SURVIVAL IN A CASE OF ACUTE ORAL CHROMIC ACID POISONING WITH ACUTE RENAL FAILURE TREATED BY HAEMODIALYSIS

A comprehensive review on human health effects of chromium: insights on induced toxicity

The growing use of heavy metals in most industrial activities has led to it being considered as the most important environmental pollutant that may cause harm and toxicity to animals and humans. Chromium has been found in the environment in different oxidation states such as Cr⁰, Cr(III), and Cr(VI) and is released from a variety of anthropogenic and natural activities. At among, trivalent and hexavalent chromium are the most stable forms. Considerably, Cr(VI) is frequently more toxic than Cr(III) because of its particular solubility and high mobility. Chronic exposure and bioaccumulation of chromium, as a heavy metal, can cause toxicity and numerous pathophysiological defects, including allergic reactions, anemia, burns, and sores especially in the stomach and small intestine, damage to sperm along with the male reproductive system, and affect various biological systems. Chromium pollution can have severe consequences for water and the soil environment. This article reviews the toxicological effects of Cr(VI) and Cr(III) and their mechanisms of toxicity and carcinogenicity.

Environmental Metals and Cardiovascular Disease in Adults: A Systematic Review Beyond Lead and Cadmium

Published systematic reviews concluded that there is moderate to strong evidence to infer a potential role of lead and cadmium, widespread environmental metals, as cardiovascular risk factors. For other non-essential metals, the evidence has not been appraised systematically. Our objective was to systematically review epidemiologic studies on the association between cardiovascular disease in adults and the environmental metals antimony, barium, chromium, nickel, tungsten, uranium, and vanadium. We identified a total of 4 articles on antimony, 1 on barium, 5 on chromium, 1 on nickel, 4 on tungsten, 1 on uranium, and 0 on vanadium. We concluded that the current evidence is not sufficient to inform on the cardiovascular role of these metals because of the small number of studies. Few experimental studies have also evaluated the role of these metals in cardiovascular outcomes. Additional epidemiologic and experimental studies, including prospective cohort studies, are needed to understand the role of metals, including exposure to metal mixtures, in cardiovascular disease development.

Hydroxycut-induced Liver Toxicity

In the recent era, use of various nutritional supplements is highly encouraged amongst the people of United States. Weight loss supplements are major part of the nutritional supplements and their usage is unregulated in the US. Obesity is a major health concern in the US and Americans spend around $30 billion a year for weight loss supplements. At times, these supplements can be responsible for documented or undocumented adverse drug effects. The health consequences related to these supplements are often overlooked by the general public, even though FDA issues advisories regarding them. One common supplement used for weight loss was Hydroxycut (Iovate Health Sciences Research, Oakville, Ontario, Canada). Hydroxycut was recalled from the market after a FDA warning in May 2009 because of 23 reports of serious health problems ranging from jaundice and elevated liver enzymes to liver damage. 1 This case report adds evidence for Hydroxycut - induced hepatotoxicity. A 27 year old man with right upper quadrant pain and jaundice was found to have elevated liver enzymes and was taking Hydroxycut along with other supplements. Liver biopsy showed drug induced hepatotoxicity. Discontinuation of Hydroxycut dramatically improved liver functions and related symptoms.

Exposure to multiple metals from groundwater-a global crisis: geology, climate change, health effects, testing, and mitigation

This paper presents an overview of the global extent of naturally occurring toxic metals in groundwater. Adverse health effects attributed to the toxic metals most commonly found in groundwater are reviewed, as well as chemical, biochemical, and physiological interactions between these metals. Synergistic and antagonistic effects that have been reported between the toxic metals found in groundwater and the dietary trace elements are highlighted, and common behavioural, cultural, and dietary practices that are likely to significantly modify health risks due to use of metal-contaminated groundwater are reviewed. Methods for analytical testing of samples containing multiple metals are discussed, with special attention to analytical interferences between metals and reagents. An overview is presented of approaches to providing safe water when groundwater contains multiple metallic toxins.

