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Clin. Lab. 7/2024
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Clin. Lab. 2024;70:1333-1340
©Copyright ORIGINAL ARTICLE
A Novel and Simple Method for a Differentiation of Alcohol Types
Alper Gümüş 1, Burak Gümüş 2, Ali K. Erenler 3, Uğur Çom 4, Mehmet Şahin 5, Mehmet N. Sutaşir 6
1 University of Health Sciences, Başakşehir Çam and Sakura City Hospital, Biochemistry Department, İstanbul, Turkey
2 Hitit University, Medical Faculty, Forensic Medicine Department, Çorum, Turkey
3 Hitit University, Medical Faculty, Emergency Medicine Department, Çorum, Turkey
4 The Council of Forensic Medicine, Çorum, Turkey
5 Atıf Hoca Iskilip State Hospital, Biochemistry Department, Çorum, Turkey
6 University of Health Sciences, Başakşehir Çam and Sakura City Hospital, Emergency Medicine Department, İstanbul, Turkey
SUMMARY
Background: Alcohol poisoning is a significant global problem that has become an epidemic. The determination of
the alcohol type is hereby essential as it may affect the course of the treatment; however, there is no routine labo-
ratory diagnostic method for alcohol types other than for ethanol. In this study, we aimed to define a simple meth-
od for alcohol type differentiation by utilizing a combination of breathalyzer and spectrophotometrically mea-
sured serum ethanol results.
Methods: A breathalyzer and spectrophotometry were used to measure four different types of alcohol: ethanol,
isopropanol, methanol, and ethylene glycol. To conduct serum alcohol analysis, four serum pools were created,
each containing a different type of alcohol. The pools were analyzed using the spectrophotometric method with an
enzymatic ethanol test kit. An experiment was conducted to measure the different types of alcohol using impreg-
nated cotton and a balloon, simulating a breathalyzer test. An algorithm was created based on the measurements.
Results: Based on the results, the substance consumed could be methanol or isopropanol if the breathalyzer test
indicates a positive reading and if the blood ethanol measurement is negative. If both the breathalyzer and the
blood measurements are negative, the substance in question may be ethylene glycol.
Conclusions: This simple method may determine methanol or isopropanol intake. This straightforward and inno-
vative approach could assist healthcare professionals in different fields with diagnosing alcohol intoxication and,
more precisely, help reducing related morbidity and mortality.
(Clin. Lab. 2024;70:1333-1340. DOI: 10.7754/Clin.Lab.2024.240121)
Correspondence:
Alper Gümüş
University Of Health Sciences
Başakşehir Çam and Sakura City Hospital
Biochemistry Department
Olimpiyat Bulvarı Yolu
34480 Başakşehir
İstanbul
Turkey
Email: dralpergumus@gmail.com
Phone: + 90 5334377669
ORCID ID: 0000-0002-4453-6339
____________________________________________
Manuscript accepted January 24, 2024
KEYWORDS
alcohol poisoning, ethanol, isopropanol, methanol,
ethylene glycol, breathalyzer
INTRODUCTION
The consumption of homemade or distilled alcohol pro-
duced in unsanitary conditions has increased in Turkey.
Experts say the rise in the price of ethanol drove illegal
producers to substitute it with methanol, fueling the
string of deaths from the lethal substance by doing so.
Even a small amount of methanol can be poisonous and
can end in death [1,2]. In potentially intoxicated indi-
viduals, breath alcohol analyzers are used by law en-
forcement and healthcare personnel to estimate the eth-
A. Gümüş et al.
Clin. Lab. 7/2024
1334
anol concentration [3]. Alcohol poisoning (ethanol,
methanol, or ethylene glycol) is challenging in clinical
practice. The prevalence of admissions to the emergen-
cy department due to alcohol poisoning has been re-
ported to be 8.8 per million in the USA and 25 per mil-
lion in our country [4,5]. Common characteristics of al-
cohol poisoning are high anion gap metabolic acidosis
and increased osmolality. While these compounds cause
increased serum osmolality, their accumulating metabo-
lites cause an increased anion gap [6]. Ethanol and iso-
propanol are commonly ingested and cause gastrointes-
tinal irritation; they do not produce metabolic acidosis.
On the other hand, methanol and ethylene glycol are
toxic alcohols, because they cause severe physiologic
morbidity [6].
