Acute copper intoxication. Pathophysiology and therapy with a case report

Re-evaluation of the existing health-based guidance values for copper and exposure assessment from all sources

Copper is an essential micronutrient and also a regulated product used in organic and in conventional farming pest management. Both deficiency and excessive exposure to copper can have adverse health effects. In this Scientific Opinion, the EFSA 2021 harmonised approach for establishing health-based guidance values (HBGVs) for substances that are regulated products and also nutrients was used to resolve the divergent existing HBGVs for copper. The tightly regulated homeostasis prevents toxicity manifestation in the short term, but the development of chronic copper toxicity is dependent on copper homeostasis and its tissue retention. Evidence from Wilson disease suggests that hepatic retention is indicative of potential future and possibly sudden onset of copper toxicity under conditions of continuous intake. Hence, emphasis was placed on copper retention as an early marker of potential adverse effects. The relationships between (a) chronic copper exposure and its retention in the body, particularly the liver, and (b) hepatic copper concentrations and evidence of toxicity were examined. The Scientific Committee (SC) concludes that no retention of copper is expected to occur with intake of 5 mg/day and established an Acceptable Daily Intake (ADI) of 0.07 mg/kg bw. A refined dietary exposure assessment was performed, assessing contribution from dietary and non-dietary sources. Background copper levels are a significant source of copper. The contribution of copper from its use as plant protection product (PPP), food and feed additives or fertilisers is negligible. The use of copper in fertilisers or PPPs contributes to copper accumulation in soil. Infant formula and follow-on formula are important contributors to dietary exposure of copper in infants and toddlers. Contribution from non-oral sources is negligible. Dietary exposure to total copper does not exceed the HBGV in adolescents, adults, elderly and the very elderly. Neither hepatic copper retention nor adverse effects are expected to occur from the estimated copper exposure in children due to higher nutrient requirements related to growth.

Acute copper sulfate poisoning resulting from dermal absorption

We report a Korean worker who experienced dermal exposure to a hot copper sulfate solution at his workplace and developed severe acute copper sulfate poisoning. A 53-year-old male worker, who was employed in a lead smelter for 5 years, slipped, and his right lower leg entered a copper sulfate solution, leading to severe burns of the right lower leg. Two days later, he developed severe intravascular hemolysis with methemoglobinemia. He also suffered from acute kidney injury, had an asymptomatic cerebral ischemic stroke, and melena due to multiple shallow gastric ulcers. His serum copper level was mildly elevated (153.6 μg/dL, reference: 64.0-134 μg/dL). He was transfused with red blood cell concentrate and supported by hemodialysis. After 13 sessions of hemodialysis and several blood transfusions, he completely recovered. Most previously reported incidents of severe acute copper sulfate poisoning were from accidental or suicidal oral intake. There are few previous reports of systemic copper sulfate toxicity following exposure through burned skin.

Copper-Induced Changes in Reproductive Functions: In Vivo and In Vitro Effects

The goal of this study is to summarize the current knowledge on the effects of one of the essential metals, copper (Cu) on the reproductive system. The development of past four decades addressing effects of Cu on reproductive organs is reviewed. The most relevant data obtained from in vivo and in vitro experiments performed on humans and other mammals, including effects of copper nanoparticles (CuNPs) on the reproductive functions are presented. Short term Cu administration has been found to exert deleterious effect on intracellular organelles of rat ovarian cells in vivo. In vitro administration in porcine ovarian granulosa cells releases insulin-like growth factor (IGF-I), steroid hormone progesterone (P4), and induces expression of peptides related to proliferation and apoptosis. Adverse effect of Cu on male reproductive functions has been indicated by the decrease in spermatozoa parameters such as concentration, viability and motility. Copper nanoparticles are capable of generating oxidative stress in vitro thereby leading to reproductive toxicity. Toxic effect of CuNPs has been evident more in male mice than in females. Even though further investigations are necessary to arrive at a definitive conclusion, Cu notably influences the reproductive functions by interfering with both male and female reproductive systems and also hampers embryo development in dose-dependent manner.

