We read with great interest the study of Ostapenko et al. 1 reporting about an outbreak of acute cholestatic liver injury in Russia con- nected to the consumption of unrecorded alcohol. As background, it has to be mentioned that alcohol consumption is the most im- portant risk factor for death and burden of disease in Russia (see Rehm et al. 2 and Zaridze et al. 3 ). Of course alcohol-attributable liver disease plays an important role in this relationship. In the study of Ostapenko et al., 1 the alcohol that was consumed by the patients was an antiseptic liquid for indoor disinfection, which contained ethanol (93%), diethyl phthalate (DEP) (0.08 – 0.15%) and polyhexamethyleneguanidine hydrochloride (PHMG, CAS #57029-18-2) (0.10 – 0.14%). PHMG is an effective antiseptic and is commonly used for suppression of hospital infection in the Russian Federation, 4 and DEP is added to denature the alcohol. 5 Several previous studies had also detected PHMG together with DEP in disinfectants that were used as an ethanol source in other poisoning cases in Russia. 4,6,7 On the basis of clinical manifestations and laboratory fi nd- ings of 579 poisoned patients, Ostapenko et al. 1 concluded that the cholestatic hepatits was caused by PHMG, while a history of alcohol-induced hepatitis and cirrhosis contributed to a more se- vere course of the poisoning. Other factors such as DEP or chronic viral hepatitis may have further contributed to multifactorial liver damage. While we agree with the authors that the outbreak may have been caused by PHMG, we disagree with the conclusion of an almost causal relationship. At least, the paper lacks adequate dis- cussion of the alternative hypothesis, that is, that the outbreak was purely caused by extreme amounts of ethanol ingestion and high- risk drinking patterns.