Sosa Nestor R, Rodriguez Giselle M, Schier Joshua G, Sejvar James J
Gorgas Memorial Institute, Panama City, Panama.
Social Security Metropolitan Hospital, Panama City, Panama.
Ann Emerg Med. 2014 Jul;64(1):38-47. doi: 10.1016/j.annemergmed.2013.12.011. Epub 2014 Jan 15.
Diethylene glycol is a toxic industrial solvent responsible for more than 13 mass poisonings since 1937. Little is known about the clinical spectrum, progression, and neurotoxic potential of diethylene glycol-associated disease because of its high mortality and the absence of detailed information in published mass poisoning reports. This incident includes the largest proportion of cases with neurotoxic signs and symptoms. We characterize the features of a diethylene glycol mass poisoning resulting from a contaminated cough syrup distributed in Panama during 2006.
This was a retrospective chart review and descriptive analysis in a tertiary level, urban health care facility. A case was a person admitted to the Social Security Metropolitan Hospital in Panama City between June 1 and October 22, 2006, with unexplained acute kidney injury and a serum creatinine level of greater than or equal to 2 mg/dL, or unexplained chronic renal failure exacerbation (>2-fold increase in baseline serum creatinine level) and history of implicated cough syrup exposure. Main outcomes and measures were demographic, clinical, laboratory, diagnostic, histopathologic, and mortality data with descriptive statistics.
Forty-six patients met inclusion criteria. Twenty-four (52%) were female patients; median age was 67 years (range 25 to 91 years). Patients were admitted with acute kidney injury or a chronic renal failure exacerbation (median serum creatinine level 10.0 mg/dL) a median of 5 days after symptom onset. Forty patients (87%; 95% confidence interval [CI] 74% to 95%) had neurologic signs, including limb (n=31; 77%; 95% CI 62% to 89%) or facial motor weakness (n=27; 68%; 95% CI 51% to 81%). Electrodiagnostics in 21 patients with objective weakness demonstrated a severe sensorimotor peripheral neuropathy (n=19; 90%; 95% CI 70% to 99%). In 14 patients without initial neurologic findings, elevated cerebrospinal fluid protein concentrations without pleocytosis were observed: almost all developed overt neurologic illness (n=13; 93%; 95% CI 66% to 100%). Despite use of intensive care and hemodialysis therapies, 27 (59%) died a median of 19 days (range 2 to 50 days) after presentation.
A high proportion of patients with diethylene glycol poisoning developed progressive neurologic signs and symptoms in addition to acute kidney injury. Facial or limb weakness with unexplained acute kidney injury should prompt clinicians to consider diethylene glycol poisoning. Elevated cerebrospinal fluid protein concentrations without pleocytosis among diethylene glycol-exposed persons with acute kidney injury may be a predictor for progressive neurologic illness.
自1937年以来，二甘醇是一种有毒的工业溶剂，已导致13起以上大规模中毒事件。由于二甘醇相关疾病的高死亡率以及已发表的大规模中毒报告中缺乏详细信息，人们对其二甘醇相关疾病的临床谱、病情进展和神经毒性潜力知之甚少。这起事件中出现神经毒性体征和症状的病例比例最高。我们描述了2006年在巴拿马分发的受污染止咳糖浆导致的二甘醇大规模中毒的特征。
这是一项在三级城市医疗保健机构进行的回顾性病历审查和描述性分析。病例定义为2006年6月1日至10月22日期间入住巴拿马城社会保障大都会医院的患者，伴有无法解释的急性肾损伤且血清肌酐水平大于或等于2mg/dL，或无法解释的慢性肾衰竭加重（基线血清肌酐水平增加2倍以上）且有接触相关止咳糖浆的病史。主要结局和指标为人口统计学、临床、实验室、诊断、组织病理学和死亡率数据，并进行描述性统计。
46例患者符合纳入标准。24例（52%）为女性患者；中位年龄为67岁（范围25至91岁）。患者在症状出现后中位5天因急性肾损伤或慢性肾衰竭加重（中位血清肌酐水平10.0mg/dL）入院。40例患者（87%；95%置信区间[CI]74%至95%）有神经系统体征，包括肢体（n = 31；77%；95%CI 62%至89%）或面部运动无力（n = 27；68%；95%CI 51%至81%）。对21例有客观肌无力的患者进行的电诊断显示为严重的感觉运动性周围神经病（n = 19；90%；95%CI 70%至99%）。在14例最初无神经系统表现的患者中，观察到脑脊液蛋白浓度升高但无细胞增多：几乎所有患者都发展为明显的神经系统疾病（n = 13；93%；95%CI 66%至100%）。尽管采用了重症监护和血液透析治疗，27例（59%）患者在就诊后中位19天（范围2至50天）死亡。
二甘醇中毒患者中很大一部分除急性肾损伤外还出现了进行性神经系统体征和症状。伴有无法解释的急性肾损伤的面部或肢体无力应促使临床医生考虑二甘醇中毒。在有急性肾损伤的二甘醇接触者中，脑脊液蛋白浓度升高但无细胞增多可能是进行性神经系统疾病的一个预测指标。