Efficacy and reusability of alginate-immobilized live and heat-inactivated Trichoderma asperellum cells for Cu (II) removal from aqueous solution

Cu(II) removal efficacies of alginate-immobilized Trichoderma asperellum using viable and non-viable forms were investigated with respect to time, pH, and initial Cu(II) concentrations. The reusability potential of the biomass was determined based on sorption/desorption tests. Cu(II) biosorption by immobilized heat-inactivated T. asperellum cells was the most efficient, with 134.22mg Cu(II) removed g(-1) adsorbent, compared to immobilized viable cells and plain alginate beads (control) with 105.96 and 94.04mg Cu(II) adsorbed g(-1) adsorbent, respectively. Immobilized non-viable cells achieved equilibrium more rapidly within 4h. For all biosorbents, optimum pH for Cu(II) removal was between pH 4 and 5. Reusability of all biosorbents were similar, with more than 90% Cu(II) desorbed with HCl. These alginate-immobilized cells can be applied to reduce clogging and post-separation process incurred from use of suspended biomass.

Acute copper sulphate poisoning: a case report and literature review

Voluntary copper poisoning is a rare mode of suicide. We report a case of copper sulphate poisoning in a patient presenting delusions with mystic demands for purification. The initial gastrointestinal symptoms were followed by intravascular haemolysis and renal failure. The course was favourable after symptomatic treatment and specific copper chelation therapy. However, the pathogenesis is not fully understood and with the present state of knowledge, no one treatment can be said to be superior to another. The authors discuss the various treatments of this rare poisoning through a review of the available literature.

Acute copper toxicity following copper glycinate injection

We present a patient who developed multi-organ failure due to severe copper toxicity following attempted suicide by s.c. injection of copper glycinate. Acute copper toxicity is rare in the developed world, although it occurs more frequently in developing world countries, where it is a common mode of suicide. Acute toxicity usually results from oral ingestion and there are several local and systemic effects. Specific management can be difficult as there is little evidence regarding the efficacy of chelating agents in acute toxicity.

[Acute cupric sulfate intoxication: pathophysiology and therapy about a case report]

A case of acute copper sulfate intoxication is presented here, as an illustration of high toxic copper dose. A 38-years-old patient with a light mental deficit ingested half a glass of copper sulfate. This patient first suffered from nausea and vomiting, then an intravascular haemolysis occurred during the hospitalisation in our intensive care unit. The outcome was favourable under aetiologic and symptomatic treatment: administration of D-penicillamine as a copper antidote and packed red cell transfusion. The patient left the intensive care unit after 9 days. Acute copper intoxication is not an exceptional situation, with a potentially severe outcome.

Suicide by ingestion of a CCA wood preservative

Chromated-copper-arsenate (CCA) is a compound used worldwide for wood preservation. Occupational hazards from chronic exposure to CCA are well known, but acute ingestion of CCA wood preservative is very rare. We describe a case of suicide by ingestion of a CCA wood preservative. A 33-year-old man attempted suicide by ingesting an unknown liquid, later identified as a CCA wood preservative, 75 min before his arrival in the emergency department. He was in severe respiratory distress, drooling, tachycardic, and hypotensive. There was an orange color on the palms of both hands. Severe, green colored burns of the buccal mucosa were observed. He was intubated shortly after arrival. The larynx was edematous, but a 7-mm endotracheal tube was successfully introduced. Blood tests revealed partially compensated metabolic acidosis. The patient deteriorated rapidly; the systolic blood pressure dropped to 70 mmHg, and he passed bloody diarrhea. He developed multiple premature atrial contractions and supraventricular tachycardia, and later in the intensive care unit, refractory ventricular tachycardia and ventricular fibrillation. The patient was declared dead 212 h after his arrival. Unfortunately, postmortem blood levels of heavy metals and autopsy were not performed because of refusal by the family for religious reasons.

