Fatal acute arsenic poisoning by external use of realgar: Case report and 30 years literature retrospective study in China.

Realgar (arsenic sulfide) is widely used in combination with other herbs as Chinese patent medicine to treat a variety of diseases in China. As a mineral arsenic, its mild toxicity was also well known. Longtime over-dose usage or wrongly oral intake of realgar can cause chronic arsenic poisoning and/or death, but acute fatal arsenic poisoning resulted from short-term dermal use of realgar-containing medicine was very rare. Here, we present the case of a 35-year-old Chinese man, who was diagnosed with severe psoriasis and died of fatal acute arsenic poisoning after he applied a local folk prescription ointment containing mainly the realgar to the affected skin for about 4 days. The autopsy showed multiple punctate hemorrhages over the limbs, pleural effusion, edematous lungs with consolidation, mild myocardial hypertrophy and normal-looking kidneys. The histopathological examination of renal tissue showed severe degeneration, necrosis and desquamation of renal tubular epithelial cells, presence of protein cast and a widened edematous interstitium with interstitial fibrosis. The presence of arsenic in large amount in the ointment (about 6%), in blood (1.76 µg/mL), and in skin (4.71 µg/g), were confirmed analytically. We also provide the clinical records of the deceased and briefly reviewed 7 similar cases in literature (6 in Chinese and 1 in English) in the past 30 years in China.

A Fatal Case of Acute Arsenic Poisoning.

This manuscript reported a case of fatal arsenic poisoning. A woman with schizophrenia took arsenic-containing "pills," which consisted of arsenic trioxide and realgar (arsenic (II) sulfide) and wrapped with gauze. The victim consumed 1.09 and 0.819 g arsenic on two occasions, respectively, with the interval between the two doses of 3 days. The woman died on the sixth day after the first dose without any treatment. In this case, pathological examination revealed fat degeneration of the liver rather than hepatomegaly, a rare finding in acute arsenic poisoning. Arsenic in tissue samples was measured, the total arsenic and inorganic arsenic in blood, liver, and gastric wall was 10.2 µg/mL (9.61 µg/mL), 23.1 µg/g (20.7 µg/g), and 32.3 µg/g (28.6 µg/g), respectively.

Mass poisoning with NPS: 2C-E and Bromo-DragonFly.

BACKGROUND: Reports of intoxications with new psychoactive substances (NPS) mostly involve young people, as they are the main consumers of these types of drugs. This report centers on a case that was unusual due to it being a mass-poisoning event involving middle-aged individuals who had consumed a combination of the two different new psychoactive drugs 2,5-dimethoxy-4-ethylphenethylamine (2C-E) and 1-(8-bromofuro[2,3-f][1]benzofuran-4-yl)-2-propanamine (Bromo-DragonFly, BDF). CASE HISTORY: The mass poisoning of 29 individuals (24-56 years old) resulted in their admission to six different hospitals with severe symptoms of intoxication. All symptoms manifested after consumption of an unknown drug formulation around lunchtime during an esoteric weekend seminar. INVESTIGATION: Urine (n = 11) and blood samples (n = 29), collected from the 29 individuals for police investigation, were analyzed with immunochemical techniques, GC/MS and LC-MS/MS. 2C-E was confirmed in seven urine samples, but not in blood. BDF was confirmed in all urine samples, and in 17 blood samples. The blood samples exhibited BDF concentrations between ca. 0.6 and ca. 2.0 µg/L, while urine concentrations of BDF ranged from ca. 1.6 to 35 µg/L. The concentration of 2C-E in urine was found to be between ca. 1.5 and 183 µg/L. All patients made a complete recovery, although some had required mechanical ventilation. CONCLUSION: The investigation and the presentation of this case illustrates not only mass intoxication with 2C-E and BDF, with corresponding blood and urine concentrations, but also the necessity of collecting urine samples in cases where NPS-consumption is suspected, in order to improve the chances of analytical detection.

Surma eye cosmetic in Afghanistan: a potential source of lead toxicity in children.

