1. A YOUNG WOMAN SURVIVED A LETHAL DOSE OF ARSENIC TRIOXIDE DUE TO AGGRESSIVE THERAPY IN INTENSIVE CARE SETTINGS
B.Vantroyen°,MD; J-F Heilierx, PharmD; A.Meulemans°, MD; A Michels+, PhD; J-P Buchetx, PhD; S Vanderschueren*, MD, PhD; V Haufroidx, PhD, PharmD; M Sabbe°, MD, PhD
° Department of Emergency Medicine, University Hospital Gasthuisberg, Catholic University of Louvain, Louvain, Belgium
+ Faculty of Physical Education and Physiotherapy, Louvain, Belgium
* Department of General Internal Medicine, University Hospital Gasthuisberg, Catholic University of Louvain, Louvain, Belgium
x Department of Industrial Toxicology and Occupational Medicine, Catholic University of Louvain, Brussels, Belgium
A case of acute poisoning with arsenic trioxide successfully treated with intensive therapy and close follow up is reported. The patient survived the highest ingested dose ever described.
CASE REPORT
A case of a 27 year old woman who ingested 9000mg arsenic trioxide (As2O3) is reported. Classical symptoms of an acute arsenic(As) poisoning such as gastrointestinal cramps, vomiting, diarrhea, ECG changes and disturbed liver function tests have been observed.
The absorption of the ingested As was minimized by a continuous gastric irrigation with highly concentrated NaHCO3 (60meq/L), started 8 hours after ingestion [1]. To complete digestive tract emptying, intestinal cleansing with polyethylenic glycol was performed. (Fig 1)
In addition, treatment with forced diuresis, BAL (2,3-dimercaptopropanol) and DMSA (meso-2,3-dimercaptosuccinid acid) was promptly started to increase As renal elimination. Despite this approach, the patient deteriorated (confusion, increased respiratory rate, hyperglycemia, decreased FEV1 and vital capacity (Fig 2)) which supported the need for an alternative therapy.
A methodology to enhance the formation of methylated As derivatives, which are potentially less toxic and which can be excreted more easily, was set up. This treatment was deducted from an in vitro study [2]. It was started after permission of the local ethical committee and consisted of 400mg HO-Vit B12, 150mg folinic acid, 2.4g methionine and 10g glutathion each day during 5 days. Urinary levels of total As, inorganic As, as well as monomethylated arsenic acid (MMA) and dimethylated arsenic acid (DMA) were measured up to one year after ingestion (Fig 3). The patient survived this massive dose of ingested inorganic As with only polyneuropathy in the long term follow up.
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CONCLUSION
An acute intoxication with a high dose of arsenic trioxide can be treated successfully with aggressive therapy and close follow up. In addition to the standard strategies (diminishing of absorption, enhancing of elimination with forced diuresis and chelating) methylation of inorganic arsenic was induced by administration of HO-Vit B12, folinic acid, methionine and glutathion.
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REFERENCES
[1] Michaux I, Haufroid V, Dive A, Buchet JP, Bulpa P, Mahieu P et Installé E. Repetitive endoscopy and continuous alkaline gastric irrigation in a case of arsenic poisoning. Clin Toxicol 2000; 38(5):
[2] Zakharyan R and Aposhian H. Arsenite methylation by methylvitamin B12 and glutathione does not require and enzyme. Toxicol Appl Pharmacol 1999; 154:
Fig 1. Consecutive abdominal X-rays showing progressive diminishing of gastro-intestnal Arsenic load
Fig 1. Successive abdominal X-rays, showing diminution of gastrointestinal arsenic load.