Lethal complications after poisoning with chloroform--case report and literature review

Acute liver injury in a non-alcoholic fatty liver disease patient with chloroform exposure: a case report

We report a rare case of acute liver injury by daily exposure to small amounts of chloroform in non-alcoholic fatty liver disease (NAFLD) patient. The patient had been followed up in our hospital every 3 months. Although his alanine aminotransferase (ALT) levels were steady around 30 ~ 60 U/L until August 2014, ALT level was spontaneously increased to more than 1,000 U/L at the follow-up point in late August 2014. As he was diagnosed as acute liver injury by chloroform exposure, we withdrew him from the exposure of chloroform and treated him with 600 mg/day of ursodeoxycholic acid. Afterwards, his ALT level rapidly improved and normalized within 1 month. To verify the influences of chloroform exposure, we measured plasma chloroform levels by gas chromatography. Although plasma chloroform concentration was 7.1 ng/ml (normal range: < 0.2 ng/ml) at the time of liver injury, the concentration had decreased to 0.7 ng/ml by 1 month later. Despite the fact that he had put on a face mask to protect from aspiration of chloroform, liver injury still occurred in the present case. Chloroform has a high solubility for lipids and accumulation of lipids in the liver might become a risk factor for liver injury by chloroform.

Modifiable contributing factors to COVID-19: A comprehensive review

The devastating complications of coronavirus disease 2019 (COVID-19) result from an individual's dysfunctional immune response following the initial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Multiple toxic stressors and behaviors contribute to underlying immune system dysfunction. SARS-CoV-2 exploits the dysfunctional immune system to trigger a chain of events ultimately leading to COVID-19. The current study identifies eighty immune system dysfunction-enabling toxic stressors and behaviors (hereafter called modifiable contributing factors (CFs)) that also link directly to COVID-19. Each CF is assigned to one of the five categories in the CF taxonomy shown in Section 3.3.: Lifestyle (e.g., diet, substance abuse); Iatrogenic (e.g., drugs, surgery); Biotoxins (e.g., micro-organisms, mycotoxins); Occupational/Environmental (e.g., heavy metals, pesticides); Psychosocial/Socioeconomic (e.g., chronic stress, lower education). The current study shows how each modifiable factor contributes to decreased immune system capability, increased inflammation and coagulation, and increased neural damage and neurodegeneration. It is unclear how real progress can be made in combatting COVID-19 and other similar diseases caused by viral variants without addressing and eliminating these modifiable CFs.

A Chemist with a Strange Etiology of Rhabdomyolysis: A Case Report of a Rare Toxicological Emergency

Introduction

Chloroform, a halogenated hydrocarbon, causes central nervous depression, hepatotoxicity, nephrotoxicity, and rhabdomyolysis. Historically, chloroform had been used as a general anaesthetic and today is still used in chemical industries. Lack of proper personal protective equipment and adequate knowledge about its toxic effects can lead to serious harm.

Case report

A 33-year-old gentleman presented to the emergency department (ED) with altered mental status. Given his depressed mental status, the decision was made to intubate shortly after arrival for airway protection. Further history raised suspicion of occupational chloroform exposure. Brown-colored urine further strengthened suspicion of chloroform poisoning with resultant rhabdomyolysis. Forced alkaline diuresis and N-acetylcysteine were started in the ED. His mental status and respiratory efforts improved on hospital day two, and he was ultimately extubated. Creatine phosphokinase and myoglobin levels were initially high but gradually came down by hospital day six. On hospital day 10, the patient was deemed stable and safely discharged.

Conclusion

A patient with chloroform inhalation who suffered resultant rhabdomyolysis and hepatotoxicity was successfully treated with early initiation of forced alkaline diuresis, N-acetylysteine, and hemodialysis.

Airborne volatile organic compounds at an e-waste site in Ghana: Source apportionment, exposure and health risks

Informal e-waste recycling processes emit various air pollutants. While there are a number of pollutants of concern, little information exists on volatile organic compounds (VOCs) releases at e-waste sites. To assess occupational exposures and estimate health risks, we measured VOC levels at the Agbogbloshie e-waste site in Ghana, the largest e-waste site in Africa, by collecting both fixed-site and personal samples for analyzing a wide range of VOCs. A total of 54 VOCs were detected, dominated by aliphatic and aromatic compounds. Mean and median concentrations of the total target VOCs were 46 and 37 μg/m³ at the fixed sites, and 485 and 162 μg/m³ for the personal samples. Mean and median hazard ratios were 2.1 and 1.4, respectively, and cancer risks were 4.6 × 10^-4 and 1.5 × 10^-4. These risks were predominantly driven by naphthalene and benzene; chloroform and formaldehyde were also high in some samples. Based on the VOC composition, the major sources were industry, fuel evaporation and combustion. The concentration gradient across sites and the similarity of VOC profiles indicated that the e-waste site emissions reached neighboring communities. Our results suggest the need to protect e-waste workers from VOC exposure, and to limit emissions that can expose nearby populations.