Surma is a traditional eye cosmetic used as an eyeliner for infants in Afghanistan, as well as in many other countries in Asia, the Middle East, and Africa. Surma has been reported to contain lead and to be a potential source of lead toxicity in children, which can lead to permanent damage to multiple organ systems. To our knowledge, assessment for lead in surma found in Afghanistan has not been performed. We determined the quantitative lead content of a convenience sample of 10 surma products acquired in Afghanistan. Analysis revealed that 70% of surma samples contained high levels of lead (range 35-83%). The remaining samples contained low levels of lead (range 0.04-0.17%). CONCLUSION: The majority of surma samples contained very high levels of lead, a troubling finding that could potentially correlate with lead toxicity in Afghan children. Making available lead-free surma alternatives and providing health education, for both healthcare professionals and the general population, in locations where surma use is prevalent and for those involved in care of refugees and immigrants from Afghanistan, may be strategies to prevent lead poisoning in children. What is Known: • Surma is a traditional cosmetic used as an eyeliner for infants in Afghanistan as well as in many countries in Asia, the Middle East, and Africa. • Surma has been reported to contain lead and to be a source of lead toxicity in children. What is New: • Assessment for lead content in surma found in Afghanistan has not been performed. • In this convenience sample of 10 surma products acquired in Afghanistan, 70% contained very high levels of lead.

The vitamin B12 analog cobinamide is an effective hydrogen sulfide antidote in a lethal rabbit model.

BACKGROUND AND PURPOSE: Hydrogen sulfide (H2S) is a highly toxic gas for which no effective antidotes exist. It acts, at least in part, by binding to cytochrome c oxidase, causing cellular asphyxiation and anoxia. We investigated the effects of three different ligand forms of cobinamide, a vitamin B12 analog, to reverse sulfide (NaHS) toxicity. METHODS: New Zealand white rabbits received a continuous intravenous (IV) infusion of NaHS (3 mg/min) until expiration or a maximum 270 mg dose. Animals received six different treatments, administered at the time when they developed signs of severe toxicity: Group 1-saline (placebo group, N = 9); Group 2--IV hydroxocobalamin (N = 7); Group 3--IV aquohydroxocobinamide (N = 6); Group 4--IV sulfitocobinamide (N = 6); Group 5--intramuscular (IM) sulfitocobinamide (N = 6); and Group 6-IM dinitrocobinamide (N = 8). Blood was sampled intermittently, and systemic blood pressure and deoxygenated and oxygenated hemoglobin were measured continuously in peripheral muscle and over the brain region; the latter were measured by diffuse optical spectroscopy (DOS) and continuous wave near infrared spectroscopy (CWNIRS). RESULTS: Compared with the saline controls, all cobinamide derivatives significantly increased survival time and the amount of NaHS that was tolerated. Aquohydroxocobinamide was most effective (261.5 ± 2.4 mg NaHS tolerated vs. 93.8 ± 6.2 mg in controls, p < 0.0001). Dinitrocobinamide was more effective than sulfitocobinamide. Hydroxocobalamin was not significantly more effective than the saline control. CONCLUSIONS: Cobinamide is an effective agent for inhibiting lethal sulfide exposure in this rabbit model. Further studies are needed to determine the optimal dose and form of cobinamide and route of administration.

Modern scientific evidence pertaining to criminal investigations in the Chosun dynasty era (1392-1897 A.C.E.) in Korea.

A guidebook detailing the process of forensic investigation was written in 1440 A.C.E. It outlines the fundamentals and details of each element of criminal investigation during the era of the Chosun dynasty in Korea. Because this old guidebook was written in terms of personal experience rather than on scientific basis, it includes many fallacies from the perspective of modern forensic science. However, the book describes methods to form a scientific basis for the experiments performed. We demonstrate the modern scientific basis for ancient methods to monitor trace amounts of blood and detect lethal arsenic poisoning from a postmortem examination as described in this old forensic guidebook. Traces of blood and arsenic poisoning were detected according to the respective color changes of brownish red, due to the reaction of ferric ions in blood with acetic ions of vinegar, and dark blue, due to the reaction of silver with arsenic sulfide.

