The left image above is from the urine of a dog with many of these crystals. [1] Later symptoms may include a decreased level of consciousness, headache, and seizures. A urine sample was sent for microscopy and showed multiple calcium oxalate monohydrate (COM) crystals, which supported the clinical suspicion of ethylene glycol poisoning. Ethylene glycol is the E in the MUDPILES mnemonic, meaning that it causes an elevated anion gap metabolic acidosis. Chemical properties. Urine sediments of dogs with experimentally induced ethylene glycol poisoning were examined by light microscopy and X-ray diffraction. Confocal laser scanning microscopy demonstrated oxalate crystals deposition within the tubular epithelial cells and widespread necrosis of the tubular epithelium in the proximal tubules. Download Free PDF. Scandinavian Journal of Clinical and Laboratory Investigation: Vol. Premium PDF Package. Long term outcomes may include kidney failure and brain damage. Calcium oxalate is a combination of calcium ions and the conjugate base of oxalic acid, the oxalate anion. Challenges in the diagnosis of ethylene glycol poisoning. 3, pp. A urine sample was sent for microscopy and showed multiple calcium oxalate monohydrate (COM) crystals, which supported the clinical suspicion of ethylene glycol poisoning. Calcium oxalate crystals in acute ethylene glycol poisoning: a confocal laser scanning microscope study in a fatal case. Acute ingestions present with altered sensorium and an osmolal gap. In cases of ethylene glycol poisoning, calcium oxalate may be excreted not only as dihydrate crystals, but also as monohydrate crystals. Emamiyan MZ, Vaezi G, Tehranipour M, Shahrohkabadi K, Shiravi A. Avicenna J Phytomed. 2018 Mar-Apr;8(2):170-178. -, Pomara C, Fiore C, D’Errico S, et al. 2005 Dec 20;155(2-3):179-84. doi: 10.1016/j.forsciint.2004.11.012. COVID-19 is an emerging, rapidly evolving situation. Stage 1 (0.5 to 12 hours) consists of neurological and gastrointestinal symptoms; people may appear to be intoxicated, exhibiting symptoms such as Ethylene glycol is a colorless, odorless, sweet-tasting chemical.  |  [Cigar-like oxalate crystals in ethylene glycol poisoning]. They can be observed in cases of ethylene glycol toxicity. Ethylene glycol is found in many household products and is a common toxic ingestion. Ann Clin Biochem. 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). Calcium oxalate is a combination of calcium ions and the conjugate base of oxalic acid, the oxalate anion. Massive calcium oxalate crystalluria was observed in all poisoned dogs. They can be observed in cases of ethylene glycol toxicity. ... Monohydrate crystals are seen in the ethylene glycol (antifreeze) poisoning. Preventive effects of the aqueous extract of. Massive calcium oxalate … Epub 2004 Dec 15. Uric acid crystals in the urine are more tricky because they are pleimorphic–they can have many shapes. 231-234. Toxicol Sci. Secondary Oxalate Nephropathy: A Systematic Review. Ethylene glycol is found in many household products and is a common toxic ingestion. Ann Clin Biochem. Common w/ kidney stones, also toxic effects of ethylene glycol poisoning. Uric acid crystals in the urine are more tricky because they are pleimorphic–they can have many shapes. 2008 Mar;122(2):173-7. doi: 10.1007/s00414-007-0208-0. lymphoma). -. Blood glucose imbalances Lumlertgul N, Siribamrungwong M, Jaber BL, Susantitaphong P. Kidney Int Rep. 2018 Jul 29;3(6):1363-1372. doi: 10.1016/j.ekir.2018.07.020. The patient was treated with continuous intravenous ethyl alcohol infusion and hemodialysis. PDF. Ethylene glycol intoxication: pathophysiology, diagnosis, and emergency management. This site needs JavaScript to work properly. Urine sediments of dogs with experimentally induced ethylene glycol poisoning were examined by light microscopy and X-ray diffraction. Glycolic acid causes severe acidosis and oxalate precipitates as calcium oxalate in the kidneys and other tissues. Quick diagnosis and treatment are essential to prevent renal failure and life-threating complications. International Scientific Literature, Ltd. Clin Exp Nephrol. 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. When urine left at room temperature or refrigerated then urine becomes cloudy because of the precipitation of crystals or amorphous material.  |  Are calcium oxalate crystals involved in the mechanism of acute renal failure in ethylene glycol poisoning? When discussing toxic alcohols, it is important to define what constitutes a “toxic” alcohol. USA.gov. Accidents involving ethylene glycol ingestion often occur with children. 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. -, McQuade DJ, Dargan PI, Wood DM. Urinary calcium oxalate monohydrate crystals in ethylene glycol poisoning. Visual appearance of calcium oxalate crystals (circled above) in a urine sample ( source ) Urine analysis under a Wood’s lamp. 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. 2014;51:167–78. Clinical Toxicology, 2008. See this image and copyright information in PMC. -, Hodgman M, Marraffa JM, Wojcik S, Grant W. Serum calcium concentration in ethylene glycol poisoning. Calcium Oxalate Monohydrate Crystals: A Clue to Ethylene Glycol Poisoning. Ethylene glycol poisoning was immediately suspected, because the patient had previously been hospitalized with similar symptoms after intake of antifreeze coolant. Two days after admission, the patient was awake and in clinical recovery. HHS 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). Ethylene glycol poisoning can cause dysrhythmias and heart failure. Urinary crystals … Oxalate crystals in the urine However these criteria may be too conservative; if there is clinical concern or if laboratory testing will take an extended amount of time to return it is advisable to initiate therapy earlier. Calcium oxalate monohydrate, a metabolite of ethylene glycol, is toxic for rat renal mitochondrial function. This site needs JavaScript to work properly. Most intoxications are associated with ingestion of antifreeze, which is typically 95% EG. National Library of Medicine. ANNA J. The role of histopathology in forensic practice: an overview. Ethylene glycol exposure is characterized by an osmolal gap and a metabolic acidosis with an elevated anion gap. Clipboard, Search History, and several other advanced features are temporarily unavailable. (Anti-freeze) Acidic urine. 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). Case report: Nephrotoxicity is the dominant effect of significant ethylene glycol poisoning. PDF. Monohydrate crystals are the predominant form of oxalate crystal seen with ethylene glycol poisoning. Am J Med Sci. Clipboard, Search History, and several other advanced features are temporarily unavailable. This can be highly suggestive of ethylene glycol poisoning under the right circumstances. Assessment of a semi-quantitative screening method for diagnosis of ethylene glycol poisoning. Am J Case Rep. 2018 Jun 14;19:689-693. doi: 10.12659/AJCR.908569. Epub 2005 Jan 21. Using new technology to answer old questions in forensic investigations. 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. A relevant clue to isopropanol ingestion is positivity for acetone in the urine or blood without attendant hyperglycemia. 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/. Acidic urine. 42, No. 1999 Jun;26(3):295-300, 335; quiz 301-2. Triple phosphate crystals or struvite stones: Form in alkaline urine and composed of magnesium, ammonium, and phosphate.  |  2011 Apr;341(4):338. doi: 10.1097/MAJ.0b013e3181e15dbd. Envelope-like dihydrate calcium oxalate crystals are usually found in the sediment of these patients. Ethylene glycol poisoning was immediately suspected, because the patient had previously been hospitalized with similar symptoms after intake of antifreeze coolant. COVID-19 is an emerging, rapidly evolving situation.  |  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). Skip to main page content National Institutes of Health. 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. It is poisonous if swallowed. Monohydrate crystals are the predominant form of oxalate crystal seen with ethylene glycol poisoning. -, Sankaralingam A, Thomas A, James DR, Wierzbicki AS. The presence of crystals in the urine is called Crystalluria. Free PDF. Ann Emerg Med . 1994 Feb 10;114(4):435-6. 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). 1990 Jun. Please enable it to take advantage of the complete set of features! Calcium Phosphate: Can have different morphologies depending on state of hydration. 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/. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Some look almost football-shaped; other look more like crystal aggregates. 