Severe chlorate poisoning: report of a case

Acute renal toxicity of sodium chlorate: Redox imbalance, enhanced DNA damage, metabolic alterations and inhibition of brush border membrane enzymes in rats

Sodium chlorate (NaClO₃ ) is widely used in paper and pulp industries and as a non-selective herbicide. Humans can be exposed to NaClO₃ through contaminated drinking water due to its improper and unchecked usage in industries and as herbicide. NaClO₃ is also present as a major stable by-product in drinking water that has been disinfected with chlorine dioxide. In this study, we have investigated the effect of a single acute oral dose of NaClO₃ on rat kidney. Adult male Wistar rats were divided into one control and four NaClO₃ treated groups that were orally given different doses of NaClO₃ and euthanized 24 hr after the treatment. Oral administration of NaClO₃ resulted in increased hydrogen peroxide levels, lipid, and protein oxidation while thiol and glutathione content and activities of brush border membrane enzymes were decreased in kidney in a NaClO₃ dose-dependent manner. Significant alterations in the activities of enzymes involved in carbohydrate metabolism and antioxidant defense were also observed. Administration of NaClO₃ induced DNA fragmentation and increased DNA-protein cross-linking. Histological studies showed marked damage in kidney from NaClO₃ treated animals. These results strongly suggest that NaClO₃ induces nephrotoxicity via redox imbalance that results in DNA and membrane damage, metabolic alterations and brush border membrane enzyme dysfunction.

Sodium chlorate, a herbicide and major water disinfectant byproduct, generates reactive oxygen species and induces oxidative damage in human erythrocytes

Sodium chlorate (NaClO₃) is a widely used non-selective herbicide. It is also generated as a byproduct during disinfection of drinking water by chlorine dioxide. In the present work, the effects of NaClO₃ on human erythrocytes were studied under in vitro conditions. Incubation of erythrocytes with different concentrations of NaClO₃ at 37 °C for 90 min resulted in significant hemolysis. Cell lysates were prepared from NaClO₃-treated and untreated (control) erythrocytes and assayed for various biochemical parameters. Methemoglobin levels were significantly increased and methemoglobin reductase activity was reduced upon NaClO₃ treatment. There was a significant increase in protein oxidation and lipid peroxidation with a decrease in reduced glutathione and total sulfhydryl content. This suggests the induction of oxidative stress in erythrocytes upon exposure to NaClO₃. The occurrence of oxidative stress was confirmed by significantly increased generation of reactive oxygen species and lowered antioxidant response of the cells. NaClO₃ treatment also increased nitric oxide levels showing induction of nitrosative stress. The activities of major antioxidant and membrane-bound and metabolic enzymes were significantly altered upon incubation of erythrocytes with NaClO₃. The erythrocytes became more osmotically fragile while electron microscopic images showed gross morphological alterations in NaClO₃-treated cells. These results show that NaClO₃ induces oxidative stress in human erythrocytes, which results in extensive membrane damage and lowers the antioxidant response.

Maternal cautopyreiophagia as a rare cause of neonatal hemolysis: a case report

Hyperbilirubinemia in the first 24 hours of life in a newborn is pathologic, necessitating additional evaluation. We report the first case of hemolysis and subsequent hyperbilirubinemia in an otherwise normal term neonate resulting from oxidative stress in the form of maternal cautopyreiophagia: the ingestion of burnt matchstick heads. During the third trimester of pregnancy, the infant's mother consumed more than 300 burnt matchstick heads weekly for 4 weeks. Matches contain potassium chlorate, a powerful oxidant that when ingested can ultimately lead to the destruction of erythrocytes, disseminated intravascular coagulation, kidney injury, or death. The infant's bilirubin rose as high as 17 mg/dL at 22 hours of life; however, the infant did well with a brief course of phototherapy. This case highlights the importance of prenatal questioning about maternal ingestion of potentially oxidative substances and assessing the possible risk for the infant.

A case of severe chlorite poisoning successfully treated with early administration of methylene blue, renal replacement therapy, and red blood cell transfusion: case report

The case of a 55-year-old man who attempted suicide by ingesting <100 mL of 28% sodium chlorite solution is presented. On arrival in the intensive care unit, the patient appeared cyanotic with lowered consciousness and displayed anuria and chocolate brown serum.Initial laboratory tests revealed 40% of methemoglobin. The formation of methemoglobin was effectively treated with methylene blue (10% after 29 hours).To remove the toxin, and because of the anuric acute renal failure, the patient received renal replacement therapy. Despite these therapeutic measures, the patient developed hemolytic anemia and disseminated intravascular coagulation, which were treated with red blood cell transfusion and intermittent hemodialysis. These interventions led to the improvement of his condition and the patient eventually fully recovered. Patient gave written informed consent.This is the third known case of chlorite poisoning that has been reported. Based upon this case, we suggest the management of sodium chlorite poisoning to comprise the early administration of methylene blue, in addition to renal replacement therapy and transfusion of red blood cells.

