Successful therapy of paediatric ethylene glycol poisoning: a case report and annual survey by a regional poison centre

Severe poisoning with ethylene glycol, often used as antifreeze, is a rare, life-threatening event. Neurological symptoms are accompanied by metabolic acidosis with elevated anion gap and osmotic gap. We report on a 7-year-old boy suffering from severe ethylene glycol intoxication. Early diagnosis based on typical clinical signs and rapid initiation of specific therapy with ethanol resulted in complete and rapid recovery without haemodialysis becoming necessary. While one laboratory initially had not been able to detect ethylene glycol in the patient's blood, an ethylene glycol serum level of 3900 mg/L was measured by a second laboratory, the highest value ever reported in the scientific literature for paediatric cases. Ethylene glycol poisoning is verified by quantitative glycol analysis in serum, but only few laboratories are able to perform this investigation in emergency cases. Therefore, in the beginning diagnosis has to be based on patient's history and clinical signs. Every substantial suspicion of ethylene glycol poisoning has to be treated with an antidote (fomepizole or ethanol) immediately. CONCLUSION: Ethylene glycol poisoning is rare in the paediatric age group in our series of glycol poisonings. One should keep in mind, that early diagnosis and treatment due to clinical signs is important and haemodialysis usually is not necessary.     

Intentional infantile ethylene glycol poisoning presenting as an inherited metabolic disorder.

A 6-month-old girl was hospitalized on three occasions for irritability, vomiting, acidosis, and hypotonia. During the third hospitalization hyperglycinemia and urinary glycolic acid were detected. Ethylene glycol was discovered in the infant's blood and bottled formula. Clinicians must consider ethylene glycol intoxication as a cause of recurrent infantile metabolic acidosis.     

Home environment and acute propylene glycol intoxication in a two-year old. An unusual case report]

BACKGROUND: Acute propylene glycol intoxication in a two-year-old toddler underlines the potentially serious toxicity in children of this chemical agent present as a diluent in many drugs and environmental products such as cosmetics, diapers, cleansing towels, despite a common consideration of safety and lack of toxicity. CASE REPORT: A two-years-old boy previously healthy was found in the morning by his parents in his cradle, lethargic, responsive only to sharp pain. On admission, vital signs were: temperature 38.5 degrees C, lethargy, polypnea; propylene glycol intoxication through disposable cleansing towels chewing was ascertained by anamnesis and blood urine analyses which revealed metabolic acidosis and serum propylene glycol peak. CONCLUSION: Environmental acute propylene glycol intoxication must be considered and searched for in front of a metabolic acidosis case of unknown origin in children.     

Fomepizole treatment of ethylene glycol poisoning in an infant

The enzyme alcohol dehydrogenase metabolizes ingested ethylene glycol (EG) to the toxic compounds glycolic and oxalic acids. Renal failure, acidosis, hypocalcemia, and death may follow. Traditional treatment of EG poisoning may require ethanol, a competitive substrate of alcohol dehydrogenase, and hemodialysis, that removes both EG and its toxic metabolites. A new alcohol dehydrogenase inhibitor, fomepizole (4-methylpyrazole), was approved in 1997 for patients at least 12 years old with suspected or confirmed EG poisoning. Fomepizole has not been studied adequately in the pediatric population. We present a case of an 8-month-old male infant who drank up to 120 mL of EG and developed acidosis and oxalate crystalluria. He was treated with fomepizole and hemodialysis. Even after the completion of hemodialysis, fomepizole appeared to effectively block the production of EG toxic metabolites and to allow the resolution of acidosis; the patient recovered within 48 hours. This is the first report of fomepizole treatment of EG poisoning in an infant.4-methylpyrazole, fomepizole, poisoning, ethylene glycol, hemodialysis, infant, child, pediatrics.     