Survival after severe acute chromic acid poisoning complicated with renal and liver failure

Chromic acid is a strong metal acid and acute poisoning is very rare, but very serious with severe skin injury, renal and liver failure. The majority of published cases were suicide attempts with lethal outcomes. We describe the case of a 55-year-old man who had accidentally taken a sip of 20% chromic acid (estimated chromium intake: 2.3 g). Renal and liver failure were not present at presentation, but appeared later in the course of disease. He was treated with hemodialysis, no chelating agents or other methods for enhancing elimination were used. Liver and renal function improved over the next 30 days and the patient was discharged after 45 days of hospitalization with no need for dialysis. In the follow-up period of eight months his renal function remained depressed, but stable.

Hydroxycut hepatotoxicity: A case series and review of liver toxicity from herbal weight loss supplements

Dietary supplements represent an increasingly common source of drug-induced liver injury. Hydroxycut is a popular weight loss supplement which has previously been linked to hepatotoxicity, although the individual chemical components underlying liver injury remain poorly understood. We report two cases of acute hepatitis in the setting of Hydroxycut exposure and describe possible mechanisms of liver injury. We also comprehensively review and summarize the existing literature on commonly used weight loss supplements, and their individual components which have demonstrated potential for liver toxicity. An increased effort to screen for and educate patients and physicians about supplement-associated hepatotoxicity is warranted.

[Chromic acid burns: systematic prevention of systemic toxicity]

Chromic acid burns can lead to systemic toxicity by cutaneous absorption of the chrome seen surfaces more than 1% of the total body surface area. In order to illustrate the necessity of anticipate systematically this toxicity by a specific treatment, we describe the case of a patient with systemic toxicity in the least severe situation of chromic acid burn: the chromic acid was diluted to 0,02%, the burn was superficial second degree, both thermic and chemical, on the forearm, and extended only to 1% of the total body surface area. In spite of the specific treatment, our patient had a blood transfer of the chrome, however without any consequences on the renal and hepatic functions. He cicatrised in 2 weeks, and his blood and urinary chromium levels were normalised in 3 weeks. Without this specific early treatment, what would have been the consequences of a systemic toxicity even more important?

Trace element risk assessment: essentiality vs. toxicity

Risk assessment of essential trace elements examines high intakes resulting in toxicity and low intakes resulting in nutritional deficiencies. This paper analyzes the risk assessments carried out by several U.S. governmental and private organizations for eight essential trace elements: chromium, copper, iodine, iron, manganese, molybdenum, selenium, and zinc. The compatibility of the toxicity values with the nutritionally essential values is examined, in light of recently derived values, termed Dietary Reference Intakes, set by the U.S. Food and Nutrition Board of the Institute of Medicine. The results show that although there are differences in the values set by the different organizations, increased coordination has resulted in values that are more compatible than revealed in past evaluations.

Non-herbal nutritional supplements-the next wave: a comprehensive review of risks and benefits for the C-L psychiatrist

The continuing popularity of complementary medicine has led to the frequent appearance of new products in the marketplace. Non-herbal supplements are now a popular choice for patients seeking relief from a variety of medical conditions. As with herbal medicines, there are concerns about the safety of these products in those with physical illness. Clearly, consultation-liaison psychiatrists will encounter patients using non-herbal products or inquiring about them. This article seeks to provide knowledge about the risks and benefits of non-herbal supplements that consultation-liaison psychiatrists are likely to encounter.

Suicide by ingestion of a CCA wood preservative

Chromated-copper-arsenate (CCA) is a compound used worldwide for wood preservation. Occupational hazards from chronic exposure to CCA are well known, but acute ingestion of CCA wood preservative is very rare. We describe a case of suicide by ingestion of a CCA wood preservative. A 33-year-old man attempted suicide by ingesting an unknown liquid, later identified as a CCA wood preservative, 75 min before his arrival in the emergency department. He was in severe respiratory distress, drooling, tachycardic, and hypotensive. There was an orange color on the palms of both hands. Severe, green colored burns of the buccal mucosa were observed. He was intubated shortly after arrival. The larynx was edematous, but a 7-mm endotracheal tube was successfully introduced. Blood tests revealed partially compensated metabolic acidosis. The patient deteriorated rapidly; the systolic blood pressure dropped to 70 mmHg, and he passed bloody diarrhea. He developed multiple premature atrial contractions and supraventricular tachycardia, and later in the intensive care unit, refractory ventricular tachycardia and ventricular fibrillation. The patient was declared dead 212 h after his arrival. Unfortunately, postmortem blood levels of heavy metals and autopsy were not performed because of refusal by the family for religious reasons.

