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In the first method generic kamagra chewable 100mg mastercard erectile dysfunction treatment machine, blue food coloring or methylene blue is added to enteral feeds and the tracheal secretions are assessed for blue discoloration discount kamagra chewable 100mg mastercard buy generic erectile dysfunction drugs. Potential problems with this method include tissue absorption of the dye as well as increased risk of infection if the dye is contaminated purchase generic kamagra chewable from india impotence groups. The second method tests tracheal secretions with glucose oxidase reagent strips for aspirated carbohydrates. The glucose method is nonspecific because varying concentrations of glucose have been recovered from tracheal secretions in nonfed, parenterally fed, and enterally fed patients . As previously mentioned, a formal speech and swallowing evaluation should be obtained whenever a swallowing condition is suspected or diagnosed. Precautionary rather than reactionary measures are likely to be far more effective, with less associated morbidity and mortality. A tracheoesophageal fistula is a rare complication resulting from injury to the posterior tracheal wall. This can occur from excessive endotracheal tube cuff pressure, direct injury during placement of a percutaneous tracheostomy, or erosion from the tip of a tracheostomy tube. For a mechanically ventilated patient, a tracheoesophageal fistula may present with increased secretions, evidence of aspiration of gastric contents, recurrent pneumonias, a persistent cuff leak, or severe gastric distention. The diagnosis can be made by bronchoscopy and esophagoscopy or by computed tomography scan of the mediastinum. Although definitive repair often requires surgical intervention, aspiration can be minimized by placing the cuff of the tracheostomy tube distal to the fistula . Although a cuffed endotracheal tube does not offer complete protection against aspiration, all patients with severely altered consciousness with an enteral feeding tubes in place should be prophylactically intubated, whenever possible, for airway protection. Prophylactic antibiotics, corticosteroids, postpyloric feeding, gastric promotility agents, or gastric acid suppression cannot be routinely recommended at this time to prevent or minimize aspiration . Oral care with topical chlorhexidine has not shown any significant reductions in the frequency of ventilator-associated pneumonia for most patient populations, and routine use is not recommended [42,43]. After an aspiration event, clinical status and radiographic changes progress within the next 24 to 36 hours. Patients who develop this syndrome invariably have a marked disturbance of consciousness that can occur from sedative drug overdose or general anesthesia that interferes with vocal cord protection. Foreign Body Aspiration Aspiration of solid particles causes varying degrees of respiratory obstruction. When foreign bodies are inhaled into the tracheobronchial tree, 38% of patients give a clear diagnostic history, 22% give a history of an acute choking and coughing episode, and 40% complain of cough, dyspnea, and wheezing. Although the chest radiograph may demonstrate the foreign object, atelectasis, or obstructive emphysema, it is normal in 80% of the cases. Food asphyxiation should be suspected in middle-aged or elderly patients with poor dentition or dentures that impair chewing adequately or in those sedated by alcohol or other drugs who attempt to swallow solid food. One key to a large foreign body aspiration that may obstruct the larynx or trachea is that the patient cannot speak. Particles that reach the lower respiratory tract and do not totally obstruct the trachea can be removed by coughing or bronchoscopically. Those that totally obstruct the trachea must be removed immediately by subdiaphragmatic abdominal thrusts sometimes followed by finger sweeps of the unconscious individual and chest thrusts in the markedly obese person and women in advanced stages of pregnancy . Bacterial Pneumonia and Lung Abscess Most bacterial pneumonias are a consequence of aspiration of oropharyngeal infectious material in association with impairment of lower respiratory tract defenses . However, we now find that aspiration pneumonia has a microbiologic spectrum that includes more Staphylococcus aureus and enteric gram-negative bacilli. Community-acquired pneumonia can occur when bacteria colonize the oropharynx prior to aspiration and are unable to be cleared by mucociliary clearance and detoxification by the alveolar phagocytes that have been rendered ineffective. Normal respiratory defenses and mucociliary clearance may be compromised by a preceding viral infection or underlying medical conditions that predispose to a bacterial “superinfection” . Even the microbiology of abscesses has changed