A case of sodium chlorite toxicity managed with concurrent renal replacement therapy and red cell exchange

INTRODUCTION

Sodium chlorite is a powerful oxidizing agent with multiple commercial applications. We report the presentation and management of a single case of human toxicity of sodium chlorite.

CASE REPORT

A 65-year-old man presented to hospital after accidentally ingesting a small amount of a sodium chlorite solution. His principal manifestations were mild methemoglobinemia, severe oxidative hemolysis, disseminated intravascular coagulation, and anuric acute kidney injury. He was managed with intermittent hemodialysis, followed by continuous venovenous hemofiltration for management of acute kidney injury and in an effort to remove free plasma chlorite. Concurrently, he underwent two red cell exchanges, as well as a plasma exchange, to reduce the burden of red cells affected by chlorite. These interventions resulted in the cessation of hemolysis with stabilization of serum hemoglobin and platelets. The patient survived and subsequently recovered normal renal function.

DISCUSSION

This is only the second case of sodium chlorite intoxication reported in the medical literature and the first to report the use of renal replacement therapy in combination with red cell exchange in its management.

Effects of short-term sodium chlorate exposure on pigs

The present study evaluated the effects of exposure to different doses of sodium chlorate in 10-week-old pigs. Twenty pigs were divided into four equal groups and treated with different doses of sodium chlorate: 0, 125, 250 and 500 mg kg-1 body weight per day via the drinking water for 7 consecutive days. The results showed a significant decrease (P < 0.05) in red blood cell and white blood cell counts, packed cell volume, haemoglobin, blood urea nitrogen (P < 0.001) and creatinine levels, and an increase in aspartate aminotransferase and alanine aminotransferase (P < 0.05) activities in swine administered sodium chlorate at a dose of 500 mg kg-1 body weight per day. The histopathological study revealed increased numbers of vacuoles in the convoluted tubules, tubular necrosis and degeneration of the renal tubular epithelial cells, depletion of nuclei and lobular necrosis of the liver in all pigs treated with sodium chlorate at 500 mg kg-1 body weight per day. Thus, 7-day administration of sodium chlorate at 500 mg kg-1 body weight per day to pigs affects the liver and kidney tissues as well as the haematologic and serum biochemical parameters.

The role of therapeutic plasma exchange in poisonings and intoxications

Poisonings, intoxications, and drug overdoses are common occurrences and rapid lowering of the toxin level is a cornerstone of all effective therapies. Therapeutic plasma exchange (TPE) has several unique characteristics that allow it to be a potentially effective therapy in rapidly achieving this goal. Specifically, TPE allows for the removal of large molecular weight, protein-bound molecules that have a small volume of distribution. Due to the nature of poisonings, intoxications, and drug overdoses, no randomized controlled trials studying the efficacy of TPE in these situations exist. Thus, careful interpretation and analysis of case reports and series are required to assess the potential efficacy of this therapy. Recent data suggest that TPE may also be effective in the therapy of patients receiving biologic treatments who develop life-threatening complications due to therapy.

Pharmacokinetics of ruminally dosed sodium [36Cl]chlorate in beef cattle

The recently recognized potential of sodium chlorate as a possible preharvest food safety tool for pathogen reduction in meat animals has spurred interest in the pharmacokinetics of intraruminally dosed chlorate. Six Loala cattle were assigned (one heifer and one steer per treatment) to one of three intraruminal doses of radiolabeled sodium [36Cl]chlorate (21, 42, or 63 mg/kg body weight) administered in four equal aliquots over a 24-h period. Blood and serum were collected (29 samples in 48 h). Total radioactive residues were measured and the radioactive moieties were speciated. Chlorate appeared rapidly in blood and serum after dosing. For animals administered a dose of 42 or 63 mg/kg, the half-life of absorption was estimated at 0.6-0.9 h. Serum chlorate concentrations progressively increased with aliquot administration until peaking at 6-21 parts per million at 26 h. Between aliquot administrations, serum chlorate levels typically peaked in 3.5 h or less. The half-life of chlorate elimination ranged between 6.9 and 11 h, depending on the dose. Ultimately, absorption of chlorate removes it from its desired site of action, the lower gastrointestinal tract, thereby reducing its efficacy. Further research is needed to develop a chlorate formulation that will allow passage to the lower gastrointestinal tract.

