Survival following massive arsenic ingestion

The protective effect of natural or chemical compounds against arsenic-induced neurotoxicity: Cellular and molecular mechanisms

Arsenic is a notorious metalloid that exists in the earth's crust and is considered toxic for humans and the environment. Both cancerous and non-cancerous complications are possible after arsenic exposure. Target organs include the liver, lungs, kidney, heart, and brain. Arsenic-induced neurotoxicity, the main focus of our study, can occur in central and peripheral nervous systems. Symptoms can develop in a few hours, weeks, or years depending on the quantity of arsenic and the duration of exposure. In this review, we aimed to gather all the compounds, natural and chemical, that have been studied as protective agents in cellular, animal, and human reports. Oxidative stress, apoptosis, and inflammation are frequently described as destructive mechanisms in heavy metal toxicity. Moreover, reduced activity of acetylcholinesterase, the altered release of monoamine neurotransmitters, down-regulation of N-methyl-D-aspartate receptors, and decreased brain-derived neurotrophic factor are important underlying mechanisms of arsenic-induced neurotoxicity. As for neuroprotection, though some compounds have yet limited data, there are others, such as curcumin, resveratrol, taurine, or melatonin which have been studied more deeply and might be closer to a reliable protective agent. We collected the available information on all protective agents and the mechanisms by which they fight against arsenic-induced neurotoxicity.

Treatment of lead and arsenic poisoning in anuric patients - a case report and narrative review of the literature

Background

Heavy metal poisoning can cause debilitating illness if left untreated, and its management in anuric patients poses challenges. Literature with which to guide clinical practice in this area is rather scattered.

Case presentation

We present a case of symptomatic lead and arsenic poisoning from use of Ayurvedic medicine in a 28-year-old man with end-stage kidney disease on chronic hemodialysis. We describe his treatment course with chelating agents and extracorporeal blood purification, and review the relevant literature to provide general guidance.

Conclusion

Cumulative clinical experience assists in identifying preferred chelators and modalities of extracorporeal blood purification when managing such patients. However, a larger body of real-world or clinical trial evidence is necessary to inform evidence-based guidelines for the management of heavy metal poisoning in anuric patients.

Massive acute arsenic poisonings

Arsenic poisonings are still important in the field of toxicology, though they are not as frequent as about 20-30 years ago. In this paper, the arsenic concentrations in ante- and post-mortem materials, and also forensic and anatomo-pathological aspects in three cases of massive acute poisoning with arsenic(III) oxide (two of them with unexplained criminalistic background, in which arsenic was taken for amphetamine and one suicide), are presented. Ante-mortem blood and urine arsenic concentrations ranged from 2.3 to 6.7 microg/ml, respectively. Post-mortem tissue total arsenic concentrations were also detected in large concentrations. In case 3, the contents of the duodenum contained as much as 30.1% arsenic(III) oxide. The high concentrations of arsenic detected in blood and tissues in all presented cases are particularly noteworthy in that they are very rarely detected at these concentrations in fatal arsenic poisonings.

Acute arsenic poisoning in two siblings

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 inorganic arsenic from an outdated pesticide that was misidentified as spring water. The 4-month-old child ingested a dose of arsenic that was lethal despite extraordinary attempts at arsenic removal, including chelation therapy, extracorporeal membrane oxygenation, exchange transfusion, and hemodialysis. The 2-year-old fared well with conventional therapy.

Treatment and toxicokinetics of acute pediatric arsenic ingestion: danger of arsenic insecticides in children

OBJECTIVES

To describe the toxicokinetics and management of acute pediatric arsenic ingestion.

DESIGN

Case report and literature review.

SETTING

Tertiary pediatric intensive care unit, St. John's Children's Hospital, Springfield, IL.

PATIENT

A 22-month-old boy ingested approximately twice the estimated lethal dose of arsenic trioxide (As(2)O(3)) ant bait. Only one household arsenical insecticide is available in the United States and is presumed to be shielded from human exposure. He survived without detectable sequelae. Initially, the patient developed signs of acute hemodynamic compromise with tachycardia, hypertension, gastrointestinal symptoms, and poor urine output. He became lethargic with muscle weakness and was somnolent but never developed encephalopathy, seizures, or late onset peripheral neuropathy.

INTERVENTIONS

He was stabilized with fluid resuscitation, placed on a sodium bicarbonate intravenous drip, and treated with intramuscular dimercaprol (British anti-Lewisite), 5 mg/kg every 6 hrs for 3 days. When the British anti-Lewisite and the sodium bicarbonate drip were discontinued, oral meso 2,3-dimercaptosuccinic acid (Succimer) was administered three times a day for 5 days and thereafter twice daily until the urine arsenic concentration decreased below 50 microg/L.

