[Life-threatening metabolic acidosis after ingestion of fire extinguisher powder]. / Lebensbedrohliche Acidose nach Ingestion von ABC-Löschpulver.

We present the case of a 31-year old male with ingestion of fire extinguisher powder in an attempted suicide. After consulting several poison information centres, the intoxication was initially classified as harmless; nevertheless, the patient was admitted to our intensive care unit for cardiopulmonary monitoring. Subsequently, due to the ingestion of ammonium sulphate and ammonium dihydrogen phosphate containing powder the patient developed severe metabolic acidosis with distinct electrolyte imbalance that required temporary haemodialysis.

Serum phosphate levels are related to all-cause, cardiovascular and COPD mortality in men.

Hyperphosphatemia has been associated with increased mortality in chronic kidney disease but the nature of such a relation in the general population is unclear. To investigate the association between phosphate (P) levels and all-cause and cause-specific mortality, we assessed two cohorts from the Rotterdam Study, with follow-up of 14.5 (RS-I) and 10.9 (RS-II) years until January 2012 with availability of fasting phosphate levels. Deaths were classified according to International Classification of Diseases into 7 groups: cardiovascular, cancer, infections, external, dementia, chronic lung diseases and other causes. Sex-stratified Weibull and competing-risks models were adjusted for age, BMI and smoking. Hazard ratios are expressed per 1 mg/dL increase in phosphate levels. The total number of participants included 3731 (RS-I, 2154 women) and 2494 (RS-II, 1361 women) subjects. The main outcome measures were all-cause and cause-specific mortality. A significant positive association was found between phosphate and all-cause mortality in men (pooled HR (95% CI): 1.46 (1.26-1.69)) but not in women (0.90 (0.77-1.05)). In men, higher phosphate increased the risk for cardiovascular mortality (1.66 (1.29-2.14)), other causes (1.67 (1.16-2.40)) and chronic lung disease mortality (1.94 (1.02-3.72)), the latter driven by mortality due to chronic obstructive pulmonary disease (COPD) (4.44 (2.08-9.49)). No relations were found for mortality due to infections, cancer, dementia or external causes. In conclusion, serum P is associated with increased all-cause, cardiovascular and COPD mortality in men but not women. The association with COPD mortality is novel and needs further research on underlying mechanisms.

[Phosphate Intoxication after Application of Enema--a Life-threatening Iatrogenic Complication]. / Phosphatintoxikation nach Klysmagabe--eine lebensgefährliche iatrogene Komplikation.

INTRODUCTION: Enemas are used in pediatric patients with constipation. Retention of phosphate containing enemas with prolonged resorption or reduced renal elimination of phosphate can result in life-threatening hyperphosphatemia with subsequent lethal hypocalcemia and acidosis. CASE PRESENTATION: We report the case of a 6-month-old child who received phosphate-containing enema to treat acute aggravation of constipation. The used enema here was not licensed for this age group. Phosphate intoxication resulted (phosphate 19.87 mmol/l) and presented like a sepsis. Hyperphosphatemia was treated by hemodialysis. A non-diagnosed Hirschsprung disease had led to prolonged resorption of phosphate containing enema and to an ileus and toxic megacolon that had to be operated. CONCLUSION: Insufficient elimination of phosphate containing enema can result in lethal or life threatening hyperphosphatemia, hypocalcemia and metabolic acidosis. These can be treated efficaciously by hemodialysis. Because of the high risk of intoxication in using enemas containing phosphate in infants or in patients with gastrointestinal or renal comorbidities, physicians treating constipation should choose enemas without phosphate but with ingredients with lower risk like glycerol or sorbitol in this age group.

Findings of biopsy-proven chronicity and end-stage renal failure associated with oral sodium phosphate solution.

Bowel purgatives containing oral sodium phosphate (OSP) solution are used frequently in general practice and they have the potential of causing acute kidney injury especially in patients with some identified risk factors. Kidney injury may lead to chronicity and end-stage renal disease. Here we present, with renal biopsy findings, an elderly patient suffering from end-stage renal failure due to OSP solution.

Fire extinguisher: an imminent threat or an eminent danger?

