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Li Y, Yu G, Shi L, Zhao L, Wen Z, Kan B, Wang W, Jian X. Severe methyl bromide poisoning causing early acute renal failure and anuria: a case report. J Int Med Res 2022; 50:3000605221122619. [PMID: 36250482 PMCID: PMC9578171 DOI: 10.1177/03000605221122619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Methyl bromide is a pre-plant soil fumigant that is widely used to control nematodes, insects, and fungi in farmlands. Methyl bromide enters the human body through dermal absorption or inhalation and can damage the respiratory, nervous, circulatory, urinary, and other systems. A 62-year-old man who had inhaled a large amount of methyl bromide was admitted to our department. He presented with respiratory failure and pink foamy sputum. He was started on dexamethasone, alanyl glutamine, sulbactam, furosemide, vitamin B1, mouse nerve growth factor, and other treatments, and mechanical ventilation and continuous venovenous hemodiafiltration (CVVHF) were performed daily. He subsequently developed coagulopathy because of the CVVHF, for which protamine, recombinant human brain natriuretic peptide, and albumin were administered intravenously. Notably, the patient developed sustained anuria and eventually died owing to multiple organ failure; specifically, failure of the brain, heart, lungs, and kidneys. This report presents the diagnosis, clinical course, management, and prognosis of a patient who was treated at our hospital for severe methyl bromide poisoning.
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Affiliation(s)
- Yaqian Li
- Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, China
| | - Guangcai Yu
- Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, China,School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Longke Shi
- Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, China,School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Liwen Zhao
- Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, China,School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Zixin Wen
- Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, China,Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250012, China
| | - Baotian Kan
- Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, China,Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250012, China
| | - Wenjun Wang
- Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, China,Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250012, China
| | - Xiangdong Jian
- Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, China,School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China,School of Nursing and Rehabilitation, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China,Xiangdong Jian, Department of Poisoning and Occupational Diseases, Emergency Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107 Wenhuaxi Road, Jinan, Shandong 250012, China.
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Lecailtel S, Broucqsault-Dedrie C, Vanbaelinghem C, Nyunga M, Colling D, Herbecq P. How unclogging a sink can be lethal: case report of an accidental methyl bromide poisoning leading to a multiple organ failure. J Intensive Care 2015; 3:12. [PMID: 27408727 PMCID: PMC4940809 DOI: 10.1186/s40560-015-0079-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 02/20/2015] [Indexed: 11/10/2022] Open
Abstract
Methyl bromide (CH3Br) is a colorless and odorless volatile gas, used as an insecticide, fire extinguisher, fumigant, and refrigerant. Although forbidden since 1987 for domestic use, it is still used in industry, for example, to fumigate agricultural fields which are for importation in the United States. Here is the case of a 74-year-old man who was accidentally exposed to methyl bromide after using an old fire extinguisher. Even though he finally survived, he developed a severe multiple organ failure and spent 2 months in intensive care unit. We present in this report all the difficulties we had to diagnose this unusual poisoning.
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Affiliation(s)
| | | | | | - Martine Nyunga
- Intensive Care Unit, Victor Provo Hospital, Roubaix, France
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The neurological effects of methyl bromide intoxication. J Neurol Sci 2013; 335:36-41. [PMID: 24094859 DOI: 10.1016/j.jns.2013.09.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/12/2013] [Indexed: 11/20/2022]
Abstract
Used primarily as a fumigant or as a substrate in chemical processes, methyl bromide is a highly toxic gas. The gas is usually absorbed by inhalation and effects on the lungs, gastrointestinal tract, skin, and brain are seen. Numerous instances of acute and chronic neurologic injury have been reported: acute poisoning results in seizures, myoclonus, ataxia or cerebral oedema beginning as early as 30 min after exposure while subacute or chronic intoxication presents with diverse slowly progressive neurological and neurobehavioral symptoms. Serum bromide levels may be elevated, but often return rapidly to normal. Electroencephalography may show frontally-predominant slow waves or polyspikes with following slow wave, and MRI reveals characteristic involvement in the dentate nucleus of the cerebellum, the brainstem, and the splenium of the corpus callosum. Symmetric and selective lesions in characteristic sites are observed on imaging and on histopathological examination. These are likely produced by methylation of intracellular lipids, protein and glutathione; production of toxic metabolites; defective neurotransmitter function; and abnormal oxidative phosphorylation. This article reviews the toxic effects of this gas, the pathophysiology and symptoms of its effects on the nervous system, and characteristic findings on MRI; and presents an illustrative case of methyl bromide intoxication due to exposure at a factory producing the compound commercially.
