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Acute Arsenic Poisoning in Two Siblings

Melisa W. Lai, MD*‡§㛳; Edward W. Boyer, MD, PhD*§¶; Monica E. Kleinman, MD§#; Nancy M. Rodig, MD§**; and Michele Burns Ewald, MD*‡§㛳

ABSTRACT. We report a case series of acute arsenic poisoning of 2 siblings, a 4-month-old male infant and his 2-year-old sister. Each child ingested solubilized in-organic arsenic from an outdated pesticide that was mis-identified as spring water. The 4-month-old child in-gested a dose of arsenic that was lethal despite extraordinary attempts at arsenic removal, including che-lation therapy, extracorporeal membrane oxygenation, exchange transfusion, and hemodialysis. The 2-year-old fared well with conventional therapy. Pediatrics 2005; 116:249–257;arsenic, poisoning, toxicokinetics, pharmaco-kinetics, British anti-lewisite, dimercaprol, succimer, DMSA, DMPS, chelation therapy, extracorporeal mem-brane oxygenation, ECMO, exchange transfusion, hemodi-alysis, heavy metal poisoning, survival, pediatric lethal dose.

ABBREVIATIONS. DMSA, 2,3-dimercaptosuccinic acid; DMPS, 2,3-dimercapto-1-propanesulfonate; BAL, British anti-lewisite; ECMO, extracorporeal membrane oxygenation.

A

rsenic is a heavy metal that is odorless, col-orless, and tasteless in solubilized form. It is ubiquitous throughout our environment at low background levels and is used most commonly in mining operations (for smelting), in the agricul-tural field (as an herbicide and pesticide, although not for food crops in the United States), and in the electronics industry (for semiconductors and lasers). Inorganic arsenic is a highly toxic transition metal; poisoning from this metal has been treated primarily with supportive care and antidote administration. Children in the United States are unlikely to ingest significant amounts from concentrated sources, and clinically significant dermal absorption of arsenic from “pressure-treated” wood (lumber treated with chromated copper arsenate), which has been used to build numerous playgrounds and decks, has not been demonstrated.1,2 However, accidental

poison-ings still occur, and there is the potential for thera-peutic dosing errors with arsenic trioxide (Trisenox [Cell Therapeutics, Seattle, WA]), which is used to treat patients with acute promyelocytic leukemia. Arsenic also still plays a role in acts of suicidal and homicidal intent.

Unfortunately, no existing therapies have been ef-fective in massive overdoses. We describe a child who was treated successfully with conventional ther-apy for arsenic poisoning, as well as the use of sev-eral adjunctive therapies for an infant with life-threatening acute arsenic poisoning. These novel approaches may be useful for other patients with sublethal ingestions for whom conventional treat-ments are ineffective or inadequate.

CASE REPORTS Ingestion

A 4-month-old male patient and his 2-year-old sister attended a cookout with their parents. The host provided the parents with a clear, unmarked, plastic container that contained a liquid and purportedly stored spring water (Fig 1). A drinking cup was filled for the toddler, and Enfamil with Iron (Mead Johnson Nutritional Division, Evansville, IN) was reconstituted with the liquid and given to the infant. The 4-month-old patient (patient 1) ingested between 2 and 3 fl oz of the material. The 2-year-old patient (patient 2) drank a small amount and spat it out, telling her parents that it “tasted bad.” Within 10 minutes, both children began vomiting. The parents brought their children to a local emergency department in their private vehicle. En route, patient 1 developed bloody emesis.

On arrival at the community hospital emergency department, both children were still vomiting but had normal vital signs. Notably, the emergency department staff observed that the recon-stituted infant formula was purple in color. While the father retrieved the bottle of “spring water” from the cookout, support-ive measures were started at the hospital, including intravenous fluid therapy for both children.

Approximately 3 hours after ingestion, both children had ceased vomiting and their father returned with the bottle that contained the liquid. A nurse found a product label that described an outdated herbicide that was 40% arsenic by volume (23.1% by weight) (Fig 2). The children were transferred to a tertiary care pediatric hospital.

Course of Patient 1

During transfer, patient 1 became comatose. On arrival, he was orotracheally intubated and central venous access was obtained. The patient was tachycardic and hypotensive despite intravenous administration of 30 mL/kg normal saline solution. A continuous infusion of dopamine was initiated, and the patient was admitted to the ICU. Standard chelation therapy with British anti-lewisite (BAL) through intramuscular injection of 5 mg/kg every 4 hours was provided. Within 6 hours after ingestion, the pupils of patient 1 became fixed and dilated; he had no spontaneous movement despite withholding of sedation after intubation. Blood gas anal-ysis showed severe metabolic acidosis despite treatment with sodium bicarbonate, and the patient had evidence of disseminated intravascular coagulation (Table 1).

From the *Regional Center for Poison Control and Prevention Serving Massachusetts and Rhode Island and Divisions of ‡Emergency Medicine, #Critical Care Medicine, and **Nephrology, Children’s Hospital, Boston, Massachusetts; §Harvard Medical School, Boston, Massachusetts; ¶Depart-ment of Emergency Medicine, University of Massachusetts, Worcester, Mas-sachusetts; and㛳Department of Emergency Medicine, Mount Auburn Hos-pital, Cambridge, Massachusetts.

Accepted for publication Nov 8, 2004. doi:10.1542/peds.2004-1957 No conflict of interest declared.

