Bismuth Subsalicylate Coagulopathy in a Patient with Chronic Liver Disease.

Bismuth subsalicylate (BSS) is the active ingredient in over-the-counter antacid and antidiarrheal medications. Coagulopathy in the setting of acetylsalicylic acid toxicity is well documented but not in setting of bismuth subsalicylate overuse. We present a case report of coagulopathy from BSS poisoning in a patient with underlying cirrhosis. The patient's high prothrombin time suggests inhibition of vitamin K-dependent coagulation factors. The patient had decreased factor V activity, which is responsible for converting prothrombin to thrombin. Patients with cirrhosis often have hypoprothrombinemia which may be exacerbated by salicylate-induced coagulopathy. Given the widespread use of BSS products, physicians should recognize coagulopathy as a possible manifestation of toxicity especially in patients with underlying liver disease.

Bismuth intoxication resulting in acute kidney injury in a pregnant adolescent girl.

Çelebi-Tayfur A, Yaradilmis RM, Ulus F, Çaltik-Yilmaz A, Özayar E, Kosar B, Büyükkaragöz B, Horasanli E. Bismuth intoxication resulting in acute kidney injury in a pregnant adolescent girl. Turk J Pediatr 2019; 61: 292-296. Bismuth intoxication is a rare cause of acute kidney injury (AKI) and is usually reversible by appropriate therapeutic measures. We present here a case of an adolescent pregnant girl who developed AKI due to an overdose of colloidal bismuth subcitrate (CBS, total amount of 6 g). She received parenteral chelating agent dimercaprol for 14 days. Continuous venovenous hemodiafiltration (CVVHD) with high-flux membrane was carried out in the first 3 days of chelating therapy and intermittent hemodialysis for 11 days, thereafter. The patient recovered clinically and was discharged after 21 days. She gave birth to a healthy term boy. At the last visit, the baby was 6 months old with normal growth and development as well as normal kidney functions. Neither deterioration in renal functions nor emergence of proteinuria was recorded in the patient during follow-up care after hospital discharge. In cases of AKI due to an overdose of CBS, treatment with dimercaprol combined with high flux hemodiafiltration and subsequently hemodialysis appears to be both useful and safe for bismuth elimination.

Severe iatrogenic bismuth poisoning with bismuth iodoform paraffin paste treated with DMPS chelation.

BACKGROUND: Bismuth iodoform paraffin paste (BIPP) is used for the packing of wound and surgical cavities. Features of both bismuth and iodoform toxicities have been associated with the use of BIPP, but there are no previous reports of 2,3-dimercaptopropane-1-sulphonate (DMPS) chelation therapy for bismuth poisoning secondary to its use. CASE REPORT: A 67-year-old man presented with a pelvic tumor requiring extensive surgical resection. BIPP packing was required post-operatively for surgical wound breakdown. A few days after insertion, the patient developed neurological features of bismuth toxicity (blood and urine bismuth concentrations were 340 microg/L and 2800 microg/L, respectively), which was treated with removal of the BIPP packing and DMPS chelation [27 days of intravenous DMPS (5 mg/kg 4 times daily for 5 days, 5 mg/kg three times daily for 5 days followed by 5 mg/kg twice a day for 17 days) followed by 24 days of oral DMPS (200 mg three times a day for 10 days, followed 200 mg twice daily for 14 days)]. This resulted in improvement in his symptoms and a decline in his pre-chelation bismuth concentration of 480 microg/L to 5 microg/L following chelation. There were no adverse effects during chelation. CONCLUSIONS: DMPS chelation appears to be a potentially effective chelating agent in bismuth toxicity.

Fanconi's syndrome, acute renal failure, and tonsil ulcerations after colloidal bismuth subcitrate intoxication.

A 22-year-old woman ingested 5.4 g of colloidal bismuth subcitrate (CBS) in a suicide attempt. After ingestion, she presented with Fanconi's syndrome and acute renal failure to our unit. On the third day after ingestion, she was anuric. Ulcerations of both tonsils were observed 8 days after intoxication. Sodium-2,3-dimercapto-1-propanesulfonate (DMPS) is shown to be an effective chelating agent of heavy metal intoxications, but it has only a small effect on elimination of bismuth salts in patients with renal insufficiency without hemodialysis. In our case, we initiated hemodialysis and intravenous treatment with DMPS 60 hours after intoxication. By repeated measurements of bismuth concentrations in serum and dialyzed fluid, we showed its successful elimination. Serum bismuth level decreased from 640 microg/L to 15 microg/L within 6 days. With elimination of bismuth, renal function improved, and tonsil ulcerations healed. Hemodialysis was discontinued on day 14. Follow-up examination 6 weeks later showed normal renal function. Clinicians should be aware that acute renal failure and tonsil ulcerations can occur after CBS intoxication. Generally, acute renal failure caused by CBS intoxication is reversible. Treatment with the chelating agent DMPS in combination with hemodialysis is highly effective in reducing the serum bismuth level in patients with acute renal failure.

Autometallographic tracing of bismuth in human brain autopsies.

For decades, drugs containing bismuth have been used to treat gastrointestinal disorders. Although a variety of adverse effects, including neurological syndromes, have been recorded, the biological/toxicological effects of bismuth ions are far from disclosed. Until recently, only quantitative assessments were possible, but resent research has made histochemical tracing of bismuth possible. The technique involves silver enhancement of bismuth crystallites by autometallography (AMG). In the present study, the localization of bismuth was traced by AMG in sections of paraffin-embedded brain tissue obtained by autopsy from 6 patients suffering from bismuth intoxication in a period ranging from 1975 through 1977. Tissue was analyzed at light and electron microscopical levels, and the presence of bismuth further confirmed by proton-induced x-ray emission (PIXE). Clinical data and bismuth concentrations in blood, cerebellum, and thalamus were measured by atomic absorption spectrophotometry (AAS) and are reported here. Histochemical analyses demonstrate that bismuth accumulated in neurons and glia cells in the brain regions examined (neocortex, cerebellum, thalamus, hippocampus). Cerebellar blood vessels stained most intensely. The PIXE and AAS data correlated with the histochemical staining patterns and intensities. At the ultrastructural level, bismuth was found to accumulate intracellularly in lysosomes and extracellularly in the basement membranes of some vessels.

Pearls and pitfalls in the approach to patients with neurotoxic syndromes.

Neurotoxins are an important cause of neurologic disorders. A vast number of potentially neurotoxic compounds exist, including prescription drugs, illicit substances, and exposures through the workplace, residence, hobbies, and the environment. Effects of neurotoxins can mimic neurologic illnesses; therefore, it is important to consider neurotoxins in the differential diagnosis of any patient with neurological dysfunction. Paramount to the diagnosis of a possible neurotoxic syndrome is establishing causation. This can be done by a systematic approach utilizing principles in epidemiology and applying them to the individual patient. This approach is discussed in the following article in an attempt to bring structure to solving problems in a complex area of medicine.

Heavy metal poisoning in glass worker characterised by severe.

The paper presents the clinical description of the masticatory organ and biochemical assessment of dental tissue in a patient employed in a glassworks for 20 years. During 12 years the patient has suffered baldness ("Alopecia areata") and atypical extensive and non-healing cutaneous lesions. Dental examination revealed changes typical of chronic poisoning by cadmium and bismuth compounds.

Iatrogenic bismuth poisoning. Case report.

A case of bismuth intoxication following the intraoral use of BIPP-impregnated gauze packs is presented. This report illustrates the need for caution when using potentially toxic compounds in the oral cavity where significant quantities can be absorbed to produce symptoms of poisoning.