J. clin. Path., 1973, 26, 32-36 Identification of crystals deposited in brain and kidney after xylitol administration by biochemical, histochemical, and electron diffraction methods G. W. EVANS', GAEL PHILLIPS, T. M. MUKHERJEE, M. R. SNOW, J. R. LAWRENCE, AND D. W. THOMAS From the Institute of Medical and Veterinary Science, Frome Road, Adelaide, South Australia, and the Renal Unit, The Queen Elizabeth Hospital, Woodville, South Australia SYNOPSIS The positive identification of crystals of calcium oxalate occurring in brain and kidney after xylitol administration is described. Biochemical, histochemical, conventional light and electron microscopical methods, including selected area electron diffraction, were used to characterize the crystals. The syndrome resulting from intravenous infusion of certain xylitol-containing solutions has been described in detail by Thomas, Edwards, Gilligan, Lawrence, and Edwards (1972a) and by Thomas, Gilligan, Edwards, and Edwards (1972b). The crystals which occurred in the brain and kidney of some of the patients in that series were positively charac- terized in one case which is described here. Case Details The patient (case 19 from the series of Thomas et al, 1972a) was a male, aged 58 years, who three months before admission had received a renal homotransplant following haemodialysis for chronic renal failure consequent on severe hypertension. On 24 December 1969 he was admitted to hospital with acute pancreatitis and despite severe hyper- tension (210/130) the BUN at that time was 24 mg/100 ml and the serum creatinine was 1 2 mg/100 ml. The haemoglobin was 12 8 g/100 ml. The signs of acute pancreatitis resolved during controlled fluid therapy but the patient developed an epigastric mass, thought to be a 'pseudocyst of the pancreas'. In an attempt to improve his general condition he was given xylitol-containing solutions as an intravenous source of calories. Acidosis developed soon after xylitol was administered and subsequently renal 'Requests for reprints should be addressed to G.E., Clinical Chemistry Division, Institute of Medical and Veterinary Science, Frome Road, Adelaide, Soutb Australia 5000. Received for publication 24 October 1972. function deteriorated with rising serum creatinine (6-9 mg/100 ml), urea nitrogen (80 mg/100 ml), and uric acid (13 mg/100 ml) (Fig. 1). At this time the patient also developed 'midbrain' signs, including bilateral sixth nerve paresis, disturbances of con- jugate gaze, and nystagmus. A renal biopsy was performed four days after xylitol therapy was begun and in sections rosettes and sheaves of birefringent crystals were seen in the lumen of renal tubules and within tubular cells. Xylitol infusion had been stopped on the previous E 0 - 0. E C c E a, 10 9 8 7- 6- 5- 4- 3- 2- '\\ /'l A\r,,j \\ 'N 5 10 15 DAYS Xylitol /A,,_ 4 Dialysis S a 20 25 30 29 27 25 23 21 9 17 5 13 I I 9 Fig. 1 Graph showing rising serum creatinine (solid line) and falling serum bicarbonate (discontinuous line) following xylitol therapy. Haemodialysis is indicated by smaller arrows. 32 E C c r, group.bmj.com on July 16, 2011 - Published by jcp.bmj.com Downloaded from