Address correspondence to Melisa W. Lai, MD, American Association of Poison Control Centers, 3201 New Mexico Ave NW, Washington, DC 20016. E-mail: melisa.lai@alumni.brown.edu

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Continuous resuscitation with intravenous crystalloid and col-loid therapy and vasoactive infusions failed to prevent cardiovas-cular collapse. The patient developed ventricardiovas-cular fibrillation and multiple ventricular nonperfusing tachyarrhythmias, devolving into torsades de pointes (Fig 3), and was treated with lidocaine hydrochloride, magnesium sulfate, bretylium tosylate, and defi-brillation. Twelve hours after ingestion, the patient underwent extracorporeal membrane oxygenation (ECMO) on an emergency basis.

For a brief period after cannulation, some pupillary reactivity returned and the patient exhibited some spontaneous and non-posturing movement. He was anuric from the time of ingestion until 2 hours after initiation of ECMO, when he produced 107 mL of urine in 2.5 hours and then became anuric again. The patient had an ongoing capillary leak and became markedly edematous. He continued to receive intramuscular injections of BAL (5 mg/ kg) every 4 hours for chelation. Extracorporeal elimination of arsenic through 2 runs of hemodialysis and a single-volume ex-change transfusion was attempted.

Because of the failure of the preceding therapies, patient 1 received the experimental chelator 2,3-dimercapto-1-propanesul-fonate (DMPS). This therapy also failed to produce clinical im-provement. The patient sustained ventricular tachyarrhythmias refractory to pharmacologic and electrical conversion. Supportive measures were discontinued 36 hours after ingestion. Although the patient weighed 8 kg at admission, his weight at autopsy was 23 kg.

A spot urinary arsenic concentration had been obtained during the patient’s brief period of urine production, 14 hours after ingestion and after 2 doses of BAL; the urinary arsenic concentra-tion was 9000␮g/L. During the patient’s first hemodialysis ses-sion, dialysis was performed with 102 L of dialysate. Dialysate toward the end of this session had an arsenic concentration of 20 ␮g/L, indicating a minimal arsenic removal of 2.04 mg. At au-topsy, the patient’s serum arsenic concentration was 730␮g/L.

Course of Patient 2

Patient 2 was admitted to the ICU for hemodynamic monitor-ing. She had sinus tachycardia, with heart rates ranging from 130 to 180 beats per minute in the initial 12 hours after ingestion. She demonstrated no hypotension or arrhythmias. She received intra-venous fluids at twice the maintenance rate and standard chela-tion therapy with BAL (5 mg/kg) through intramuscular injecchela-tion every 4 hours. While in the ICU, her QTcprolonged to as long as

527 milliseconds at 22 hours after ingestion, decreasing to⬍450 milliseconds without specific therapy. Her electrocardiographic results remained normal for the remainder of her hospital course. On hospital day 4, the patient was transitioned to oral chelation therapy with 2,3-dimercaptosuccinic acid (DMSA), and BAL ad-ministration was discontinued.

Serial 24-hour urinary arsenic concentrations were measured for patient 2 during hospital days 2 through 13 (Fig 4). The peak urinary arsenic concentration was 4920 ␮g/L from her first 24-hour collection (24-hours 19 – 43 after ingestion), quickly decreasing to 100␮g/L by the time of her discharge on hospital day 13. One week after chelation therapy was discontinued, the patient’s uri-nary arsenic concentration decreased to 56 ␮g/L. Her urinary arsenic concentration was 10 ␮g/L 3 weeks after chelation and was undetectable 7 weeks later. Patient 2 retained normal renal function throughout her course. She maintained a urine output of 2.6 to 5.4 mL/kg per hour. Her creatinine levels ranged from 0.2 to 0.6 mg/dL during her hospitalization. In the follow-up period, the patient has had normal urine output, according to her parents, and creatinine levels were measured at 0.2 to 0.3 mg/dL. Neurologic examination results were normal except for the patient being described at presentation as less interactive than usual; within 24 hours after admission, her mental status had normalized. Subse-quent neurologic examination results were normal. Patient 2 con-tinues to be monitored by the toxicology service as an outpatient. At 1 year after ingestion, she displays no signs of arsenic-associ-ated illness or toxicity and has met or surpassed expected devel-opmental milestones.

Calculated Amounts of Ingested Arsenic

Aliquots of the clear liquid and reconstituted infant formula were sent to the Massachusetts State Laboratory Institute (Jamaica Plain, MA) for determination and confirmation of arsenic concen-trations. The measured arsenic levels were as follows: clear liquid: 7.6% arsenic by weight; infant formula (including formula solute): 5.8% arsenic by weight. On the basis of an estimated 2 fl oz of formula ingested, patient 1 ingested (2 fl oz)⫻(29.57 mL/fl oz)⫻ (1000 mg/mL)⫻(5.8% arsenic)⫽3430 mg of arsenic. Patient 1 weighed 8 kg and thus might have ingested 428 mg/kg arsenic.