Toxic epidermal necrolysis after extensive dermal use of realgar-containing (arsenic sulfide) herbal ointment.

BACKGROUND: Realgar (arsenic sulfide) is thought to be safe with few reports on toxicities or adverse effects and has been used in Traditional Chinese Medicine for many centuries. Serious realgar poisoning is rare, and we report a fatal case resulted from short-term use of realgar-containing herbal medicine through dermal route. CASE DETAILS: A 24-year-old man with atopic dermatitis had received 18 days of oral herbal medicine and realgar-containing herbal ointments over whole body from a Traditional Chinese Medicine (TCM) practitioner. Seven days after the herbal use, he had diminished appetite, dizziness, abdomen discomfort, itching rash, and skin scaling. He later developed generalized edema, nausea, vomiting, decreased urine amount, diarrhea, vesico-edematous exanthems, malodorous perspiration, fever, and shortness of breath. He was taken to the hospital on Day 19 when the dyspnea became worse. Toxic epidermal necrolysis complicated with soft tissue infection and sepsis was noted, and he later died of septic shock and multiple organ failure. The post-mortem blood arsenic level was 1225 µg/L. Herbal analysis yielded a very high concentration of arsenic in three unlabeled realgar-containing ointments (45427, 5512, and 4229 ppm). CONCLUSION: Realgar-containing herbal remedy may cause severe cutaneous adverse reactions. The arsenic in realgar can be absorbed systemically from repeated application to non-intact skin and thus should not be extensively used on compromised skin.

Fatal and non-fatal cases of lime sulfide exposure and pathogenetic mechanisms underlying pancreatic injury: Case reports with an animal experiment.

Lime sulfide poisoning by the oral route is rarely encountered in the practice of forensic science, whereas hydrogen sulfide poisoning is seen frequently. We report here two cases of fatal lime sulfide poisoning with several related cases and in addition induced histological damage with acute inflammation in animal models under at similar concentrations. We also evaluated sulfide and thiosulfate concentrations and speculated as to the cause of pancreatic damage in these cases.

[Fatal calcium polysulfide overdose presenting corrosive chemical injury of esophagus and sulf-hemoglobinemia].

A-79-year-old woman ingested a cup of unknown violet agricultural solution intentionally. She was vomiting and smelt of sulfur. Arterial blood gas showed metabolic acidosis and marked cyanosis regardless of relatively high PaO2, caused by sulfhemoglobinemia. A nasogastric tube could not be inserted because of marked stenosis caused by endoscopically proven severe corrosive chemical injury (burn) of esophagus. Considering the smell and the clinical presentation, we concluded that the causative agent was calcium polysulfide or lime-sulphur solution, a common agricultural product used as a fungicide. Despite supportive therapy including infusion of NaNO2, the patient expired 4.5 hours after ingestion. Calcium polysulfide ingestions cause direct injury to the upper gastrointestinal tract, and react with gastric HCl producing poisonous H2S gas, which interferes cytochrome oxidase activity, developing tissue hypoxia, shock, and metabolic acidosis. Sulfhemoglobin is also produced causing severe cyanosis.

[Use of kohl and severe lead poisoning in Brussels]. / Usage de khôl et intoxication saturnine grave à Bruxelles.

The authors report the observation of lead poisoning in a young Moroccan woman, which was caused by prolonged use of a khol made of lead sulphide. Khol is a black eye make-up used since Ancient Egypt. Clinically, this poisoning presented with abdominal crampoid pain, encephalopathy (manifested as anxiety and irritability), a Burtonian gingival border and microcytic sideropenic anaemia. Emergency chelate treatment permitted to improve clinical state and to decrease blood levels (initial blood concentration: 490 micrograms/dl; concentration six weeks after treatment: 49 micrograms/dl). The interest of such a case is recognizing, in French speaking regions, of a public health problem, largely ignored, although real, considering the high lead concentrations found in a majority of kohls available in Brussels and this very old cultural practice among Muslim populations.

