Cranial nerve deficit: A clue to the diagnosis of ethylene glycol poisoning

CASEREPORTS Patient 1 A 57-year-old white man was transferred to the Dallas Veterans Administration with a four-day history of mild abdominal pain and anuria. Past medical history was significant for a femoral-femoral bypass. On examination the patient was alert, oriented, lucid, and appeared well. Vital signs were normal. Mild diffuse abdominal tenderness without rebound was noted. The following values were obtained during laboratory evaluation (mEq/L): sodium 138, potassium 4.2, chloride 100, and bicarbonate 22; the blood urea nitrogen level was 67 mg/dL, and the creatinine level was 12.5 mg/dL. Urinalysis revealed 300 mg/dL protein by dipstick, greater than 50 red blood cells per high-power field, occasional granular casts, and no crystals (X3). The hematocrit was 34.7%, and the white blood cell count was 9,800/mm3. Renal sonographic results were normal. Given persistent anuria, the history of peripheral vascular disease, and abdominal pain, a diagnosis of renal artery occlusion was entertained. Results of a renal arteriogram were completely normal. Hemodialysis was begun 10 days after the patient’s initial admission. On Day 11 of hospitalization, the patient was noted to be dysarthric and to have evidence of cranial nerve V, VII, and VIII abnormalities. Physical examination demonstrated drooping of the right side of the face and an inability to completely close the right eye. Decreased sensation to pinprick was present on the right side of the face, and the patient was deaf bilaterally. Results of computerized tomographic examination of the brain were normal. Examination of the cerebrospinal fluid showed 51 to 70 white blood cells/mm3 (90% polymorphonuclear leukocytes), protein 198 mg/dL, and glucose 52 mg/dL. VDRL, cryptococcal antigen, and all microbial culture specimens were negative. On the twelfth, day of hospitalization, the patient developed bilateral facial diplegia and sensory loss. The left cornea1 reflex was absent and a gag reflex could no longer be elicited. Nerve conduction studies confirmed the presence of bilateral peripheral VII nerve palsies. On Day 13, the patient’s sensorium decreased; by Day 14, frank coma was present, and the patient required