The toxicology of zinc chloride smoke producing bombs and screens.

CONTEXT: Zinc chloride (ZnCl2)-based smoke bombs and screens are in use since the Second World War (1939-1945). Many case descriptions on ZnCl2 smoke inhalation incidents appeared since 1945. OBJECTIVE: We provide a comprehensive overview of the clinical symptoms and underlying pathophysiology due to exposure to fumes from ZnCl2 smoke producing bombs. In addition, we give a historical overview of treatment regimens and their outcomes. METHODOLOGY: We performed a literature search on Medline, Scopus and Google Scholar databases using combinations of the following search terms "smoke bomb", "smoke screen", "ZnCl2", "intoxication", "poisoning", "case report", "HE smoke", "hexachloroethane smoke", "smoke inhalation" and "white smoke". We retrieved additional reports based on the primary hits. We collected 30 case reports from the last seven decades encompassing 376 patients, 23 of whom died. Of all the patient descriptions, 31 were of sufficient detail for prudent analysis. RESULTS AND CONCLUSIONS: Intoxication with clinical signs mainly took place in war situations and in military and fire emergency training sessions in enclosed spaces. Symptoms follow a biphasic course mainly characterised by dyspnoea, coughing and lacrimation, related to irritation of the airways in the first six hours, followed by reappearance of early signs complemented with inflammation related signs and tachycardia from 24 h onwards. Acute respiratory stress syndrome developed in severely affected individuals. Chest radiographs did not always correspond with clinical symptoms. Common therapy comprises corticosteroids, antibiotics and supplemental oxygen or positive pressure ventilation in 64% of the cases. Of the 31 patients included, eight died, three had permanent lung damage and 15 showed complete recovery, whereas in five patients outcome was not reported. Early signs likely relate to caustic reactions in the airway lining, whereas inhaled ZnCl2 particles may trigger an inflammatory response and associated delayed fibrotic lung damage. Smoke bomb poisoning is a potentially lethal condition that can occur in large cohorts of victims simultaneously.

An autopsy case of zinc chloride poisoning.

Ingestion of large amounts of zinc chloride causes corrosive gastroenteritis with vomiting, abdominal pain, and diarrhea. Some individuals experience shock after ingesting large amounts of zinc chloride, resulting in fatality. Here, we present the results of an administrative autopsy performed on a 70-year-old man who ingested zinc chloride solution and died. After drinking the solution, he developed vomiting, abdominal pain, and diarrhea, and called for an ambulance. Except for tachycardia, his vital signs were stable at presentation. However, he developed hypotension and severe metabolic acidosis and died. The patient's blood zinc concentration on arrival was high at 3030µg/dL. Liver cirrhosis with cloudy yellow ascites was observed, however, there were no clear findings of gastrointestinal perforation. The gastric mucosa was gray-brown, with sclerosis present in all gastric wall layers. Zinc staining was strongly positive in all layers. There was almost no postmortem degeneration of the gastric mucosal epithelium, and hypercontracture of the smooth muscle layer was observed. Measurement of the zinc concentration in the organs revealed the highest concentration in the gastric mucosa, followed by the pancreas and spleen. Clinically, corrosive gastroenteritis was the cause of death. However, although autopsy revealed solidification in the esophagus and gastric mucosa, there were no findings in the small or large intestine. Therefore, metabolic acidosis resulting from organ damage was the direct cause of death.

Neuroprotective Role of Lazaroids Against Aluminium Chloride Poisoning.

Aluminium (Al) is neurotoxic primarily because of its interference with biological enzymes in key mechanisms of metabolic pathways. Mitochondria being a major site of reactive oxygen species (ROS) production, it seems that the oxidative damage to mitochondrial proteins may underlie the pathogenesis of Al induced neurodegeneration. The present study investigates the effectiveness of the anti-oxidant property of lazaroids (U-74500A), a known lipid peroxidation inhibitor as neuroprotective agent against Al induced neurotoxicity. Al chloride was administered orally at a dose level of 100 mg/kg body wt/day in water and U-74500A was administered at a dose of 0.25 mg/kg body wt i.p. in citrate buffer for a period of 8 weeks on alternate days. Following Al exposure there was a significant increase in lipid peroxidation (LPO), ROS levels and reduction in the activity of mitochondrial complexes in all the three regions of rat brain, i.e., cerebral cortex, mid brain, and cerebellum. This decrease in the activities of electron transport complexes in turn affected the ATP synthesis and ATP levels adversely in the mitochondria. These alterations were also depicted in the histology which shows signs of hypoxia, paucity of neurons in cortical region and loosening of fibers in the white matter. U-74500A co-administration was able to restore alterations in the LPO, ROS levels as well as all the three mitochondrial complexes and caspase expression. Therefore, it is suggested that 21-aminosteroids (lazaroids), by attenuating LPO and mitochondrial dysfunction, holds a promise as an agent that can potentially reduce Al-induced adverse effects in brain.

