Survival After a Lethal Dose of Arsenic Trioxide

Abstract

A case of a 27-year-old woman who ingested 9000 mg arsenic trioxide (As2O3) is reported. Classical symptoms of an acute arsenicum (As) poisoning such as gastrointestinal cramps, vomiting, diarrhea, ECG changes and disturbed liver function tests were observed. The absorption of the ingested As was minimalized by a continuous gastric irrigation with highly concentrated NaHCO3 and intestinal cleansing with NaHCO3 and polyethyleneglycol was performed. Forced diuresis, BAL (2,3-dimercaptopropanol) and DMSA (meso-2,3-dimercaptosuccinic acid) were started and therapy to enhance the formation of methylated As derivatives, which are potentially less toxic and which can be excreted more easily, was then administered. The patient survived this massive dose of ingested inorganic As with only polyneuropathy one year later.

Heavy metal poisoning: management of intoxication and antidotes

“…However, increased urinary arsenic clearance has not been consistently demonstrated following DMSA therapy [33,35]. Neuropathy progression despite chelation therapy has been reported [17,33]. DMSA is only U.S. Food and Drug Administration (FDA) approved for the treatment of lead toxicity in children but has orphan status for the treatment of mercury poisoning [35].…”

“…Early symptoms consist of a symmetric sensorimotor neuropathy, which may be initially misdiagnosed as Guillain-Barré syndrome [6,26]. Patients who develop arsenic-induced neuropathy note pain, numbness, and paresthesias in a stocking glove distribution [6,17]. Electrophysiological studies are consistent with axonal degeneration, showing a decrease in amplitude, and with severe poisonings velocity [6].…”

“…Altered mental status with confusion can be seen [17] and "seizures" or hypoxic convulsions may signal a pre-terminal event [8,19]. Cardiac abnormalities have been noted following arsenic exposure, particularly following treatment with arsenic trioxide.…”

Successful Treatment of Potentially Fatal Heavy Metal Poisonings

“…Recently published cases describe survival after ingestion of 5 and 9 grams of arsenic trioxide (6,10). Both of these cases had aggressive decontamination and combined BAL and succimer chelation therapy.…”

Mineral Arsenicals in Traditional Medicines: Orpiment, Realgar, and Arsenolite

“…Short-term toxicity of arsenic trioxide is the major concern in the use of this agent to against malignancies, and at least three sudden deaths have been reported (Westervelt et al, 2001). Prompt chelation treatment is beneficial for short-term arsenic trioxide intoxication; for example, there was a potentially lethal case in which a patient ingested with 9000 mg of arsenic trioxide was rescued by prompt emergency care, forced diuresis, and chelation therapy with 2,3-dimercaptopropanol and meso-2.3-dimercaptopropanol ( Vantroyen et al, 2004). The clinical doses of arsenic trioxide (5-10 mg i.v.)…”