Copper

Copper is an essential trace element, which is an important catalyst for heme synthesis and iron absorption. Following zinc and iron, copper is the third most abundant trace element in the body. Copper is a noble metal, like silver and gold. Useful industrial properties include high thermal and electrical conductivity, low corrosion, alloying ability, and malleability. Most of the metallic copper appears in electrical applications. Copper is a constituent of intrauterine contraceptive devices and the release of copper is necessary for their contraceptive effects. The average daily intake of copper in the US is about 1 mg Cu with the primary source being the diet. The bioavailability of copper from the diet is about 65-70% depending on a variety of factors including chemical form, interaction with other metals, and dietary components. The biological half-life of copper from the diet is 13-33 days with bilary excretion being the major route of elimination. Copper sulfate is a gastric irritant that produces erosion of the lining of the gastrointestinal tract. Chronic copper toxicity is rare and primarily affects the liver. Wilson's disease and Indian childhood cirrhosis are examples of severe chronic liver disease that results from the genetic predisposition to the hepatic accumulation of copper. The serum copper concentration ranges up to approximately 1.5 mg/L in healthy persons. Gastrointestinal symptoms occur at whole blood concentrations near 3 mg Cu/L. Chelating agents (CaNa2EDTA, BAL) are recommended in severe poisoning, but there are little pharmacokinetic data to evaluate the effectiveness of these agents.

Accidental ingestion of a zinc and copper sulfate preparation

CASE REPORT

An 86-year-old woman accidentally ingested a preparation containing zinc and copper sulfate. At ninety minutes after ingestion, the peak plasma concentration was 1979 micrograms/dL for zinc and 209 micrograms/dL for copper, suggesting preferential absorption of zinc. The major complications were gastric and bronchial inflammation due to the corrosive properties of these compounds. Systemic manifestations also developed with cardiovascular failure and renal insufficiency, but the patient made a complete recovery. In addition to symptomatic treatment, chelation therapy with dimercaprol and D-penicillamine was given for 48 h.

CONCLUSION

The available clinical and toxicokinetic data do not support the benefits of chelation in addition to supportive therapy.

Chronic copper intoxication due to ingestion of coins: a report of an unusual case

We report an unusual case of acute copper intoxication in a patient who died after swallowing more than 700 coins mainly of 1p and 2p denomination. At autopsy the liver showed fibrosis and extensive copper deposition was demonstrated in the histological sections. Electron probe microanalysis also confirmed the presence of copper in the hepatic tissue.

Refractory shock secondary to copper sulfate ingestion

Presented is the case of a 62-year-old man with refractory shock secondary to copper sulfate ingestion. The patient's history was complicated by the presence of peptic ulcer disease, myocardial disease, and a known abdominal aortic aneurysm. Despite the presence of such characteristic signs and symptoms as hemorrhagic gastroenteritis, hemolytic anemia, and refractory hypotension, the diagnosis of copper sulfate ingestion was delayed for several days after ingestion, when the family first volunteered that the patient had vomited blue-green material the day before his admission to the hospital. This delay contributed significantly to the patient's ultimate demise.

Massive copper sulfate ingestion resulting in hepatotoxicity

Intentional overdosage of copper salts is seen infrequently in the U.S., but is fairly common in other countries (1). Toxic blood levels can be seen after oral ingestion of as little as one gram of copper sulfate in an adult (2). We report a case of a patient who ingested 250 grams of copper sulfate, developed transient hepatic dysfunction, and recovered after the prompt administration of chelation therapy.

[Acute fatal copper intoxication. Casuistic and considerations on differential diagnosis (author's transl)]

If the diagnosis of copper-intoxication cannot be made by determination of copper in the collected specimen of the intestine, there may be problems in the differential diagnosis. In Wilson's disease and other cases of symptomatical hypercupriaemia copper content of brain tissues is elevated, while it is normal in acute copper intoxication.