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. Envelope-shaped crystals of calcium oxalate may be seen in the urine except in case of significant renal failure (8). 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, … Clipboard, Search History, and several other advanced features are temporarily unavailable.  |  Urine fluorescence using a Wood's lamp to detect the antifreeze additive sodium fluorescein: a qualitative adjunctive test in suspected ethylene glycol ingestions. [1] Early symptoms include intoxication, vomiting and abdominal pain. Calcium Oxalate Monohydrate Crystals: A Clue to Ethylene Glycol Poisoning. BACKGROUND Ethylene glycol poisoning remains an important presentation to Emergency Departments. Skip to main page content National Institutes of Health. Toxicity and death may occur after drinking even a small amount. 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). Calcium oxalate monohydrate crystals in ethylene glycol poisoning. NIH 2009 Nov;47(9):859-69. doi: 10.3109/15563650903344793. Toxicology. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Images in Clinical Medicine from The New England Journal of Medicine — Urinary Calcium Oxalate Crystals in Ethylene Glycol Intoxication 2005 Mar;84(1):195-200. doi: 10.1093/toxsci/kfi062. Calcium oxalate crystals may not be present until the later stages of intoxications. The values of glycolic and oxalic acid from samples taken at admission were very high but significantly decreased during therapy (Fig. Microscopic demonstration of calcium oxalate monohydrate crystals in a urine sample. Microscopic demonstration of calcium oxalate…. Massive calcium oxalate … Calcium oxalate crystals in patient urine samples. 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. Case Rep Crit Care. Toxicological examinations revealed ethylene glycol; the blood level was 250 mg/L and in urine the concentration was 0.3%. 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. Most ethylene glycol poisonings occur due to the ingestion of antifreeze. When urine left at room temperature or refrigerated then urine becomes cloudy because of the precipitation of crystals or amorphous material. Tidsskr Nor Laegeforen. 2017;13:153–57. 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. 2005 Mar 30;208(3):347-55. doi: 10.1016/j.tox.2004.11.029. An adult male was taken to the local hospital by the team rescue and was apparently unconscious; severe metabolic acidosis and renal failure led to death a few hours after the arrival. Presence in the urine of either fluorescein or calcium oxalate crystals indicates ethylene glycol exposure, but their absence does not exclude this poisoning. HHS Clipboard, Search History, and several other advanced features are temporarily unavailable. Direct toxicity, cortical edema, and inhibition of mitochondrial activity, as evidenced by decreased succinate dehydrogenase activity, are possible mechanisms of crystal damage. Ethylene glycol poisoning: an unusual cause of altered mental status and the lessons learned from management of the disease in the acute setting. 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. Discussion: 3; Table 1). Clin Toxicol (Phila). Download PDF. National Library of Medicine. NLM The cytotoxicity of oxalate, metabolite of ethylene glycol, is due to calcium oxalate monohydrate formation. Ammonium biurate Pomara C, Fiore C, D'Errico S, Riezzo I, Fineschi V. Clin Toxicol (Phila). Ammonium biruate crystals can be seen in normal urine. Early symptoms include intoxication, vomiting and abdominal pain. J Med Toxicol. Ethylene glycol may be swallowed accidentally, or it may be taken deliberately in a suicide attempt or as a substitute for drinking alcohol (ethanol). Confocal laser scanning microscopy. It is most commonly encountered as automotive antifreeze.Diethylene glycol behaves similarly to ethylene glycol in an overdose. NLM Please enable it to take advantage of the complete set of features! Urine sediments of dogs with experimentally induced ethylene glycol poisoning were examined by light microscopy and X-ray diffraction. The authors report the case of a man 49 years of age with near-fatal ethylene glycol poisoning. (1982). 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. 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. NIH Epub 2014 Mar 1. 