A case of sodium chlorite toxicity managed with concurrent renal replacement therapy and red cell exchange

Chlorine Dioxide: Friend or Foe for Cell Biomolecules? A Chemical Approach

This review examines the role of chlorine dioxide (ClO₂) on inorganic compounds and cell biomolecules. As a disinfectant also present in drinking water, ClO₂ helps to destroy bacteria, viruses, and some parasites. The Environmental Protection Agency EPA regulates the maximum concentration of chlorine dioxide in drinking water to be no more than 0.8 ppm. In any case, human consumption must be strictly regulated since, given its highly reactive nature, it can react with and oxidize many of the inorganic compounds found in natural waters. Simultaneously, chlorine dioxide reacts with natural organic matter in water, including humic and fulvic acids, forming oxidized organic compounds such as aldehydes and carboxylic acids, and rapidly oxidizes phenolic compounds, amines, amino acids, peptides, and proteins, as well as the nicotinamide adenine dinucleotide NADH, responsible for electron and proton exchange and energy production in all cells. The influence of ClO₂ on biomolecules is derived from its interference with redox processes, modifying the electrochemical balances in mitochondrial and cell membranes. This discourages its use on an individual basis and without specialized monitoring by health professionals.

Acute kidney injury secondary to chlorine dioxide use for COVID-19 prevention

Chlorine dioxide has been historically used as a disinfecting agent for drinking water supplies and surfaces. Widespread use as an alternative option for prevention and treatment of COVID‐19 has emerged due to a lack of specific treatment. We present the case of a 55‐year‐old male who developed acute kidney injury and disseminated intravascular coagulation after chlorine dioxide prophylactic ingestion, with regression after therapy with hemodialysis.

Siblings with pediatric sodium chlorite toxicity causing methemoglobinemia, renal failure and hemolytic anemia

INTRODUCTION

Over the past decade, Miracle Mineral Solution (sodium chlorite) has been promoted as a cure-all for many conditions.

CASE REPORT

A 9-year-old boy presented with his brother after they accidentally ingested a small amount of undiluted 22.4% sodium chlorite. Symptoms included nausea, vomiting, diarrhea, and dyspnea. Oxygen saturation remained 71% despite supplemental oxygen (15L/min). The patient was noted to have dark chocolate-appearing blood, minimal urine output, diffuse pallor and cyanosis. He developed methemoglobinemia, renal failure requiring renal replacement therapy and hemolysis requiring blood transfusion.

DISCUSSION

These are the 7^th and 8^th reported cases of sodium chlorite toxicity by ingestion and the second and third in children. Takeaway for Physicians: Miracle Mineral Solution is a commonly purchased potentially lethal compound that can cause methemoglobinemia with respiratory failure, hemolytic anemia requiring transfusion and renal failure requiring dialysis.

Determination of inorganic anions in the whole blood by ion chromatography

A fast, precise, and accurate method that can simultaneously determine 7 anions in whole blood was established by on line dialysis-double suppression ion chromatography. Performance parameters which could affect the determination of anions were optimized, including the selection of protein precipitant in samples, the amount of filtrate discarded, selection of eluent flow rate, influence of the Ag-Na column on experimental results, influence of ethylenediamines on ClO₂^-, and investigation of nitrogen drying. Finally, 3.6 mmol/L sodium carbonate was selected as eluent, with a flow rate of 0.8 mL/min, to separate the 7 anions. Blood and alcohol (v/v, 1:4) were used to precipitate the proteins in blood. The 7 anions reached an adequate recovery rate when the first 2 mL of filtrate from the C18 column was discarded. The recovery rate at LLOQ, low, medium, and high concentrations was 80-120%. The correlation coefficients (r²) of the calibration curves of the targeted anions ranged from 0.9975 to 0.9998. The limit of detection (LOD) was 0.309-7.71 μg/L. This method has simple pretreatment, high accuracy, and good reproducibility and selectivity, and is suitable for the separation and determination of anions in blood.

Chlorite reactivity with myoglobin: Analogy with peroxide and nitrite chemistry?

Stopped-flow UV-vis data allow for the first time direct spectroscopic detection of a ferryl species during the reaction of met myoglobin (Mb) with chlorite, analogous to what is observed in the reaction with peroxides. Ferryl is also observed in the reaction of oxy Mb+chlorite. A pathway involving Fe-O-O-ClO₂ is explored by analogy with the Fe-O-O-NO and Fe-O-O-NO₂ previously proposed as intermediates in the reactions of oxy globins with nitric oxide and nitrite, respectively. However, Fe-O-O-ClO₂ is not detectable in these stopped-flow experiments and is in fact, unlike its nitrogenous congeners, predicted by density functional theory (DFT) to be impossible for a heme complex. Deoxy Mb reacts with chlorite faster than met - suggesting that, unlike with hydrogen peroxide (with which deoxy Mb reacts slower than met), binding of chlorite to the heme is not a rate-determining step (hence, most likely, an outer-sphere electron transfer mechanism); to correlate this, a Fe-O-Cl-O adduct was not observed experimentally for the met or for the deoxy reactions - even though prior DFT calculations suggest it to be feasible and detectable.