Patient 2 was estimated to have ingested 2.5 mL of water after spitting out her sips, ie, (2.5 mL)⫻(1000 mg/mL)⫻(7.6% arsenic)

⫽190 mg of arsenic. Patient 2 weighed 13 kg and thus might have ingested 14.6 mg/kg arsenic. The minimal lethal dose of arsenic among humans has been estimated to be as low as 1.43 mg/kg.3

DISCUSSION Pharmacokinetics of Arsenic

Arsenic exists in nontoxic and toxic forms. The nontoxic organic arsenobetaine [As(CH3)3CH2CO2] is found in trace amounts in all living matter and marine organisms. In contrast, inorganic compounds are highly toxic and are found in varying quantities throughout the earth’s crust, in either a trivalent (arsenite, As3⫹) or pentavalent (arsenate, As5⫹)

oxi-dation state. When ingested as a water-soluble salt, inorganic arsenic in either oxidation state is absorbed rapidly from the gastrointestinal tract, with nearly 100% bioavailability; its rapid distribution from blood produces a serum half-life of only 1 hour.4

Clearance from the blood follows in 3 phases.5,6 In

phase 1 (half-life: 1–2 hours),⬃90% of arsenic redis-tributes from serum to tissues. In phase 2 (estimated half-life: 30 hours), the remaining 10% of serum ar-senic redistributes to tissues (including

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cytes); arsenic accumulation in erythrocytes occurs at an erythrocyte/plasma ratio of 3:1. Phase 3 (esti-mated half-life: 300 hours) involves redistribution of arsenic from tissues and erythrocytes to plasma, fol-lowed by renal elimination.

Arsenic undergoes renal elimination, with ⬃46% to 68.9% of inorganic arsenic being excreted within the first 5 days of exposure.7 Chelation does not

enhance the rate of elimination of arsenic from the body but renders the metal nontoxic by preventing the poisoning of several vital enzyme systems.

Molecular Toxicologic Features of Arsenic

Once distributed into soft tissues, arsenic pene-trates cells and inhibits cellular energy production through mechanisms dependent on the element’s ox-idation state. Arsenite (As3⫹) binds to sulfhydryl

moieties on dihydrolipoamide, preventing regenera-tion of the necessary Krebs cycle cofactor lipoamide (Fig 5A).

Arsenate (As5⫹), which may undergo

biotransfor-mation to As3⫹, is less toxic than As3⫹ but also

depletes cellular energy. As5⫹ has the same

oxida-tion state as and shares many chemical properties with inorganic phosphate (P5⫹) and can substitute

for P5⫹ in ATP production. Arsenic-poisoned

en-zymes produce 1-arseno-3-phosphoglycerate rather than 1,3-bisphosphoglycerate. 1-Arseno-3-phospho-glycerate hydrolyzes spontaneously, so that ATP continues to be produced. However, the arsenic-ox-ygen bond is significantly weaker than the phospho-rus-oxygen bond, and 1-arseno-3-phosphoglycerate hydrolysis yields dramatically less energy (Fig 5B).

Clinical Effects

Acute arsenic intoxication produces a distinctive toxidrome (Table 2). The hallmark of acute arsenic poisoning is severe hematemesis and diarrhea, fol-lowed by the abrupt onset of profound hypotension,

tachycardia, cardiovascular collapse, and coma. In-dividuals who survive the acute phase may develop subsequent debilitating sensorimotor neuropathy, al-teration in mental status, and patchy alopecia.

Acute Toxicity (0 –24 Hours)

Hematemesis and diarrhea, often the sentinel signs of severe poisoning, occur within 1 to 4 hours of ingestion and may be related to a direct irritant effect of arsenic on the gastric mucosa. Gastrointestinal volume loss is compounded by profound capillary permeability produced by arsenic’s interruption of cellular energy production. Although the exact mechanism remains unknown, QTc prolongation and tachyarrhythmias, including torsades de pointes, may develop within the first 24 hours after ingestion.8–12Cerebral edema, microhemorrhage,

en-cephalopathy, and seizures may also arise from loss of capillary integrity.13 Acute renal failure is

com-mon and multifactorial in origin, resulting from in-terruption of cellular energy production, shock, di-rect toxicity to renal tubules, and tubular deposition of myoglobin.14

Subacute Toxicity (24 Hours to 4 Weeks)

Subacute arsenic toxicity involves predominately the neurologic, cardiovascular, and integumentary systems. Within days to weeks after ingestion, many untreated or undiagnosed patients describe debilitat-ing peripheral neuropathy, characterized by excruci-ating pain and severe motor weakness. Patients may also exhibit central nervous system depression and cognitive dysfunction (hallucinations, delirium, de-creased memory, and confusion).15,16Persistent QT

c

prolongation and the accompanying risk of torsades de pointes occur among patients with clinically sig-nificant body burdens of arsenic.17 Aldrich-Mees

lines, ie, whitish transverse discoloration of the nails resulting from temporary interruption of growth

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plate activity, may occur within 40 days after acute arsenic poisoning but are rarely seen, occurring for only 5% of patients.18Patchy alopecia appears 3 to 6

weeks after severe poisoning.

Chronic Toxicity (4 Weeks)

Patients exposed to frequent small amounts of ar-senic are subject to less severe but more insidious manifestations of toxicity. These findings have been monitored and reported numerous times since the installation of thousands of tube wells throughout Bangladesh in the 1970s. These wells became con-taminated with arsenic due to its high content within

the earth’s crust in this area. Multiple articles chron-icle the higher rates of hyperkeratoses, hyperpig-mentation, and lung and skin cancers that are seen throughout the region. Peripheral neuropathies may persist from large single acute ingestions or may develop from chronic small exposures to the metal.

