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

Abstract

IntroductionBarium, 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 presentationOne 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.ConclusionThis 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.

Acute barium poisoning in a dog after ingestion of handheld fireworks (party sparklers)

“…This recovery is similar to the only other reported case of barium intoxication in a dog, such that it seems reasonable to expect a favorable outcome with appropriate supportive care . In people, barium toxicosis has led to an overall mortality rate of 12% in published cases over the past 70 years, whereas 2 recent series of 44 cases in Brazil and 27 cases in Bangladesh led to the death of 21% and 44% of the affected individuals, respectively . Death from barium toxicosis may in part be due to delay of treatment or resource restriction in cases of mass poisonings with most death occurring due to respiratory failure, emphasizing the importance of quick access to intensive care for survival of severe cases of barium poisoning.…”

“…Serum potassium levels as low as 1.7 mmol/L were identified in our case. From observations of 2 mass poisonings of people with barium via contaminated food, 3 distinct clinical stages of barium toxicosis emerged . The first stage consisted in the development of gastrointestinal signs (eg, vomiting and diarrhea) and mild paresthesia.…”

“…In refractory cases with cardiac instability or renal impairment, hemodialysis has been reported to be effective in reducing barium concentrations . Respiratory paralysis, resulting in marked respiratory acidemia, may require mechanical ventilation …”

Barium poisoning: an uncommon cause of severe hypokalemia

“…There were no deaths. Further epidemics have been described with contaminated flour in Bangladesh, potato flour in Israel [5], and salt in China [6]. Individual exposures have been reported with industrial exposure to barium salts [7], ingestion of barium containing shaving powder [8], and fireworks [9].…”

Depilatory Agents intoxication and factors contributing to its mortality: A 9-year review

“…15 Muscle weakness and hypokalemia are the main clinical features of barium poisoning. 16 In the present study, the medical records of all patients who presented with CABD poisoning during a 9-year period from 2000 to 2009 were reviewed. The mortality rate related to CABD was 5.8% in this study that is close to the rate reported in similar studies.…”