Mass barium carbonate poisoning with fatal outcome, lessons learned: a case series.

INTRODUCTION: Barium, a heavy divalent alkaline metal, has long been known to cause human toxicity. The common mode is accidental ingestion and the common compound is Barium carbonate. Here we report an incident of food poisoning in 27 law enforcement personnel with rapidly developing sequelae and a high mortality due to ingestion of Barium carbonate contaminated flour. CASE PRESENTATION: One midnight, 27 adult males were rushed to emergency department of Chittagong Medical College Hospital with abdominal pain, vomiting, loose motion, cramps and generalized paraesthesia. The ailment started 1-2 hours after Iftar (evening meal to break day long fast during Ramadan) which included fried vegetables coated with a flour paste. On admission, twenty of them were restless, agitated. 22 reported weakness of limbs and were unable to walk. 10 had hypotension. 22 had rapid and shallow respiration. 5 had carpopedal spasm. Different grades of limb weakness were noted with loss of tendon jerks. Ten (N12) patients had hypokalaemia, three had hypoglycaemia, 4 patients had high creatine kinase. ECG showed flat ST with U waves in 4 patients. Potassium containing intravenous fluid and Oxygen was administered. Due to limited availability of mechanical ventilators patients were put on artificial respiration using Ambu bag; manually maintained by doctors, paramedics and attendants. Four patients were transferred to another hospital for mechanical ventilation. A total of 12 patients died over next 16 hours, 4 within 3 hrs. Other patients gradually improved. Chemical analysis of the vomitus, blood and flour used for preparation of meal revealed the presence of Barium. It was assumed that the flour was contaminated with the similar looking Barium carbonate powder which was kept in the kitchen as a rodenticide. CONCLUSION: This event exemplifies the weakness of usual health care facility in resource poor settings to cope with this kind of massive poisoning event. The multiple reported incidences of accidental barium poisoning due to unintentional mixing with food signifies the fact that the use and availability of barium carbonate should be restricted. We hope to draw attention to this relatively uncommon poisoning and to the need for development of poison information centre in resource poor countries.

Mass barium carbonate poisoning with fatal outcome, lessons learned: a case series.

INTRODUCTION: Barium, a heavy divalent alkaline metal, has long been known to cause human toxicity. The common mode is accidental ingestion and the common compound is Barium carbonate. Here we report an incident of food poisoning in 27 law enforcement personnel with rapidly developing sequelae and a high mortality due to ingestion of Barium carbonate contaminated flour. CASE PRESENTATION: One midnight, 27 adult males were rushed to emergency department of Chittagong Medical College Hospital with abdominal pain, vomiting, loose motion, cramps and generalized paraesthesia. The ailment started 1-2 hours after Iftar (evening meal to break day long fast during Ramadan) which included fried vegetables coated with a flour paste. On admission, twenty of them were restless, agitated. 22 reported weakness of limbs and were unable to walk. 10 had hypotension. 22 had rapid and shallow respiration. 5 had carpopedal spasm. Different grades of limb weakness were noted with loss of tendon jerks. Ten (N12) patients had hypokalaemia, three had hypoglycaemia, 4 patients had high creatine kinase. Electrocardiogram showed flat ST with U waves in 4 patients. Potassium containing intravenous fluid and Oxygen was administered. Due to limited availability of mechanical ventilators patients were put on artificial respiration using Ambu bag; manually maintained by doctors, paramedics and attendants. Four patients were transferred to another hospital for mechanical ventilation. A total of 12 patients died over next 16 hours, 4 within 3 hrs. Other patients gradually improved. Chemical analysis of the vomitus, blood and flour used for preparation of meal revealed the presence of Barium. It was assumed that the flour was contaminated with the similar looking Barium carbonate powder which was kept in the kitchen as a rodenticide. CONCLUSION: This event exemplifies the weakness of usual health care facility in resource poor settings to cope with this kind of massive poisoning event. The multiple reported incidences of accidental Barium poisoning due to unintentional mixing with food signifies the fact that the use and availability of Barium carbonate should be restricted. We hope to draw attention to this relatively uncommon poisoning and to the need for development of poison information centre in resource poor countries.

Hyponatremia in severe malaria: evidence for an appropriate anti-diuretic hormone response to hypovolemia.

Although hyponatremia occurs in most patients with severe malaria, its pathogenesis, prognostic significance, and optimal management have not been established. Clinical and biochemical data were prospectively collected from 171 consecutive Bangladeshi adults with severe malaria. On admission, 57% of patients were hyponatremic. Plasma sodium and Glasgow Coma Score were inversely related (r(s) = -0.36, P < 0.0001). Plasma antidiuretic hormone concentrations were similar in hyponatremic and normonatremic patients (median, range: 6.1, 2.3-85.3 versus 32.7, 3.0-56.4 pmol/L; P = 0.19). Mortality was lower in hyponatremic than normonatremic patients (31.6% versus 51.4%; odds ratio [95% confidence interval]: 0.44 [0.23-0.82]; P = 0.01 by univariate analysis). Plasma sodium normalized with crystalloid rehydration from (median, range) 127 (123-140) mmol/L on admission to 136 (128-149) mmol/L at 24 hours (P = 0.01). Hyponatremia in adults with severe malaria is common and associated with preserved consciousness and decreased mortality. It likely reflects continued oral hypotonic fluid intake in the setting of hypovolemia and requires no therapy beyond rehydration.