Management of Acute Arsenic Poisoning

Aggressive Fluid Resuscitation and Cardiovascular Support

Fluid resuscitation remains the mainstay of initial management of arsenic poisoning.19Because arsenic

and its chelators are excreted principally in the urine,

Fig 3. Rhythm strip for patient 1, showing an episode of torsades de pointes occurring⬃11 hours after ingestion.

TABLE 1. Selected Laboratory Values of Patient 1

Time After Ingestion, h

6 8 11.5 12.5 13 15 17.5 21 27 35

AST, U/L — 46 — — — 160 — — — 1892*

ALT, U/L — 33 — — — 132 — — — 1372*

Albumin, g/dL — 2.7 — — — — — — — 3.8

Alkaline phosphatase, U/L — 271 — — — 51 — — — 53

Amylase, U/L — — — — — — — — — 17

Total bilirubin, mg/dL — 0.2 — — — 0.4 — — — 1.8

Direct bilirubin, mg/dL — 0.1 — — — 0.2 — — — 0.5

GGTP, U/L — 10 — — — 10 — — — 13

Total protein, g/dL — 4.4 — — — — — — — 4.5

LDH, U/L — 326 — — — 330 — — — 2177*

Sodium, mmol/L 140 147 153* 156* 164* 162* 158* 156* 158* 161*

Potassium, mmol/L 3.11 2.52* 2.3* 3.73* — 2.09* 2.07* 2.95 3.47 5.32

Chloride, mmol/L 112 123 132 129 120 121 121 122 124 113

CO2, mmol/L 13* 14* 13* 10* 22 17 19 21 24 10

BUN, mg/dL 22 22 22 16 18 16 15 5 3 7

Creatine, mg/dL 0.8 0.8 0.6 0.4 0.5 0.6 0.6 0.2 0.1 0.6

Glucose, mg/dL 286* 183 68 90 64 191 171 166 156 97

Ionized calcium, mmol/L — 1.04 — 0.9 — 1.05 1.08 1.35 1.44 0.87

Calcium, mg/dL — 6.5 7.4 5.7 9.5 8 7.9 9.9 10.5 9.8

Magnesium, mg/dL — 1.9 2.3 — 5.6 2.8 2.4 2 2.1 2.6

Phosphorus, mg/dL — 4.5 4.6 — 5.1 3.4 2.8 1.7 1.4 5.1

Hematocrit, % — — 27.2* 17* 18.8* 38.4 44.6 41.2 41.5 29.1*

Hemoglobin, g/dL — — 9* 5.5* 6.4* 12.8 15.1 14.6 14.1 10.2*

MCV, fL — — 78 78.5 82.6 88.4 86.5 85.4 84.7 88.7

Platelet count, platelets per␮L (⫻1000) — — 329 112 41 86 178 131 164 112 WBC count, cells per␮L (⫻1000) — — 15.91* 3.75 4.79 10.11 8.15 7.9 4.23 4.83

CPK, U/L — — — — — 648 — — — —

CK-MB, ng/mL — — — — — 108.7 — — — —

CK-MB index, % — — — — — 16.8 — — — —

ABG HCO3, mmol/L 13 14 — 13 24 22 22 27 27 11

ABG O2saturation, % 99 100 — 99 100 100 100 100 100 100

ABG Pco2, mm Hg 24.6 35.1 — 49.8 42 60.1 49.9 50.4 43.9 21.6

ABG pH 7.33 7.213 7.02 7.379 7.171 7.256 7.353 7.413 7.325

ABG Po2, mm Hg 142.7 352.3 — 231 613.6 51.5 262.6 319.2 280.5 388.3

Fibrinogen, mg/dL — — 101* — — — — — — 58*

PT, s — — 21.1* — — — — — — 26.6*

PTT, s — — 51.2* — — — — — — 102.7*

INR — — 3.02* — — — — — — 4.89*

Twelve hours after ingestion, the patient’s deterioration accelerated precipitously. Thirteen hours after ingestion, the patient was receiving ECMO for cardiovascular support. He died 36 hours after ingestion. AST indicates aspartate aminotransferase; ALT, alanine aminotrans-ferase; GGTP,␥-glutamyl transpeptidase; LDH, lactate dehydrogenase; BUN, blood urea nitrogen; MCV, mean cell volume; WBC, white blood cell; CPK, creatine phosphokinase; CK-MB, creatinine kinase, muscle and brain; ABG, arterial blood gas; PT, prothrombin; PTT, partial thromboplastin time; INR, international normalized ratio; —, not measured.

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maintaining renal perfusion is critical. Clinicians of-ten fail to appreciate the volume of intravenously administered fluid required for adequate resuscita-tion. Acutely poisoned patients develop enormous fluid deficits through gastrointestinal losses alone (vomiting and diarrhea), which can lead to hypovo-lemic shock. Intravascular volume depletion is ag-gravated by increased capillary permeability and a systemic inflammatory response syndrome-like re-sponse.14,20The degree of capillary leak and resultant

tissue edema is dramatic. As noted, patient 1 weighed 8 kg at admission; at autopsy, his weight was 23 kg.