Ethanol: A standard alcoholic beverage contains about
fifteen grams of ethanol. It is available in various forms
and may be found in high concentrations in many
household products such as mouthwash, colognes, per-
fumes, and as a diluent or medication solvent. The
bright colors and flavors of these products may appeal
to children and cause severe intoxication if ingested, es-
pecially if mistaken for harmless candies or beverages.
Ethanol depresses the central nervous system (CNS). It
enhances the inhibitory neurotransmitter γ-aminobutyric
acid receptors and blocks excitatory N-methyl-d-aspar-
tic acid receptors. Modulating these systems leads to de-
veloping tolerance, dependence, and withdrawal syn-
drome when ethanol intake ceases in independent indi-
viduals.
Because of the phenomenon of tolerance, blood ethanol
levels correlate poorly with the degree of intoxication.
Ethanol ingestion is the most common cause of an os-
molar gap (OG) in serum electrolyte analysis. It may be
associated with mild metabolic acidosis, but a signifi-
cant anion gap metabolic acidosis suggests the presence
of lactic acidosis, ketoacidosis, or methanol or ethylene
glycol toxicity [7].
Isopropanol: Isopropanol, also known as isopropyl al-
cohol and 2-propanol, has a molecular weight of 60.10
and is a colorless, volatile liquid with a bitter, burning
taste and an aromatic odor. It is found in many readily
available, inexpensive household products, such as rub-
bing alcohol. Isopropanol is widely used in industry as a
solvent and disinfectant and is a component of various
skin and hair products, cleaners, detergents, paint thin-
ners, and deicers. Ketosis and an OG without acidosis
are the hallmarks of isopropanol toxicity. The primary
metabolite, acetone, does not cause eye, kidney, cardiac,
or metabolic toxicity, although high acetone levels may
contribute to CNS depression. Acetone is eliminated
primarily by the kidneys, with some excretion through
the lungs. The primary clinical toxicities of isopropanol
are CNS depression, caused by the parent compound
and acetone, and gastric irritation from isopropanol. Se-
rum isopropanol and acetone levels may be assessed, al-
though isopropanol levels may not be readily available
from hospital laboratories. Isopropanol levels of 50 mil-
ligrams/dL (8 mmol/L) are often related to an intoxica-
tion in individuals not habituated to ethanol. Still, alco-
holic individuals may be considerably more resistant to
the CNS effects of isopropanol [6].
Methanol: Methanol, the basic alcohol (CH3OH, mo-
lecular weight 32.05), is a colorless, volatile liquid with
a distinctive "alcohol" odor. Methanol is used to synthe-
size other chemicals, and may be found in automotive
windscreen cleaning solutions, solid fuel for stoves and
chafing dishes, model airplane fuel, carburetor cleaner,
gas line antifreeze, photocopying fluid, and solvents.
Trivial amounts are found in fruits and vegetables, as-
partame-containing products, and fermented spirits [8] –
ingesting contaminants found within illicitly distilled
liquor results in adverse health effects. Illicitly distilled
liquor is also known as moonshine, bootleg, white light-
ning, corn liquor, or hooch [7]. Absorption of methanol
occurs orally, through the skin, and through inhalation –
absorption after oral administration is rapid, with a
mean absorption half-life of 5 minutes [6]. While meth-
anol itself has a low toxicity, it is metabolized in the
liver at a rate 8 of 85 mg/L, 1 hour, 1 to toxic formalde-
hyde by the enzyme alcohol dehydrogenase (ADH), and
within only several minutes to formic acid, which is di-
rectly correlated with increased morbidity and mortality
[9]. The process results in metabolic and lactic acidosis
[10] Consequently, multiple organ systems are affected.
Severe metabolic acidosis, seizure, coma, and death
may be observed [8].
Ethylene glycol: Ethylene glycol (CH2CH2(OH)2, mo-
lecular weight 62.07) is a colorless, odorless, sweet-tast-
ing liquid. Like methanol, ethylene glycol itself has a
mild toxicity (it is a stronger inebriant than both metha-
nol and ethanol, and it causes gastric irritation), and it is
the hepatic oxidation of ethylene glycol that creates the
toxic metabolites responsible for metabolic acidosis and
end-organ damage. The liver metabolizes about 80% of
an ingested dose, whereas the other 20% is excreted un-
changed in the urine [8].
