IMAGES IN EMERGENCY MEDICINE Pramil Vaghasia, MD; Ruchi Bansal, MD; Horiana B. Grosu, MD 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2013.10.005
Figure. Examination of the patient’s mouth.
[Ann Emerg Med. 2014;64:16.] An 87-year-old woman with end-stage renal disease, superior vena cava thrombosis, and anticoagulation therapy with warfarin presented with complaints of tongue swelling and hoarseness. There was no history of trauma. On physical examination, a large, soft, purple-red swelling involving the sublingual space consistent with a hematoma was visualized (Figure). Laboratory values revealed an international normalized ratio level of 8. Within 2 hours from presentation, the patient started complaining of difficulty breathing as the hematoma continued to enlarge, displacing her tongue superiorly and causing airway obstruction.
For the diagnosis and teaching points, see page 47. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com 16 Annals of Emergency Medicine
Volume 64, no. 1 : July 2014
Sosa et al 23. Alfred S, Coleman P, Harris D, et al. Delayed neurologic sequelae resulting from epidemic diethylene glycol poisoning. Clin Toxicol. 2005;43:155-159. 24. Gilbert EH, Lowenstein SR, Koziol-McLain J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27:305-308. 25. Instituto Commemorativeo Gorgas de Estudio de la Salud. Prevalencias de factores de riesgos cardiovascular. Available at: http://www.gorgas.gob.pa/PREFREC/CAPITULO%202.pdf. Accessed October 21, 2013. 26. Besenhofer LM, Adegboyega PA, Bartels M, et al. Inhibition of metabolism of diethylene glycol prevents target organ toxicity in rats. Toxicol Sci. 2010;117:25-35. 27. Landry GM, Martin S, McMartin KE. Diglycolic acid is the nephrotoxic metabolite in diethylene glycol poisoning inducing necrosis in human proximal tubule cells in vitro. Toxicol Sci. 2011;124:35-44. 28. Schier JG, Hunt DR, Perala A, et al. Characterizing concentrations of diethylene glycol and suspected metabolites in human serum, urine and cerebrospinal fluid from the Panama DEG mass poisoning. Clin Toxicol; 2013; Nov 25 [epub ahead of print]. 29. Landry G, Dunning C, McMartin K. Diglycolic acid, the nephrotoxic metabolite of diethylene glycol, produces cytotoxicity via molecular mimicry and metabolic disruption [abstract]. Clin Toxicol. 2012;50:575.
Volume 64, no. 1 : July 2014
Features of Mass Diethylene Glycol Poisoning 30. Eng GD. Lyme disease presenting with bilateral facial nerve palsy. Arch Phys Med Rehabil. 1990;71:749-750. 31. George MK, Pahor AL. Sarcoidosis: a cause for bilateral facial palsy. Ear Nose Throat J. 1991;70:492-493. 32. Gevers G, Lemkens P. Bilateral simultaneous facial paralysis—differential diagnosis and treatment options. A case report and review of literature. Acta Otorhinolaryngol Belg. 2003;57:139-146. 33. Wechsler AF, Ho DD. Bilateral Bell’s palsy at the time of HIV seroconversion. Neurology. 1989;39:747-748. 34. Rao R. Neurologic principles. In: Goldfrank LR, Nelson LS. In: Lewin N, et al, eds. Goldfrank’s Toxicologic Emergencies. 9th ed. New York, NY: McGraw Hill; 2011:275-284. 35. Conklin L, Sejvar J, Kiezak S, et al. Long-term renal and neurological outcomes among survivors of diethylene glycol poisoning. JAMA Internal Medical. 2014;174:912-917. 36. Burnett JW, Weinrich D, Williamson JA, et al. Autonomic neurotoxicity of jellyfish and marine animal venoms. Clin Auton Res. 1998;8:125-130. 37. Low PA. Autonomic neuropathies. Curr Opin Neurol. 2002;15:605-609. 38. Schier JG, Rubin CS, Miller D, et al. Medication-associated diethylene glycol mass poisoning: a review and discussion on the origin of contamination. J Public Health Policy. 2009;30:127-143.