MEASUREMENTS AND MAIN RESULTS

Continuous monitoring in the pediatric intensive care unit included continuous electrocardiogram, arterial blood pressure, urine output, vital signs, arterial blood gases, serum and urine arsenic concentrations, electrolytes, electromyography, and determination of arsenic toxicokinetics. The child's serum arsenic concentration was the highest ever reported with survival.

CONCLUSIONS

Recovery from arsenic poisoning was attributable to the restoration and maintenance of adequate cardiac output and renal perfusion in early shock, which allowed depot intramuscular British anti-Lewisite to circulate and eliminate the poison. Although an intravenous antiarsenical chelating agent would be advantageous in treating shock from arsenic poisoning, none is currently available. We urge the immediate use of British anti-Lewisite therapy on patient presentation with suspected toxic arsenic ingestion.

Survival after massive arsenic poisoning self-treated by high fluid intake

CASE REPORT

A 23-year-old male pharmacist ingested 1040 mg arsenic trioxide (788 mg trivalent arsenic, 13 mg/kg). After 7 asymptomatic hours, frequent vomiting and diarrhea occurred. Fearing death from shock, he drank 5 L of water over 5 hours. When he was brought to our hospital with chief complaint of constricted vision about 20 hours after ingestion, the major abdominal symptoms had already subsided. Despite a lethal plasma arsenic on admission, all toxic symptoms including hepatic dysfunction, erythematous dermal eruption, and peripheral neuropathy improved during his hospital stay with no treatment except for dimercaptopropanol.

Heavy metal toxicity, Part I: arsenic and mercury

This review is Part I of a two-part series focusing on heavy metal toxicity. Part I will cover arsenic and mercury toxicity. Acute and chronic arsenic toxicity, as well as arsine gas toxicity, will be reviewed. The clinical presentation, with focus on the nervous, cardiovascular, pulmonary, gastrointestinal, hepatic, renal, hematopoietic, and dermatologic systems, is delineated. Mercury exposure, including exposure to short chain alkyl mercury, elemental mercury, and acute inorganic salt, is reviewed. The discussion of clinical toxicity focuses on the nervous, cardiovascular, pulmonary, gastrointestinal, and renal systems, as well as on the teratogenic effects of mercury. Recommendations for diagnostic tests and management plans are discussed, including chelation regimens.

Acute arsenic poisoning: absence of polyneuropathy after treatment with 2,3-dimercaptopropanesulphonate (DMPS)

Two men aged 19 and 21 years ingested 1 g and 4 g respectively from 3 kg of a white crystalline powder that they thought was a substance of abuse. It was later identified as almost pure arsenic trioxide. Both had nausea and vomiting and one developed acute renal failure. Each was treated with 2,3-dimercaptopropanesulphonate (DMPS), and made a full recovery with no evidence of prolonged renal or neurological impairment. The DMPS-arsenic complex is probably associated with lower penetration into the CNS and as a consequence treatment with DMPS may result in lower acute and chronic neurotoxicity than treatment with the currently standard recommended chelating agent dimercaprol (British Anti-Lewisite; BAL).

Massive acute arsenic poisoning

A 28-year-old male ingested 75 g of arsenic trioxide in a successful suicide attempt. The presentation, management and postmortem findings are presented and discussed.

Effects of glutathione depletion on the acute nephrotoxic potential of arsenite and on arsenic metabolism in hamsters

Our previous study showed that pretreatment with buthionine sulfoximine (BSO), which inhibits glutathione synthesis, results in acute renal failure with oliguria in hamsters ingesting sodium arsenite (5 mg As/kg). For a deeper understanding of the relationship between arsenic metabolism and the subsequent development of nephrotoxicity, we studied excretion, tissue retention, biotransformation, pharmacokinetics, and histopathological events in the kidneys of hamsters both with and without BSO pretreatment. The total amount of arsenic excreted in the urine and feces within 72 hr of arsenite administration was more than fivefold lower in BSO-pretreated animals than in the controls without pretreatment (9.2 versus 53.4% of the arsenic dose). The persistence of high amounts of total arsenic was apparent in the blood, liver, and kidneys of BSO-pretreated hamsters, even though the content of inorganic arsenic steadily decreased with time. The disappearance of inorganic arsenic from the blood showed a biphasic elimination pattern characterized first by a rapid component with a half-life of 4.5 hr and second by a slower component with a half-life of 58.0 hr in the BSO-pretreated hamsters, while these half-lives were 0.6 and 11.0 hr, respectively, in the controls. BSO pretreatment not only impaired the excretion of inorganic arsenic, but also impaired its methylation. Combined BSO/arsenite treatment resulted in renal tubular necrosis which was prominent at 1 hr after arsenite administration. By 1 hr, the renal content of inorganic arsenic in the BSO-pretreated animals was 1.7 times higher than that in the controls. This study demonstrates that glutathione depletion elicits the nephrotoxic manifestations of arsenic poisoning.