Acute generalized exanthematous pustulosis induced by chromium picolinate

A case of acute generalized exanthematous pustulosis (AGEP) due to chromium picolinate is described. This supplemental form of chromium has received a great deal of interest recently because of its possible beneficial effects on both muscle strength and body composition. There have been no previous reports to our knowledge of adverse cutaneous reactions to this agent. Various aspects of AGEP are reviewed.

Acute, fatal, oral chromic acid poisoning

CASE REPORT

We report a 35-year-old woman who developed severe acidosis, massive gastrointestinal hemorrhage, acute renal failure, and hepatic injury following ingestion of chromic acid (50 mL) and died 12 hours after ingestion. Postmortem liver biopsy revealed a fatty degeneration with chromium concentration 3.6 mumol/g. The kidney, with chromium concentration 2.6 mumol/g, had extensive necrosis and ischemic lesions. Erythrocyte chromium was 1903 mumol/L at 3 hours declining to 865 mumol/L at 11 hours.

Chromium

Chromium occurs primarily in the trivalent state (III), which is the most stable form, or in the hexavalent state (VI), which is a strong oxidizing agent. Elemental chromium (0) does not occur naturally on earth. Trivalent chromium (III) is an essential trace metal necessary for the formation of glucose tolerance factor and for the metabolism of insulin. Commercial applications of chromium compounds include tanning (III), corrosion inhibition, plating, glassware-cleaning solutions, wood preservatives (VI), manufacture of safety matches, metal finishing (VI), and the production of pigments (III, VI). Hexavalent chromium (VI) contaminated local soil when chromium waste slag was part of the fill material present in residential, public, and industrial areas. In some urban areas, about two-thirds of the chromium in air results from the emission of hexavalent chromium from fossil fuel combustion and steel production. The remaining chromium in air is the trivalent form. The residence time of chromium in air is < 10 days, depending on the particle size. Trivalent compounds generally have low toxicity and the gastrointestinal tract poorly absorbs these compounds. Hexavalent chromium is a skin and mucous membrane irritant and some of these hexavalent compounds are strong corrosive agents. Hexavalent chromium compounds also produce an allergic contact dermatitis characterized by eczema. Sensitivity to trivalent compounds is much less frequent, but some workers may react to high concentrations of these compounds. Hexavalent chromium is recognized by the International Agency for Research on Cancer and by the US Toxicology Program as a pulmonary carcinogen. The increased risk of lung cancer occurs primarily in workers exposed to hexavalent chromium dust during the refining of chromite ore and the production of chromate pigments. Although individual studies suggest the possibility of an excess incidence of cancer at sites outside the lung, the results from these studies are inconsistent.

Chromium picolinate toxicity

OBJECTIVE

To describe a case of toxicity secondary to chronic ingestion of 6-12 times the recommended daily allowance of over-the-counter (OTC) chromium picolinate.

CASE SUMMARY

A 33-year-old white woman presented with weight loss, anemia, thrombocytopenia, hemolysis, liver dysfunction (aminotransferase enzymes 15-20 times normal, total bilirubin 3 times normal), and renal failure (serum creatinine 5.3 mg/dL; blood urea nitrogen 152 mg/dL). She had ingested chromium picolinate 1200-2400 microg/d for the previous 4-5 months to enhance weight loss. The patient had chromium plasma concentrations 2-3 times normal. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome were ruled out by clinical findings, peripheral blood smears, and a bone marrow biopsy. The patient was managed with supportive measures and received blood product transfusions and hemodialysis. Hemolysis stabilized and liver function improved over 6 days. Liver function returned to normal prior to discharge. Renal function began to return on day 12 and her serum creatinine on discharge was 1.3 mg/dL. One year later, all laboratory values were within normal limits.

DISCUSSION

Trivalent chromium is an essential trace element that is considered safe when ingested in normal quantities. Trivalent chromium compounds are used by patients to enhance weight loss, increase lean body mass, and/or improve glycemic control. Information regarding the toxicity of chromium picolinate is limited.

