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Diethylene glycol poisoning in Gurgaon, India, Jagvir Singh, 1 A. Dutta, 2 Shashi Khare, 3 N. Dubey, 4 A. Harit, 5 N.

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Diethylene glycol poisoning in Gurgaon, India, Jagvir Singh, 1 A. Dutta, 2 Shashi Khare, 3 N. Dubey, 4 A. Harit, 5 N. Jain, 6 T. Wadhwa, 7 S. Gupta, 8 A. Dhariwal, 9 D. Further information was obtained from house visits and community surveys; blood and stool samples were collected from other ill children, healthy family members and community contacts.

Samples of drinking-water and water from a tube-well were tested for coliform organisms. Acute renal failure developed after an episode of acute febrile illness with or without watery diarrhoea or mild respiratory symptoms for which the children had been treated with unknown medicines by private medical practitioners. On admission to hospital the children were not dehydrated. Kidney biopsy showed acute tubular necrosis. Thirty-three children were known to have died despite being treated with peritoneal dialysis and supportive therapy.

Thus, poisoning with diethylene glycol seems to be the cause of acute renal failure in these children. Keywords: ethylene gycols, toxicity, poisoning; drug contamination; expectorants, toxicity; antitussive agents, toxicity; kidney failure, acute; child, preschool; infant; India. The Federal Food, Drug and Cosmetic Act was passed by the United States Congress in in reaction to a public health accident that occurred in when people died from diethylene glycol poisoning.

Diethylene glycol, a highly toxic organic solvent that causes acute renal failure and death when ingested, was used as a diluent in sulfanilamide, the first sulfa antimicrobial drug 1, 2. The legislation, which was the first to require that new drugs be tested for toxicity before being put on the market, protected the American public against a recurrence of the tragedy.

However, despite the existence of similar, appropriate legislation in India, 14 patients died in Bombay now Mumbai in when they were given glycerine contaminated with diethylene glycol 3. We report a second episode of poisoning occurring in in India as a result of children ingesting diethylene glycol; at least 33 children are known to have died. About cases of acute renal failure were seen in the hospital over the last five years.

Paediatricians were able to determine the etiology in most of the cases, but were unable to do so for a large number of children who were admitted from April Most of these children died. All of these children became ill initially with an acute febrile illness with or without mild respiratory or gastrointestinal symptoms such as diarrhoea or vomiting, or both. All of the children had been treated by private medical practitioners qualified as well as unqualified and had some unknown medicines administered, orally or as injections.

On 5 May the hospital informed the National Institute of Communicable Diseases about these cases. This triggered an epidemiological investigation to discover the cause. The results are presented in this report. They were asked to determine whether other hospitals in Delhi had seen similar cases.

They found that similar cases had been seen by two other hospitals on or after 19 April two cases had been admitted to Safdarjang Hospital and 9 to the All India Institute of Medical Sciences. For this investigation, a case was defined as a patient admitted to hospital in April or later and diagnosed as having unexplained acute renal failure. The 9 cases admitted to the All India Institute have been excluded from this report for administrative reasons.

Nevertheless, the excluded cases had epidemiological and clinical characteristics similar to those of the cases admitted to the other two hospitals. Parents of many of the children and the doctors who had treated them were also interviewed.

It became apparent that most of the children who had had unexplained acute renal failure came either from the Gurgaon district or had gone there for treatment of acute febrile illness or diarrhoea. Health officials in the Gurgaon district were contacted to find out whether similar cases had been admitted to the district hospital or to private hospitals in the district.

Data were also collected on cases of pyrexia of unknown origin and diarrhoea thad tad been treated at the district hospital during and Researchers visited the houses of many of the children who had died before the epidemiological investigations began or who were still hospitalized, to discover whether there were any common factors and to discover how these children might have differed from other children in the neighbourhood.

These visits were combined with house-to-house surveys of the surrounding community to enquire about any cases of acute febrile illness, diarrhoea or severe oliguria that had occurred since April. Enquiries were also made about the doctors who had treated the children and the types or names of medicine prescribed.

Blood and stool samples were collected from children who had any illness during these visits as well as from apparently healthy family members and community contacts.

Two samples of drinking-water stored in covered cement tanks were collected from the houses of children who had had unexplained renal failure. Two samples of running water from a tube-well in a nearby village were also collected. These water samples were tested for coliform organisms. The treatment histories of the children showed that a large proportion of them had been treated by a local doctor for minor ailments before being referred to the specialized hospitals in Delhi with severe oliguria or anuria.