The dilemma of approving antidotes

Clinical trials with antidotes are difficult to perform for a variety of practical, ethical, and financial reasons. As acute poisoning is a rare event, the commercial interest in basic and clinical research is low. Poisoned patients are usually not available for normal clinical trial procedures and, if they are, they cannot give informed consent. This situation results in a dilemma: antidotes are essential drugs. A resolution of the Council of Europe requests to guarantee the optimal availability of antidotes and the improvement of their use. As comprehensive data on the efficacy of antidotes are often missing, a marketing authorisation under exceptional circumstances according to Article 14(8) of Regulation (EC) No. 276/2004, will often be the only way to get an approval, as: (1) the indications for which the product in question is intended are encountered so rarely that the applicant cannot reasonably be expected to provide comprehensive evidence ("orphan drug"), (2) in the present state of scientific knowledge, comprehensive information cannot be provided, or (3) it would be contrary to generally accepted principles of medical ethics to collect such data. Typically, data on antidotes are obtained from a patchwork of studies with animals, human tissue and a few observations from human poisoning corroborated with data from clinical observations and biochemistry. Generalisations from chemical and mechanistic similarities between groups of poisons are usual, but often lack scientific evidence. Current standards of good clinical practice can rarely be observed. Therefore, public funding and other financial support are necessary incentives to initiate trials in this important area.

Effect of sodium [36Cl]chlorate dose on total radioactive residues and residues of parent chlorate in beef cattle

The objectives of this study were to determine total radioactive residues and chlorate residues in edible tissues of cattle administered at three levels of sodium [36Cl]chlorate over a 24-h period and slaughtered after a 24-h withdrawal period. Three sets of cattle, each consisting of a heifer and a steer, were intraruminally dosed with a total of 21, 42, or 63 mg of sodium [36Cl]chlorate/kg of body weight. To simulate a 24-h exposure, equal aliquots of the respective doses were administered to each animal at 0, 8, 16, and 24 h. Urine and feces were collected in 12-h increments for the duration of the 48-h study. At 24 h after the last chlorate exposure, cattle were slaughtered and edible tissues were collected. Urine and tissue samples were analyzed for total radioactive residues and for metabolites. Elimination of radioactivity in urine and feces equaled 20, 33, and 48% of the total dose for the low, medium, and high doses, respectively. Chlorate and chloride were the only radioactive chlorine species present in urine; the fraction of chlorate present as a percentage of the total urine radioactivity decreased with time regardless of the dose. Chloride was the major radioactive residue present in edible tissues, comprising over 98% of the tissue radioactivity for all animals. Chlorate concentrations in edible tissues ranged from nondetectable to an average of 0.41 ppm in skeletal muscle of the high-dosed animals. No evidence for the presence of chlorite was observed in any tissue. Results of this study suggest that further development of chlorate as a preharvest food safety tool merits consideration.

Acquired methemoglobinemia: a retrospective series of 138 cases at 2 teaching hospitals

Methemoglobin is a form of hemoglobin that does not bind oxygen. When its concentration is elevated in red blood cells, functional anemia and tissue hypoxia may occur. We performed a retrospective case series to describe the cases of acquired methemoglobinemia (methemoglobin level >2%) detected and the clinical circumstances under which they occurred at 2 tertiary care hospitals and affiliated outpatient clinics over 28 months. We surveyed co-oximetry laboratory data to identify patients with methemoglobinemia. We reviewed these patients' medical records to extract the clinical information and context. One hundred thirty-eight cases of acquired methemoglobinemia were detected over the 28 months. There was no gender predisposition, and the condition occurred over a wide range of ages (patients aged 4 days to 86 years). Cases occurred in many areas of the hospital, including outpatient clinics. One fatality and 3 near-fatalities were directly attributable to methemoglobinemia. Dapsone was the most common etiology of acquired methemoglobinemia, accounting for 42% of all cases. The mean peak methemoglobin level among these individuals was 7.6%. In 5 of the patients with the most severely elevated levels, 20% benzocaine spray (Hurricaine Topical Anesthetic spray, Beutlich Pharmaceuticals, Waukegan, IL) was the etiology, associated with a mean peak methemoglobin level of 43.8%. Eleven pediatric patients developed methemoglobinemia either from exogenous exposure, such as drugs, or due to serious illness, such as gastrointestinal infections with dehydration. Almost all (94%) patients with methemoglobinemia were anemic. Drugs that cause acquired methemoglobinemia are ubiquitous in both the hospital and the outpatient setting. Acquired methemoglobinemia is a treatable condition that causes significant morbidity and even mortality. We hope that a heightened awareness of methemoglobinemia will result in improved recognition and treatment. Primary prevention efforts have the potential to reduce the morbidity and mortality associated with this condition.

