Ethanol Case Studies. Robert L. Fitzgerald, Ph.D., DABCC VAMC/UCSD.

Transcription

1 Ethanol Case Studies Robert L. Fitzgerald, Ph.D., DABCC VAMC/UCSD

2 Case Studies Endogenous ethanol Post-collection ethanol production in urine Overdose of ethanol?

3 Just dessert: Man blames yeast for drunk-driving driving conviction Drunk Driver gives new meaning to the term pie-eyed Defendant claims to have had 2 mixed drinks, and a lot of dessert such as pies Defendants BAC was 0.15% Call it driving under the influence of pastry District judge finds defendant guilty Defendant appeals to Circuit court

4 The Twinkie Defense Defense expert introduces The Yeast Syndrome Published by Bantam Books The Japanese are convinced that the atomic blast produced mutations in the organism resulting in stupendous proliferation of Candidas

5 Microbial Ethanol Production In vivo ethanol can be produced by yeasts, fungi, protozoa and certain bacteria Krebs showed that about 1 oz of pure ethanol are produced in the human intestine per day (Sci. Am. 1973; 66). Ethanol produced in gut is subject to immediate metabolism by hepatocytes

6 Alcoholic Fermentation Mammalian cells convert glucose to pyruvate and then lactate Microbial fermentation is the same except for the last step Some microbes convert pyruvate to ethanol

7 Alcoholic Fermentation OO CH 3 C CO - Pyruvate Decarboxylase O CH 3 CH Alcohol Dehydrogenase OH CH 3 CH 2 Pyruvate Acetaldehyde Ethanol

8 Excretion of Low MW Volatiles 10 healthy men Highest measured endogenous ethanol was % w/v 5 g of ethanol in a drink raised the measured ethanol 200 times that of endogenous levels A.W. Jones. J Anal Toxicol 1985;9:

9 Can Microorganisms Produce Alcohol in a Living Person? 47 yo male stabbed in abdomen after drinking with a friend Given 10 L of blood but died 24 hours after fight Gastric ethanol was 2200 mg/dl BAC was 90 mg/dl Moriya et al. J Forensic Sci. 1994;39(3):

10 Can Microorganisms Produce Alcohol in a Living Person? Animals were injected (abdominal) with 10% glucose mixed w/ rat blood Injured the small intestine Measured BAC 5 mg/dl in heart blood Concluded that detectable endogenous ethanol might have been produced Moriya et al. J For Sci. 1994;

11 Endogenous Ethanol in Jejunal Bypass Jejunal bypass often leads to hepatic damage Causes bacterial colonization from colon Max BAC measured was 4 mg/dl Ethanol not responsible for hepatic lesions Mezey et al. Am J Clin Nutr 1975;28:

12 Blind Loop Syndrome Self filling diverticulum in rats Conclusions: Microbes do produce ethanol Microbes increase EtOH metabolism 1 st pass effect Animals with intestinal overgrowths had to consume more ethanol to reach a certain alcohol level as compared with controls. Baroana et al. Gastroenterology 1986;90:103-10

13 Endogenous Ethanol by Intestinal Fermenation C. Albicans seen in some SIDS cases C. Albicans produces ethanol Even where C. Albicans dominated flora EtOH not detected Geertinger P. et al. Z. Rechtmed. 1982;89(3):167-72

14 Auto-Brewery syndrome as Drunk Driving Defense Endogenous alcohol in healthy people and patients with metabolic disorders BAC ranged from 0 to 0.08 mg/dl EtOH too low for medical or forensic significance Intoxication by endogenously produced ethanol lacks merit Logan BK and Jones AW. Med Sci Law 2000;40(3):206-15

15 Case #1 Endogenous Ethanol Conclusions Judge has little appetite for man s pastry defense Defendant fined and sent to jail

16 Case #2 Post Collection Ethanol Production Employee tested positive for ethanol in a urine sample and was discharged Urine was collected without preservatives Urine was shipped across the country (2 days transit) not refrigerated during summer Urine was tested by GC 5 days after collection

17 Post Collection Production Subject is known diabetic Positive urine glucose on 3 of last 7 tests Urine alcohol is 29 mg/dl (0.029 % w/v) Testing done with chain of custody No glucose in sample at time of analysis Could this ethanol result from post collection production?

18 Ethanol production in urine Follow up testing by microbiology 4 months later No yeast isolated including C. Albicans However: 7,000 col/ml lactose fermenting gram neg rods 40,000 col/ml enterococci < 10,000 col/ml gram positive flora

19 Invitro Ethanol in Urine Tested 3 yeast species and six bacterial species (clinical isolates from urine) Spiked urine samples with and without sugars (glucose, fructose, galactose or sucrose) Tested effect of NaF Sulkowski HA. et al. J Forensic Sci 1995;40:

20 Invitro Ethanol in Urine Conclusions: All three yeasts produced ethanol from glucose 3 of 6 bacteria produced ethanol from glucose Max ethanol concentration at 24 hours Elevated temperature increased production Sodium fluoride effective preservative Sulkowski HA. et al. J Forensic Sci 1995;40:

21 Urinary Ethanol After Collection 14 urine specimens All specimens initially negative for EtOH Urine glucose ranged from 0 to 2000 mg/dl 5 specimens produced ethanol Highest EtOH was 2300 mg/dl (14 day) At 2 days highest EtOH was 283 mg/dl Saady et al. J Forensic Sci 1993;38(6):

22 Urinary Ethanol After Collection Conclusions: In absence of preservative samples containing glucose and yeast produced significant EtOH 12 hrs needed for significant EtOH at R.T. Yeast present in 4% of urine specimens Saady et al. J Forensic Sci 1993;38(6):

