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Cao Zhang AM, Zale AD, Tabbara N, Yui JC. Concomitant oxidative haemolysis and methaemoglobinaemia following inhaled nitric oxide in a patient with G6PD deficiency. BMJ Case Rep 2024; 17:e259709. [PMID: 39209743 DOI: 10.1136/bcr-2024-259709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
We report the case of a man in his 50s who developed acute respiratory distress syndrome and right heart failure, necessitating intubation and initiation of inhaled nitric oxide (iNO) to decrease right ventricular afterload and improve the right heart function. The course was complicated by acute anaemia, with a diagnostic workup revealing methaemoglobinaemia and evidence of oxidative haemolysis indicated by blister and bite cells on peripheral blood film. The patient received conservative management, including successive red blood cell transfusion and gradual iNO weaning due to suspected glucose-6-phosphate dehydrogenase (G6PD) deficiency. Discontinuation of iNO led to the resolution of both oxidative haemolysis and methaemoglobinaemia. Subsequent enzymatic assay, conducted 4 months later, confirmed G6PD deficiency. This case highlights a rare instance of concurrent methaemoglobinaemia and oxidative haemolytic anaemia following iNO in a patient with underlying G6PD deficiency.
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Affiliation(s)
| | - Andrew D Zale
- Department of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Nadeem Tabbara
- Division of Hematology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jennifer C Yui
- Division of Hematology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Mack KA, Kaczkowski W, Sumner S, Law R, Wolkin A. Special Report from the CDC: Suicide rates, sodium nitrite-related suicides, and online content, United States. JOURNAL OF SAFETY RESEARCH 2024; 89:361-368. [PMID: 38858061 PMCID: PMC11262023 DOI: 10.1016/j.jsr.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND In 2022, suicide ranked as the 11th leading cause of death in the United States with 49,513 deaths. Provisional mortality data from 2022 indicate a 2.8% increase in the number of suicides compared to 2021. This paper examines overall suicide trends, sodium nitrite ingestion as an emerging suicide method, and the role that online forums play in sharing information about suicide methods (including sodium nitrite ingestion). METHODS Suicides were identified from CDC's National Vital Statistics System (2018-July 2023 provisional) multiple cause-of-death mortality files using International Classification of Diseases (ICD), Tenth Revision underlying cause-of-death codes U03, X60-X84, and Y87.0 and T code T50.6 (antidotes and chelating agents). Google search popularity metrics were captured from January 2019 to January 2023. Case reports of sodium nitrite related suicide and suicide attempts (through February 2024) were identified in the medical and forensic literature. RESULTS At least 768 suicides involving antidotes and chelating agents (including sodium nitrite) occurred between 2018 and July 2023, set in the context of 268,972 total suicides during that period. Overall, suicides involving antidotes and chelating agents (including sodium nitrite) represent <1% of all suicides, however, numbers are rising. CONCLUSIONS Suicide methods are known to change over time. These changes can be influenced by, among other factors, online forums and means accessibility, such as internet purchase availability. CDC remains committed to prevention through comprehensive public health strategies that protect individuals, families, and communities. PRACTICAL APPLICATIONS States and community partners might consider leveraging physicians, emergency responders, and other appropriate crisis response groups to disseminate information on sodium nitrite self-poisoning and its antidote, methylene blue. Efforts should be part of a comprehensive public health approach to suicide prevention.
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Affiliation(s)
- Karin A Mack
- Centers for Disease Control & Prevention, National Center for Injury Prevention and Control, Atlanta, GA, United States.
| | - Wojciech Kaczkowski
- Centers for Disease Control & Prevention, National Center for Injury Prevention and Control, Atlanta, GA, United States
| | - Steven Sumner
- Centers for Disease Control & Prevention, National Center for Injury Prevention and Control, Atlanta, GA, United States
| | - Royal Law
- Centers for Disease Control & Prevention, National Center for Injury Prevention and Control, Atlanta, GA, United States
| | - Amy Wolkin
- Centers for Disease Control & Prevention, National Center for Injury Prevention and Control, Atlanta, GA, United States
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Smith EM. Sodium nitrite suicide and social media influence. Nursing 2023; 53:44-47. [PMID: 37973013 DOI: 10.1097/01.nurse.0000991568.99431.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
ABSTRACT This article addresses the increase in suicide rates in the US, emphasizing the emergence of sodium nitrite ingestion as a method of self-harm, particularly among adolescents and young adults influenced by social media. Given the rising incidence of sodium nitrite-related suicide attempts, healthcare providers must remain vigilant and prepared to respond effectively.
