Cough syrup Contamination| What is Diethylene Glycol?

Cough syrup Contamination| What is Diethylene Glycol?

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#Coughsyrupdeath #NEET #NEETPG #FMG #INICET

DEG diethylene Glycol is an industrial solvent and is part of car engine hydraulic fluid as well. Its use is well known but the safe limit of usage has to be known to doctors. DEG causes Acute tubular necrosis and leads to acute kidney injury. Recent report in Gujrat, Kheda where 5 children died allegedly by consumption of contaminated cough syrup is a tip of iceberg and such cases must be investigated thoroughly without bias and report made public and especially to health professionals. In 2022, WHO had passed scathing remarks against Indian drug manufacturing processes after death of children in Gambia again allegedly by consumption of cough syrup that did not mean quality criteria.

A recent report by Central drugs standards control organization reports that out of 2104 samples testes in labs, a huge 128 which is 6% failed the quality tests.  International standards allow not more than 0.1 g per 100 ml of syrup which is not abided by some manufacturers leading to renal subtype of acute kidney injury.

So what should you know about ethylene glycol and diethyl glycol for your practice and exams? Both compounds are metabolized by alcohol dehydrogenase and cause high anion gap metabolic acidosis and increased osmolal gaps.

DEG metabolism leads to production of EG metabolism leads to production of
1.   2-hydroxyacetic acid
2.      Digylcolic acid
1.       Glycolic acid
2.      Oxalic acid

These products then lead to crystallization of calcium oxalate crystals and leads to Acute Kidney Injury and also liver failure. Complete oxidation of ethylene glycol will depress the TCA cycle leading to lactic acid production (Type A lactic acidosis).

Antidote is Fomepizole (Not FDA approved). Preference is based on efficacy and lower side effects as compared to Ethanol. Supportive management and hemodialysis may be required.

Antidote treatment criteria:

  1. Serum ethylene glycol concentration > 62 mg/dl
  2. Documented history of ingestion with osmolal gap> 23 mOSM kg H20
  3. Documented history of ingestion plus any 2 of the following
    • a.      pH < 7.3
    • b.      Serum Bicarbonate < 20 mmol
    • c.      Osmolal Gap > 25 mOsm Kg H20
    • d.      Presence of urinary oxalate crystals

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