Breath alcohol analyzers are used by law enforcement
personnel to estimate the blood ethanol concentration of
suspected intoxicated persons. Individuals with in-
creased breath ethanol concentrations can be incarcerat-
ed, sent home, or brought to the emergency department
(ED) to evaluate ethanol intoxication, associated illness,
or injury [3].
On the other hand, the best laboratory test for diag-
nosing methanol or ethylene glycol poisoning is mea-
suring the specific serum level of the alcohol [8].
Differentiation of alcohol types in a hospital setting is a
clinical challenge. In this study, we aimed to develop a
novel, rapid, and straightforward method for alcohol
type determination by using a combination of breatha-
lyzer tests and serum ethanol concentrations.
Alcohol Type Differentiation: a Novel Approach
Clin. Lab. 7/2024
1335
MATERIALS AND METHODS
This study was approved by the Ethics Committee of
Başakşehir Çam and Sakura City Hospital and con-
ducted in Turkey according to the Helsinki Charter
(KAEK/2021.09.214).
A negative plasma pool was created from samples that
were obtained from individuals who did not consume
any alcohol. The pooled serum was divided into five
equal parts. Using commercially obtained alcohols, five
subgroups were formed separately for ethanol (ethanol
absolute EMPLURA, Merck, Burlington, MA), isopro-
panol (isopropanol (2-Propanol) EMSURE® ACS, ISO,
Reagent Merck, Burlington, MA), methanol (methanol
EMSURE® ACS, ISO, Reagent Merck, Burlington,
MA), and ethylene glycol (ethylene glycol EMSURE®
ACS, ISO, Reagent Merck, Burlington, MA.). The first
group was the alcohol-negative group. Alcohol deriva-
tives were added to the other samples, so the final con-
centration was at the specified level of 50 mg/dL, 100
mg/dL, 200 mg/dL, and 400 mg/dL. Alcohol measure-
ment was performed by a standard breathalyzer test
used in a hospital setting. The study design is demon-
strated in Table 2.
To carry out this task, a device was established. To re-
plicate the natural process of exhaling, a sterile cotton
swab was used to apply alcohol to the mouthpiece of
the breathalyzer. Then, a balloon attached to the mouth-
piece was filled with air by an air compressor similar to
a standard lung capacity (~ 5 L). The air was transferred
to the breathalyzer, mimicking a human lung. The pro-
cedure was performed 20 times for each type of alcohol,
and the results were recorded as (+) or (-). See the de-
vice in Figure 1.
This study was conducted with NAM-07 breathalyzers
(ARMAS Electronics, Türkiye) equipped with a new-
generation electrochemical sensor. According to the
user guide, it has high sensitivity and specificity due to
its new-generation sensor technology. It is used both in
healthcare facilities and in traffic controls. The automat-
ic measurement mode is usually used in individuals
who can blow into the breathalyzer properly. Manual
and passive modes can be used in individuals who can-
not blow properly or in those with altered mental status.
Technical features of the breathalyzer are as follows:
Sensor: New generation electrochemical. Mouthpiece:
Disposable (packed one by one for hygiene). Measure-
ment mode: Automatic, manual, and passive. Measure-
ment range: 0.00 - 5.00‰ range. Sensitivity: 0.00 -
1.00‰, range ± 0.05‰. For the value between 0.00 -
1.00, ± 5%. Standard deviation: < 0.008‰. Preparation
period: Lower than 8 seconds after the device is turned
on. Resulting time: 20 seconds after sampling. Temper-
ature: -10°C and +50°C.
To create a serum pool, four containers were filled with
serum and four types of alcohol were added to each
container. Samples were taken from the pools and were
analyzed for ethanol twenty times, using the enzymatic
method. The results of serum obtained from the pool
and the breathalyzer (as (+) or (-)) were compared, and
an algorithm was created. Measurements were made 20
times from the pools formed at the levels determined
according to the type of alcohol, both by alcoholmeter
and by enzymatic spectrophotometric method.
RESULTS
Initially, our study was designed to measure alcohol
levels quantitatively. Despite the enzymatic method
providing consistent results when grouped by different
levels of ethanol, the breathalyzer results did not indi-
cate a correlation with the alcohol levels. Based on this
observation, it was decided to evaluate the results quali-
tatively. Table 3 displays the summarized measure-
ments of ethanol, methanol, isopropanol, and ethylene
glycol results from both breathalyzer and serum tests.
