UMEM Educational Pearls

Category: Toxicology

Title: Arsenic and Agatha Christie

Keywords: Arsenic poisoning (PubMed Search)

Posted: 10/19/2017 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

Agatha Christie is an English crime novelist who frequently used poisons in her books to murder the victims. In her book, Murder is Easy, Ms. Christie uses arsenic/arsenic trioxide to kill several characters.

 

Primary source of arsenic in general population is contaminated food, water and soil. Arsenic exists in several forms: elemental, gaseous (arsine), organic and inorganic (trivalent or pentavalent).

 

Arsenic trioxide has also been used to treat acute promyelocytic leukemia in China; it’s use in other leukemia, lymphoma, and other solid tumors are currently being investigated.

 

Arsenic primarily inhibits the pyruvate dehydrogenase complex and multiple other enzymes involved in the citric cycle/oxidative phosphorylation, resulting in mitochondrial dysfunction.

 

Acute toxicity of arsenic after ingestion

  1. GI symptoms (minutes to several hours) – nausea, vomiting, abdominal pain and cholera like diarrhea.
  2. Cardiovascular: QT prolongation/torsade de pointes, orthostatic hypotension, ventricular dysrhythmias, myocardial dysfunction and shock.
  3. CNS (days): encephalopathy, delirium, coma, and seizure due to cerebral edema and microhemorrhages.
  4. Respiratory: ARDS, respiratory failure,
  5. Others: AKI, leukemoid reaction, hemolytic anemia, and hepatitis.

 

 Management

  1. Chelation: dimercaptrol (BAL) or succimer
  2. Whole bowel irrigation if radiopaque material is present (abdominal XR)
  3. Electrolyte and fluid management
  4. Cardiac monitoring and pressor support in hypotension