Use of airway pressure release ventilation in a child with refractory hepatopulmonary syndrome after liver transplantation

HPS is a life‐threatening condition in patients with end‐stage liver disease, in which intrapulmonary vascular dilatations result in intrapulmonary shunts and hypoxemia. The only successful treatment is liver transplantation. Hypoxemia may be severe prior to transplantation; however, it can worsen or become refractory after liver transplantation and result in increased post‐operative mortality. Here, we present the case of a 10‐month‐old female infant with progressive end‐stage liver disease and severe HPS, who developed refractory hypoxemia after a successful liver transplantation. After 19 days of unsuccessful attempts to reverse the hypoxemia using conventional mechanical ventilation and HFOV, the patient responded dramatically to APRV, with rapid improvement in her PaO₂ and sharp decline in her OI. She was able to begin weaning from APRV two days later and was extubated within seven days. APRV was successful in treating refractory hypoxemia in this patient with severe HPS after liver transplantation, possibly by modifying distribution of pulmonary blood flow. Although we cannot rule out coincidental natural resolution of the HPS, APRV could be a useful rescue therapy in patients with HPS and refractory hypoxemia.     

Hepatopulmonary syndrome associated with nodular regenerative hyperplasia after liver transplantation in a child

HPS is a significant complication of portal hypertension in children with chronic liver disease and is an established indication for LT. It is characterized clinically by the triad of pulmonary vascular dilatation causing hypoxemia in the setting of advanced liver disease. NRH, a cause of non‐cirrhotic portal hypertension, is characterized by diffuse benign transformation of the hepatic parenchyma into small regenerative nodules with minimal or no fibrosis. Development of NRH and HPS in pediatric LT recipients has not been reported, although occasional cases have been reported in adult LT recipients. In this report, we discuss a case of a three‐yr‐old male who developed HPS, two yr after LT. Pulmonary and cardiac causes for hypoxemia were ruled out by appropriate investigations including a chest X ray, echocardiogram, cardiac catheterization, and a CT angiographic study. The diagnosis of HPS was confirmed via bubble echocardiogram that demonstrated intrapulmonary shunting. Open liver biopsy revealed marked NRH. The patient underwent liver retransplantation that resulted in complete reversal of his pulmonary symptoms and normal oxygen saturations within three months after LT.     

Anesthetic management of a pediatric patient with pulmonary arteriovenous fistula undergoing liver transplantation – a case report

For patients with HPS who require anesthesia for a procedure, HPV should be maintained to prevent worsening hypoxemia. Here, the case of a 9‐yr‐old girl who was scheduled for a living donor liver transplantation is presented. The patient suffered from end‐stage liver disease with HPS due to biliary atresia, which contributed to the development of a diffuse pulmonary AVF. Consequently, anesthetic management of this patient involved two different types of pulmonary shunt. It is important to maintain HPV, not only to prevent worsening of the hypoxia caused by HPS but also to inhibit an increase in PVR that could cause an increase of shunt flow through the pathological fistula. A TIVA technique was performed, and a nitrous oxide inhaler was prepared in case of a possible increase in PVR during the reperfusion period. There were no adverse events during the operation. Thus, anesthesiologists should be aware of the pathophysiological status of HPS and its potential to progress to a pulmonary AVF in order to meticulously determine an anesthesia plan that accounts for the hypoxia and PVR that are associated with HPS.     

Coma in a premature infant associated with the transdermal absorption of propylene glycol

A case of propylene glycol intoxication in a premature infant is reported. The infant went into a state of coma after treatment for burns with antiseptic dressings. Cessation of the topical treatment resulted in complete recovery. An exceptionally high level of the dressings' solvent, propylene glycol, found in the urinary chromatogram, was believed to be the causative agent. It is suggested that topical preparations containing propylene glycol should not be used in premature infants during the first weeks of life.     