with the majority being due to aerobic (most commonly Staphylococcus species) organisms. Lung abscesses are now considered to be a result of more virulent community-acquired pneumonia pathogens and not because of aspiration of anaerobes alone . The intubated patient is particularly susceptible to aspiration pneumonia because the endotracheal or tracheostomy tube bypasses the aerodynamic filtration protection of the upper respiratory tract and physically hinders mucociliary clearance. The intubated patient who requires a narcotic is at even greater risk because cough is also suppressed. Once a bacterial pneumonia or lung abscess is suspected, the causative organism(s) should be identified and appropriate antibiotic therapy should be given (see Chapter 181). Chemical Pneumonitis Reminiscent of a chemical burn, airway and parenchymal injury may develop after an aspiration event that triggers a cascade of inflammatory mediators [5,41]. Fever, cough, rales, sputum production, hypoxemia, and infiltrates on chest radiograph may all be presenting signs and symptoms that are nonspecific. What distinguishes this syndrome from the other aspiration sequelae, however, is the rapid, self-limited course and clinical resolution over several days without the need for antimicrobial therapy. Infectious aspiration pneumonia may not be a primary event but may develop as a superinfection of aspiration- induced pulmonary injury, depending on the contents of the aspirated material and the patient’s underlying clinical condition. Exogenous Lipoid Pneumonia Exogenous lipoid pneumonia is the result of aspirating any kind of lipid or oil-based substance including mineral oil, animal oil (e. Although patients with exogenous lipoid pneumonia usually do not appear toxic, the clinical presentation occasionally cannot be distinguished from that of acute bacterial pneumonia. The important clues to the diagnosis must come from the history, physical examination, and upper gastrointestinal studies. Although fat stains performed on unfixed expectorated sputum, bronchoalveolar lavage specimens, or lung biopsy may reveal numerous lipid-laden alveolar macrophages, this finding only supports the diagnosis of exogenous lipoid pneumonia. Lipid-laden macrophages can also arise from an endogenous source or represent a nonspecific response of the lung to injury  because the lung is capable of making its own lipid. Quantitative cultures obtained with telescoping plugged catheters at bronchoscopy may be needed to rule out a bacterial infection, and lung biopsy may be needed to rule out cancer and to make the appropriate diagnosis. After the diagnosis is made, however, the inciting agent is usually identified with pointed questioning of patient practices. If not diagnosed promptly, recurrent aspirations of lipid or small amounts of liquid gastric contents, or both, can present as recurrent hemoptysis, recurrent pneumonias, chronic interstitial fibrosis, bronchiolitis, or bronchiectasis . Rarely, exogenous lipoid pneumonias are complicated by organisms of the Mycobacterium fortuitum complex . Although corticosteroids may be helpful for cases of acute lipid aspiration, acute exogenous lipoid pneumonias usually resolve on their own. Examples of conditions that predispose to an aspiration tracheobronchitis include a debilitated state, the postoperative period, endotracheal intubation, recent extubation, and neuromuscular diseases . Aspiration tracheobronchitis should be suspected for patients with cough, wheezing, and bronchorrhea, defined as expectoration of more than 30 mL of phlegm in 24 hours. Matsuse T, Oka T, Kida K, et al: Importance of diffuse aspiration bronchiolitis caused by chronic occult aspiration in the elderly. Khorvash F, Abbasi S, Meidani M, et al: the comparison between proton pump inhibitors and sucralfate in the incidence of ventilator associated pneumonia in critically ill patients. Cook D, Guyatt G, Marshall J, et al: A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Brady S, Donzelli J: the modified barium swallow and the functional endoscopic evaluation of swallowing.
The lack of labial protec- tion and the close apposition of the anus mean that the Examination of the prepubertal child requires coopera- vulva and lower vagina are constantly exposed to faecal tion from both the patient and the mother and requires bacterial contamination buy cheap kamagra chewable online erectile dysfunction medication online pharmacy. The hypo‐oestrogenic state in extreme sensitivity if a successful examination is to be the vagina means that there are no lactobacilli and carried out kamagra chewable 100 mg low cost erectile dysfunction questionnaire. Positioning the child for examination may therefore the vagina has a resulting pH of 7 buy 100mg kamagra chewable mastercard erectile dysfunction treatment drugs, making it an require considerable time in