23 Micro-organisms organisms and EtOH Greatest increases of ethanol in postmortem tissues associated not with yeast by with enterobacteriacia or enterococci Other bacteria that produce ethanol include proteus sp, Bacillus sp, staphylococcus sp 17 different yeasts found in humans produce ethanol Corry J.E.L. J Appl Bacter 1978;44:1-56

24 Ethanol Producing Micro-organisms organisms At least 17 different yeasts At least 58 different bacteria All of the above are found on or in humans At least 24 different molds (decaying matter) Corry J.E.L. J Appl Bacter 1978;44:1-56

25 Case #2 Urine EtOH 0.029% Problems for the Prosecution: Stability of C. Albicans for 5 months unknown Lots of bacteria detected in sample Known diabetic Glucose metabolized to ethanol No preservatives in urine

26 Case #2 Urine EtOH 0.029% Problems for the Defense Defendant had no C. Albicans Defendant had no glucose Verdict: Defendant gets job back

27 Case #2 Conclusions Multiple organisms can produce ethanol post collection Every study examined demonstrated that 1% NaF prevented microbial growth (no ethanol produced) If urine specimens are to be used to detect EtOH need to analyze within hours or add preservative

28 Case #3 31 yo male presented to ER in acute distress Disoriented, vomiting CO 2 < 5 mmol/l (24-31) Admission labs: ABG ph = 6.85 ( ) pco2 = 14 mm Hg (35-45) Lactic acid = 30.3 mmol/l ( ) Plasma Ethanol 217 mg/dl

29 Admitting Labs (cont.) Glucose = 63 mg/dl ( ) Sodium = 129 mmol/l ( ) BUN = 30 mg/dl (8 23) Osmolality = 376 mosm/kg ( ) Calcium = 8.2 ( ) Potassium = 4.3 ( )

30 Osmolality A colligative property Number of solute particles in Kg of water Can be calculated by following formula: 1.86 (Na mmol/l) + (gluc mg/dl) + (BUN mg/dl) Measured by freezing point depression

31 Osmol gap Measured Osmol Calculated Osmol = Osmol gap Major causes of elevated Osmol gap: Methanol Ethanol Diuretic Isopropanol Ethylene glycol

32 Case #3 Osmol gap 1.86 (Na mmol/l) + (gluc mg/dl) + (BUN mg/dl) (129) + (63/18) + (30/2.8) + 9 = Calculated Osmolality 264 mosm/kg = Calculated Osmolality Measured Osmol Calculated Osmol = Osmol gap = 112 mosm/kg = Osmol gap

33 Case 3 Explanation of Osm Gap? Ethanol = 217 mg/dl 217 mg/dl = 47 mosm mosm/kg 47 mosm/kg = 65 mosm/kg

34 Gamble Gram 142 Na + Cl Inorganic acids Organic acids Proteins Unmeasured Unmeasured K + Ca + Mg + HCO Cations 153 Anions

35 Anion Gap (Measured cations) (Measured Anions) = Anion gap (Na + + K + ) (Cl - + HCO 3- ) = Anion gap ( ) ( ) = Anion gap 16 = Anion gap Anion gap normally 10 to 20 mmol/l

36 Case #3 Anion gap (Na + + K + ) (Cl - + HCO 3- ) = Anion gap ( ) (78 + 5) = Anion gap 50 = Anion gap Normal Anion gap is 10 20

37 Major causes of Elevated Anion Gap Ketoacidosis (diabetic, alcoholic, starvation) Renal Failure Lactic acidosis Poisonings (salicylates, methanol, ethylene glycol)

38 Case #3 (cont) Unexplained elevated osmolality High anion gap Metabolic acidosis These findings suggest? Methanol or Ethylene glycol

39 Case 3 Stat volatiles Negative for methanol Negative for ethylene glycol Interview with patient who denies ingestion of antifreeze, rubbing alcohol or other liquids besides whiskey and wine

40 What did he drink? Call to lab indicates large peak that was not reported- propylene glycol at 40 mg/dl Propylene glycol is a common agent used to dissolve drugs for injections Propylene glycol is supposed to be a safer alternative to ethylene glycol for antifreeze

41 Propylene Glycol Metabolism OH OH ADH OH O Ald d.h. OH O CH 3 CHCH 2 CH 3 CHCH CH 3 CHCHO - Propylene Glycol Lactic Acid

42 Propylene Glycol Case Reports Several case reports related to anion gap acidosis with Osm gap with injectables One case report with coingestion of ethanol and propylene glycol antifreeze Concentrations of propylene glycol 470 mg/dl-1300 mg/dl Lowest ph in these case reports was 7.2 Anesth Analg 2002;94: Crit Care Med 2003;31(2):

43 Ethylene Glycol Treatment Ethanol drip to % w/v Bicarbonate for acidosis Hemodialysis and Ca replacement 4-methylpyrazole to inhibit ADH

44 Case #3 Treatment 4 amphs of bicarbonate ph = 6.9 IV fluid replacement w/o sig increase in urinary output Renal failure, Osm gap, acidosis therefore dialyzed Dialyzed for 4 hours Acid base corrected with dialysis

45 Case #3 Arterial ph

46 Case #3 Arterial P Case #3 Arterial PCO CO 2

47 Case #3 Outcome Pt developed ARDS Pt became septic Pt received antibiotics, ventilation assistance and intermittent dialysis Pt eventually recovered and was discharged 12 days after admission

48 Case #3 Conclusions Propylene glycol vs Alcoholic ketoacidosis Lab played important role in therapy Patient set records for surviving ph < 6.9 Important that Toxicologists discuss lab results with lab staff