A 2 year old boy presents with fever for 3 days which responded to administration of paracetamol, Three days later he developed acute renal failure, marled acidosis and encephalopathy. His urine showed *nt of oxalate crystals. The blood anion gap and osmolal gap were increased. Which of the following is the most likely diagnosis –
Correct Answer: Diethyl glycol poisoning
Description: The clinical effects of DEG can be divided into three intervals. The first phase typically involves gastrointestinal effects such as nausea, vomiting, abdominal pain and diarrhea. Patients may be inebriated and mild hypotension has been repoed. Patients may have an abnormal osmolal gap and develop an anion gap metabolic acidosis. The onset of symptoms can develop soon after ingestion, or can be delayed depending on the amount ingested and co-ingestants (such as ethanol). Small ingestions may result in resolution of symptoms without fuher sequelae. Progression to the second phase occurs 1-3 days following exposure and also depends on the amount ingested. The hallmark of the second phase is acute renal failure. If left untreated, patients may die within a week after the onset of anuria. Additionally, mild to moderate hepatotoxicity is often seen. Multiple other effects have been repoed including cardiac dysrhythmias and pancreatitis, which may be secondary to the metabolic acidosis and renal failure. The degree of renal injury predicts the severity of the third phase of this poisoning, which are neurologic complications. These effects can be delayed until 1-2 weeks post-ingestion. Multiple varying neurologic sequelae have been described. Peripheral neuropathies are a common occurrence. Cranial nerve abnormalities have been repoed including bilateral facial paralysis. Widespread denervation of limb muscles has been demonstrated; patients may become quadraparetic and unresponsive. The clinical coarse during this phase is unpredictable with long-term recovery in some patients, and permanent neurologic damage with death in others. Ref Harrison 20th edition pg 789
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