Jumping to conclusions on ethylene glycol poisoning

Dr. Mickey Segal, CEO of clinical decision support company SimulConsult shared his comments about a story in today's Boston Globe (Radio host is arrested on air in wife's death).

The allegation of poisoning may indeed be true but I think it is important to consider all reasonable hypotheses. If the case were of an infant I would consider the metabolic hypothesis to be as strong as the poisoning hypothesis; in an adult the poisoning is more likely.

Here's what he told the Globe reporter:I wanted to inject a note of caution into your reporting of the suspicion of ethylene glycol poisoning today:I wrote an article about mistakes that have been made in allegations of poisoning, including this section on ethylene glycol:

Methylmalonic acidemia: a child appeared to have died of ethylene glycol poisoning, found by two independent labs. The mother was sentenced to life in prison, but while in prison, gave birth to a second son, who was found to have methylmalonic acidemia. Reexamination of serum from the first child also showed methylmalonic acidemia; the labs had misidentified propionic acid as ethylene glycol. The mother was eventually released from prison. Note, however, that the opposite error can also occur: intentional poisoning with ethylene glycol can be misinterpreted as an inborn error of metabolism.

Methylmalonic acidemia typically shows up in newborns, but it can show up later:

CblA, cblB, cblC, and cblH forms of MMA typically present during early infancy. MMA forms CblD and cblF typically present during later infancy or childhood. On occasion, the cblC form of MMA may present during childhood and/or adolescence.

Those considering this case should be sure to consider both the poisoning hypothesis and the metabolic hypothesis.