order to gain the confidence ideal culture medium for low‐virulence organisms. External examination the complaint is usually of discharge which may be should be performed with minimal handling of the vulva offensive, yellow or green in colour and parents often and, in order to expose the vaginal orifice, gentle traction bring stained underwear as evidence of the condition. Examination of the vulva reveals inflammation and by the mother rather than the physician. Children also have the habit of can be obtained using syringes with flexible catheters or exploring their genitalia and in some cases masturbat- occasionally a swab may be inserted if the hymenal orifice ing. In adolescents, vaginal examination should be can prove extremely difficult to treat. Vulvovaginitis may avoided unless there is good evidence that it is absolutely also occur in childhood in those who have an impaired Dewhurst’s Textbook of Obstetrics & Gynaecology, Ninth Edition. Bacterial Non‐specific (common) Diagnostic procedures Specific (rare) There are two aspects of the diagnosis in this condition Fungal (rare) in children. It is imperative that the clinician has good illumi- Pinworms nation, particularly if there is a history of a vaginal for- Viral (rare) eign body. It is usually possible to examine the vagina Dermatitis through the hymen using an otoscope. Lichen sclerosus the second aspect of diagnosis involves the taking of Contact bacteriological specimens. This can be extremely diffi- Sexual abuse cult in a small child, as it is unlikely that the child will be Enuresis cooperative. The best way to take a bacteriological specimen is to use a pipette, which is much less irritating than a cottonwool swab. The pipette allows 1–2mL of normal local host defence deficiency due to the lack of an innate saline to be expelled into the lower part of the vagina, the local protective response from neutrophils. If a diagnosis of pinworms is to be excluded, then specific bacterial contamination, which in the majority a piece of sticky tape over the anus early in the morning of cases is due to poor hygiene. If a specific pathogen before the child gets out of bed will reveal the presence of is isolated, for example Streptococcus pneumoniae, eggs on microscopy. The vast majority of children do not have a pathological Candidal infection in children is extremely rare, organism. The primary treatment in this group is advice although as a common cause of vulvovaginitis in the about perineal hygiene. All parents of children with chronic adult, it is a common misdiagnosis in children. Candida vaginal disease are extremely worried that this may cause in children is usually associated with diabetes mellitus or long‐term detrimental effects to their daughters, particu- immunodeficiency and almost entirely related to these larly the fear of sexual dysfunction or subsequent infertility. The presence of viral infections, There is no evidence that this is the case and therefore par- for example herpes simplex or condylomata acuminata, ents should be reassured that this is a local problem only. Management of these children is directed towards diligent Vulval skin disease is not uncommon in children, par- hygiene of the perineum. The child must be taught to clean ticularly atopic dermatitis in those children who also her vulva, particularly after defecation, from front to back, have eczema. Referral to a dermatologist is appropriate as this avoids the transfer of enterobacteria to the vulval in these circumstances. After micturition the mother and child should be children and may cause persistent vulval itching. The instructed to clean the vulva completely and not to leave skin undergoes atrophy and fissuring and is very suscep- the vulval skin wet, as this damp warm environment is an tible to secondary infection. Sexual abuse in children may present with vaginal dis- the mother must also be informed that vulval hygiene charge. Any child who has recurrent attacks of vaginal through daily washing should be performed, but that the discharge should alert the clinician to this possibility. Excessive washing However, as non‐specific bacterial infection is a com- of the vulva must be avoided as this leads to recurrent exfo- mon problem in children, the clinician must proceed liation and vulval dermatitis. During acute attacks of non‐ with considerable caution in raising the possibility of specific recurrent vulvovaginitis, children often complain sexual abuse. Only those bacterial infections related to of burning during micturition due to the passage of urine venereal disease, for example gonorrhoea, may be cited across the inflamed vulva. There is no evi- It is important that the clinician remembers that many dence that topical oestrogen and antibiotic creams are of girls suffer from urinary incontinence, particularly at any benefit and should not be prescribed. In