Acute phosphate toxicity following rectal administration of phosphate-containing preparations was documented earlier. However, acute phosphate toxicity due to inhalation of monoammonium phosphate (MAP) is rarely reported. The present report describes the systemic toxicity following intentional inhalation of MAP, a dry chemical powder present in fire extinguishers, in a 25-year-old healthy man with normal renal function resulting in hyperphosphatemia (11.0 mg/dL), hypocalcemia (ionized calcium, 1.18 mg/dL; total calcium, 3.6 mg/dL), hypomagnesemia (1.2 mg/dL), seizures, and 4 episodes of pulseless polymorphic ventricular tachycardia requiring defibrillation. In view of the easy accessibility of fire extinguishers and its likely use for suicidal or homicidal purposes, physicians and practitioners working in emergency departments should be aware of this entity. Early recognition, removal of phosphate by hemodialysis, and supportive care have prevented this case from acute phosphate nephropathy and further complications.

Sediment and nutrients transport in watershed and their impact on coastal environment.

Sediment and nutrients yields especially from farmlands were studied in a watershed in Ishigaki island, Okinawa, Japan. The transport processes of these materials in rivers, mangrove, lagoon and coastal zones were studied by using various observation methods including stable isotope analysis. They were simulated by using a WEPP model which was modified to be applicable to such small islands by identifying several factors from the observations. The model predicts that a proper combination of civil engineering countermeasure and change of farming method can reduce the sediment yield from the watershed by 74%. Observations of water quality and coral recruitment test in Nagura bay indicate that the water is eutrophicated and the corals cannot grow for a long time. Based on these observations, a quantitative target of the reduction of sediment and nutrients yield in watershed can be decided rationally.

Fatal acute sodium phosphate enemas intoxication.

We describe a patient who died as a result of severe hypocalcaemia and hyperphosphatemia after treatment with a sodium-phosphate enema. Physicians should be aware of the risk when using these enemas, even in normal doses, especially in elderly patients without signs of renal failure, as in our patient.

Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure.

The findings of diffuse tubular injury with abundant tubular calcium phosphate deposits on renal biopsy are referred to as nephrocalcinosis, a condition typically associated with hypercalcemia. During the period from 2000 to 2004, 31 cases of nephrocalcinosis were identified among the 7349 native renal biopsies processed at Columbia University. Among the 31 patients, 21 presented with acute renal failure (ARF), were normocalcemic, and had a history of recent colonoscopy preceded by bowel cleansing with oral sodium phosphate solution (OSPS) or Visicol. Because the precipitant was OSPS rather than hypercalcemia, these cases are best termed acute phosphate nephropathy. The cohort of 21 patients with APhN was predominantly female (81.0%) and white (81.0%), with a mean age of 64.0 yr. Sixteen of the 21 patients had a history of hypertension, 14 (87.5%) of whom were receiving an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. The mean baseline serum creatinine was 1.0 mg/dl, available within 4 mo of colonoscopy in 19 (90.5%) patients. Patients presented with ARF and a mean creatinine of 3.9 mg/dl at a median of 1 mo after colonoscopy. In a few patients, ARF was discovered within 3 d of colonoscopy, at which time hyperphosphatemia was documented. Patients had minimal proteinuria, normocalcemia, and bland urinary sediment. At follow-up (mean 16.7 mo), four patients had gone on to require permanent hemodialysis. The remaining 17 patients all have developed chronic renal insufficiency (mean serum creatinine, 2.4 mg/dl). Acute phosphate nephropathy is an underrecognized cause of acute and chronic renal failure. Potential etiologic factors include inadequate hydration (while receiving OSPS), increased patient age, a history of hypertension, and concurrent use of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.

Phosphate enema toxicosis in a pygmy goat wether.

Phosphate enema toxicity was diagnosed in a 7-month-old, castrated male, pygmy goat. On presentation, clinical findings included mild depression, tachycardia, tachypnea, rumen stasis, muscle tremors, hypocalcemia, hypokalemia, hypochloremia, hyperphosphatemia, azotemia, and metabolic acidosis. Fluid diuresis and parenteral antimicrobial therapy resulted in recovery after 3 d of treatment.

Fatal intravenous injection of potassium in hospitalized patients.

We describe 4 cases of fatal intravenous injection of potassium in the hospital setting. These cases illustrate the subtlety of findings in such deaths and remind the forensic pathologist to consider this type of event in sudden, unexpected death of hospitalized patients.

Extreme hyperphosphatemia and acute renal failure after a phosphorus-containing bowel regimen.

Phosphate intoxication, manifested by hypocalcemic tetany and acute renal failure, may complicate bowel-cleansing preparations which contain phosphate. These preparations are commonly used to prepare patients for various gastrointestinal procedures. Often, patients who receive these regimens are at increased risk of phosphate intoxication from diseases which slow gastrointestinal transit or decrease renal excretion (renal insufficiency). We present a patient who developed oliguric acute renal failure from severe phosphate intoxication associated with a phosphate-containing bowel-cleansing regimen.