Diethylene glycol poisoning: a narrative review of mechanism of toxicity, detection methods, regulatory failures and recurrent mass poisonings

Abstract

Abstract Background Diethylene glycol is a toxic industrial solvent with no therapeutic application, yet it continues to contaminate pharmaceutical syrups through adulteration of excipients such as glycerin and propylene glycol. Its low cost and visual indistinguishability from pharmaceutical-grade solvents make substitution easy, whether deliberate or due to inadequate quality control. Paediatric populations are disproportionately affected, as children frequently receive cough and antipyretic syrups during illness, administered by parents in good faith and unaware of contamination. Main body After ingestion, Diethylene glycol is metabolised into toxic compounds that cause severe metabolic acidosis, acute kidney injury, neurological impairment, and death. Since the 1937 Elixir Sulfanilamide disaster, recurrent mass poisoning outbreaks have been documented globally, including recent incidents in India notably in Madhya Pradesh and Rajasthan, including the Chhindwara case, which exposed child fatalities linked to contaminated syrups and highlighted persistent regulatory failures. This review examines the toxicokinetics of diethylene glycol poisoning, its clinical manifestations in children, and documents both global and Indian outbreak incidents. It further analyses the systemic causes underlying recurring events, such as inadequate raw material verification, supply-chain lapses, and economic incentives driving adulteration. Detection involves analysis of raw materials, finished syrups, biological samples using gas chromatography, gas chromatography–mass spectrometry, and high-performance liquid chromatography. Simple low-cost colorimetric assays and rapid screening tests offer effective preliminary detection before confirmatory analysis. Conclusion Diethylene glycol contamination of pharmaceutical syrups represents a preventable yet recurring public health crisis, driven by regulatory gaps and economic pressures within pharmaceutical supply chains. Protecting paediatric populations requires strict enforcement of raw material standards, mandatory testing at multiple stages of production, and affordable routine screening protocols particularly in resource-limited settings where oversight is weakest.