The local doctor was interviewed to provide data on clinical features and treatment of these children. Many other qualified and unqualified doctors practising in Gurgaon were also interviewed. Blood samples from cases and contacts were collected in plain vials as well as blood culture bottles using aseptic precautions.

The samples collected in plain vials were used for serological testing and isolation of viruses. Stool samples were collected in viral transport medium Hanks balanced salt solution as well as Cary Blair medium.

Stool samples were subjected to virus isolation in various cell lines RD, HEp2, Vero by standard procedures. The vials were observed for 7 days. All cytopathogenic agents isolated were subjected to enterovirus typing by a microneutralization test using pooled antisera procured from the National Institute for Public Health and Environmental Protection RIVM, the Netherlands. Some formulations of medicines manufactured by companies in Gurgaon and two surrounding districts Faridabad and Bahadurgarh were collected by the Joint Drugs Controller of India and tested at the Central Drugs Laboratory, Calcutta, for evidence of contamination.

A total of 36 children with unexplained acute renal failure were admitted to two hospitals in Delhi between 1 April and 9 June Thirty-three of the children are known to have died in hospital or at home after being discharged against medical advice.

Only two patients were discharged after improving. The status of one patient who was discharged in critical condition is not known. The progression of the epidemic is shown in Fig. Table 1 shows the aged and sex of the children.

The age-specific and sex-specific case fatality rates were not significantly different. The episode was centred in the Gurgaon district, Haryana state, and adjoining areas. Three children came from the Rewari district in Haryana; one from the Faridabad district, also in Haryana; and two came from the Alwar district in Rajasthan.

However, it was later discovered that at least 3 of them were actually residents of the Gurgaon district and that they had given addresses of relatives in Delhi at the time of admission; 2 had become ill while staying with relatives in Gurgaon. All the villages or urban areas reported only single cases. Field visits to the villages and urban areas where patients lived revealed that a few other cases of fever and diarrhoea had occurred in the neighbourhood, and there had been no increase in such cases.

No other case of unexplained acute renal failure or death from anuria or severe oliguria was identified. Table 2 shows the number of cases of pyrexia of unknown origin and diarrhoea treated in the district hospital in Gurgaon between January and April There was no increase in the number of cases of fever or diarrhoea in when compared with All cases of fever or diarrhoea treated in the district hospital in improved. No case of severe oliguria or anuria was seen by the district hospital.

However, a private specialized hospital in Gurgaon town reported that 5 patients with acute renal failure had been seen there. These patients had been treated by local private practitioners for minor illnesses before developing acute renal failure. There were no apparent links between the cases except that most of the children either lived in the Gurgaon district or had visited Gurgaon town for treatment of a minor illness before developing acute renal failure.

Unfortunately, this paediatrician did not have any records of treating these children. Although he admitted that he had treated some children for fever or respiratory illness or watery diarrhoea before they developed anuria, he was surprised that many of them had developed acute renal failure. He also admitted that he prescribed antibiotics, acetaminophen syrup, cough syrup, or oral rehydration salts to these children.

All these medicines were given to patients from his dispensary. He also said that he had not changed his treatment practices or any other aspect of his practice recently. He was curious to know why only some of the children he had treated had developed acute renal failure, because he treated a large number of cases about every day.

None of the children had had any significant illness in the past. All of them had been treated for minor illnesses fever, cough, or diarrhoea by local private practitioners before developing severe oliguria or anuria. Clinical examination after admission to the hospitals in Delhi revealed that most of them were well hydrated. Their vital signs were stable as were most of their haemodynamic functions.

There was no significant organomegaly. Their chests were clear. The occasional patient had high blood pressure. There was no evidence of focal neurological lesions. All children were given peritoneal dialysis as well as supportive treatment. Of the 2 patients discharged after improving, one remained in hospital for 10 days and the other for The patients who died were not clinically different from those who survived.

Sodium concentrations were within the normal range, but potassium concentrations were markedly increased in most children.

Analysis of blood gases showed that most patients were acidotic. Serum bilirubin concentrations remained within the normal range in most of the cases; 9 children had median concentrations of 0.

Coagulation profiles were within normal limits. One patient had thrombocytopenia. Chest radiographs were normal in all cases.

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Educalingo cookies are used to personalize ads and get web traffic statistics. We also share information about the use of the site with our social media, advertising and analytics partners. Meaning of "antitusivo" in the Spanish dictionary. The definition of antitussive in the dictionary is to combat cough. Antitussive infusions are prepared with yarrow and coltsfoot. Con milenrama y tusilago se preparan infusiones antitusivas.

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