Ethylene Glycol Toxicity Presenting with Non‐Anion Gap Metabolic Acidosis

Ethylene glycol classically produces an elevated anion gap metabolic acidosis. We report a series of patients with ethylene glycol toxicity with a component of non-anion gap metabolic acidosis without known associated confounding factors. A retrospective review of Poison Control Center records were searched more than 8 years (2000-2007) for ethylene glycol and antifreeze. Cases were reviewed and excluded for miscoding, information calls, animal exposures, or non-ingestion exposures. The bicarbonate gap, or delta ratio (DR), was calculated using the formula: DR = (AG - 12)/[24 - measured serum where anion gap (AG) = [Na(+)] - [Cl(-)] - , all in mEq/l. Non-anion gap metabolic acidosis was considered present when the DR < 1. Of 254 cases, 175 were excluded. Of the remaining 79 cases, 14 had a component of non-anion gap metabolic acidosis at presentation. Their calculated anion gap was 14-28, and measured serum ranged from 2-20 mEq/l. A normal anion gap was present in two patients who presented with non-anion gap metabolic acidosis. The DR ranged from 0.28-0.95. Seven out of 14 patients with non-anion gap metabolic acidosis had elevated serum [Cl(-)]. In the other cases, no explanation for the non-anion gap metabolic acidosis could be determined. The absence of a significant anion gap elevation in the setting of metabolic acidosis after ethylene glycol ingestion without other confounding factors (such as ethanol, lithium carbonate or bromide) has not previously been recognized. Clinicians should be aware of the potential for non-anion gap metabolic acidosis in patients with ethylene glycol toxicity, and should not exclude the diagnosis in patients who present with a non-anion gap metabolic acidosis. Further study is needed to determine the mechanisms by which this occurs.