The US Food and Drug Administration allows about 50 g/kg of propylene glycol in foods. In 2014, some European countries reported that Fireball contained amounts of propylene glycol that exceeded the European Union limitations of 1 g/kg. Management options include fomepizole, due to its mechanism of inhibiting alcohol dehydrogenase, and dialysis in cases of renal failure and severe acidosis.įireball Cinnamon Whiskey is a mixture of Canadian whiskey, cinnamon flavoring, and sweeteners that contains propylene glycol. 7 Propylene glycol is metabolized by alcohol dehydrogenase in the liver into lactic acid and then pyruvic acid. FIRE BALL SHOTS SKINOther adverse effects include acute kidney injury, cardiac arrhythmias, skin necrosis, and hypotension. The acute effects of propylene glycol poisoning are primarily central nervous system depression and lactic acidosis. One case described high anion gap metabolic acidosis with high osmolal gap in the setting of liquor containing propylene glycol. 3–5 However, there have not been many case reports of severe lactic acidosis in the setting of liquor containing propylene glycol. There have been several reports of severe lactic acidosis occurring in the setting of iatrogenic unintentional overdosing of medications that use propylene glycol as a diluent, including lorazepam and diazepam. Propylene glycol is considered a relatively safe alcohol compared with methanol and ethylene glycol. The second patient also had high anion gap metabolic acidosis and a high osmolal gap. He was extubated, and his dialysis catheter was removed before discharge.īoth patients had severe lactic acidosis and acute kidney injury in the setting of Fireball Whiskey consumption. During the hospital course, his condition improved significantly. After hemodialysis, his sodium improved to 135 mmol/L potassium, 4.1 mmol/L bicarbonate, 26 mmol/L and lactic acid, 2.1 mmol/L ( Figure 1). Given his severe metabolic acidosis, he underwent hemodialysis. He went into shock and required vasopressor support. He was intubated due to severe metabolic acidosis and impending respiratory failure and was treated with intravenous fluids and antibiotics. Blood ethylene glycol and methanol levels were normal. He had a history of Fireball Whiskey consumption. Examination disclosed scleral icterus, tachycardia, and rales in lungs. His temperature was 34.4☌ heart rate, 116 beats/minute respiratory rate, 24 breaths/minute blood pressure, 117/82 mm Hg and oxygen saturation, 54% on room air. A 41-year-old man with a past medical history of alcohol use, delirium tremens, and anxiety presented to the emergency department with shortness of breath, cough, and nausea.
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