Chelation

Chelating agents scavenge arsenic and bind it into a stable metal-chelate complex. Although chelators are not thought to reverse the enzymatic inhibition produced by arsenic, early chelation before confir-mation of arsenic ingestion has produced increased rates of survival in small case series of acutely poi-soned individuals.21–24Unfortunately, only a limited

number of chelating agents are available, and they are limited by bioavailability, binding ratios, weight-based dosing, mode of administration, and adverse effect profiles.

Dimercaprol (BAL in oil [Taylor Pharmaceuticals, San Clemente, CA]) remains the standard chelator for acute arsenical poisoning in the United States. It is estimated to bind 30 mg of arsenic for every 50 mg of BAL given.25 Because it is administered as an

intramuscular injection, BAL may have unpredict-able bioavailability among patients with severe shock and uncertain peripheral perfusion. As the only arsenical chelator able to cross the blood-brain barrier, BAL may offer some protection against tox-icity in the central nervous system; however, concern exists that BAL could enhance arsenic redistribution to the brain and worsen central nervous system ef-fects.26,27

BAL has significant adverse effects. The chelator causes fever and hypertension and can exacerbate fluid losses attributable to nausea and vomiting. Ster-ile abscesses may form at injection sites. BAL is also contraindicated for patients with glucose-6-phos-phate dehydrogenase deficiency, because it may cause hemolysis, and it should not be given in cases of suspected iron toxicity, because the BAL-iron com-plex is itself toxic.28Finally, BAL is lipid soluble and

is constituted in peanut oil to prevent oxidation. It is therefore contraindicated for patients with peanut allergy, and it is constrained to administration only as an intramuscular injection, which impairs its dis-tribution and effectiveness in shock states.

Succimer (DMSA, Chemet) is a water-soluble ana-log of BAL that can be administered orally. Pediatri-cians may be most familiar with its use as a chelator for childhood lead poisoning. Approximately 20% of an oral dose of succimer is absorbed from the gas-trointestinal tract, with nearly all absorbed DMSA being available to chelate metal in a 1:1 ratio.29

DMSA had effectiveness comparable to that of BAL in decreasing arsenic concentrations in mouse livers, kidneys, brains, and spleens.30No standardized

pro-tocol for DMSA administration in arsenic poisoning exists; current dosing guidelines are extrapolated from methods for lead chelation. Described adverse effects of DMSA include transient increases in transaminase levels, nausea and vomiting, rash, thrombocytosis, paresthesias, and pruritus.

DMPS (Unithiol) is a water-soluble analog of BAL that can be administered orally, intravenously, or intramuscularly. Developed in the former Soviet Union in the 1950s, DMPS is not approved by the Food and Drug Administration but has been used successfully in Europe for arsenic chelation.23,31,32In

the United States, DMPS was used for the mass arsenic poisonings in New Sweden, Maine, in April 2003, when the regional stocks of BAL had been exhausted. At that time, it was found to enhance

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excretion and to increase urinary arsenic concentra-tions, even after several days of BAL therapy.33

Increased urinary elimination of arsenic from DMPS may be attributable to chelation of metabo-lized (methylated) arsenic species. Biomethylation of As3⫹ may activate or enhance arsenic toxicity.34

DMPS forms a complex with the first methylated species of the biomethylation sequence, monomethyl-arsonic acid, reducing availability for subsequent bio-methylation and additional toxicity.35

Up to triple the urinary monomethylarsonic acid concentration was seen within 2 hours after oral administration of DMPS to patients suffering from chronic arsenic intoxication.32 This increase in

ar-senic metabolite elimination may support the effec-tiveness of immediate administration of DMPS in acute arsenic poisoning in the future.

d-Penicillamine is no longer recommended for use

in arsenic intoxication. It showed little efficacy in an animal model.36

Extracorporeal Elimination

Numerous methods have been directed toward the mechanical removal or extracorporeal elimination of arsenic, including N-acetylcysteine, endoscopy, gas-tric irrigation with alkaline irrigant, alternative par-enteral chelators, and hemodialysis.37,38 Because of

arsenic’s short distribution half-life of only 1 hour, extracorporeal elimination methods are ineffective for removal of the metal once it is distributed to the tissues, and the metal-chelate complex may be of too great a mass for hemodialysis or hemofiltration.39,40

Children, however, may be better candidates for extracorporeal elimination methods, because they re-tain less arsenic in soft tissues than do adults,41

Fig 5. A indicates the mechanism of trivalent arsenic toxicity. Pyruvate is converted to acetyl-CoA through the pyruvate dehydrogenase complex (box). Lipoamide is a necessary cofactor for this conversion. Dihydrolipoamide is recycled normally to lipoamide by dihydro-lipoamide dehydrogenase. Arsenite (As3⫹) interrupts these biochemical processes by binding to the sulfhydryl moieties on

dihydroli-poamide, preventing regeneration of lipoamide and thus preventing acetyl-CoA production for entry into the Krebs cycle. B indicates the mechanism of pentavalent arsenic (As5⫹) toxicity. As5⫹has the same oxidation state as and shares many chemical properties with P5⫹.

As5⫹substitutes for inorganic phosphate in ATP production. Arsenic-poisoned enzymes produce 1-arseno-3-phosphoglycerate rather

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which possibly permits some reequilibration of ar-senic into the vascular system. This finding correlates with a report of pediatric spontaneous excretion twice as fast as in adults.42 These distinctions may

make extracorporeal elimination techniques more ef-fective in the pediatric population.