The development of hypertrophic pyloric stenosis in a patient with prostaglandin-induced foveolar hyperplasia

Background. Hypertrophic pyloric stenosis (HPS) has been described in association with several obstructive antropyloric lesions including idiopathic foveolar hyperplasia (gastric mucosal hypertrophy), feeding tubes, eosinophilic gastroenteritis, and hypertrophic antral polyps. Non obstructive antral webs have also been described with HPS. Patient and methods. We present a case of gastric-outlet obstruction in association with HPS, namely, prostaglandin-induced foveolar hyperplasia. This entity has been previously described, but rarely in association with HPS. We report a female infant requiring prostaglandin therapy for pulmonary atresia who developed dose-related prostaglandin-induced foveolar hyperplasia and symptoms of progressive non-bilious vomiting. Results. Intially, ultrasonography demonstrated evidence of antral mucosal hypertrophy as the cause for gastric-outlet obstruction. The patient subsequently developed progressive thickening of the antropyloric muscle, resulting in sonographic appearances of hypertrophic pyloric stenosis. Pyloromyotomy was eventually required for treatment of HPS. Conclusion. A common denominator of most of the above-described entities is thickening and/or hypertrophy of the antral mucosa. We suggest that the antropyloric musculature may hypertrophy in an effort to overcome the gastric-outlet obstruction caused by the adjacent thickened antral mucosa. In other words, these entities may represent examples of “secondary” hypertrophic pyloric stenosis. Received: 28 September 1998 Accepted: 9 June 1999     

Severe ethylene glycol ingestion treated without hemodialysis

Fomepizole (4-methylpyrazole, Antizol) is being increasingly used in the treatment of ethylene glycol toxicity in adults. Little experience exists with this drug, however, in the pediatric population. We present a case of ethylene glycol poisoning in a child where use of fomepizole averted intravenous ethanol infusion and hemodialysis, limited the duration of intensive care monitoring, and decreased the overall cost of treatment.     

Autoimmune hepatitis in a child presenting with hepatopulmonary syndrome (HPS)

HPS has been described in 9–20% of children with end‐stage liver disease. We present a case of a previously, asymptomatic nine‐yr‐old incidentally found to have low oxygen saturation. Physical exam was remarkable for digital clubbing, splenomegaly and orthodeoxia. Laboratory evaluation revealed a low platelet count, hyperammonemia, and prolonged coagulation studies. Sonography showed evidence of splenomegaly and portal venous hypertension. High resolution CT thorax and CTA were normal. HPS was confirmed by agitated saline contrast enhanced echocardiography and Tc‐99m MAA scan with evidence of intrapulmonary vascular dilatations. Liver biopsy was performed and consistent with autoimmune hepatitis. A high clinical index of suspicion should be maintained for HPS in pediatric patients who have unexplained hypoxemia as typical signs and symptoms of severe liver disease are often absent. In this report, we discuss a case of HPS complicated AIH in a pediatric patient and review the relevant literature.     

Novel therapies for ethylene glycol intoxication.

Ethylene glycol is a serious toxin that children frequently ingest. Diagnosis and treatment of this poisoning are challenging and frequently involve the use of novel therapies. In the past year, fomepizole (4-methylpyrazole) has been approved for use as an antidote in the treatment of ethylene glycol poisoning in adults, and the first article reporting the use of fomepizole in a pediatric ethylene glycol exposure was published. As a result, the therapy of ethylene glycol poisoning in children is likely to change from the traditional approach of ethanol administration coupled with hemodialysis to the administration of fomepizole with or without hemodialysis.     

Hyponatremia in patients with nocturnal enuresis treated with DDAVP

Treatment of nocturnal enuresis with DDAVP is associated with a low incidence of adverse effects. The only reported serious adverse effect is seizure or altered level of consciousness due to water intoxication. We reviewed 14 articles that reported data on serum sodium in patients treated with DDAVP for nocturnal enuresis and 11 articles that reported patients who developed a seizure or altered level of consciousness during treatment with DDAVP for nocturnal enuresis. Excess fluid intake was identified as a contributing factor in 6 of the 11 case reports.     