Total gastrectomy due to ferric chloride intoxication.

INTRODUCTION: The ferric chloride intoxication is frequently caused by accident. Its toxicity is generally underrated, which can lead to fatal evolution or irreversible consequences. In this case, the caustic condition of the substance is related to the toxic properties of iron. CASE PRESENTATION: A 36-year-old male patient arrives by ambulance indicating sensory deterioration. He presents erosive injuries in the buccal cavity and in the oropharynx, brownish teeth and metabolic acidosis. Toxicology tests and ferritin blood dosage are requested, which show a result from 1400 mg/dl. The symptoms are interpreted as acute iron intoxication. Due to the unfavorable evolution of his condition, an abdominal and pelvic CT scan are performed, which show extensive pneumoperitoneum and free fluid in the abdominal cavity. An exploratory laparotomy, a total gastrectomy with esophagostomy and feeding jejunostomy, washing and drainage due to perforated gastric necrosis caused by caustic ingestion are performed. DISCUSSION: In our country, there is a high rate of intoxication caused by iron compounds, although it is not statistically measured. Nevertheless, the ferric chloride intoxication is extremely infrequent. The ingestion of this product leads to complications, which are associated with the iron concentration and its condition as a caustic agent. CONCLUSIONS: The surgical indications in the presence of intoxication caused by iron compounds are: stomach evacuation of iron, gastric necrosis, perforation or peritonitis and stenosis. Early or prophylactic gastrectomy is contraindicated. However, if complications that require immediate surgical intervention arise, there should be no hesitation and the corresponding procedure should be performed.

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.

Stimulation of gene expression and activity of antioxidant related enzyme in Sprague Dawley rat kidney induced by long-term iron toxicity.

The trace elements such as iron are vital for various enzyme activities and for other cellular proteins, but iron toxicity causes the production of reactive oxygen species (ROS) that causes alterations in morphology and function of the nephron. The present study was designed to determine the effect of long-term iron overload on the renal antioxidant system and to determine any possible correlation between enzymatic and molecular levels. Our data showed that reduced glutathione (GSH) levels, which is a marker for oxidative stress, strikingly decreased with a long-term iron overload in rat kidney. While renal mRNA levels of glucose 6-phosphate dehydrogenase (G6pd), 6-phosphogluconate dehydrogenase (6pgd) and glutathione peroxidase (Gpx) were significantly affected in the presence of ferric iron, no changes were seen for glutathione reductase (Gsr) and glutathione S-transferases (Gst). While the iron affected the enzymatic activity of G6PD, GSR, GST, and GPX, it had no significant effect on 6PGD activity in the rat kidney. In conclusion, we reported here that the gene expression of G6pd, 6pgd, Gsr, Gpx, and Gst did not correlate to enzyme activity, and the actual effect of long-term iron overload on renal antioxidant system is observed at protein level. Furthermore, the influence of iron on the renal antioxidant system is different from its effect on the hepatic antioxidant system.

Barium determination in gastric contents, blood and urine by inductively coupled plasma mass spectrometry in the case of oral barium chloride poisoning.

A serious case of barium intoxication from suicidal ingestion is reported. Oral barium chloride poisoning with hypokalemia, neuromuscular and cardiac toxicity, treated with intravenous potassium supplementation and hemodialysis, was confirmed by the determination of barium concentrations in gastric contents, blood, serum and urine using the inductively coupled plasma mass spectrometry method. Barium concentrations in the analyzed specimens were 20.45 µg/L in serum, 150 µg/L in blood, 10,500 µg/L in urine and 63,500 µg/L in gastric contents. Results were compared with barium levels obtained from a non-intoxicated person.

Fatal cesium chloride toxicity after alternative cancer treatment.

