Acute arsenic poisoning

Abstract

A 43-year-old male attempted suicide in July, 2001, by drinking 54 g of arsenic trioxide (As2O3). The patient, a chemist by profession, prepared this amount of arsenic trioxide in his factory laboratory using a commercial solution of arsenic trichloride (AsCl3) as a base. He was admitted 5 h later. On arrival he was pale and diaphoretic, but his vital signs were normal. He was initially treated with gastric lavage and charcoal. 2 h later he developed vomiting, diarrhoea, thirst, pharyngeal constriction and paresthaesias in the legs. Initial blood tests were normal, except for a white cell count of 12·5×109/L. We measured blood and urine arsenic levels daily using inductively coupled plasma/ mass spectrometry. On the first day, the arsenic level in urine was 67 500 μg/L (normal <50 μg/L) and 132 μg/L (normal <5 μg/L) in blood. We gave him intravenous fluids and and 5 mg/kg of dimercaprol (British Anti-Lewisite, or BAL) intramuscularly every 6 h. An abdominal radiograph showed a large radio-opaque mass in the gastric antrum and a speckled pattern in the intestine (figure). We did a laparotomy and temporarily clamped the pylorus, and then attempted to remove the arsenic by gastric lavage with 22 L of 0·45% saline. Intraoperative fluoroscopy showed abundant radio-opaque material. We then tried to remove the arsenic endoscopically, but failed, as the arsenic had adhered strongly to the gastric mucosa. We finally did a gastrotomy and manually removed most of it.