patients who have per- at this stage may help to prevent further adhesion forma- sistent vaginal discharge despite treatment, an ultra- tion. Finally, in taking a history it is important to estab- sound scan may detect a foreign body or, if a history of a lish that there has not been any trauma to the vulva, as foreign body is forthcoming, it is probably best to carry very rarely labial adhesions may be the result of sexual out an examination under anaesthetic and remove any abuse. Treatment should be appro- priate but if trauma is suspected, sexual abuse must always be considered with referral to the appropriate Adolescence team. The adolescent gynaecological patient usually presents with one of three disorders: (i) problems associated with Labial adhesions the menstrual cycle and menstrual dysfunction, (ii) pri- Labial adhesions are usually an innocent finding and a mary amenorrhoea (see Chapter 38); and (iii) teenage trivial problem, but its importance is that it is frequently hirsutism. They occur most frequently in children aged between 3 Menstrual problems months and 3 years, with a prevalence of about 3%. It As can be seen in the description of puberty (Chapter 38), is believed that labial adhesions result from vulvar menstrual cycles are rarely established as normal ovula- inflammation in a hypo‐oestrogenic environment. It is usual for labia minora stick together in the midline, usually from cycles to be irregular and bleeding sometimes prolonged posterior to anterior until only a small opening is left initially, and it can take some girls several years to achieve through which urine is passed. It may be difficult to distin- the gynaecologist understands this phenomenon, as the guish the opening at all. The vulva has the appearance of management of these cases is usually not active treat- being flat, and there are no normal tissues beyond the ment but support and explanation to the mother and clitoris evident. There are usually Trying to establish a history of heavy menstrual bleeding no symptoms associated with this condition, although can be challenging in this age group. The patients have older children may complain that there is some spraying little experience and may well not understand normality. As late childhood ensues and ovar- Expectation from maternal influence is also a contribu- ian activity begins, there is spontaneous resolution of the tory factor and so efforts should be made to interview problem in 80% of children. Normal menstrual loss treatment is required and the parents should be reas- should not exceed 80 mL during a period, although in 5% sured that their daughters are entirely normal. In those of individuals it is heavier than this and causes no trou- children in whom there are some clinical problems, local ble. Getting some idea from frequency of pad change or oestrogen cream can be applied for about 2 weeks. If a history of pro- is complete resolution of the labial adhesions in 90% of longed bleeding during surgical or dental procedures is cases. In the case of failure of oestrogen treatment, topi- obtained, screening for a coagulopathy is appropriate. Gynaecological Disorders of Childhood and Adolescence 555 the clinician is faced with attempting to assess whether 12 weeks. Amenorrhoea rates of 60% at 1 year and 70% the child truly has menstrual loss that is medically seri- at 2 years can be achieved.
Severe intractable skin disease or involvement of organs other than the skin may require immunosuppressive therapy with high-dose prednisone 1 to 2 mg/kg/d order kamagra chewable 100 mg with visa erectile dysfunction images, sometimes with steroid-sparing support from methotrexate purchase 100mg kamagra chewable with amex erectile dysfunction treatment fort lauderdale, cyclosporine order kamagra chewable 100mg visa erectile dysfunction groups in mi, azathioprine, cyclophosphamide, or mycophenolate mofetil . Disorders with large vessel vasculitis are usually diagnosed when bruits, asymmetric pulses, claudication, or neurologic deficits are present. In less than 20% of cases of Takayasu’s arteritis, erythema nodosum–like nodules or pyoderma gangrenosum–like ulcers may be present. Cutaneous findings, although present in 80% of patients, are nonspecific in Kawasaki’s disease, a syndrome associated with coronary artery aneurysms in 12% of affected children. The eruption of Kawasaki’s disease is polymorphous, and patients may present with macules, papules, wheals, targetoid plaques, papulovesicles, pustules, or a scarlatiniform eruption most commonly on the abdomen, groin, perineum, and buttocks. There is often desquamation of the fingertips and mucous membrane involvement may include conjunctival injection, dryness of the lips, erythema of the mouth, and prominent tongue papillae (strawberry tongue). Varicella and pneumococcal sepsis are less frequently associated and rare or isolated