When Alcohol Saves a Life: A Case of Severe Anion-Gap Metabolic Acidosis from Ethylene Glycol Poisoning

Introduction: Ethylene glycol is a toxic alcohol commonly found in antifreeze. When ingested, it is metabolized by alcohol dehydrogenase into glycolic and oxalic acids, which cause severe anion-gap metabolic acidosis, nephrotoxicity, and multi-organ failure. Treatment includes inhibition of alcohol dehydrogenase with fomepizole as the first-line antidote. In scenarios where fomepizole is unavailable, ethanol can be used as an alternative treatment. Supportive care measures including bicarbonate therapy, electrolyte management, and hemodialysis are often indicated in severe cases to correct acidosis and clear ethylene glycol and its metabolites. Case Description: We present a 60-year-old male with a history of alcohol abuse and GERD who was found unresponsive by his partner. On arrival to the emergency department, initial labs revealed profound metabolic derangements with an unmeasurably low serum bicarbonate, arterial pH 6.5, a discrepancy between serum lactate and ABG lactate, hyperkalemia of 6.7 mEq/L, and an osmolar gap of 93. Acute kidney injury was evident with oliguria, rising creatinine, and urinalysis demonstrating calcium oxalate crystals. These findings raised high suspicion for ethylene glycol poisoning. Antidotal therapy with fomepizole was ordered, however, due to a shortage, the care team initiated life-saving measures with emergent hemodialysis and administered ethanol as a substitute antidote. After intensive care support, the patient's acidosis resolved, he was weaned off ventilation, and his renal function recovered without need for ongoing dialysis. Discussion: Both ethanol and fomepizole inhibit ADH, though fomepizole is preferred for its predictable kinetics and lesser side effect profile. In this case, ethanol was effectively used as a substitute when fomepizole was inaccessible. EXTRIP and AACT guidelines advise hemodialysis in EG poisoning if there is severe acidosis, end-organ damage, or a high EG level. Historically, before fomepizole, ethanol infusion plus dialysis enabled survival in many EG poisonings, showing that ethanol remains a viable life-saving therapy when used appropriately. This case underscores the public health need for antidote availability and hospital preparedness: if fomepizole is not on hand, protocols for ethanol use and urgent dialysis are critical to optimize outcomes in toxic alcohol emergencies.