CONCLUSIONS

Chromium supplements may cause serious renal impairment when ingested in excess. Medication histories should include attention to the use of OTC nutritional supplements often regarded as harmless by the public and lay media.

[Severe potassium dichromate poisoning after accidental nasal introduction]

BACKGROUND

Nasal foreign body (NFB) is a common situation in pediatrics. Poisoning is a rare complication of NFB insertion. We report a case of acute potassium dichromate poisoning secondary to NFB insertion.

CASE REPORT

Six days after insertion of a NFB, progressive occurrence of diarrhea, vomiting, nasal obstruction, acute renal failure, pancreatitis, hepatitis and drowsiness justified hospitalization of a 3-year-old girl in the pediatric intensive care unit. Acute potassium dichromate poisoning was confirmed by high plasma chromium level and by the spectrophotometric analysis of the crystal. Recovery was satisfactory with supportive treatment. An official survey allowed to discover that the crystal was freely sold and that its toxicity was unknown by dealers, while no information was given to the customers.

CONCLUSION

Transmucosal absorption of toxics is an unusual severe potential hazard that should be evoked to allow a rapid management. After the discovery and withdrawal of a NFB, occurrence of systemic symptoms, even trivial, must make one suspect a poisoning. In this circumstance, analysis of the foreign body should be done, associated with toxicologic dosages. This case report illustrates that potassium dichromate poisoning is a severe medical condition and that its clinical presentation assume a large widespread of symptoms due to multiple organ involvement.

Hexavalent chromium-contaminated soils: options for risk assessment and risk management

Risk assessment involves establishing scientifically defensible dose-response relationships for end points of concern. For Cr(VI)-contaminated soils, this includes conducting dose-response assessments for blood, liver, and kidney toxicity following oral exposure; lung cancer following inhalation exposure; and allergic contact dermatitis following dermal exposure. This dose-response information is then integrated with a site-specific exposure assessment (or default assumptions) in order to develop a site-specific (or generic) soil criterion within the framework of a comprehensive risk characterization. Risk managers develop cleanup standards designed to protect against all possible adverse effects, taking into account these site-specific (or generic) criteria and other factors such as technical feasibility, cost-benefit analyses, and socio-political concerns. Recently a push for cost-benefit analyses of environmental decisions has occurred, further supporting the need for risk assessors to prepare a comprehensive risk characterization, with its attendant uncertainties. These risk assessment and management issues are brought to the forefront by risk assessors and risk managers dealing with Cr(VI)-contaminated soils. This article offers a review and analysis of the risk characterization of Cr(VI)-contaminated soils, showing that the differing toxicities with route of exposures do not necessarily lead to different characterizations or risk. Soil concentrations in the range of 130 to 450 ppm appear to protect against noncancer toxicity from oral exposure, cancer toxicity from inhalation exposure, and allergic contact dermatitis from dermal exposure.

Unusual findings in a fatal case of poisoning with chromate compounds

An interesting case of acute poisoning by chromate compounds is reported. A 51-year-old man committed suicide by ingesting a fatal dose of sodium chromate solution. He unexpectedly lost consciousness 6 h after the ingestion and died approximately 20.5 h later. An examination of the blood showed noticeable hepatic damage and thrombocytopenia. The postmortem examination revealed extensive bleeding in the alimentary tract and a severe hepatic lesion due to hepatocellular necrosis. However, the renal disorder was unusually light in the microscopic and clinical findings. Moreover, the renal lesion was observed mainly in the distal tubules instead of the proximal tubules which is more typical in cases of acute poisonings by diverse heavy metals including chromium. The patient's death was assumed to have been caused by circulatory collapse due to internal bleeding and the direct toxicity of chromate compounds with hepatic malfunction and possibly disseminated intravascular coagulation (DIC).

Death by tanning--a case of fatal basic chromium sulphate poisoning

A woman ingested 400 ml of leather tanning solution containing 48 g of basic chromium sulphate (CrOHSO4). This substance forms hydrogen ions and trivalent chromium when it reacts with tissue proteins. The patient died of cardiogenic shock, complicated by pancreatitis and gut mucosal necrosis and haemorrhage. There are no reported cases of toxicity due to oral ingestion of trivalent chromium. Toxicity of hexavalent and trivalent chromium is discussed and suggestions made for management of future cases.

