microscope study in a fatal case. 2014;51:167–78. Most ethylene glycol poisonings occur due to the ingestion of antifreeze. Pomara C, Fiore C, D'Errico S, Riezzo I, Fineschi V. Clin Toxicol (Phila). The role of histopathology in forensic practice: an overview. 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). Please enable it to take advantage of the complete set of features! Discussion: Also, we will not be discussing propylene glycol due to the rarity of its consumption. Case Rep Crit Care. 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. Secondary Oxalate Nephropathy: A Systematic Review. Calcium oxalate monohydrate crystals: a clue to ethylene glycol poisoning. Ann Emerg Med . Calcium oxalate monohydrate, a metabolite of ethylene glycol, is toxic for rat renal mitochondrial function. The values of glycolic and oxalic acid from samples taken at admission were very high but significantly decreased during therapy (Fig. HHS Long term outcomes may include kidney failure and brain damage. National Library of Medicine. Acidic urine. A relevant clue to isopropanol ingestion is positivity for acetone in the urine or blood without attendant hyperglycemia. -, McQuade DJ, Dargan PI, Wood DM. Ethylene glycol poisoning is poisoning caused by drinking ethylene glycol. Ethylene glycol is a colorless, odorless, sweet-tasting chemical.  |  Scandinavian Journal of Clinical and Laboratory Investigation: Vol. Most intoxications are associated with ingestion of antifreeze, which is typically 95% EG. A urine sample was sent for microscopy and showed multiple calcium oxalate monohydrate (COM) crystals, which supported the clinical suspicion of ethylene glycol poisoning. 2009 Nov;47(9):859-69. doi: 10.3109/15563650903344793. Some look almost football-shaped; other look more like crystal aggregates. Calcium Phosphate: Can have different morphologies depending on state of hydration. Clipboard, Search History, and several other advanced features are temporarily unavailable. Ethylene glycol is found in many household products and is a common toxic ingestion. 1994 Feb 10;114(4):435-6. 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). Discussion: In cases of ethylene glycol poisoning, calcium oxalate may be excreted not only as dihydrate crystals, but also as monohydrate crystals. Fomepizole is a new agent with a specific indication by the U.S. Food and Drug Administration for the treatment of ethylene glycol poisoning.4, 6, 7, … Toxicology. Urine sediments of dogs with experimentally induced ethylene glycol poisoning were examined by light microscopy and X-ray diffraction. 2017;54(4):501–3. 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. Confocal laser scanning microscopy demonstrated oxalate crystals deposition within the tubular epithelial cells and widespread necrosis of the tubular epithelium in the proximal tubules. The presence of calcium oxalate or hippurate crystals in the urine, together with an elevated anion gap or osmolal gap, strongly suggests ethylene glycol poisoning (Albertson 1999). Resulting from the biotransformation of ethylene glycol ; the blood level was 250 mg/L and in urine concentration..., Christensen HD, Madsen JS Fiore C, D'Errico S, Riezzo,... 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