Sodium chlorite increases production of reactive oxygen species that impair the antioxidant system and cause morphological changes in human erythrocytes

Sodium chlorite (NaClO₂ ) is used in the production of chlorine dioxide for bleaching and stripping of textiles, pulp, and paper. It is also used as disinfectant in municipal water treatment and as a component in therapeutic rinses and gels. The effect of NaClO₂ on human erythrocytes has been studied under in vitro conditions. Incubation of 5% suspension of erythrocytes with NaClO₂ (0.1-2.0 mM) at 37°C for 30 min resulted in marked cell lysis (1.2-3.8 fold) and increased their osmotic fragility. Several parameters were assayed in cell lysates prepared from NaClO₂ -treated and -untreated (control) erythrocytes. Compared to controls, exposure to NaClO₂ caused significant increase in protein oxidation (1.1-8.07 fold), lipid peroxidation (1.08-4.95 fold) with decrease in total sulfhydryl (-5 to -61%), and glutathione levels (-7 to -86%). Methemoglobin content was tremendously increased, by 5-52 fold when compared to control, while methemoglobin reductase activity decreased (-17 to -93%) upon NaClO₂ treatment. NaClO₂ enhanced the generation of reactive oxygen species by 3-21 fold and lowered the metal reducing and free radical quenching ability of erythrocytes. It also caused an increase in nitric oxide levels (2.7-15.4 fold) showing generation of nitrosative stress too. The activities of major antioxidant and membrane bound enzymes were significantly altered. Gross morphological changes, from discocytes to echinocytes, were seen in NaClO₂ -treated erythrocytes under electron microscope. These results show that NaClO₂ induces oxidative stress in human erythrocytes, damages the membrane, and impairs the cellular antioxidant defence system. This oxidative damage can shorten the life span of erythrocytes in blood resulting in red cell senescence. © 2016 Wiley Periodicals, Inc. Environ Toxicol 32: 1343-1353, 2017.

Study of Twenty One Cases of Red Cell Exchange in a Tertiary Care Hospital in Southern India

INTRODUCTION

Red Cell Exchange (RCE) is removal of a patient's red blood cells while replacing with donor red blood cells either manually or using automated systems. RCE is beneficial in patients with Sickle Cell Disease (SCD) either during sickling crisis or prior to major surgical procedures to bring down the sickling percentage as high sickling percentage during prolonged anaesthesia may lead to vaso-occlusive crisis. It is also employed in patients infested with malaria and babesiosis where parasitic index remain high despite medical management. RCE is also tried as an adjuvant therapy in certain poisons like nitrobenzene and carbon monoxide when first line management fails.

AIM

To study the effectiveness, clinical outcome, challenges and complications of RCE in various clinical scenario and to understand how this procedure can be effectively utilized in the management of patients in Indian scenario.

MATERIALS AND METHODS

This retro prospective study was conducted in tertiary care center in southern India which analyzed 21 RCE procedures performed on patients with different clinical conditions. Of the 21 RCE performed, 18 procedures were performed on patients with case of sickle cell disease, Two procedures were performed on patients infested with severe falciparum malaria and one procedure was performed on a patient with nitrobenzene poisoning. All procedures were performed using Spectra Optia(®) Apheresis System - Terumo BCT.

RESULTS

All the 18 patients who underwent the RCE for sickle cell anaemia were admitted for hemi-arthroplasty for avascular necrosis of the head of femur. The average initial HbS levels were between 73-85% and post RCE it was brought down to 22-29% and was achieved in a single sitting in all the cases. Among the two patients infested with severe falciparum malaria, RCE helped in reducing the infestation rate. In case of nitrobenzene poisoning, RCE helped in improvement of oxygen saturation and patient showed significant improvement.

CONCLUSION

RCE is an safe and clinically effective therapeutic modality with very minimal to nil side effects. RCE is possibly underutilized therapy in developing world like India due to various reasons like inadequate awareness/ technical expertise, lack of equipments and facilities to identify the clinical conditions per se etc.

Kikuchi-Fujimoto disease presenting after consumption of 'Miracle Mineral Solution' (sodium chlorite)

We present a case report of a 41-year-old woman of Malay ethnicity who presented with an 11-day history of fever and left-sided lymphadenopathy after consuming 'Miracle Mineral Solution' (sodium chlorite solution) for the first time. A diagnosis of Kikuchi-Fujimoto disease was established via lymph node biopsy after other differentials were excluded. The aetiology of Kikuchi-Fujimoto disease remains controversial, but viral, autoimmune and physicochemical causes have been suggested as possibilities. In this case, we hypothesise that oxidative injury from sodium chlorite initiated an inflammatory response, which triggered the onset of Kikuchi-Fujimoto disease.

A case of severe chlorite poisoning successfully treated with early administration of methylene blue, renal replacement therapy, and red blood cell transfusion: case report

The case of a 55-year-old man who attempted suicide by ingesting <100 mL of 28% sodium chlorite solution is presented. On arrival in the intensive care unit, the patient appeared cyanotic with lowered consciousness and displayed anuria and chocolate brown serum.Initial laboratory tests revealed 40% of methemoglobin. The formation of methemoglobin was effectively treated with methylene blue (10% after 29 hours).To remove the toxin, and because of the anuric acute renal failure, the patient received renal replacement therapy. Despite these therapeutic measures, the patient developed hemolytic anemia and disseminated intravascular coagulation, which were treated with red blood cell transfusion and intermittent hemodialysis. These interventions led to the improvement of his condition and the patient eventually fully recovered. Patient gave written informed consent.This is the third known case of chlorite poisoning that has been reported. Based upon this case, we suggest the management of sodium chlorite poisoning to comprise the early administration of methylene blue, in addition to renal replacement therapy and transfusion of red blood cells.