Occupational exposure and health risks of volatile organic compounds of hotel housekeepers: Field measurements of exposure and health risks

Hotel housekeepers represent a large, low-income, predominantly minority, and high-risk workforce. Little is known about their exposure to chemicals, including volatile organic compounds (VOCs). This study evaluates VOC exposures of housekeepers, sources and factors affecting VOC levels, and provides preliminary estimates of VOC-related health risks. We utilized indoor and personal sampling at two hotels, assessed ventilation, and characterized the VOC composition of cleaning agents. Personal sampling of hotel staff showed a total target VOC concentration of 57 ± 36 µg/m3 (mean ± SD), about twice that of indoor samples. VOCs of greatest health significance included chloroform and formaldehyde. Several workers had exposure to alkanes that could cause non-cancer effects. VOC levels were negatively correlated with estimated air change rates. The composition and concentrations of the tested products and air samples helped identify possible emission sources, which included building sources (for formaldehyde), disinfection by-products in the laundry room, and cleaning products. VOC levels and the derived health risks in this study were at the lower range found in the US buildings. The excess lifetime cancer risk (average of 4.1 × 10-5 ) still indicates a need to lower exposure by reducing or removing toxic constituents, especially formaldehyde, or by increasing ventilation rates.

3-methyadenine attenuates chloroform-induced hepatotoxicity via autophagy activation

Chloroform is a common contaminant in the drinking water. Exposure of human to chloroform leads to severe hepatotoxicity. In the present study, chloroform-induced acute liver injury was investigated in mice using 3-methyadenine (3-MA), a common autophagy inhibitor. At 24 h after intraperitoneal injection of 0.5 mL/kg chloroform, serum alanine aminotransferase (ALT) levels were increased significantly; extensive necrosis and inflammation occurred as identified by histological examinations. Moreover, chloroform induced an increase in lipid peroxidation as demonstrated by increased formation of malondialdehyde (MDA) in the liver tissues. Hepatic antioxidants including glutathione (GSH) and superoxide dismutase (SOD) were decreased by chloroform treatment. All these changes were significantly inhibited by 3-MA treatment. Further mechanistic insights demonstrated that chloroform up-regulated pro-inflammatory cytokine, IL-1β, in the livers and blood, which was suppressed by 3-MA. Surprisingly, Western blots results showed that after 24-hours of chloroform treatment 3-MA activated autophagy as indicated by decreased levels of LC3B II and p62 protein. Co-treatment of chloroquine with 3-MA to inhibit autophagy would abrogate the hepatoprotection of 3-MA in chloroform hepatotoxicity. Taken together, findings in the present study suggested that a widely-used autophagy inhibitor, 3-MA, significantly reduced chloroform hepatotoxicity in mice via autophagy activation. Findings in this study also suggested that caution should be exercised when using 3-MA to modulate autophagy in vivo.

Anesthetized by chloroform before hanging

We present a unique case of suicidal hanging. The deceased was a 31-year-old male who was found hanging from a tree in a dense thicket, with his lower limbs in contact with the ground (partial suspension). There was an apparatus similar to a facial mask placed around his nose and mouth. A strong chemical smell was emanating from the apparatus, which was identified as chloroform (Formyl trichloride/CHCl₃). A ligature with a soft cloth beneath it was around his neck. A ligature mark was present around the neck. The decedent's blood alcohol levels were 112 mg/dl. The blood and stomach contents were negative for chloroform. A complete death investigation, including scene investigation and complete autopsy examination, confirmed the cause of death as hanging. The manner of death was suicide. This case highlights how the deceased had used several methods whilst committing suicide to minimize pain, including the inhalation of chloroform, which would have also resulted in the inability to engage in protective actions during the act.

