臨床医学に環境・労働の観点を

・最初にオタッキーな話になりますが、「小箱とたん」のまんが『スケッチブック』で、 空閑 木陰（くが こかげ） が根岸大地にポリエチレンテレフタラート（テレルタレートとも言いますが）のお茶買ってきてという場面がありました。根岸「？」、部長「ペットボトルだ」というオチでした。（細かいところは、正しくないかも、うろ覚えなので）わたし、このまんがでペットボトルのペットの意味をしりました。マンガって、ためになるなあ。

・エチレングリコールは、上記ＰＥＴのような物質の原料になるほか、溶剤、潤滑油、界面活性剤、代用グリセリン等に使用されています。甘みがあり、甘味料として「使用」されたこともあるそうです。その性状は、Haz-Mapをどうぞ↓

http://hazmap.nlm.nih.gov/cgi-bin/hazmap_generic?tbl=TblAgents&id=488

（何年か前に、ワインに不凍液が入れられていた事件がありましたが、あれは、ジ・エチレングリコールだったみたいですね。）

・アメリカでは、エチレングリコールは、エタノールに次いで、中毒の多い物のようです↓

Ethylene glycol intoxication: Disparate findings of immediate versus delayed presentation

W V Med J 2006 Jul-Aug;102(4):32-4

Pellegrino B, Parravani A, Cook L, Mackay K

Abstract

Ethylene glycol is a common household substance responsible for a large number of ingestions in the U.S. each year. In 2001, nearly 5,000 ethylene glycol exposures were reported with more than 1,600 patients requiring medical treatment. There were 16 deaths attributed to ethylene glycol in 2001, second only to ethanol overdose for lethal ingestions. Diagnosis of ethylene glycol ingestion is relatively straight-forward when an individual with a history of exposure is found to have a high anion-gap metabolic acidosis and an elevated osmolar gap. Appropriate treatment can be immediately employed and the diagnosis confirmed by the finding of elevated ethylene glycol levels in the serum. In the absence of exposure history, the differential diagnosis of a high anion-gap metabolic acidosis and an elevated osmolar gap will also lead to consideration of ethylene glycol ingestion. This well-recognized presentation of ethylene glycol toxicity includes findings expected in individuals who present for care soon after their ingestion. A less well-known pattern may be seen in those for whom care is delayed. We present a patient with delayed presentation of ethylene glycol ingestion and review the physiology and biochemistry that underlies this different presentation. Unfortunately, without history or strong laboratory evidence, ethylene glycol ingestion may be easily overlooked in individuals with delayed presentation.

・エチレングリコールの一般的な治療法は、↓

Treatment of Ethylene Glycol Poisoning

http://www.aafp.org/afp/2002/0901/p807.html

 Am Fam Physician.

2002 Sep 1;66(5):807-813.

Ingestion of ethylene glycol may be an importan oisoning. t contributor in patients with metabolic acidosis of unknown cause and subsequent renal failure. Expeditious diagnosis and treatment will limit metabolic toxicity and decrease morbidity and mortality. Ethylene glycol poisoning should be suspected in an intoxicated patient with anion gap acidosis, hypocalcemia, urinary crystals, and nontoxic blood alcohol concentration. Fomepizole is a newer agent with a specific indication for the treatment of ethylene glycol poisoning. Metabolic acidosis is resolved within three hours of initiating therapy. Initiation of fomepizole therapy before the serum creatinine concentration rises can minimize renal impairment. Compared with nervous system and hypoglycemia, and easier maintenance of effective plasma levels.

エチレングリコール中毒を疑うときは、上記青字のところでしょうか？  

・で、今回標題にした問題は、以下のケースレポートです。珍しいみたいです。

 Journal of Medical Case Reports 2010, 4:220

Delayed ethylene glycol poisoning presenting with abdominal pain and multiple cranial and peripheral neuropathies: a case report

Journal of Medical Case Reports 2010, 4:220

http://www.jmedicalcasereports.com/content/4/1/220

Introduction

Ethylene glycol poisoning may pose diagnostic difficulties if the history of ingestion is not volunteered, or if the presentation is delayed. This is because the biochemical features of high anion-gap metabolic acidosis and an osmolar gap resolve within 24 to 72 hours as the ethylene glycol is metabolized to toxic metabolites. This case illustrates the less well-known clinical features of delayed ethylene glycol poisoning, including multiple cranial and peripheral neuropathies, and the clinical findings which may point towards this diagnosis in the absence of a history of ingestion.

Case presentation

A 53-year-old Afro-Caribbean man presented with vomiting, abdominal pain and oliguria, and was found to have acute renal failure requiring emergency hemofiltration, and raised inflammatory markers. Computed tomography imaging of the abdomen revealed the appearance of bilateral pyelonephritis, however he failed to improve with broad-spectrum antibiotics, and subsequently developed multiple cranial neuropathies and increasing obtundation, necessitating intubation and ventilation. Computed tomography of the brain showed no focal lesions, and a lumbar puncture revealed a raised cerebrospinal fluid opening pressure and cyto-albuminological dissociation. Nerve conduction studies revealed a sensorimotor radiculoneuropathy mimicking a Guillain-Barre type lesion with an atypical distribution. It was only about two weeks after presentation that the history of ethylene glycol ingestion one week before presentation was confirmed. He had a slow recovery on the intensive care unit, requiring renal replacement therapy for eight weeks, and complicated by acute respiratory distress syndrome, neuropathic pain and a slow neurological recovery requiring prolonged rehabilitation.

Conclusions

Although neuropathy as a result of ethylene glycol poisoning has been described in a few case reports, all of these were in the context of a known history of ingestion. As the diagnosis may well be obscured if the history of ingestion is not elucidated, it is important to be aware of this possibility especially if presentation is delayed.

まあ、なんせ中毒の場合、それを引用したという病歴があれば診断用意ですが、逆に無い場合診断困難と言うことですね。

以下日記

・本日は6時40分に病院着。事務処理と回診。午前中外来。本日珍しく午後から会議がないので結構長く病棟にいるのと、事務処理ができました。で、早くも仕事の疲れが出ているので17時過ぎたらすぐ帰ろうと思っていたら、病棟より電話。患者さんの意識レベル低下。あわてていくと、結局低血糖だったのですが、ご家族への説明何かで、ちょっと遅くまでいないといけなくなりました。帰宅は20時すぎ。風呂入って、本日はラーメンなべの夕食。明日は、午前中外来、夜も外来で忙しいので、このブログかいたらさっさと寝ます。