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[NEJM临床医学影像]:乙二醇中毒的草酸钙结晶
2017年10月28日 临床影像, 临床话题 暂无评论

Images in Clinical Medicine

Calcium Oxalate Crystals in Ethylene Glycol Toxicity

Mohamad Hanouneh, Teresa K. Chen

N Engl J Med 2017; 377: 1467

An 80-year-old man with a remote history of alcohol-use disorder presented to the emergency department with altered mental status after a fall at home. He was somnolent and unable to provide any further history. Serum studies revealed a creatinine level of 2.4 mg per deciliter (212 μmol per liter; reference range, 0.6 to 1.3 mg per deciliter [53 to 115 μmol per liter]), a bicarbonate level of 9 mmol per liter (reference range, 21 to 32), an anion gap of 26 mmol per liter (reference range, 7 to 16), and a serum osmolality of 357 mOsm per kilogram of water (reference range 275 to 295), with an osmolal gap of 49 mOsm per kilogram of water (reference range, <10). Examination of urine sediment by means of light microscopy revealed calcium oxalate monohydrate crystals with two different morphologic features: narrow rectangles with pointed ends (Panel A, arrows) and dumbbell-shaped crystals (Panel B). Under polarized light, the crystals were positively birefringent; crystals were blue when parallel to the light and yellow when perpendicular to the light (Panel C). Given the high clinical probability of ethylene glycol toxicity, blood was drawn for measurement of the ethylene glycol level, and treatment with fomepizole and dialysis were initiated immediately. Ethylene glycol poisoning most commonly occurs after the ingestion of antifreeze or deicing solution. The patient’s ethylene glycol level, which became available 40 hours after the serum was drawn, was 211 mg per deciliter (34 mmol per liter; reference range, <1 mg per deciliter [<0.2 mmol per liter]). His mental status and renal function normalized after treatment with fomepizole for 3 days and four hemodialysis sessions over 5 days. The patient later reported that he had unintentionally ingested antifreeze.

一名80岁男性患者早年曾有饮酒史,患者因在家中跌倒后意识障碍到急诊就诊。患者嗜睡,无法提供其他病史。血清学检查发现肌酐2.4 mg/dl(212 μmol/L;参考范围,0.6 - 1.3 mg/dl [53 - 115 μmol/L]),HCO3水平 9 mmol/L(参考范围,21 - 32),阴离子间隙 26 mmol/L(参考范围,7 - 16),血清渗透压 357 mOsm/kg(参考范围, 275 - 295),渗透压间隙 49 mOsm/kg (参考范围 <10)。尿沉渣镜检发现两种形态的单水草酸钙结晶:末端较尖的细长长方形(图A,箭头),以及哑铃形结晶(图B)。在偏振光下,结晶呈双折射;与光线平行时为蓝色,与光线垂直时为黄色(图C)。由于临床高度怀疑乙二醇中毒,因此留取血标本测定乙二醇浓度,并立即开始甲吡唑(fomepizole)及透析治疗。乙二醇中毒最常见于服用防冻液或除冰液后。留取血清标本后40小时,患者乙二醇浓度回报为 211 mg/dl(34 mmol/L;参考范围 ,<1 mg/dl  [<0.2 mmol/L])。经过甲吡唑治疗3天,且在5天内接受了4次血液透析治疗后,患者意识及肾脏功能恢复正常。随后,患者承认误服防冻液。

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