Nonylphenol aggravates non-alcoholic fatty liver disease in high sucrose-high fat diet-treated rats

Exposure to environmental endocrine disruptors (EEDs) contributes to the pathogenesis of many metabolic disorders. Here, we have analyzed the effect of the EED-nonylphenol (NP) on the promotion of non-alcoholic fatty liver disease (NAFLD) in rats fed high sucrose-high fat diet (HSHFD). Fifty Sprague-Dawley rats were divided into five groups: controls fed a normal diet (C-ND); HSHFD-fed controls (C-HSHFD); and rats fed a HSHFD combined with NP at doses of 0.02 μg/kg/day (NP-L-HSHFD), 0.2 μg/kg/day (NP-M-HSHFD), and 2 μg/kg/day (NP-H-HSHFD). Subchronic exposure to NP coupled with HSHFD increased daily water and food intake (p < 0.05), hepatic echogenicity and oblique liver diameter (p < 0.05), and plasma levels of alanine aminotransferase, aspartate aminotransferase, total cholesterol, triglycerides, and low density lipoprotein cholesterol (p < 0.05). Combined exposure to NP and HSHFD induced macrovesicular steatosis with dilation and congestion of the central vein, liver inflammatory cell infiltration, and expression of genes regulating lipid metabolism, SREBP-1C, FAS, and Ucp2. These results demonstrate that NP aggravates NAFLD in HSHFD-treated rats by up-regulating lipogenic genes, and that HSHFD increases the toxic effects of NP. Thus subchronic NP exposure may lead to NAFLD, especially when combined with a high-sucrose/high-fat diet.

Systemic inflammatory response due to chloroform intoxication--an uncommon complication

Well-known adverse effects of chloroform are drowsiness, nausea, and liver damage. Two cases with an uncommon complication due to chloroform intoxication are presented. In the first case, a general physician, because of nausea and dyspnea, admitted a 34-year-old woman to hospital. She developed a toxic pulmonary edema requiring mechanical ventilation for a few days, and a systemic inflammatory response syndrome (SIRS) with elevated white blood cell counts, a moderate increase of C-reactive protein, and slightly elevated procalcitonin levels. There were inflammatory altered skin areas progressing to necrosis later on. However, bacteria could be detected neither in blood culture nor in urine. Traces of chloroform were determined from a blood sample, which was taken 8 h after admission. Later, the husband confessed to the police having injected her chloroform and put a kerchief soaked with chloroform over her nose and mouth. In the second case, a 50-year-old man ingested chloroform in a suicidal attempt. He was found unconscious in his house and referred to a hospital. In the following days, he developed SIRS without growth of bacteria in multiple blood cultures. He died several days after admission due to multi-organ failure. SIRS in response to chloroform is a rare but severe complication clinically mimicking bacterial-induced sepsis. The mechanisms leading to systemic inflammation after chloroform intoxication are currently unclear. Possibly, chloroform and/or its derivates may interact with pattern recognition receptors and activate the same pro-inflammatory mediators (cytokines, interleukins, prostaglandins, leukotrienes) that cause SIRS in bacterial sepsis.

Escalating chronic kidney diseases of multi-factorial origin in Sri Lanka: causes, solutions, and recommendations

During the last two decades, Sri Lanka, located close to the equator, has experienced an escalating incidence of chronic kidney disease (CKD) of unknown aetiology (CKDue) in dry zonal areas. Similar incidences of unusual CKDs have been reported in the dry zonal, agricultural areas of several other equatorial countries. In Sri Lanka, the incidence of CKDue is highest in the North Central Province (NCP), where approximately 45 % of the country's paddy fields are located. However, in recent years, the disease has spread into areas adjacent to as well as distant from the NCP. The cause of CKD in Sri Lanka is unknown, and may likely due to interactions of different potential agents; thus, CKD is of multi-factorial origin (CKD-mfo). These factors include, the negative effects from overuse of agrochemicals. Nevertheless, the potential interactions and synergism between probable agents have not been studied. This systematic review discusses the proposed hypotheses and causes of CKD-mfo in Sri Lanka, and ways to decrease the incidence of this disease and to eradicate it, and provide some recommendations. During the past decade, a number of groups have investigated this disorder using different methodologies and reported various correlations, but failed to find a cause. Research has focussed on the contamination of water with heavy metals, agrochemicals, hard water, algae, ionicity, climate change, and so forth. Nevertheless, the levels of any of the pollutants or conditions reported in water in NPC are inconsistent not correlated with the prevalence of the disease, and are too low to be the sole cause of CKD-mfo. Meanwhile, several nephrotoxins prevalent in the region, including medications, leptospirosis, toxic herbs, illicit alcohol, locally grown tobacco, and petrochemicals, as well as the effects of changed habits occured over the past four decades have not been studied to date. Taken together, the geographical distribution and overall findings indicate that combinations of factors and/or their interactions are likely to precipitate CKD-mfo, which kills more than 5,000 people annually in Sri Lanka; most victims are middle-aged male farmers. Much anecdotal evidence from this region suggests that consumption of contaminated water is the most likely source of this deadly disease. Although the aetiology is unknown, prevention of this "environmentally acquired" disease seems relatively straightforward. Solutions include (a) preventing environmental pollution, (b) stopping the irresponsible use and decreasing the usage of agrochemicals, and encouraging the use of environmentally friendly agricultural methods, (c) taking proper precautions when using agrochemicals and safe disposal of their containers, (d) changing the risky behaviour of farmers and educating them to preserve the environment, and (e) providing clean potable water to all affected regions. Implementing a well-coordinated, in-depth, region-wide, broad-based research study together with a long-term effective surveillance programme across the country is essential to curbing this disease. Unless firm actions are taken promptly, more than three million healthy people in the country, live in agricultural regions, are at risk for contracting CKD-mfo and succumb to premature deaths, which are preventable.