BACKGROUND: Cesium chloride (CsCl) is sold as a treatment for several types of cancers. The purported mechanism of action is alkalinization of relatively acidic neoplastic cells. The efficacy of CsCl has not been demonstrated in controlled experiments. Oral and intravenous CsCl use has been associated with seizures, cardiotoxicity, syncope, and death. Although intratumoral treatment with various antineoplastic agents is described, no cases of intratumoral cancer treatment with CsCl have been found in the medical literature. The case described here appears to be of the first reported patient with CsCl toxicity secondary to subcutaneous exposure after attempted intratumoral injection. CASE DETAILS: A 61-year-old woman presented in cardiac arrest 20 hours after injecting 9 mL of an oral CsCl preparation around a mass in her breast. She had been taking the CsCl orally for approximately 1 year to treat her breast mass. The patient had a headache and nausea for several hours after injection and then experienced ventricular tachycardia arrest at home. She received advanced cardiac life support care and multiple antiarrhythmic medications and underwent electrical cardioversion early in the course of the arrest. After stabilization, her electrocardiogram revealed QT interval prolongation to >700 milliseconds. Upon discovery of her CsCl exposure, she was treated with Prussian blue. Her initial whole blood cesium level was 100,000 µg/L (reference range <10 µg/L). Her QT prolongation resolved after several days, but she experienced no meaningful postarrest neurologic recovery and died at home less than a week after exposure. DISCUSSION: CsCl is sold as an alternative treatment for cancer. There is no demonstrable efficacy, and clear evidence shows life-threatening toxicity. Reported here is a case of fatal CsCl toxicity after attempted intratumoral injection.

Fatal barium chloride poisoning: four cases report and literature review.

Barium is an alkaline earth metal which has a variety of uses including in the manufacturing industry and in medicine. However, adverse health effects and fatalities occur due to absorption of soluble barium compounds, notably the chloride, nitrate, and hydroxide, which are toxic to humans. Although rare, accidental and suicidal modes of poisoning are sporadically reported in the literature.We describe 4 cases of poisoning due to barium chloride in China. In witnessed cases, severe gastrointestinal symptoms, hypokalemia leading to muscle weakness, cardiac arrhythmias, and respiratory failure were noted. Autopsy showed some nonspecific but common findings, such as subendocardial hemorrhage in the ventricles, visceral petechiae, and fatty changes in the liver. Interestingly, microscopic examination showed degenerative changes and amorphous, flocculent foamy materials in the renal tubules. Toxicology was relevant for barium in blood and tissues. Three of the cases were accidental and 1 homicidal in nature. A round-up of relevant literature on fatal barium compounds poisoning is also provided. Forensic pathologists should be aware of the clinical presentations of barium compound poisoning and especially look for any evidence of hypokalemia. Still, postmortem toxicological and histological studies are essential for an accurate identification of the cause of death.

[Interpretation of dark neurons in experimental model of ischemia, neurointoxication and brain infection].

INTRODUCTION: Findings of dark neurons is still a big controversy. Do they represent a simple artifact or neuropatological findings? The aim is to explain the appearance of "dark" neurons in different experimental animal models. MATERIAL AND METHODS: The experiments included three experimental models. Neuroischemia: where in postmortal fixed rat brain after 10', 30', 45', 1.5h, 3h, 6h, 12h, 24h histologically was examined the appearance of dark neurons; intoxication: after 28 days of oral administratio AlCl3 in rats analyse changes in the brain; neuroinfection: where hamsters perorally given culture larvae T. canis and after 5 weeks analyse neuropatological findings in the brain. All brains were processed by standard histological techniques and stained with H&E, Walton and Cresil violet methods. RESULTS: Neuroishemia--in the group fixed brain specimens after 10 and 30' found only insignificant number of dark neurons increases until the time of fixation, their number was increasing, and after 12 and 24 hours dark shape assumed virtually all neurons. Neuroinfection: laminar flow is characterized by deterioration of nerve cells and the concentration of dark neurons in V lamina of cerebral cortex. Neuroinfection--in the area granulomatous pathohistological lesions and other changes observed increased concentration of irreversible stages of dark neurons. DISCUSSION AND CONCLUSION: The same histopathology characteristics of dark neurons in all experimental models can be attributed to postmortem artificial ischemia, to which to every tissue is exposed during histological processing. The abundance of appearance of dark neurons depend on the length of exposure to ischemia and the previous patophysiological state of tissue especially if the pretreatment included a harmful substances. Any harmful substances leading to pathophysiological changes in vivo cause increased sensitivity of cells to arteficial ischemia and the development of dark neurons.