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. Luqman A, Stanifer J, Asif Siddiqui OM, Naseer A, Wall BM. Acute ingestions present with altered sensorium and an osmolal gap. ... Monohydrate crystals are seen in the ethylene glycol (antifreeze) poisoning. Epub 2007 Oct 9. Individuals intentionally consume ethylene glycol, usually in the form of antifreeze, as an inexpensive alcohol substitute or as a suicidal agent. 1.  |  Ethylene glycol poisoning is poisoning caused by drinking ethylene glycol. Envelope-like dihydrate calcium oxalate crystals are usually found in the sediment of these patients. Vittorio Fineschi. Epub 2016 Sep 2. Propylene glycol toxicity is seen mainly in an inpatient setting with IV infusions that conta… Forensic Sci Int. Forensic Sci Med Pathol. PDF. 2017 Aug;21(4):741-742. doi: 10.1007/s10157-016-1332-2. The presence of crystals in the urine is called Crystalluria. The severity of ethylene glycol toxicity is related to the metabolic acidosis resulting from the biotransformation of ethylene glycol into toxic metabolites. Introduction: Turillazzi E, Karch SB, Neri M, Pomara C, Riezzo I, Fineschi V. Int J Legal Med. 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. Toxicological examinations revealed ethylene glycol; the blood level was 250 mg/L and in urine the concentration was 0.3%. Calcium oxalate crystals in acute ethylene glycol poisoning: A confocal laser scanning microscope study in a fatal case. Discussion: In cases of ethylene glycol poisoning, calcium oxalate may be excreted not only as dihydrate crystals, but also as monohydrate crystals. Are calcium oxalate crystals involved in the mechanism of acute renal failure in ethylene glycol poisoning? 2, Fig. 2009 Nov;47(9):859-69. doi: 10.3109/15563650903344793. Calcium oxalate monohydrate crystals: a clue to ethylene glycol poisoning. They generally only form in an acidic urine. Clin Toxicol (Phila) 2008;46:322–24. Triple phosphate crystals or struvite stones: Form in alkaline urine and composed of magnesium, ammonium, and phosphate. 2014 Sep;10(3):401-12. doi: 10.1007/s12024-014-9536-9. Conclusions: Chemical properties. Singh R, Arain E, Buth A, et al. These 95% commercial antifreeze preparations are diluted ~50% with water when used in vehicle cooling systems. They generally only form in an acidic urine. According to the annual report of the American Association of Poison Control Centers, ethylene glycol … [1] Long term outcomes may include kidney failure and brain damage. Later symptoms may include a decreased level of consciousness, headache, and seizures. 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. USA.gov. Ethylene glycol poisoning is poisoning caused by drinking ethylene glycol. 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. Clin Toxicol (Phila). CASE REPORT In this case report, we present a patient who was admitted unconscious to the hospital. 2008 Apr;46(4):322-4. doi: 10.1080/15563650701419011. Also, we will not be discussing propylene glycol due to the rarity of its consumption. All animals are susceptible to ethylene glycol (EG) toxicity, but it is most common in dogs and cats. 2016;2016:9157393. PDF. Symptoms of ethylene glycol poisoning usually follow a three-step progression, although poisoned individuals will not always develop each stage. 2017;54(4):501–3. eCollection 2018 Nov. Sheta HM, Al-Najami I, Christensen HD, Madsen JS. Download PDF Package. 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Develop each stage are more tricky because they are pleimorphic–they can have different morphologies depending on state of.. 1 ] later symptoms may include a decreased level of consciousness, headache, and several other features... Acidosis resulting from the urine are more tricky ethylene glycol poisoning urine crystals they are pleimorphic–they can have many shapes mechanism of renal! Pleimorphic–They can have different morphologies depending on state of hydration ; other look more like crystal aggregates,... During therapy ( Fig microscopy demonstrated oxalate crystals involved in the sediment of these crystals of renal!: 10.1016/j.tox.2004.11.029 effect of significant renal failure and brain damage: pathophysiology,,. Ethyl alcohol infusion and hemodialysis crystals or amorphous material toxicological examinations revealed ethylene glycol poisoning microscopy and X-ray.... May occur after drinking even a small amount toxic for rat renal mitochondrial function ; 47 ( 9:859-69....