reports include H. The common end point is that of extensive microvascular thrombosis that affects cutaneous and visceral blood supply. In meningococcemia, endotoxin results in release of cytokines and activation of coagulation pathways, and infection is associated with substantially decreased levels of protein C . Irregular areas of blue–black or dusky discoloration develop within the center of erythematous patches, and lesional skin becomes indurated. Lesions associated with infection tend to involve distal parts first and spread proximally, whereas idiopathic and coagulopathy- associated disease may remain localized to the lower extremities. Disease complications include scarring, secondary infections, digital or limb necrosis, and autoamputation [108–110]. Early recognition of disease and identification of the underlying trigger is essential in this rapidly progressive condition. Supportive care includes aggressive fluid resuscitation, electrolyte monitoring, and replacement of blood products. Recognition of these findings is therefore essential for early diagnosis and prompt evaluation for more extensive disease. Skin lesions are thought to be a direct result of arterial or venous occlusion and subsequent ischemia. The most common finding is livedo reticularis or livedo racemosa, seen in up to 40% of patients, and up to 70% of patients who have systemic lupus. These present as a netlike pattern of dusky erythema often found on the upper or lower extremities; they are thought to be more common in cases with underlying arterial disease and are less often seen in venoocclusive disease . Other associated findings include cyanotic macules, ecchymosis and purpura, ulcerations of the ears, face, and legs, porcelain- white scars (atrophie blanche) at the ankles, thrombophlebitis, Raynaud’s phenomenon, digital ischemia, and gangrene. Some advocate the use of aspirin in those without a history of thrombosis or with superficial venous thrombosis only. Otherwise, long-term warfarin anticoagulation with an internal normalized ratio goal of 3 to 4 is recommended. Rituximab has been shown to be effective for decreasing cutaneous ulcerations and thrombocytopenia; however, it has not been shown to decrease thrombotic events . Most individuals on warfarin do not experience this complication, and therefore additional risk factors are likely required to induce necrosis. Poorly demarcated, indurated erythema develops asymmetrically over fatty areas such as the breast, buttock, thighs, and lower abdomen. Induration progresses over 24 to 72 hours to edema with a peau d’orange surface, blue–black discoloration, and hemorrhagic bullae. Histology of involved skin shows noninflammatory thrombosis and fibrin deposition in small dermal vessels with necrosis of the dermis and subcutaneous fat . Deep tissue necrosis, secondary infection, and multiorgan failure are more likely with more widespread disease. Type I disease is notable for more frequent and severe attacks related to hyperviscosity, and may manifest on the skin as livedo reticularis or Raynaud’s phenomenon. Vascular occlusion rather than immune complex deposition predominates, as these cryoglobulins have a decreased ability to activate the complement cascade. These underlying conditions are thought to trigger B-cell hyperactivation, which promotes production of cryoglobulins. Meltzer’s triad of palpable purpura, arthralgia, and myalgia may be apparent in 25% to 30% of patients. Blood samples should be collected in prewarmed vials and maintained at 37°C to prevent precipitation of cryoglobulins. Although involved skin characteristically shows noninflammatory occlusion of dermal vessels by immunoglobulin precipitates, leukocytoclastic vasculitis may be apparent in up to 50% of cases. For more severe disease, options include immunosuppressive agents, plasmapheresis, rituximab plus systemic corticosteroids, and radiation or chemotherapy to treat the associated hematologic malignancy. Morbidity and mortality are attributed to associated diseases, and death often results from cardiac disease or infection . Embolic Diseases Embolization of cholesterol or atheromatous material, fat, or tumor may result in striking systemic and cutaneous findings. Cholesterol embolization is typically a result of interventional vascular procedures such as left heart catheterization or angiograms, and can also be associated with cardiac surgery, thrombolysis, and aortic dissection. Less frequently, patients with severe and extensive atherosclerotic disease may experience spontaneous embolization, or emboli triggered by coughing or straining. Presenting signs and symptoms of embolic disease include mental status changes, pulmonary edema, heme-positive stools, and acute renal failure. Cutaneous findings are striking when apparent and include livedo reticularis, a coarse netlike pattern of violaceous erythema