Acute renal failure in a case of fatal chromic acid poisoning

Despite its frequent use in industry, acute poisoning by chromic acid has very rarely been reported. We report a patient who developed massive gastrointestinal hemorrhage, acute renal failure, and hepatic injury following chromic acid ingestion, and subsequently died. Postmortem liver and kidney biopsies revealed centrilobular necrosis and severe acute tubular necrosis, respectively.

Chromium-induced kidney disease

Kidney disease is often cited as one of the adverse effects of chromium, yet chronic renal disease due to occupational or environmental exposure to chromium has not yet been reported. Occasional cases of acute tubular necrosis (ATN) following massive absorption of chromate have been described. Chromate-induced ATN has been extensively studied in experimental animals following parenteral administration of large doses of potassium chromate (hexavalent) (15 mg/kg body weight). The chromate is selectively accumulated in the convoluted proximal tubule where necrosis occurs. An adverse long-term effect of low-dose chromium exposure on the kidneys is suggested by reports of low molecular weight (LMW) proteinuria in chromium workers. Excessive urinary excretion of beta 2-microglobulin, a specific proximal tubule brush border protein, and retinol-binding protein has been reported among chrome platers and welders. However, LMW proteinuria occurs after a variety of physiologic stresses, is usually reversible, and cannot by itself be considered evidence of chronic renal disease. Chromate-induced ATN and LMW proteinuria in chromium workers, nevertheless, raise the possibility that low-level, long-term exposure may produce persistent renal injury. The absence of evidence of chromate-induced exposure may produce persistent renal injury. The absence of evidence of chromate-induced chronic renal disease cannot be interpreted as evidence of the absence of such injury. Rather, it must be recognized that no prospective cohort or case-control study of the delayed renal effects of low-level, long-term exposure to chromium has been published.

Poisoning with a traditional remedy containing potassium dichromate

A fatal case of potassium dichromate ingestion is documented. A retrospective review of serum and organ levels of chromium demonstrates that charcoal haemoperfusion, peritoneal and haemodialysis are ineffective therapies for the toxin. Other treatments for this poisoning are reviewed, the poor prognosis of dichromate ingestion, and the paucity of effective therapy underlined. The application of dichromates in traditional medications is briefly discussed; this is a toxin which may be more prevalent than previously thought. It is proposed that the exposure limits of dichromate be more widely publicised.

Chromic acid burns; beware, be aggressive, be watchful

Two cases involving the development of systemic toxicity and prolonged wound healing in small percentage area burns to chromic acid are reported. The treatment of chromic acid burns is reviewed and a protocol of management suggested.

Chromic acid burns and acute chromium poisoning

The problems encountered during the treatment of a patient with burns covering 40 per cent of the body surface caused by hot chromic acid and the resulting chromium poisoning are described. Anuria developed on the second day after injury and the patient died on the sixth day.

Acute chromium poisoning in a 2 year old child

Sodium dichromate ingestion in children is uncommon and potentially lethal. The most appropriate management is uncertain because of the lack of sound data contained in the few reports of successfully treated patients. Immediate treatment should include urgent induction of emesis, administration of ascorbic acid as an antidote, followed by supportive treatment.

The role of surgery in chromic acid burns: our experience with two patients

Two patients with chromic acid burns are described, one having a 10 per cent body surface area (BSA) burn, the other a 70 per cent BSA burn. Hexavalent chromium, being more mobile physiologically, is more toxic than trivalent chromium. Both, however, are readily absorbed through burned skin, and cause renal failure. For this reason, emergency excision of burned areas has been advocated as first line treatment. However, this is not always feasible as, for instance, when the size of the burn is large, and is of uncertain value when patients are referred late.

Kidney function in stainless steel welders

Seventeen male manual metal-arc stainless steel welders (mean exposure time 20 years) had far higher levels of chromium in urine than individually matched controls (medians 23 vs 1.5 mumol/mol creatinine; 10.5 vs 0.7 microgram/g creatinine). However, there were no signs of kidney damage in tests of function of tubuli (beta-hexosaminidase, lysozyme, and beta 2-microglobuline) or glomeruli (albumine clearance).