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Abstract
Methyl bromide (MeBr) is a chemically reactive compound that has found use as a fire retardant and fumigant used for wood, soil, fruits and grains. Its use is banned in many countries because of its ozone-depleting properties. Despite this ban, the use of MeBr persists in some parts of the world (e.g. New Zealand) due to its important role in maintaining strict biosecurity of exported and imported products. Its high chemical reactivity leads to a broad toxicological profile ranging from acute respiratory toxicity following inhalation exposure, through carcinogenicity to neurotoxicty. In this article, we discuss the chemistry of MeBr in the context of its mechanisms of toxicity. The chemical reactivity of MeBr clearly underlies its toxicity. Bromine (Br) is electronegative and a good leaving group; the δ+ carbon thus facilitates electrophilic methylation of biological molecules including glutathione (GSH) via its δ- sulphur atom, leading to downstream effects due to GSH depletion. DNA alkylation, either directly by MeBr or indirectly due to reduction in GSH-mediated detoxification of reactive alkylating chemical species, might explain the carcinogenicity of MeBr. The neurotoxicity of MeBr is much more difficult to understand, but we speculate that methyl phosphates formed in cells might contribute to its neurone-specific toxicity via cholinesterase inhibition. Finally, evidence reviewed shows that it is unlikely for Br⁻ liberated by the metabolism of MeBr to have any toxicological effect because the Br⁻ dose is very low.
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Affiliation(s)
- A T Bulathsinghala
- Department of Chemistry, University of Canterbury, Christchurch, New Zealand
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Stromberg PE, Cumpston KL. Cases from NACCT acute and intensive care symposium: altered mental status, seizures, and rash in a fumigation company employee. Clin Toxicol (Phila) 2013; 51:182-5. [PMID: 23473464 DOI: 10.3109/15563650.2013.772624] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Methyl bromide is a halogenated aliphatic hydrocarbon that exists as a colorless gas or a volatile liquid. Methyl bromide historically had been used in fire extinguishers but is more commonly used as a gas fumigant for soil-borne diseases and pests. Methyl bromide is being phased out due to concerns for ozone depletion but can still be found. It is readily absorbed through the lungs while dermal absorption can also occur. Signs and symptoms of severe exposures include headache, respiratory distress, pulmonary hemorrhage, and seizures. In large pulmonary exposures, death can occur as rapidly as 1 h usually from respiratory failure. Methyl bromide can penetrate clothing and protective equipment presenting challenges to first responders. There is a debate over the mechanism of toxicity of methyl bromide and the role of hemodialysis and chelation in treatment. CASE DETAILS A 22-year-old female employee of a fumigation company contacted emergency medical services (EMS) after opening a tank of compressed methyl bromide in her car. She was initially combative and confused. She underwent two water dermal decontaminations and was transported to the nearest tertiary center. She rapidly progressed to obtundation with seizure-like activity and dysrhythmias. Despite the supportive care and resuscitative efforts, she died approximately 1 h after her call to EMS. DISCUSSION Methyl bromide exposures can be fatal, and this case highlights the difficulty in managing these acutely poisoned patients. Questions for consideration after this case include time spent on decontamination, use of adjunctive anti-epileptic drugs, role of chelation therapy, and the role of hemodialysis in the treatment of methyl bromide poisoning.
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Affiliation(s)
- Paul E Stromberg
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0522, USA
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Preisser AM, Budnik LT, Hampel E, Baur X. Surprises perilous: toxic health hazards for employees unloading fumigated shipping containers. THE SCIENCE OF THE TOTAL ENVIRONMENT 2011; 409:3106-3113. [PMID: 21636109 DOI: 10.1016/j.scitotenv.2011.04.053] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 03/25/2011] [Accepted: 04/01/2011] [Indexed: 05/30/2023]
Abstract
The fumigation of freight containers to protect transported goods from fungal and pest infestation has increased worldwide in the last five years due to international regulations requiring fumigation or heat treatment of wooden packaging material and dunnage. We have found in 2008 that every sixth container and its contents do retain harmful concentrations of various fumigants and chemicals, representing a significant health risk for port and transport workers, customs officials, warehousemen, store employees and consumers. The shipping documents of these containers did not provide any information about the fumigation procedure or the used fumigant. We report here the cases of 26 patients introduced to our outpatient clinic with presumed intoxication to fumigants, or with symptoms due to inhaling the air out of fumigated containers. All patients were examined from 2007 to 2010 according to a standardized comprehensive diagnostic program. We were able to confirm the diagnosis based on typical symptoms and extensive clinical examination; by laboratory analysis we identified ethylene dichloride, methyl bromide, phosphine and methylene chloride. The predominant symptoms were headaches, concentration and memory problems, dizziness and nausea, irritation of the skin and mucous membranes and a reduced ability to do exercise. In addition to the neurological and neuropsychological impairments our analyses verified the development of reactive airways dysfunction syndrome (RADS) in 14 of 26 patients with long lasting symptoms due to their contact with fumigants. Intoxications with fumigants are serious and could be avoided. These systematical explored cases show the sustainable impact for health and socio-economic wellbeing. These findings also emphasize the necessity for international standards on permitted fumigants, appropriate labeling in the shipping documents and handling of fumigated containers.