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Affiliation(s)
- Erin Murphy Smith
- Erin Murphy Smith is an associate professor at the City University of New York at Kingsborough Community College
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Loiseau M, Matheux A, Sabini S, Cavard S, Advenier AS, Pasquet A, François-Purssell I, Guerard P. Suicide of an adolescent girl with sodium nitrite ordered on the internet. J Forensic Sci 2023; 68:2200-2204. [PMID: 37526251 DOI: 10.1111/1556-4029.15350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023]
Abstract
Nitrites are commonly used in the chemical, pharmaceutical, and food industries. Recently, they have been identified in cases of voluntary intoxication. We report the case of a 13-year-old girl who was found lifeless on her bed next to a glass containing a white powder and a bottle containing a white powder with a moistened appearance. External examination and autopsy revealed a nonspecific asphyxia syndrome, which was confirmed by the pathological analysis. Analysis of the samples revealed metoclopramide in the peripheral blood at a concentration of 0.402 mg/L (LC-HRMS). An analysis of the gastric contents was carried out after sodium nitrite was detected in the powders found near the body (Raman spectrometry). Nitrites were found in the gastric fluid at a concentration of 30.9 mg/L. Death occurred secondary to anoxia, following ingestion of nitrites; suicide kits are available on the web and nitrites are relatively easy to source and inexpensive. Nitrites are delivered in powder form to be dissolved in liquid, which may then be consumed with metoclopramide (or an alternative anti-emetic drug) to maximize absorption and reduce emesis. The toxic effect of nitrites lies in their oxidizing power, causing the transformation of hemoglobin into methemoglobin, which, when it accumulates, induces tissue anoxia resulting in death. There has been an alarming increase in the number of cases linked to suicide using nitrites or a nitrite suicide kit. The fact that nitrites are readily available online underscores the importance of establishing effective preventive measures such as limiting the access and use of this chemical.
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Affiliation(s)
- Mélanie Loiseau
- Forensic Medicine Department, Dijon University Hospital, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231, Dijon, France
| | - Alice Matheux
- Department of Toxicology, Dijon University Hospital, Dijon, France
- INSERM U1231, "Lipides, Nutrition, Cancer", University of Burgundy Franche-Comté, Dijon, France
| | - Sandrine Sabini
- Toxicology Unit, Forensic Physics and Chemistry Department of Forensic Science Laboratory of the French Gendarmerie (IRCGN), Cergy-Pontoise, France
| | - Stéphanie Cavard
- Forensic Medicine Department, Dijon University Hospital, Dijon, France
| | | | - Agathe Pasquet
- Department of Toxicology, Dijon University Hospital, Dijon, France
| | | | - Pascal Guerard
- Department of Toxicology, Dijon University Hospital, Dijon, France
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Desrosiers NA, Chow BLC. Impact of methemoglobin on carboxyhemoglobin saturation measurement in fatal sodium nitrate and sodium nitrite cases. J Anal Toxicol 2023; 47:750-752. [PMID: 37670565 DOI: 10.1093/jat/bkad067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 08/17/2023] [Accepted: 09/05/2023] [Indexed: 09/07/2023] Open
Abstract
An increase in suicide cases by sodium nitrate and sodium nitrite ingestion has been noted in the scientific literature. We report on the possible impact of nitrate/nitrite-caused methemoglobinemia on carboxyhemoglobin measurement by spectrophotometric methods. Elevated methemoglobin saturation may result in insufficient reducing agents to convert methemoglobin into deoxygenated hemoglobin, affecting the measured total hemoglobin and carboxyhemoglobin saturation. We highlight four cases where the cause of death was attributed to sodium nitrate or sodium nitrite ingestion. The possible impact of the nitrate/nitrite-caused methemoglobinemia on the carboxyhemoglobin saturation as measured by spectrophotometry is discussed. Further studies are needed to identify a causal relationship between nitrate/nitrite-caused methemoglobinemia and carboxyhemoglobin saturation as measured by spectrophotometric methods.