The effects of subchronic chlorate exposure in Sprague-Dawley rats

Male and female Sprague-Dawley rats were exposed to drinking water containing 3.0, 12.0 or 48.0 mM sodium chlorate. The mean drinking water consumption varied between exposure groups from 100-200 ml/kg/day. Female exposure groups consistently drank more water (23-42%) than male exposure groups thereby receiving more chlorate/kg/day at every exposure level. There were no compound related deaths; however, both males and females in the high exposure groups had significant weight loss during the 90-day exposure period. Also, in these same groups females had mild but significant decreases in the following relative organ weights; adrenals, thymus and spleen, while the relative brain weight was increased. In males, the heart, kidneys and liver were mildly decreased while the brain and testes were mildly increased. Red blood cell counts and percent hematocrit were decreased in both sexes in the high dose group. Pituitary gland (pars distalis) vacuolization and thyroid gland colloid depletion were prominent in both sexes in mid and/or high dose animals. A NOAEL of 0.36 mM chlorate/kg b.w./day in males and 0.50 mM chlorate/kg b.w./day in females were established.

Chlorate poisoning: mechanism of toxicity

Intoxications with chlorate salts are characterized by methaemoglobin formation, haemolysis and renal insufficiency. The toxic effects on the erythrocyte can be reproduced in vitro. Incubation of human and rabbit erythrocytes with chlorates induces a concentration-dependent oxidation of haemoglobin. This methaemoglobin formation is followed by denaturation of the globin, a cross-linking of erythrocyte membrane proteins and an inactivation of membrane enzymes. The high sensitivity of glucose-6-phosphate dehydrogenase to denaturation by chlorate explains the inefficacy of methylene blue to reduce methaemoglobin formed, as the antidotal effect of methylene blue depends on NADPH formed mainly by the oxidation of glucose-6-phosphate. The observed changes occur only in the presence of methaemoglobin which forms a destabilising complex with chlorate. Methaemoglobin thus autocatalytically increases methaemoglobin formation and destruction of the erythrocyte. As the rabbit is known to have a high methaemoglobin-reduction capacity, human and rabbit erythrocytes were compared. In vitro, the rabbit erythrocyte is less sensitive to oxidative attack than the human red cell. In vivo, an oral dose of sodium chlorate (1 g/kg body wt.) resulted in high serum (16 +/- 4 mM) and urine concentrations (246 +/- 99 mM) in the rabbit. Methaemoglobin was not formed nor could a nephrotoxic effect be observed. These experiments also indicate that the nephrotoxicity of chlorate is mediated by methaemoglobin catalysis.

Acute sodium chlorite poisoning associated with renal failure

A 25-year-old Chinese male presented with generalized cyanosis and respiratory distress. The patient was known to have ingested 10 g of sodium chlorite in a suicide attempt. Methemoglobinemia was found and intravenous methylene blue was given repeatedly. However, the therapy could not prevent an acute hemolytic crisis. Methemoglobinemia remained profound (43.1%) and disseminated intravascular coagulation ensued. He was put on CAVHD to correct the fluid overload and probably to remove the active metabolites of the chlorite. After 24 h, the methemoglobin was reduced to 16.9%. However, the development of acute renal failure further complicated the clinical course. Percutaneous renal biopsy suggested a picture of acute tubulointerstitial nephropathy. In addition, hemodialysis was continued for 4 weeks. After 3 months, renal function normalized. To our knowledge, there has been no clinical report of human intoxication with sodium chlorite.

Erythrocyte membrane alterations as the basis of chlorate toxicity

The effects of sodium chlorate and of sodium nitrite on human erythrocytes were studied in vitro. Nitrite rapidly oxidised haemoglobin and glutathione; reduction of methaemoglobin (Hbi) by methylene blue was complete during 3 h of incubation with nitrite. With chlorate, a concentration-dependent lag phase was seen before Hbi was formed. After prolonged incubation, Hbi could no longer be reduced with methylene blue. Several other effects were observed that explain the clinical picture of chlorate poisoning which involves haemolysis followed by disseminated intravascular coagulation and renal failure: increased permeability to cations, increased resistance to hypotonic haemolysis and prolonged filtration time through polycarbonate membranes with cylindrical pores of 5 micron diameter. This suggests an increased membrane rigidity due to membrane protein polymerisation, as demonstrated by SDS polyacrylamide gel electrophoresis. Simultaneously, erythrocyte enzymes were inactivated, primarily glucose-6-phosphate dehydrogenase which is necessary for the therapeutic effect of methylene blue. This explains the inefficacy of methylene blue in the treatment of a case of chlorate poisoning that we observed (Arch. Toxicol., 48 (1981) 281).

Improved method to measure erythrocyte filtration times increased extremely by chlorate

A method is presented that allows the measurement of erythrocyte filtration times that are extremely prolonged. Filtration times through polycarbonate sieves are increased by a factor of 40 after 2 h incubation with 30 mM sodium chlorate. This increase in red cell rigidity offers an explanation for the haemolysis observed in chlorate poisoning in vivo.