Genotoxicity surveillance programme in workers dismantling World War I chemical ammunition.

PURPOSE: To evaluate the effectiveness of personal protective measures in a dismantling plant for chemical weapons from World War I of the Belgian Defence. METHODS: Seventeen NIOSH level B-equipped plant workers exposed to arsenic trichloride (AsCl(3)) in combination with phosgene or hydrogen cyanide (HCN) were compared to 24 NIOSH level C-protected field workers occasionally exposed to genotoxic chemicals (including AsCl(3)-phosgene/HCN) when collecting chemical ammunition, and 19 matched referents. Chromosomal aberrations (CA), micronuclei (MNCB and MNMC), sister chromatid exchanges (SCE) and high frequency cells (HFC) were analysed in peripheral blood lymphocytes. Urinary arsenic levels and genetic polymorphisms in major DNA repair enzymes (hOGG1(326), XRCC1(399), XRCC3(241)) were also assessed. RESULTS: SCE and HFC levels were significantly higher in plant-exposed versus referent subjects, but MNCB and MNMC were not different. MNCB, SCE and HFC levels were significantly higher and MNMC levels significantly lower in field-exposed workers versus referents. AsCl(3) exposure was not correlated with genotoxicity biomarkers. CONCLUSIONS: Protective measures for plant-exposed workers appear adequate, but protection for field-exposed individuals could be improved.

[Acute poisoning due to barium chloride--case report]. / Ostre zatrucie chlorkiem baru--opis przypadku.

We reported a case of 52-years-old male, suffering from alcohol dependence, who ingested 20-30 ml 10% barium chloride solution as a substitute of ethanol. We observed gastrointestinal disturbances (nausea, vomiting, diarrhea), numbness and paresthesias of limbs, severe hypokalemia (1.29 mmol/l) resulting in general paralysis of skeleton muscles, dysarthria and dysphagia, ventricular arrhythmias. This patient was treated successfully with potassium chloride supplementation and was discharged after 9 days.

Acute respiratory distress syndrome after zinc chloride inhalation: survival after extracorporeal life support and corticosteroid treatment.

No standard protocol exists for the treatment of acute respiratory distress syndrome induced by inhalation of smoke from a smoke bomb. In this case, a 23-year-old man was exposed to smoke from a smoke grenade for approximately 10 to 15 minutes without protective breathing apparatus. Acute respiratory distress syndrome developed subsequently, complicated by bilateral pneumothorax and pneumomediastinum 48 hours after inhalation. Despite mechanical ventilation and bilateral tube thoracostomy, the patient was severely hypoxemic 4 days after hospitalization. His condition improved upon treatment with high-dose corticosteroids, an additional 500-mg dose of methylprednisolone, and the initiation of extracorporeal life support. Arterial oxygenation decreased gradually after abrupt tapering of the corticosteroid dose and discontinuation of the life support. On day 16 of hospitalization, the patient experienced progressive deterioration of arterial oxygenation despite the intensive treatment. The initial treatment regimen (ie, corticosteroids and extracorporeal life support) was resumed, and the patient's arterial oxygenation improved. The patient survived.

Life-threatening Torsades de Pointes resulting from "natural" cancer treatment.

INTRODUCTION: Nonradioactive cesium chloride (CsCl) is used by some alternative medicine advocates as a treatment for cancer. The therapy was proven to be neither safe nor effective. Chronic use of CsCl has resulted in cases with severe cardiotoxicity. CASE REPORT: A 65-year-old lady presented to our hospital's accident and emergency department with recurrent syncope attacks. Electrocardiogram monitoring showed QT prolongation and transient Torsades de Pointes (TDP) ventricular tachycardia. She was taking anticancer naturopathic drugs for 6 weeks before admission. One of her naturopathic drugs was subsequently confirmed containing 89% CsCl by weight. Besides conventional treatment of QT prolongation and TDP, the patient was given a 4-week course of oral Prussian blue to enhance gastrointestinal elimination of cesium. The serum half-life of cesium was reduced from 61.7 to 29.4 days after the use of Prussian blue. QT prolongation was normalized in 27 days. DISCUSSION: To our knowledge, this is the first published case of nonradioactive cesium poisoning treated with Prussian blue. A transient rise in serum cesium level was observed during Prussian blue therapy. Possible explanations for this observation include poor drug compliance during outpatient treatment and redistribution of cesium from body stores. CONCLUSION: Nonradioactive CsCl poisoning can result in severe cardiotoxicity with QT prolongation and TDP ventricular tachycardia. The key points in the management of nonradioactive cesium poisoning include cessation of cesium exposure, vigorous electrolytes replacement, and oral Prussian blue therapy.

