title: Characterizing concentrations of diethylene glycol and suspected metabolites in human serum, urine, and cerebrospinal fluid samples from the Panama DEG mass poisoning.
abstract: BACKGROUND
  Diethylene glycol (DEG) mass poisoning is a persistent public health problem. Unfortunately, there are no human biological data on DEG and its suspected metabolites in poisoning. If present and associated with poisoning, the evidence for use of traditional therapies such as fomepizole and/or hemodialysis would be much stronger.
  
  
  OBJECTIVE
  To characterize DEG and its metabolites in stored serum, urine, and cerebrospinal fluid (CSF) specimens obtained from human DEG poisoning victims enrolled in a 2006 case-control study.
  
  
  METHODS
  In the 2006 study, biological samples from persons enrolled in a case-control study (42 cases with new-onset, unexplained AKI and 140 age-, sex-, and admission date-matched controls without AKI) were collected and shipped to the Centers for Disease Control and Prevention (CDC) in Atlanta for various analyses and were then frozen in storage. For this study, when sufficient volume of the original specimen remained, the following analytes were quantitatively measured in serum, urine, and CSF: DEG, 2-hydroxyethoxyacetic acid (HEAA), diglycolic acid, ethylene glycol, glycolic acid, and oxalic acid. Analytes were measured using low resolution GC/MS, descriptive statistics calculated and case results compared with controls when appropriate. Specimens were de-identified so previously collected demographic, exposure, and health data were not available. The Wilcoxon Rank Sum test (with exact p-values) and bivariable exact logistic regression were used in SAS v9.2 for data analysis.
  
  
  RESULTS
  The following samples were analyzed: serum, 20 case, and 20 controls; urine, 11 case and 22 controls; and CSF, 11 samples from 10 cases and no controls. Diglycolic acid was detected in all case serum samples (median, 40.7 mcg/mL; range, 22.6-75.2) and no controls, and in all case urine samples (median, 28.7 mcg/mL; range, 14-118.4) and only five (23%) controls (median, < Lower Limit of Quantitation (LLQ); range, < LLQ-43.3 mcg/mL). Significant differences and associations were identified between case status and the following: 1) serum oxalic acid and serum HEAA (both OR = 14.6; 95% C I = 2.8-100.9); 2) serum diglycolic acid and urine diglycolic acid (both OR > 999; exact p < 0.0001); and 3) urinary glycolic acid (OR = 0.057; 95% C I = 0.001-0.55). Two CSF sample results were excluded and two from the same case were averaged, yielding eight samples from eight cases. Diglycolic acid was detected in seven (88%) of case CSF samples (median, 2.03 mcg/mL; range, < LLQ, 7.47).
  
  
  CONCLUSIONS
  Significantly elevated HEAA (serum) and diglycolic acid (serum and urine) concentrations were identified among cases, which is consistent with animal data. Low urinary glycolic acid concentrations in cases may have been due to concurrent AKI. Although serum glycolic concentrations among cases may have initially increased, further metabolism to oxalic acid may have occurred thereby explaining the similar glycolic acid concentrations in cases and controls. The increased serum oxalic acid concentration results in cases versus controls are consistent with this hypothesis.
  
  
  CONCLUSIONS
  Diglycolic acid is associated with human DEG poisoning and may be a biomarker for poisoning. These findings add to animal data suggesting a possible role for traditional antidotal therapies. The detection of HEAA and diglycolic acid in the CSF of cases suggests a possible association with signs and symptoms of DEG-associated neurotoxicity. Further work characterizing the pathophysiology of DEG-associated neurotoxicity and the role of traditional toxic alcohol therapies such as fomepizole and hemodialysis is needed.
authors.affiliation: Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention , Atlanta, GA , USA.
authors.forename: J G
authors.initials: JG
authors.lastname: Schier
authors.forename: D R
authors.initials: DR
authors.lastname: Hunt
authors.forename: A
authors.initials: A
authors.lastname: Perala
authors.forename: K E
authors.initials: KE
authors.lastname: McMartin
authors.forename: M J
authors.initials: MJ
authors.lastname: Bartels
authors.forename: L S
authors.initials: LS
authors.lastname: Lewis
authors.forename: M A
authors.initials: MA
authors.lastname: McGeehin
authors.forename: W D
authors.initials: WD
authors.lastname: Flanders
mesh_terms: D000085:Acetates / Q000134:cerebrospinal fluid / Q000506:poisoning; D015415:Biomarkers / Q000097:blood / Q000134:cerebrospinal fluid / Q000652:urine; D016022:Case-Control Studies; D002487:Centers for Disease Control and Prevention, U.S.; D005026:Ethylene Glycols / Q000097:blood* / Q000134:cerebrospinal fluid* / Q000506:poisoning* / Q000652:urine*; D005260:Female; D000077604:Fomepizole; D008401:Gas Chromatography-Mass Spectrometry; D006016:Glycolates / Q000097:blood / Q000134:cerebrospinal fluid / Q000506:poisoning / Q000652:urine; D006801:Humans; D007668:Kidney / Q000187:drug effects / Q000473:pathology; D016015:Logistic Models; D008297:Male; D020258:Neurotoxicity Syndromes / Q000188:drug therapy / Q000209:etiology / Q000503:physiopathology; D010176:Panama; D011041:Poisoning / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology; D011720:Pyrazoles / Q000627:therapeutic use; D006435:Renal Dialysis; D013048:Specimen Handling; D014481:United States
chemical_list: D000085:Acetates; D015415:Biomarkers; D005026:Ethylene Glycols; D006016:Glycolates; D011720:Pyrazoles; C018968:beta-hydroxyethoxyacetic acid; C013484:diethylene glycol; D000077604:Fomepizole; C571256:diglycolic acid