2,4-dinitrophenol (2,4-DNP) poisoning in young athletes: Clinical description of chronic exposure and public health perspectives – Around a case report

Abstract

To present a complete description of a 2,4-dinitrophenol (2,4-DNP) lethal acute poisoning in a chronic intoxication context, with lines of thought about sports medicine, emergency medicine and public health. We report the case of a 21-year-old man practicing intensive bodybuilding, consuming 2,4-DNP as well as anabolic steroids (stanozolol, nandrolone, testosterone, trenbolone) during the six months preceding death and with follow-up medical documentation over the entire period of consumption, including postmortem investigations (autopsy, toxicological and anatomopathologic explorations, police investigation). After a first hospital stay due to acute 2,4-DNP poisoning four months before death, the ignorance of the toxic hypothesis by the general practitioners, maintained by the patient's total denial of the link between his symptoms and his consumption, has led to a diagnostic wandering with a multiplicity of consultations and complementary examinations mainly in search of tumoral or endocrine etiologies. He was finally admitted to the emergency room after ingesting 2 g of 2,4-DNP: in absence of antidote, he was monitored, and died 12 hours after admission due to multi-organ failure. Autopsy revealed only a characteristic yellow coloration of the integuments and diffuse visceral congestion, anatomopathology of the heart showed left ventricular hypertrophy not meeting the criteria of hypertrophic cardiomyopathy, and toxicological analyses the presence of 2,4-DNP in blood (88 mg/L, pre-mortem) and urine (83 mg/L, postmortem). From a judicial point of view, the death was considered accidental and did not lead to additional investigations into the subject's supply of 2,4-DNP; this while the molecule is knowing a resurgence of interest in the bodybuilders’ world where it is presented as a fat burner and that health alerts are increasing in Anglo-Saxon countries. These alerts are part of the context of the trivialization of these substances’ use in sports circles frequented by subjects suffering from muscle dysmorphia, a psychic pathology generating a denial of the health risks associated with such consumptions. Concerning the therapy of acute 2,4-DNP poisoning, several published cases raise the question of straight away aggressive management on arrival of these patients in order to fight against hyperthermia and axial hypertonia, which are responsible lethal cases. Although the purpose of forensic autopsy is primarily judicial, and while the treatment of this case from this point of view seems regrettable, it must also be considered from a public health perspective, by generation of vigilance signals allowing the identification of consumption phenomena, the training of health professionals and the information of the populations. And if the exploration of sudden deaths linked to the sports activity of young subjects has known real progress concerning search for cardiovascular pathologies, in particular of genetic origin, the implication of xenobiotics must not be ignored, insofar as nearly 40% of these deaths remain unexplained, and especially since certain consumer profiles, in particular suffering from muscle dysmorphia, would be in denial of the health consequences of their consumption and could then under-declare them to their entourage and health professionals.