Gastric stricture following zinc chloride ingestion.

AIM: We present the case of an adult who ingested soldering fluid containing zinc chloride (ZC) in a suicide attempt. He developed a gastric stricture that was managed successfully by laparoscopic Roux-en-Y gastrojejunostomy. An extensive literature review shows that there are few reports of ZC ingestion. Furthermore, management of corrosive gastrointestinal tract injury is debatable. The evidence is summarized in this case report. RESULTS: ZC is a strong corrosive agent, which, following ingestion, is capable of producing widespread damage locally and systematically with long-lasting morbidity and significant mortality. The mainstay of treatment is supportive. Esophago-gastro-duodenoscopy is the diagnostic procedure of choice in the absence of perforation. Strictures that cannot be dilated endoscopically may require surgery. Emergency surgery is required for patients with evidence of perforation. Early and aggressive surgical resection in patients with high-grade burns may improve mortality and morbidity. CONCLUSION: Because of the lack of data, it remains debatable as to the optimal management strategies following ZC ingestion. Our patient was managed conservatively throughout the acute phase. However following recognition of the gastric stricture, surgical intervention ensued and he underwent successful laparoscopic Roux-en-Y gastrojejunostomy and was subsequently discharged having made an excellent recovery.

Gestational manganese intoxication and anxiolytic-like effects of diazepam and the 5-HT1A receptor agonist 8-OH-DPAT in male Wistar rats.

In the present study, the effects of prenatal manganese (Mn) intoxication on the anxiolytic-like effects of diazepam and the 5-HT(1A) receptor agonist R-(+)-8-hydroxy-dipropylaminotetralin (8-OH-DPAT) were examined.Wistar dams were exposed to MnCl(2).4H(2)O at 5,000 ppm in the drinking water for the duration of pregnancy. On the day of parturition, Mn was discontinued as an additive in the drinking water. Control rats were derived from dams that consumed tap water and had no exposure to Mn. Male offspring were tested at the age of 12 weeks. The anxiolytic-like effect was assessed in an elevated plus maze device and with the Vogel conflict test. The benzodiazepine anxiolytic diazepam (5 mg/kg, ip) increased the percentage of time spent in open arms in control rats (in comparison to saline treatment) (p < 0.05); no such effect was seen in Mn-exposed rats. Conversely, the serotoninergic 5-HT(1A) agonist 8-OH-DPAT (0.3 mg/kg, ip) increased the percentage of time spent in open arms in both experimental groups. In the Vogel drinking test, an anxiolytic-like effect was also observed in both test groups (in controls this was of borderline significance). In contrast, 8-OH-DPAT did not evoke an anxiolytic-like action in control or in Mn-exposed rats in the anticonflict test. In conclusion, findings indicate that gestational Mn exposure attenuated benzodiazepine-mediated anxiolytic-like effects but not those of the 5-HT(1A) receptor agonist 8-OH-DPAT.

A fatal case following exposure to zinc chloride and hexachloroethane from a smoke bomb in a fire simulation at a school.

INTRODUCTION: The common mixture for smoke bombs contains zinc oxide and a chlorine donor, which allows for the formation of fine particles of zinc chloride. We report a fatal case of exposure to a smoke bomb used for a fire training exercise at a school. CASE REPORT: A 21-year-old student inhaled zinc oxide/hexachloroethane from a smoke bomb during a fire simulation at a school. Fever and tachypnea began six hours after exposure. Radiological evaluation showed a mixed interstitial-alveolar bilateral infiltrates. Despite supportive care, the patient died of multi-organ failure nine days after inhalation. DISCUSSION: ZnCl inhalation is characterized by a lag period between exposure and evidence of respiratory toxicity, ranging from ten to 32 days, depending on the inhaled dose of ZnCl. Subjects inhaling even a small amount of aerosols from a smoke bomb should be carefully managed in a hospital setting where their respiratory function can be closely monitored. CONCLUSION: This case highlights the risk of serious injury and even death from smoke bombs containing zinc chloride aerosol in schools and suggests that these smoke bombs should not be used for fire simulation or activities where human exposure is suspected, particularly in schools.