Annals of Emergency Medicine 47
Figure. Examination of the patient’s mouth.
[Ann Emerg Med. 2014;64:16.] An 87-year-old woman with end-stage renal disease, superior vena cava thrombosis, and anticoagulation therapy with warfarin presented with complaints of tongue swelling and hoarseness. There was no history of trauma. On physical examination, a large, soft, purple-red swelling involving the sublingual space consistent with a hematoma was visualized (Figure). Laboratory values revealed an international normalized ratio level of 8. Within 2 hours from presentation, the patient started complaining of difficulty breathing as the hematoma continued to enlarge, displacing her tongue superiorly and causing airway obstruction.
For the diagnosis and teaching points, see page 47. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com 16 Annals of Emergency Medicine
Volume 64, no. 1 : July 2014
Sosa et al 23. Alfred S, Coleman P, Harris D, et al. Delayed neurologic sequelae resulting from epidemic diethylene glycol poisoning. Clin Toxicol. 2005;43:155-159. 24. Gilbert EH, Lowenstein SR, Koziol-McLain J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27:305-308. 25. Instituto Commemorativeo Gorgas de Estudio de la Salud. Prevalencias de factores de riesgos cardiovascular. Available at: http://www.gorgas.gob.pa/PREFREC/CAPITULO%202.pdf. Accessed October 21, 2013. 26. Besenhofer LM, Adegboyega PA, Bartels M, et al. Inhibition of metabolism of diethylene glycol prevents target organ toxicity in rats. Toxicol Sci. 2010;117:25-35. 27. Landry GM, Martin S, McMartin KE. Diglycolic acid is the nephrotoxic metabolite in diethylene glycol poisoning inducing necrosis in human proximal tubule cells in vitro. Toxicol Sci. 2011;124:35-44. 28. Schier JG, Hunt DR, Perala A, et al. Characterizing concentrations of diethylene glycol and suspected metabolites in human serum, urine and cerebrospinal fluid from the Panama DEG mass poisoning. Clin Toxicol; 2013; Nov 25 [epub ahead of print]. 29. Landry G, Dunning C, McMartin K. Diglycolic acid, the nephrotoxic metabolite of diethylene glycol, produces cytotoxicity via molecular mimicry and metabolic disruption [abstract]. Clin Toxicol. 2012;50:575.
Volume 64, no. 1 : July 2014
Features of Mass Diethylene Glycol Poisoning 30. Eng GD. Lyme disease presenting with bilateral facial nerve palsy. Arch Phys Med Rehabil. 1990;71:749-750. 31. George MK, Pahor AL. Sarcoidosis: a cause for bilateral facial palsy. Ear Nose Throat J. 1991;70:492-493. 32. Gevers G, Lemkens P. Bilateral simultaneous facial paralysis—differential diagnosis and treatment options. A case report and review of literature. Acta Otorhinolaryngol Belg. 2003;57:139-146. 33. Wechsler AF, Ho DD. Bilateral Bell’s palsy at the time of HIV seroconversion. Neurology. 1989;39:747-748. 34. Rao R. Neurologic principles. In: Goldfrank LR, Nelson LS. In: Lewin N, et al, eds. Goldfrank’s Toxicologic Emergencies. 9th ed. New York, NY: McGraw Hill; 2011:275-284. 35. Conklin L, Sejvar J, Kiezak S, et al. Long-term renal and neurological outcomes among survivors of diethylene glycol poisoning. JAMA Internal Medical. 2014;174:912-917. 36. Burnett JW, Weinrich D, Williamson JA, et al. Autonomic neurotoxicity of jellyfish and marine animal venoms. Clin Auton Res. 1998;8:125-130. 37. Low PA. Autonomic neuropathies. Curr Opin Neurol. 2002;15:605-609. 38. Schier JG, Rubin CS, Miller D, et al. Medication-associated diethylene glycol mass poisoning: a review and discussion on the origin of contamination. J Public Health Policy. 2009;30:127-143.
Annals of Emergency Medicine 47