The estimated arsenic burden of ⬃3430 mg for patient 1 could not have been eliminated through conventional chelation methods. Administration of BAL and DMSA according to standard dosing guide-lines would have chelated at most 192 mg, ⬍6% of the patient’s estimated arsenic burden, in a 24-hour period. The gravity of the condition of patient 1 dictated that adjunctive therapies be applied. There-fore, he received additional extracorporeal detoxify-ing treatments.

Patient 1 underwent venoarterial ECMO begin-ning 12 hours after ingestion, in response to

refrac-tory shock and cardiac rhythm disturbances. Because of the urgency of the situation, a saline-primed cir-cuit with a volume of 500 mL was used. The patient’s hematocrit level decreased from 28% to 17% after cannulation and then increased to 38% with the use of packed red blood cell replacement and ultrafiltra-tion. With an estimated blood volume of 642 mL for patient 1, these changes represented diluting and then replacing nearly one half of the patient’s total blood volume.

Once ECMO was begun, patient 1 had a return of pupillary activity and spontaneous movement, even before hemodialysis and an exchange transfusion were initiated. In addition, ECMO produced suffi-cient hemodynamic support to restore renal perfu-sion and urine output. These events suggest that ECMO may serve as a partial exchange transfusion that decreases tissue arsenic concentrations

tran-TABLE 2. Acute and Chronic Effects of Arsenic Poisoning by System

Acute (0–72 h) Chronic

Gastrointestinal Nausea, vomiting, mucosal irritation, necrosis Diarrhea

Respiratory Pulmonary edema

Cardiovascular8,17 Nonspecific T wave changes, QT c

prolongation, torsades de pointes

Nonspecific T wave changes, QTc

prolongation, torsades de pointes Neurologic Seizures, cerebral edema, necrosis Peripheral neuropathy

Renal Acute tubular necrosis, acute renal failure Chronic renal insufficiency

Skin Hyperkeratoses, hyperpigmentation

Hair and nails Patchy alopecia, Aldrich-Mees lines

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siently and may produce an improvement in organ function.

Because arsenic redistributes rapidly to tissues in-cluding erythrocytes, exchange transfusion may be beneficial in decreasing the body burden of arsenic in major intoxication. A single-volume exchange trans-fusion was performed for patient 1 at 28 hours after ingestion, with the goal of mobilizing arsenic from the tissues before administration of the experimental chelating agent DMPS.

Hemodialysis has been reserved traditionally for the elimination of arsenic from patients in renal fail-ure.21,23,43,44 Patient 1 developed renal insufficiency

and underwent his first hemodialysis session with 102 L of dialysate at 18 hours after ingestion, for the purpose of removing arsenic and arsenic-BAL com-plexes. His dialysate arsenic concentration was 20

␮g/L toward the end of the dialysis session, which indicates a minimal arsenic removal of 2.04 mg (com-pared with his spot urinary level of 9 mg/L). This amount of arsenic elimination is consistent with re-ports of adults cases, in which 4-hour hemodialysis sessions removed 2.9 to 4.68 mg of arsenic.43–45

Ar-senic’s large volume of distribution (3.3– 4 L/kg)46,47

and the small amount of arsenic removed through hemodialysis suggest that arsenic is redistributed to tissues too rapidly, with too small a serum concen-tration gradient, for effective removal through hemo-dialysis.

It is notable that although BAL does not impede arsenic removal through dialysis, the DMPS-arsenic complex may not be as readily dialyzable.48

Hemo-dialysis may be useful only to treat the electrolyte and fluid imbalances of renal failure and is unlikely to be helpful for removal of arsenic or arsenic-chela-tor complexes.

Elimination of the DMPS-arsenic complex may be enhanced with convective mass transport through continuous venovenous hemodiafiltration.48In

addi-tion, continuous venovenous hemodiafiltration pro-vides continuous exposure of the circulating blood volume to the dialysate and may be better tolerated by patients with hemodynamic instability. For pa-tient 1, continuous venovenous hemodiafiltration was considered concurrent with DMPS administra-tion, but life support measures were discontinued before its implementation. On the basis of this pa-tient’s experience with hemodialysis, we suggest consideration of continuous venovenous hemodiafil-tration for arsenic-poisoned patients given DMPS.

Plasmapheresis was also considered but was not used because the arsenic-chelator complex would be too large to be removed with this method.

CONCLUSIONS

Inorganic arsenic is a highly toxic metal that pro-duces life-threatening conditions by inhibiting en-ergy production and depleting enen-ergy stores. Be-cause of the severity and rapidity with which poisoned patients develop arsenic toxicity, clinicians should administer fluid resuscitation and chelation agents presumptively, without formal laboratory confirmation. However, clinicians may be confronted by patients so severely intoxicated that they will die

regardless of aggressive conventional therapies. Ad-junctive approaches such as administration of DMPS, exchange transfusion, ECMO, and continu-ous venovencontinu-ous hemodiafiltration may offer clinical benefit in situations where standard methods will fail.

ACKNOWLEDGMENTS

Dr Ed Boyer is also supported by the National Institutes of Health (grant DA-14929).

We thank Shannon Manzi, PharmD, and Michael W. Shannon, MD, MPH, for tremendous help and suggestions in reviewing the manuscript. We thank Doug, Sonja, and Morgan, and we remem-ber Benjamin.

