Obstructive Nephropathy Unmasking a Suicide Attempt with Ethylene Glycol Poisoning

Introduction: Ethylene glycol (EG) poisoning is a life-threatening condition that requires early diagnosis to prevent complications and death. This is a patient with obstructive nephropathy from EG poisoning who successfully recovered after fomepizole and renal replacement therapy. Case Description: 67-year-old male presented with acute encephalopathy. Vitals showed blood pressure 180/74 mmHg, respirations 22, and temperature 35.5 °C. Laboratory included K 5.8 mg/dL, bicarbonate <6 mmol/L, serum creatinine 2.2 mg/dL, BUN 22 mg/dL, lactic acid 12.7 mmol/L, urine toxicology, and ethanol normal. CT head non-revealing and CT abdomen and pelvis bilateral obstructing calculus resulting in hydronephrosis. He was taken for urgent bilateral stent placement by urology and admitted to MICU for urosepsis. Nephrology was consulted for persistent acidosis, acute kidney injury, and electrolyte derangements. Nephrology investigation showed anion gap 35 mmol/L, osmolar gap 100, ethylene glycol level 293 mg/dL, pH 7.1. Formal ethylene glycol toxicity was made, and oxalate monohydrate stones found; He was treated with IV fluids, vasopressors, IV antibiotics, fomepizole, and continuous renal replacement therapy. He fully recovered and was discharged to inpatient psychiatry after confessing suicidal attempt. Discussion: EG is a dangerous sweet-tasting, colorless, and odorless liquid used as an industrial compound. It causes significant morbidity and mortality if left untreated. More than 5,000 cases of intentional or unintentional toxicity are reported in the United States yearly, affecting mostly adult men. EG is broken down into glycolic acid, oxalic acid, glyoxylic acid, and glycolaldehyde causing kidney injury, central nervous system, and cardiopulmonary compromise. The glycolic acid is known to cause severe high anion gap metabolic acidosis, high osmolar gap, and oxalate precipitation causing kidney injury. In our case, he had acute encephalopathy, severe acidosis, high osmolar gap, and obstructive nephropathy with bilateral oxalate monohydrate stones unmasking an unknown suicide attempt. EG poisoning is challenging to diagnose and manage due to non-specific symptoms, limitations on direct EG quantification methods, and the shortened duration of an elevated osmolar gap in chronic alcohol abusers. High suspicion can prevent irreversible, and life-threatening complications.