Oxalosis and the E-Ferol Toxicity Syndrome

To the Editor.— There is a sense of déjà vu about the description by Bove et al¹ of the adverse reactions and deaths that followed the intravenous administration of the vitamin E preparation E-Ferol to low-birth-weight infants. The syndrome of renal dysfunction, hepatic dysfunction, metabolic acidosis, and tissue oxalosis has many similarities to that which occurs in patients who received parenterally large amounts of xylitol.² When first observed, the xylitol toxicity syndrome was unexpected, and, indeed, it was concluded that the oxalosis was not causally related to the infusion of xylitol.² However, both animal and biochemical studies have since confirmed that oxalate or oxalate precursors can be formed during the hepatic metabolism of xylitol,² with the enzymes fructokinase and aldolase playing important roles in the metabolic production of the oxalate precursor glycolaldehyde from xylitol.^2,3 In terms of a one-compartment model for the renal elimination of