DISCUSSION
Alcohol consumption or abuse causes 3 million deaths
per year, worldwide. This proportion represents 5.3% of
all deaths. Alcohol abuse is the reason for more than
200 illnesses and injuries. It is estimated that 5,1% of
all diseases and injuries are related to alcohol. Alcohol
consumption causes morbidity and mortality in the rela-
tively younger population. It is the cause of 13.5% of
deaths in 20 - 39 year-age groups [11]. In the era of the
COVID-19 pandemic, it is known that people tend to
consume excessive alcohol to fight against stressful sit-
uations [12].
Methanol poisoning epidemics result from the con-
sumption of unofficially produced alcoholic beverages.
Lately, these epidemics have been observed in many
countries, such as Cambodia, the Czech Republic, Ecua-
dor, Estonia, Indonesia, Kenya, Libya, Nicaragua, Nor-
way, Pakistan, Turkey, and Uganda. These epidemics
cause 20 to 800 victims. In some instances, the case-fa-
tality rate may rise to 30% [13]. In Iran, there were out-
breaks of methanol poisoning that caused a significant
number of illnesses and deaths [14]. The most recent
and most crucial epidemic was experienced during the
COVID-19 pandemic. The pandemic has affected Iran
mostly between February 19th, 2020, and April 27th,
2020. In this period, 90,481 confirmed cases and 5,710
confirmed deaths were determined. Due to misinforma-
tion suggesting that alcohol could neutralize SARS-
CoV-2, there has been a rise in illnesses and deaths re-
lated to methanol consumption. Between February and
April 2020, over 5000 poisonings and 500 confirmed
deaths occurred. Also, in some cities, it was announced
that fatalities due to methanol poisoning were more pre-
valent than deaths due to COVID-19. Unlike previous
epidemics, the methanol poisoning epidemic results
from the understanding that disinfectant and alcohol
consumption prevents a COVID-19 infection [14,15].
A. Gümüş et al.
Clin. Lab. 7/2024
1336
Table 1. Formulations and metabolisms of alcohol types.
Alcohol formula
Alcohol metabolism
Ethanol
Methanol
Isopropanol
Ethylene glycol
Alcohol poisoning has emerged as a public health pro-
blem due to the pandemic. This study proposes a rapid
method for determining the alcohol type in alcohol poi-
soning; a prominent cause of morbidity and mortality.
Our results revealed that if the breathalyzer is (+) and
serum ethanol measurement is (-), the substance taken is
either isopropanol or methanol. If both the breathalyzer
and serum measurement is (-), then the substance is
ethylene glycol.
Healthcare facilities and law officers commonly use
breathalyzers to identify ethanol intake [3]. When a
breathalyzer is used alone, it gives (+) ethanol, metha-
nol, and isopropanol results. This may result in delays
in the treatment of methanol intoxication. If both are
(+), the alcohol consumed is ethanol.
In a case report by Gümüş et al., a patient with alcohol
poisoning, who was administered an ethyl alcohol in-
fusion for an antidote therapy and subsequently died,
Alcohol Type Differentiation: a Novel Approach
Clin. Lab. 7/2024
1337
Table 2. Study design and preparation process of the sample pools.
Table 3. Results for ethanol, methanol, isopropanol, and ethylene glycol measurements with both breathalyzer and serum re-
sults.
Ethanol
Methanol
Isopropanol
Ethylene glycol
Breathalyzer measurement result
+
+
+
-
Serum ethanol measurement result
+
-
-
-
Ethanol intake may be determined if the breathalyzer result is (+) and if serum samples reveal a (+) ethanol measurement. If the breathalyzer
is (+) and serum ethanol measurement is (-), then the substance taken is either isopropanol or methanol. The substance may be ethylene glycol
if both breathalyzer and serum measurements are (-).
A. Gümüş et al.
Clin. Lab. 7/2024
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Figure 1. Figure demonstrating the experimental measurement method of alcohol types with a breathalyzer.
Figure 2. An algorithm for alcohol type determination by using a combination of breathalyzer and serum ethanol measure-
ment.
Alcohol Type Differentiation: a Novel Approach
Clin. Lab. 7/2024
1339
was presented. An autopsy was performed and initial
blood samples were taken on admission to the hospital.