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Affiliation(s)
| | - Betty L C Chow
- Toxicology Section, Centre of Forensic Sciences, Toronto, ON M3M 0B1, Canada
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Tusiewicz K, Kuropka P, Workiewicz E, Wachełko O, Szpot P, Zawadzki M. Nitrites: An Old Poison or a Current Hazard? Epidemiology of Intoxications Covering the Last 100 Years and Evaluation of Analytical Methods. TOXICS 2023; 11:832. [PMID: 37888684 PMCID: PMC10611400 DOI: 10.3390/toxics11100832] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/22/2023] [Accepted: 09/29/2023] [Indexed: 10/28/2023]
Abstract
In recent times, there has been a concerning and noteworthy rise in the global use of sodium nitrite for suicidal purposes. This is facilitated either through the employment of specialized "suicide kits" or by acquiring sodium nitrite through alternative means. Additionally, another occurrence contributing to nitrite poisoning is the recreational utilization of nitrites in the form of volatile aliphatic esters of nitrous acid, commonly referred to as "poppers". Based on current available papers and reports on the subject of nitrates, nitrites, and poppers intoxications, an epidemiological analysis and evaluation of analytical methods were performed. A total of 128 papers, documenting a collective count of 492 intoxication cases, were identified. Additionally, in order to complete the epidemiological profile of nitrite poisoning, the authors briefly examined six cases of nitrite intoxication that were under investigation in our laboratory. Furthermore, a review of nitrite poisoning cases over the past 100 years shows that the old poison is still in use and poses a substantial risk to society.
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Affiliation(s)
- Kaja Tusiewicz
- Department of Forensic Medicine, Wroclaw Medical University, 4 J. Mikulicza-Radeckiego Street, 50345 Wroclaw, Poland; (K.T.); (P.S.)
| | - Patryk Kuropka
- Institute of Toxicology Research, 45 Kasztanowa Street, 55093 Borowa, Poland; (P.K.); (E.W.)
| | - Elżbieta Workiewicz
- Institute of Toxicology Research, 45 Kasztanowa Street, 55093 Borowa, Poland; (P.K.); (E.W.)
| | - Olga Wachełko
- Institute of Toxicology Research, 45 Kasztanowa Street, 55093 Borowa, Poland; (P.K.); (E.W.)
| | - Paweł Szpot
- Department of Forensic Medicine, Wroclaw Medical University, 4 J. Mikulicza-Radeckiego Street, 50345 Wroclaw, Poland; (K.T.); (P.S.)
| | - Marcin Zawadzki
- Faculty of Medicine, Wroclaw University of Science and Technology, 27 Wybrzeże Wyspiańskiego Street, 50370 Wroclaw, Poland
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Andelhofs D, Van Den Bogaert W, Lepla B, Croes K, Van de Voorde W. Suicidal sodium nitrite intoxication: a case report focusing on the postmortem findings and toxicological analyses-review of the literature. Forensic Sci Med Pathol 2023:10.1007/s12024-023-00664-9. [PMID: 37351779 DOI: 10.1007/s12024-023-00664-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 06/24/2023]
Abstract
Sodium nitrite (NaNO2) is an inorganic compound that is commonly used as a preservative (E250) in the fish and meat industry. When ingested, sodium nitrite will lead to methemoglobinemia, hypotension, and arrhythmias. An increasing trend in the use of sodium nitrite as a suicide agent has been reported. In Belgium however it remains a rare phenomenon. The ingestion of sodium nitrite is not always apparent from the death scene investigation, especially in cases of covert administration or accidental ingestion. Hence, the forensic pathologist must be aware of this trend and the postmortem changes related to the ingestion of sodium nitrite to effectively identify these cases and determine the cause and manner of death. We describe a case of fatal self-poisoning following the oral ingestion of sodium nitrite with suicidal intent. Postmortem investigations showed signs of methemoglobinemia, such as a gray-brown discoloration of lividity and a chocolate brown discoloration of the blood. Postmortem toxicological investigation revealed methemoglobinemia (35%) in cardiac blood, hypernatremia (159.6 mmol/L) in vitreous humor, and the presence of nitrite in gastric contents (1.15 g/L) and, for the first time in a forensic case, in serum (38 µg/mL). A review of the existing literature regarding cases of sodium nitrite intoxications was performed to correlate these findings.