evident on the lower extremities and abdomen. Tender blue discoloration, petechiae, ecchymosis, ulceration, and gangrene of the feet and toes may eventuate. Pedal pulses are generally intact but bruits may be audible over the femoral artery and abdominal aorta. Similar findings on the arm and hands may result from aortic embolization to the upper extremities [121–123]. Note the livedoid (reticulated) pattern on the sole of the foot, an earlier sign of vascular occlusion. Petechiae distributed on the upper body (head, neck, chest, and subconjunctiva) are thought to be pathognomonic and are seen about 50% of the time . Emboli from atrial myxoma, a benign cardiac hamartoma, may result in cyanosis, ecchymosis, splinter hemorrhages, and tender violaceous lesions of the digits . The diagnosis of emboli should be highly suspected in any patient with characteristic skin findings, acute onset end-organ failure, and a recent invasive vascular procedure. Biopsy of the affected organ will show occlusion of vessels with needle-shaped clefts representing cholesterol crystals. Atrial myxoma is evident on echocardiogram, and sampling of affected skin will demonstrate the embolized myxomatous material. Treatments include surgical removal or bypass of emboli, amputation of gangrenous digits, and anticoagulation if disease is not thrombolytic-induced [122,125]. Other risk factors include hyperparathyroidism, obesity, white race, female sex, liver disease, malignancy, hypercoagulability, and use of corticosteroids or vitamin D .
Bilateral basal ganglia and brainstem infarction can occur in severely ethylene glycol–poisoned patients  purchase kamagra chewable mastercard erectile dysfunction doctor in kolkata. Seizures purchase kamagra chewable 100 mg visa erectile dysfunction ultrasound, coma buy kamagra chewable 100mg line vegetable causes erectile dysfunction, and severe acidosis among patients with methanol poisoning portend a poor prognosis [56,145]. The development of dilated, unresponsive pupils may indicate either severe optic nerve damage or cerebral edema . Other neurologic sequelae include a parkinsonian-like syndrome, spasticity, transient resting tremor, cognitive defects, and paraplegia. Computed tomography, magnetic resonance imaging, and autopsy studies have documented frontal lobe and basal ganglia hemorrhages and infarcts, especially in the putamen [146,147]. Bilateral putaminal hemorrhage and/or insular subcortex white matter necrosis correlate with a poor clinical outcome following methanol toxicity. The etiology of these lesions remains uncertain, but they are likely due to the direct toxicity of methanol and/or its metabolites. These abnormalities usually occur among severely acidemic patients with delayed presentation or diagnosis. Harvesting of organs for transplant is not precluded for patients who die from ethylene glycol or methanol poisoning. Several centers have reported successful experience with kidney, heart, lung, pancreatic β cell, and liver procurement from methanol-poisoned patients [127,148]. It is commonly available over the counter in 70% solutions of “rubbing alcohol,” but it is also used in cleaners, disinfectants, hand sanitizers, cosmetics, solvents, inks, and pharmaceuticals . Because of its ready availability at an inexpensive price, abusers of alcohol often ingest isopropanol as an ethanol substitute. Depending on individual tolerance, serum concentrations of 150 mg per dL or greater may induce coma, and levels of 200 mg per dL or greater can be fatal in untreated patients, although lower concentrations may produce severe adverse effects [35,153]. Therefore, metabolic acidosis is not a feature of isopropanol toxicity unless respiratory depression with hypoxia or hypotension results in lactate production. Excretion of acetone and unchanged isopropanol (20% of an absorbed dose) is predominantly renal, with some excretion by respiratory, gastric, and salivary routes. Serum acetone levels frequently remain elevated after isopropanol levels are undetectable because acetone is eliminated slowly, with a half-life of 10. Clinical Presentation An “intoxicated” patient without acidemia, yet with positive serum or urinary ketones and a fruity breath odor, should be suspected of isopropanol intoxication. Initial signs and symptoms usually consist of mild intoxication followed by gastritis, abdominal pain, nausea, vomiting, and possibly hematemesis . Because of the profound and prolonged cerebral depressive effects of isopropanol, comatose patients may develop compartment syndromes and rhabdomyolysis with myoglobinuria. Diagnostic Evaluation Patients with known or suspected isopropanol poisoning should have quantitative isopropanol and acetone serum levels along with the laboratory studies noted for acute ethanol intoxication. In patients who may have also ingested other toxic alcohols, serum