REFERENCES

1. Wester RC, Hui X, Barbadillo S, et al. In vivo percutaneous absorption of arsenic from water and CCA-treated wood residue.Toxicol Sci.2004; 79:287–295

2. Hemond HF, Solo-Gabriele HM. Children’s exposure to arsenic from CCA-treated wooden decks and playground structures.Risk Anal.2004; 24:51– 64

3. Stephanopoulos DE, Willman DA, Shevlin D, Pinter L, Gummin DD. Treatment and toxicokinetics of acute pediatric arsenic ingestion: dan-ger of arsenic insecticides in children.Pediatr Crit Care Med.2002;3: 74 – 80

4. Shen ZX, Chen GQ, Ni JH, et al. Use of arsenic trioxide (As2O3) in the

treatment of acute promyelocytic leukemia (APL), II: clinical efficacy and pharmacokinetics in relapsed patients.Blood.1997;89:3354 –3360 5. Mealey J Jr, Brownell GL, Sweet WH. Radioarsenic in plasma, urine,

normal tissues, and intracranial neoplasms: distribution and turnover after intravenous injection in man.AMA Arch Neurol Psychiatry.1959; 81:310 –320

6. Delnomdedieu M, Styblo M, Thomas DJ. Time dependence of accumu-lation and binding of inorganic and organic arsenic species in rabbit erythrocytes.Chem Biol Interact.1995;98:69 – 83

7. Pomroy C, Charbonneau SM, McCullough RS, Tam GK. Human reten-tion studies with74As.Toxicol Appl Pharmacol.1980;53:550 –556

8. Unnikrishnan D, Dutcher JP, Varshneya N, et al. Torsades de pointes in 3 patients with leukemia treated with arsenic trioxide.Blood.2001;97: 1514 –1516

9. Chiang CE, Luk HN, Wang TM, Ding PY. Prolongation of cardiac repolarization by arsenic trioxide.Blood.2002;100:2249 –2252 10. Novick SC, Warrell RP Jr. Arsenicals in hematologic cancers.Semin

Oncol.2000;27:495–501

11. Ohnishi K, Yoshida H, Shigeno K, et al. Arsenic trioxide therapy for relapsed or refractory Japanese patients with acute promyelocytic leukemia: need for careful electrocardiogram monitoring.Leukemia.

2002;16:617– 622

12. Little RE, Kay GN, Cavender JB, Epstein AE, Plumb VJ. Torsade de pointes and T-U wave alternans associated with arsenic poisoning.

Pacing Clin Electrophysiol.1990;13:164 –170

13. Gousios AG, Adelson L. Electrocardiographic and radiographic find-ings in acute arsenic poisoning.Am J Med.1959;27:659 – 663

14. Jolliffe DM, Budd AJ, Gwilt DJ. Massive acute arsenic poisoning. An-aesthesia.1991;46:288 –290

15. Danan M, Dally S, Conso F. Arsenic-induced encephalopathy. Neurol-ogy.1984;34:1524

16. Schoolmeester WL, White DR. Arsenic poisoning.South Med J.1980;73: 198 –208

17. Barbey JT, Pezzullo JC, Soignet SL. Effect of arsenic trioxide on QT interval in patients with advanced malignancies.J Clin Oncol.2003;21: 3609 –3615

18. Abernathy CO, Ohanian EV. Non-carcinogenic effects of inorganic ar-senic.Environ Geochem Health.1992;14:35– 41

19. Kamijo Y, Soma K, Asari Y, Ohwada T. Survival after massive arsenic poisoning self-treated by high fluid intake.J Toxicol Clin Toxicol.1998; 36:27–29

20. Campbell JP, Alvarez JA. Acute arsenic intoxication.Am Fam Physician.

1989;40:93–97

21. Fesmire FM, Schauben JL, Roberge RJ. Survival following massive arsenic ingestion.Am J Emerg Med.1988;6:602– 606

(9)

23. Kruszewska S, Wiese M, Kolacinski Z, Mielczarska J. The use of hae-modialysis and 2,3-propanesulphonate (DMPS) to manage acute oral poisoning by lethal dose of arsenic trioxide.Int J Occup Med Environ Health.1996;9:111–115

24. Shum S, Whitehead J, Vaughn L, Hale T. Chelation of organoarsenate with dimercaptosuccinic acid.Vet Hum Toxicol.1995;37:239 –242 25. Saady JJ, Blanke RV, Poklis A. Estimation of the body burden of arsenic

in a child fatally poisoned by arsenite weedkiller.J Anal Toxicol.1989; 13:310 –312

26. Muckter H, Liebl B, Reichl FX, Hunder G, Walther U, Fichtl B. Are we ready to replace dimercaprol (BAL) as an arsenic antidote?Hum Exp Toxicol.1997;16:460 – 465

27. Snider TH, Wientjes MG, Joiner RL, Fisher GL. Arsenic distribution in rabbits after lewisite administration and treatment with British anti-lewisite (BAL).Fundam Appl Toxicol.1990;14:262–272

28. Habal R. Lead toxicity. Available at: www.emedicine.com/MED/ topic1269.htm. Accessed May 18, 2005

29. Miller AL. Dimercaptosuccinic acid (DMSA), a non-toxic, water-soluble treatment for heavy metal toxicity.Altern Med Rev.1998;3:199 –207 30. Schafer B, Kreppel H, Reichl FX, Fichtl B, Forth W. Effect of oral

treatment with BAL, DMPS or DMSA arsenic in organs of mice injected with arsenic trioxide.Arch Toxicol Suppl.1991;14:228 –230