Accidental and intentional poisonings with ethylene glycol in infancy: diagnostic clues and management

Ethylene glycol has long been recognized as a potentially lethal poison and remains available today as automotive antifreeze and windshield deicer fluids. Ethylene glycol is rapidly absorbed from the gastrointestinal tract, with peak levels measured one to four hours after ingestion. Metabolism of the parent compound and the production of several organic acids are responsible for the metabolic acidosis observed in ethylene glycol poisoning. Target organ cellular damage is seen in the kidney, brain, myocardium, pancreas, and blood vessel walls. Renal tubular deposition of calcium oxalate crystals is felt to be responsible for the development of the severe renal injury which may accompany ethylene glycol ingestion. The clinical course is quite varied and includes inebriation, hematuria, cardiorespiratory compromise, and neurologic effects. Prompt diagnosis and initiation of treatment, including ethanol therapy and hemodialysis, is necessary to ameliorate the effects of ethylene glycol ingestion. Two cases of ethylene glycol poisoning, one accidental and one intentional, are reviewed.     

Severe valproic acid intoxication is associated with atrial tachycardia: secondary detoxication by hemoperfusion

Valproic acid is an anticonvulsant drug which is associated with serious toxicity including fatal outcome in case of severe intoxication. Secondary detoxication by hemodialysis or hemoperfusion has been employed successfully in valproic acid intoxication. Cardiac arrhythmias have only been described rarely in valproic acid intoxication in humans. We report on a 15 year-old boy with severe valproic acid intoxication (valproic acid plasma level on admission: 1 150 mg/l) who presented with coma, hypernatremia and atrial tachycardia. The patient was successfully treated with hemoperfusion and intensive supportive care without implementation of a specific antiarrhythmic therapy. We conclude that patients with severe valproic acid intoxication may benefit from secondary detoxication. In addition to generally known symptoms valproic acid intoxication may also be associated with cardiac arrhythmias.     

Successful venoarterial extracorporeal membrane oxygenation for prolonged hepatopulmonary syndrome following pediatric liver transplantation: A case report and review of the literature

HPS is a major complicating feature of end‐stage liver disease. Diagnosis is clinical, and LT is the only definitive treatment. While the general impression is that HPS improves quickly after transplantation, it may not always be the case. We describe the smallest reported child with HPS prior to LT and requiring prolonged venoarterial extracorporeal membrane oxygenation after LT; especially as it is a rare occurrence, physician managing such cases should be aware of the circumstances under which HPS may require specific treatment.     

Accidental etizolam ingestion in a child

Etizolam (ETZ) is an antidepressive thienodiazepine drug that is used worldwide. The most frequent adverse effects in adults are drowsiness and muscle weakness, and this can rarely cause paradoxical excitation; however, no information exists on intoxication in children. Furthermore, evidence bearing on its safety in children is not available. We present a case of a child who accidentally took a single dose of ETZ, approximately the same as a therapeutic dose for adults, and who showed paradoxical excitation and muscle weakness. The case presented here suggests that pediatricians and emergency physicians should be aware of the possible adverse effects in children and therapeutic approaches in intoxication of ETZ and the necessity of further investigations on a specific therapeutic guideline for overdose management especially in children.     

Acute colchicine intoxication in a child: a case report

Colchicine poisoning is an uncommon, but potentially life-threatening, toxicologic emergency. The clinical features associated with overdose and the options for treatment are discussed. Colchicine poisoning typically shows 3 phases: initially, gastrointestinal symptoms predominate; in the second phase, multiorgan failure may occur, possibly leading to death. If the patient survives, the third phase of recovery follows, during which the patient often presents with hair loss. Early fatality is due to cardiovascular collapse and respiratory failure; however, pancytopenia and overwhelming septicemia can occur later. All patients suspected of having colchicine intoxication because of its unpredictable outcome should be managed according to the principles of intensive care, irrespective of the actual degree of poisoning. In those patients who survive the initial phase of poisoning, filgrastim (granulocyte colony-stimulating factor) offers an effective method of treating pancytopenia and preventing overwhelming septicemia. Daily monitoring of the patients' hematological status is strongly recommended. We are reporting a case of previously healthy girl who developed a multisystem organ failure after colchicine intoxication. The patient recovered completely and had no residual outcome.