osmolality, ethanol, ethylene glycol, and methanol levels should also be obtained. The differential diagnosis of isopropanol poisoning includes toxic and metabolic states in which ketonemia may develop, such as alcoholic, diabetic, and starvation ketoacidosis. Patients with these conditions have elevated acetoacetate, β-hydroxybutyrate, and acetone levels compared with the isolated acetonemia seen with isopropanol intoxication. Poisoning by salicylate, cyanide, and acetone itself (which is found in nail polish and super glue remover) and inborn errors of metabolism should also be considered in the differential diagnosis of unexplained ketosis. Some degree of metabolic acidosis is expected in most of these conditions, whereas it is absent in uncomplicated isopropanol or acetone poisoning cases. Since acetone is less toxic than isopropanol, there is no indication for either fomepizole or ethanol therapy [130,150,160]. Pulmonary edema and hemorrhage are common findings on autopsy and should be anticipated in severely ill patients. Oral and dermal absorption is usually poor, but toxic amounts may be absorbed through abraded or burned skin . Although oral doses of as much as 1 g per kg are essentially nontoxic, toxicity can occur following rapid or prolonged infusion of higher doses. Elderly patients, especially those with severe underlying cardiac disease, are at increased risk and should be infused with medications containing propylene glycol at rates slower than those usually recommended. Propylene glycol toxicity has been described following extremely high doses of diazepam for ethanol withdrawal, massive ingestion of products containing propylene glycol, or the chronic dermal absorption of silver sulfadiazine through damaged skin [165–167]. Although theoretically fomepizole may be beneficial to block the metabolism of propylene glycol, this therapy cannot be universally recommended at this time without more information, including information on the relative toxicity of the parent compound to its metabolites [35,169]. Hemodialysis and continuous venovenous hemofiltration have reportedly been used to treat patients with propylene glycol toxicity, especially in the setting of renal failure, high blood concentrations, or severe metabolic acidosis [35,170,171]. Over the years, diethylene glycol has resulted in tragic outbreaks of renal failure and death following its substitution for propylene glycol in medications [174,175]. Unlike propylene glycol, diethylene glycol can cause acute renal failure, elevated liver enzymes, encephalopathy, and delayed neurologic toxicity. Since the first reported outbreak that occurred in the United States in 1937, there have been other outbreaks worldwide, including South Africa (1969), Spain (1985), India (1986 and 1998), Nigeria (1990 and 2008), Bangladesh (1990 to 1992), Argentina (1992), Haiti (1996), Panama (2006), and China (2006). These outbreaks often involved medications, such as acetaminophen, cough syrup, or teething syrup, ingested by children. Interestingly, additional neurologic symptoms may develop up to several weeks after the ingestion and include cranial nerve palsy, peripheral neuropathy, dysphonia, lethargy, mental status changes, quadriparesis, and seizures [174,177]. Although the name suggests the potential to be metabolized to two ethylene glycol molecules, this does not occur in vivo . Survivors with renal failure tend to remain dialysis dependent, and the degree of renal injury may be a predictor of delayed neurologic sequelae. Case reports exist of successful treatment of pediatric patients with fomepizole for diethylene glycol toxicity using the same dosing regimen as adults [35,116]. Stahre M, Roeber J, Kanny D, et al: Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Fulop M, Bock J, Ben-Ezra J, et al: Plasma lactate and 3- hydroxybutyrate levels in patients with acute ethanol intoxication. Jacobsen D, Ovrebo S, Ostborg J, et al: Glycolate causes the acidosis in ethylene glycol poisoning and is effectively removed by hemodialysis. Malandain H, Cano Y: Interference of glycerol, propylene glycol and other diols in enzymatic assays of ethylene glycol [abstract]. Zakharov S, Pelclova D, Navratil T, et al: Fomepizole vs ethanol in the treatment of acute methanol poisoning: comparison of clinical effectiveness in a mass poisoning outbreak. Harry P, Turcant A, Bouachour G, et al: Efficacy of 4-methylpyrazole in ethylene glycol poisoning: clinical and toxicokinetic aspects. Brendt J: Fomepizole for the treatment of pediatric ethylene and diethylene glycol, butoxyethanol, and methanol poisonings. Caballero F, Cabrer C, Gonzalez-Segura C, et al: Short- and long-term success of organs transplanted from donors dying of acute methanol intoxication. Zakharov S, Pelclova D, Urban P, et al: Czech mass methanol outbreak 2012: epidemiology, challenges and clinical features.