31. Heinrich-Ramm R, Schaller H, Horn J, Angerer J. Arsenic species ex-cretion after dimercaptopropanesulfonic acid (DMPS) treatment of an acute arsenic trioxide poisoning.Arch Toxicol.2003;77:63– 68

32. Aposhian HV, Arroyo A, Cebrian ME, et al. DMPS-arsenic challenge test, I: increased urinary excretion of monomethylarsonic acid in hu-mans given dimercaptopropane sulfonate.J Pharmacol Exp Ther.1997; 282:192–200

33. Tomassoni A, Simone K. Case presentation: Church poisonings. In: New England Regional Toxicology Consultants’ Conference; Portland, ME: July 26, 2003

34. Styblo M, Drobna Z, Jaspers I, Lin S, Thomas DJ. The role of biomethy-lation in toxicity and carcinogenicity of arsenic: a research update.

Environ Health Perspect.2002;110(suppl 5):767–771

35. Gong Z, Jiang G, Cullen WR, Aposhian HV, Le XC. Determination of arsenic metabolic complex excreted in human urine after administration of sodium 2,3-dimercapto-1-propane sulfonate.Chem Res Toxicol.2002; 15:1318 –1323

36. Kreppel H, Reichl FX, Forth W, Fichtl B. Lack of effectiveness ofd -penicillamine in experimental arsenic poisoning.Vet Hum Toxicol.1989; 31:1–5

37. Martin DS, Willis SE, Cline DM.N-Acetylcysteine in the treatment of human arsenic poisoning.J Am Board Fam Pract.1990;3:293–296 38. Michaux I, Haufroid V, Dive A, et al. Repetitive endoscopy and

con-tinuous alkaline gastric irrigation in a case of arsenic poisoning.J Toxicol Clin Toxicol.2000;38:471– 476

39. Mathieu D, Mathieu-Nolf M, Germain-Alonso M, Neviere R, Furon D, Wattel F. Massive arsenic poisoning: effect of hemodialysis and dimer-caprol on arsenic kinetics.Intensive Care Med.1992;18:47–50

40. Vaziri ND, Upham T, Barton CH. Hemodialysis clearance of arsenic.

Clin Toxicol.1980;17:451– 456

41. Chowdhury UK, Rahman MM, Sengupta MK, et al. Pattern of excretion of arsenic compounds [arsenite, arsenate, MMA(V), DMA(V)] in urine of children compared to adults from an arsenic exposed area in Bang-ladesh.J Environ Sci Health A Tox Hazard Subst Environ Eng.2003;38: 87–113

42. Cullen NM, Wolf LR, St Clair D. Pediatric arsenic ingestion.Am J Emerg Med.1995;13:432– 435

43. Hantson P, Haufroid V, Buchet JP, Mahieu P. Acute arsenic poisoning treated by intravenous dimercaptosuccinic acid (DMSA) and combined extrarenal epuration techniques.J Toxicol Clin Toxicol.2003;41:1– 6 44. Levin-Scherz JK, Patrick JD, Weber FH, Garabedian C Jr. Acute arsenic

ingestion.Ann Emerg Med.1987;16:702–704

45. Smith SB, Wombolt DG, Venkatesan R. Results of hemodialysis and hemoperfusion in the treatment of acute arsenic ingestion.Clin Exp Dial Apheresis.1981;5:399 – 404

46. Westervelt P, Pollock JL, Oldfather KM, et al. Adaptive immunity cooperates with liposomal all-trans-retinoic acid (ATRA) to facilitate long-term molecular remissions in mice with acute promyelocytic leu-kemia.Proc Natl Acad Sci USA.2002;99:9468 –9473

47. Lam MS, Ignoffo RJ. Arsenic trioxide for the treatment of acute promy-elocytic leukemia.Cancer Pract.2001;9:155–157

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DOI: 10.1542/peds.2004-1957

2005;116;249

Pediatrics

Burns Ewald

Melisa W Lai, Edward W Boyer, Monica E Kleinman, Nancy M Rodig and Michele

Acute Arsenic Poisoning in Two Siblings

Services

Updated Information &

http://pediatrics.aappublications.org/content/116/1/249

including high resolution figures, can be found at:

References

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This article cites 46 articles, 7 of which you can access for free at:

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DOI: 10.1542/peds.2004-1957

2005;116;249

Pediatrics

Burns Ewald

Melisa W Lai, Edward W Boyer, Monica E Kleinman, Nancy M Rodig and Michele

Acute Arsenic Poisoning in Two Siblings

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Figure

Fig 1. The 128-oz (1-gal) jug used to store the liquid used toreconstitute the infant formula for patient 1 (left) and the 9-ozplastic infant bottle in which the infant formula was mixed (right).At the time this picture was taken (�21 hours after reconstit
Fig 2. The label that had been wrapped around the handle of the 1-gal bottle shown in Fig 1
TABLE 1.Selected Laboratory Values of Patient 1
Fig 4. Daily urinary arsenic excretion for patient 2.By 6 weeks after ingestion, she had no detectablearsenic in her urine.
+3

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