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Affiliation(s)
- Alexandra M Preisser
- Department of Clinical Occupational Medicine, Institute for Occupational and Maritime Medicine (ZfAM), University Medical Center Hamburg-Eppendorf, Seewartenstrasse 10, D-20459 Hamburg, Germany.
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Lin JN, Lin HL, Huang CK, Lai CH, Chung HC, Liang SH, Lin HH. Myoclonic jerks due to acute bromovalerylurea intoxication. Clin Toxicol (Phila) 2008; 46:861-3. [PMID: 18668386 DOI: 10.1080/15563650802020361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Bromides are still sold as sedatives, antitussives, and anticonvulsants in many countries. Bromovalerylurea is a bromide-containing sedative-hypnotic that is occasionally combined with non-steroidal anti-inflammatory drugs in over-the-counter products. Chronic intake of excessive bromovalerylurea can produce bromide intoxication, but acute bromovalerylurea intoxication presenting with myoclonic jerks has never been described. CASE REPORT A 23-year-old woman was brought to our emergency department with unusual drowsiness. Her physical examination was normal except for frequent myoclonic jerks in all extremities that could be triggered by moving the patient or by noxious stimuli. Initial blood tests results were normal; the serum bromide concentration was 81.0 mg/L (reference <10 mg/L). Treatment with intravenous normal saline and furosemide resulted in gradual improvement in her drowsiness and myoclonic jerks. By the second hospital day, she was normal. A brain magnetic resonance imaging (MRI) was normal. At a 2-month follow-up visit, the patient had no neurological sequelae. DISCUSSION Chronic bromide intoxication caused by long-term abuse of bromovalerylurea may present as psychiatric or neurologic abnormalities. Our case of acute bromovalerylurea intoxication presented with severe myoclonic jerks and lethargy. The serum bromide concentration was similar to the reported concentrations in acute bromide intoxications. Treatment with normal saline and diuretics results in increased clearance of bromide and an improvement in clinical effects. CONCLUSION Myoclonic jerks may be one of the major presentations of acute bromovalerylurea intoxication. Physicians should consider bromide intoxication in the differential diagnosis of the causes of myoclonic jerks.
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Affiliation(s)
- Jiun-Nong Lin
- Department of Internal Medicine, E-Da Hospital/I-Shou University, Jiun-Shu Tsuen, Yan-Chau Shiang, Kaohsiung County, Taiwan, Republic of China
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Ben Slamia L, Harzallah S, Lamouchi T, Sakli G, Dogui M, Ben Amou S. [Peripheral neuropathy induced by acute methyl bromide skin exposure: a case report]. Rev Neurol (Paris) 2007; 162:1257-9. [PMID: 17151519 DOI: 10.1016/s0035-3787(06)75140-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Methyl bromide is a pesticide used as a fumigating agent in homes, for food storage and soil disinfection. Chronic and acute exposures to methyl bromide are known to cause damage to the central and peripheral nervous system. OBSERVATION We describe a case of a 31-year-old patient who developed a peripheral neuropathy due to an acute exposure on skin of methyl bromide. This patient was admitted after an accidental dermal exposure to methyl bromide while fumigating dates. The patient suffered dermal burns and vesicles on the upper limbs. Two weeks following exposure, she developed weakness of the lower and upper limbs, ataxia, paresthesiae of both legs and arms, abolition of tendon reflexes in the upper and lower limbs and Babinski sign. An axonal neuropathy was detected at the electrophysiological study. The patient recovered gradually. CONCLUSION While cases of methyl bromide are rare, this study illustrates the toxic effect on the peripheral nervous system.
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Affiliation(s)
- L Ben Slamia
- Service de Neurologie, Hôpital Sahloul, Sousse, Tunisie.
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