Blood samples taken during the autopsy were sent to an
advanced center for alcohol gas chromatography analy-
sis. As a result, ethyl alcohol was not determined in the
initial samples by the enzymatic method. After gas
chromatography, the samples revealed 343 mg/dL
methyl alcohol and 518 µg/mL formic acid in the blood
samples. Following two days of ethyl alcohol admini-
stration, the blood samples revealed 73 mg/dL ethyl al-
cohol and 44 mg/dL methyl alcohol after gas chroma-
tography. This report confirmed that while the enzymat-
ic method successfully determines ethyl alcohol, it fails
in the methyl alcohol determination. In our study, we
composed a serum pool and measured ethyl alcohol,
methyl alcohol, isopropyl alcohol, and ethylene glycol
levels using the enzymatic method. Similarly, only ethyl
alcohol could be measured by an enzymatic method
[16].
Directly measuring methanol in blood by benchtop
liquid or gas chromatography (GC) is accepted as the
"gold standard" for diagnosing methanol poisoning.
However, this is laborious, expensive, and typically per-
formed in specialized laboratories, delaying diagnosis
for several hours to days [9]. According to our results, if
the breathalyzer is (+) and serum ethanol measurement
is (-), the substance taken is either isopropanol or meth-
anol.
Early in ingestion, Ethylene Glycol contributes to signi-
ficant OG, but as metabolites start forming, the OG dis-
appears and the anion gap increases. This indicates that
OG, as a measure of the severity of poisoning, is only
valuable early in an intoxication The presence of calci-
um oxalate crystals, which may appear in the monohy-
drate form as prisms or dumbbell-shaped and in the di-
hydrate form as tent-shaped or octahedral shapes under
light examination of urine through a microscope, can
assist in diagnosis due to the presence of sodium fluo-
rescein in antifreeze. Other laboratory abnormalities in-
clude hypocalcemia causing QT prolongation on elec-
trocardiogram and microscopic hematuria, low bicar-
bonate, leukocytosis, and increased protein in the cere-
brospinal fluid [4]. According to our results, ethylene
glycol may be considered when both breathalyzer and
serum measurements are (-). Ethylene glycol cannot be
detected by a breathalyzer because of the much higher
boiling point and the lower vapor pressure of ethylene
glycol than of pure water, as is typical with most binary
mixtures of volatile liquids, unlike other types of alco-
hol [14].
Isopropanol poisoning can be diagnosed in patients with
normal acid-base parameters, hyperosmolarity, and pos-
itive urine and blood nitroprusside reactions. Hyperos-
molarity is the most common laboratory abnormality as-
sociated with isopropanol poisoning [6]. Our results re-
vealed that if the breathalyzer is (+) and the blood etha-
nol measurement is (-), the substance taken is either iso-
propanol or methanol.
A report indicates that a 47-year-old man was found
heavily intoxicated in a park. A breathalyzer (Intoxi-
lyzer 5000EN) analysis revealed 0,288 g/210 L alcohol.
In his detailed anamnesis, it was understood that he
drank antifreeze with an alcohol content of 99%. After 2
or 3 hours, the serum and urine analysis for ethyl alco-
hol and other substances was negative. The serum meth-
anol concentration was 589 mg/dL. This was a unique
case in which methanol was reported as ethanol. Ac-
cording to this report, breathalyzers may falsely report
methanol as ethanol, and diagnosis and treatment may
be delayed, resulting in methanol poisoning [3].
In concordance, our results revealed that breathalyzers
measure methanol along with ethanol, which means that
breathalyzers are not specific for ethanol but also mea-
sure other types of volatile alcohols.
Limitations of the study
Our study also has some limitations. The method sug-
gested in this study may be inadequate when a patient
consumes a mixture of different types of alcohol.
CONCLUSION
It is known that methanol may cause interference; a
falsely increased breath ethanol level in humans may be
determined when breathalyzers are used alone. Howev-
er, our results revealed that when breathalyzer and se-
rum ethanol measurements are used in combination, a
novel and simple method for alcohol type differentia-
tion may be established. When combined with the pa-
tient's history and clinical findings, our technique may
help clinicians to develop a more accurate diagnosis.
Acknowledgment:
This work was not supported by any institution or orga-
nization.
Ethical Approval:
This study was approved by the Ethics Committee of
Başakşehir Çam and Sakura City Hospital and was con-
ducted in Turkey according to the Helsinki Charter
(KAEK/2021.09.214).
Declaration of Interest:
The authors state that they have no conflicts of interest
concerning the publication of this paper.
A. Gümüş et al.
Clin. Lab. 7/2024
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