Animal adaptations for tolerance and exploitation of poisonous sulfide.

Many aquatic animal species can survive sulfide exposure to some extent through oxidation of the sulfide, which results mainly in thiosulfate. In several species, sulfide oxidation is localized in the mitochondria and is accompanied by ATP synthesis. In addition, blood-based and intracellular compounds can augment sulfide oxidation. The formation of thiosulfate requires oxygen, which results in an increase in oxygen consumption of some species. If not all sulfide is detoxified, cytochrome C oxidase is inhibited. Under these conditions, a sulfide-dependent anaerobic energy metabolism commences.

Episode of toxic gas exposure in sewer workers.

OBJECTIVES: Sewer workers are used to unpleasant smells, but may be required to investigate unusual ones. Twenty six men were involved in investigation of episodes of such a smell after neighbourhood complaints over several weeks. METHODS: Workers exposed to the smell were investigated by clinical follow up, lung function tests, and measurement of pituitary function. RESULTS: 14 of the 26 developed subacute symptoms including sore throat, cough, chest tightness, breathlessness, thirst, sweating, irritability, and loss of libido. Severity of symptoms seemed to be dose related. Minor symptoms resolved over several weeks but those more seriously affected have shown deteriorating respiratory symptoms and lung function and remain unable to work a year after the incident. In one, evidence of mild cranial diabetes insipidus was found. Analysis of gas from the sewer showed the presence of a mixture of thiols and sulphides, known to be highly odorous and not normally found in sewers. The source remains unknown. CONCLUSIONS: Several of these men seem to have developed delayed airways disease and disturbances of hypothalamic function. Such an outcome has not to our knowledge been described before. Despite the presence of the smell, standard safety gas detection equipment used to ensure the sewer was safe to enter failed to indicate the presence of a hazard. Protection against such incidents can only be provided by the use of positive pressure breathing apparatus.

Calcium polysulfide overdose: a report of two cases.

BACKGROUND: Calcium polysulfide or lime-sulfur solution is a common agricultural product used as a fungicide. Despite its easy availability, only two prior cases of intentional ingestion, both from Japan, have been reported in the literature. CASE REPORTS: Two cases of calcium polysulfide ingestion are presented. In the first case severe acidosis, coma and cardiac arrest occurred. Despite aggressive supportive therapy, the patient expired. Autopsy examination revealed hemorrhagic necrosis of the gastric mucosa. The second patient also exhibited altered mental status and metabolic acidosis. He experienced liver dysfunction, rhabdomyolysis, renal dysfunction, and aspiration pneumonia. He had endoscopically proven esophageal and gastric mucosal burns which developed into esophageal strictures. CONCLUSIONS: Calcium polysulfide ingestions cause direct caustic injury to the upper gastrointestinal tract, coma and severe metabolic acidosis.

A case of drowning linked to ingested sulfides--a report with animal experiments.

An adult male was found dead beneath a pool of sewage in the pump room of a fish market. Autopsy revealed the cause of death to be suffocation after aspirating sewage into the respiratory tract. Since hydrogen sulfide gas was detected in the atmosphere at the scene of the accident, gas poisoning was suspected and toxicological analysis of sulfides in body tissues was performed. The concentrations of sulfides in the blood, lung and kidney were 0.95 mumol@ml, 0.22 and 0.38 mumol/g, respectively. These values were remarkably higher than those in previously reported cases involving exposure to hydrogen sulfide gas. Therefore, oral intake of sulfides was assumed and the distribution of sulfides in tissues following oral administration of sodium sulfide solution was examined by means of animal experiments using rats. The concentration of sulfides in the blood from rats following oral intake was much higher than that seen following gas exposure. Based on these results, we concluded that the victim had been exposed to hydrogen sulfide gas and had then collapse into a pool of sewage containing sulfides. The sulfides which were distributed throughout the body tissues had mainly issued from the alimentary tract prior to death by drowning.