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Affiliation(s)
- D Andelhofs
- Department of Forensic Medicine, University Hospitals Leuven, Louvain, Belgium.
- Department of Forensic Biomedical Sciences, University of Leuven (KU Leuven), Louvain, Belgium.
| | - W Van Den Bogaert
- Department of Forensic Medicine, University Hospitals Leuven, Louvain, Belgium
- Department of Forensic Biomedical Sciences, University of Leuven (KU Leuven), Louvain, Belgium
| | - B Lepla
- Department of Laboratory Medicine, AZ Groeninge, Kortrijk, Belgium
| | - K Croes
- Department of Laboratory Medicine, AZ Groeninge, Kortrijk, Belgium
| | - W Van de Voorde
- Department of Forensic Medicine, University Hospitals Leuven, Louvain, Belgium
- Department of Forensic Biomedical Sciences, University of Leuven (KU Leuven), Louvain, Belgium
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Padovano M, Aromatario M, D’Errico S, Concato M, Manetti F, David MC, Scopetti M, Frati P, Fineschi V. Sodium Nitrite Intoxication and Death: Summarizing Evidence to Facilitate Diagnosis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192113996. [PMID: 36360874 PMCID: PMC9654862 DOI: 10.3390/ijerph192113996] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 10/16/2022] [Accepted: 10/24/2022] [Indexed: 06/02/2023]
Abstract
BACKGROUND Over the years, forensic pathology has registered the spread of new methods of suicide, such as the ingestion of sodium nitrite. Sodium nitrite causes increased methemoglobin, resulting in systemic hypoxia, metabolic acidosis, and cyanosis. Since sodium nitrite is a preservative, the ingestion of foods containing an excessive amount of this substance can also cause acute intoxication up to death. The present review is aimed at guiding health professionals in the identification and management of sodium-nitrite-related intoxications and deaths. METHODS A systematic literature search was carried out on PubMed by following the PRISMA statement's criteria. A total of 35 studies with 132 cases were enrolled, and the data were cataloged in Microsoft Excel. To establish the causal correlation between sodium nitrite ingestion and death, the Naranjo Adverse Drug Reaction Probability Scale was used. RESULTS In addition to the small number of cases that have currently been published, the study demonstrated that there was a general methodological discrepancy in the diagnostic process. However, some interesting results have emerged, especially in post-mortem diagnostics. CONCLUSION Sodium-nitrite-related deaths represent a challenge for forensic pathologists; therefore, it is important to promptly recognize the essential features and perform the necessary and unrepeatable examinations for the correct diagnosis of the cause of death.
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Affiliation(s)
- Martina Padovano
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Mariarosaria Aromatario
- Unit of Risk Management, Quality, and Accreditation, Sant’Andrea University Hospital, 00189 Rome, Italy
| | - Stefano D’Errico
- Department of Medicine, Surgery and Health, University of Trieste, 34137 Trieste, Italy
| | - Monica Concato
- Department of Medicine, Surgery and Health, University of Trieste, 34137 Trieste, Italy
| | - Federico Manetti
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Maria Chiara David
- Department of Public Security, Health Central Directorate, Research Center and Forensic Toxicology Laboratory, Ministry of the Interior, 00184 Rome, Italy
| | - Matteo Scopetti
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00161 Rome, Italy
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