Failure of dialysis therapy in potassium dichromate poisoning

A fatal case of oral ingestion of potassium dichromate is presented. Following an initial presentation of abdominal pain and vomiting, the patient had a rapid progression to coma with the development of methemoglobinemia, coagulopathy, gastrointestinal hemorrhage, and respiratory distress syndrome. A blood concentration of chromium on admission was 5,800 mcg/dL, 80% of which was found to be in the intracellular fraction. Supportive treatment was also initiated as a four-hour period of hemodialysis followed by a one-hour period of charcoal hemoperfusion. Neither of these treatment modalities was found to significantly remove chromium from whole blood and neither seemed to affect the progression or outcome of this intoxication. We conclude that the ingestion of potassium dichromate is highly toxic and may rapidly lead to death. Hemodialysis and charcoal hemoperfusion appear to have little role in the management of chromium intoxication.

Cutaneous absorption of trivalent chromium: tissue levels and treatment by exchange transfusion

ABSTRACT A man was accidentally immersed in hot acidic trivalent chromium sulphate solution but none was swallowed. The clinical course was dominated by burns, intravascular haemolysis, and acute renal failure. Blood concentrations of chromium were measured during treatment and tissue concentrations were measured at death. Exchange transfusion reduced blood chromium concentrations by two-thirds. The total quantities of chromium absorbed and removed by various routes were calculated. In-vitro studies showed that the chromium solution did not directly cause haemolysis.

Effects of hemodialysis and dimercaprol in acute dichromate poisoning

A 22-month-old infant died after ingesting sodium dichromate his father had brought from work. Treatment included folic acid and dimercaprol administration, hemodialysis, and exchange transfusion. To evaluate this treatment, four dogs were hemodialyzed after receiving intravenous sodium dichromate: their dialyzer chromate clearance was similar to their renal chromate clearance and their dialyzer chromate clearance was not significantly different before or after dimercaprol administration. This and other cases in the literature indicate that although chromate poisoning is often fatal, supportive care, forced diuresis, and chelating agents may be helpful. Hemodialysis may be required if renal failure occurs. Awareness of toxicity and prevention remain the most important approaches.

Chelation in metal intoxication. VIII. Removal of chromium from organs of potassium chromate administered rats

Some polyaminocarboxylic acids were examined for their ability to mobilize chromium from certain vital organs, their subcellular fractions, and blood cells of potassium chromate administered rats. Hexamethylene 1,6-diamino tetraacetic acid (TDTA), triethylene tetramine hexaacetic acid (TTHA), and ethylene diamine di (O-hydroxylphenyl acetic acid) (EDDHA) may be useful in preventing or reducing chromate toxicity. No definite relationship could be observed between the structure of the chelating agents and their chromium-removing capacity.

The time-related subcellular distribution of chromium in the rat liver cell after intravenous administration of Na2 (51)CrO 4

After intravenous administration of Na2 (51)CrO4 to rats the subcellular distribution of(51)Cr was determined at different time intervals after dosage. A time-related compartment shift from the cytosol into the mitochondrial and nuclear fractions was demonstrated. Dialysis studies indicated a firmer binding of(51)Cr to the mitochondrial and nuclear fractions than to the cytosol. Indirect evidence is presented that reduction from CrVI to CrIII takes place primarily inside the mitochondria. The hypothesis is put forward that reduction from Cr(VI) to Cr(III) may take place at any intracellular site where electron donors are available. Electron donors in the different intracellular organelles are discussed.

Intravascular haemolysis and acute renal failure following potassium dichromate poisoning

An 18-year-old girl developed acute renal failure 24 hr after ingestion of potassium dichromate. Laboratory data revealed associated intravascular haemolysis. Renal histology showed features suggestive of acute tubular necrosis. She went into diuretic phase after 11 days of oliguria and subsequently regained normal renal function. Both direct toxic damage by dichromate and intravascular haemolysis may have contributed to the development of acute tubular necrosis and acute renal failure.