Escalating chronic kidney diseases of multi-factorial origin in Sri Lanka: causes, solutions, and recommendations

During the last two decades, Sri Lanka, located close to the equator, has experienced an escalating incidence of chronic kidney disease (CKD) of unknown aetiology (CKDue) in dry zonal areas. Similar incidences of unusual CKDs have been reported in the dry zonal, agricultural areas of several other equatorial countries. In Sri Lanka, the incidence of CKDue is highest in the North Central Province (NCP), where approximately 45 % of the country's paddy fields are located. However, in recent years, the disease has spread into areas adjacent to as well as distant from the NCP. The cause of CKD in Sri Lanka is unknown, and may likely due to interactions of different potential agents; thus, CKD is of multi-factorial origin (CKD-mfo). These factors include, the negative effects from overuse of agrochemicals. Nevertheless, the potential interactions and synergism between probable agents have not been studied. This systematic review discusses the proposed hypotheses and causes of CKD-mfo in Sri Lanka, and ways to decrease the incidence of this disease and to eradicate it, and provide some recommendations. During the past decade, a number of groups have investigated this disorder using different methodologies and reported various correlations, but failed to find a cause. Research has focussed on the contamination of water with heavy metals, agrochemicals, hard water, algae, ionicity, climate change, and so forth. Nevertheless, the levels of any of the pollutants or conditions reported in water in NPC are inconsistent not correlated with the prevalence of the disease, and are too low to be the sole cause of CKD-mfo. Meanwhile, several nephrotoxins prevalent in the region, including medications, leptospirosis, toxic herbs, illicit alcohol, locally grown tobacco, and petrochemicals, as well as the effects of changed habits occured over the past four decades have not been studied to date. Taken together, the geographical distribution and overall findings indicate that combinations of factors and/or their interactions are likely to precipitate CKD-mfo, which kills more than 5,000 people annually in Sri Lanka; most victims are middle-aged male farmers. Much anecdotal evidence from this region suggests that consumption of contaminated water is the most likely source of this deadly disease. Although the aetiology is unknown, prevention of this "environmentally acquired" disease seems relatively straightforward. Solutions include (a) preventing environmental pollution, (b) stopping the irresponsible use and decreasing the usage of agrochemicals, and encouraging the use of environmentally friendly agricultural methods, (c) taking proper precautions when using agrochemicals and safe disposal of their containers, (d) changing the risky behaviour of farmers and educating them to preserve the environment, and (e) providing clean potable water to all affected regions. Implementing a well-coordinated, in-depth, region-wide, broad-based research study together with a long-term effective surveillance programme across the country is essential to curbing this disease. Unless firm actions are taken promptly, more than three million healthy people in the country, live in agricultural regions, are at risk for contracting CKD-mfo and succumb to premature deaths, which are preventable.

Toxicant-associated steatohepatitis

Hepatotoxicity is the most common organ injury due to occupational and environmental exposures to industrial chemicals. A wide range of liver pathologies ranging from necrosis to cancer have been observed following chemical exposures both in humans and in animal models. Toxicant-associated fatty liver disease (TAFLD) is a recently named form of liver injury pathologically similar to alcoholic liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD). Toxicant-associated steatohepatitis (TASH) is a more severe form of TAFLD characterized by hepatic steatosis, inflammatory infiltrate, and in some cases, fibrosis. While subjects with TASH have exposures to industrial chemicals, such as vinyl chloride, they do not have traditional risk factors for fatty liver such as significant alcohol consumption or obesity. Conventional biomarkers of hepatotoxicity including serum alanine aminotransferase activity may be normal in TASH, making screening problematic. This article examines selected chemical exposures associated with TAFLD in human subjects or animal models and concisely reviews the closely related NAFLD and ALD.