Accidental Oral Poisoning Caused by Rdx (Cyclonite): A Report of 5 Cases

Abstract

The explosive RDX (hexogen, cyclonite) is usually used for the production of C-4 explosive. The rare occurrence of accidental and intentional RDX intoxications has been reported during manufacturing process or in wartime. In this article, the authors report 5 cases of accidental oral RDX poisoning. On admission, observed signs and symptoms included repetitive generalized tonic-clonic convulsions, postictal coma, lethargy, confusion, hyperreflexia, postictal amnesia, nausea, vomiting, abdominal tenderness, sinusal tachycardia, dysrhythmia with frequent ventricular premature beats, generalized muscle spasms, and myoclonus. Leukocytosis, mild anemia, methemoglobinemia, elevated levels of blood glucose, serum aspartate transaminase, alanine transaminase, lactic dehydrogenase, creatine phosphokinase, amilase, hypokalemia, metabolic acidosis, proteinuria, glucosuria, and myoglobinuria were also noted. Plasma RDX concentrations were 268 to 969 ng/mL at 3 hours of ingestion. For management, supportive and symptomatic measures were taken. Whole-bowel irrigation might have been an effective therapeutic procedure due to probable slow gastrointestinal absorption of RDX. Three patients who developed severe metabolic acidosis underwent urgent hemodialysis. All patients were discharged 7 to 21 days after admission without any sequelae. Plasma RDX levels were strongly correlated with the clinical and laboratory manifestations. The available toxicological data on this rare accidental poisoning are reviewed in light of the literature.

Metabolic acidosis in prometryn (triazine herbicide) self-poisoning

“…Yet the most prominent feature in this patient was high anion gap metabolic acidosis determined using the following equation: anion gap = [sodium] -[chloride] -[bicarbonate] (10). Interestingly, similar metabolic acidosis was also observed in patients poisoned with other triazines such as RDX and atrazine (7,8). The mechanism of metabolic acidosis in triazine herbicide poisoning in humans is not known, but tirapazamine (3-amino-1,2,4-benzotriazine-1,4-dioxide), which is a triazine anti-cancer drug, acts as an uncoupler of obligatory linkage between the respiratory chain and the oxidative phosphorylation in human cell mitochondria (11), while simazine (6-chloro-N2,N4-diethyl-1,3,5-triazine-2,4-diamine), which is one of the triazine herbicides, is known to decrease parameters of oxidative phosphorylation in animals (12).…”

“…Nevertheless, hemodialysis effectively corrected high anion gap metabolic acidosis in prometryn poisoning and perhaps also removed its hydrophilic and possible toxic metabolites, what could contribute to the patient's clinical improvement during hemodialysis (6). Interestingly, a similar correction of high anion gap metabolic acidosis resistant to sodium bicarbonate by hemodialysis was also observed in the above-mentioned patients who ingested triazine explosive RDX (8). The administration of sodium bicarbonate in triazine poisoned patients for correction of acidosis is questionable since bicarbonate has only been shown to improve the outcome in patients poisoned with agents whose elimination may be increased through alkalinization and patients poisoned with drugs that cause a blockade of cardiac sodium channels (10).…”

“…In the above-mentioned patient concomitant ingestion of atrazine, aminotriazole, ethylene glycol and formaldehyde resulted in coma, shock, metabolic acidosis, gastrointestinal bleeding, hepatic necrosis, renal failure, disseminated intravascular coagulation, and death after three days (7). Additionally there is a report of five patients who accidentally ingested triazine explosive RDX (hexahydro-1,3,5-trinitro-1,3,5-triazine) (8). Observed signs and symptoms in those patients included nausea, vomiting, abdominal tenderness, generalized tonic-clonic convulsions, postictal coma, generalized muscle spasms, myoclonus, sinus tachycardia, and ventricular premature beats (8).…”

“…Additionally there is a report of five patients who accidentally ingested triazine explosive RDX (hexahydro-1,3,5-trinitro-1,3,5-triazine) (8). Observed signs and symptoms in those patients included nausea, vomiting, abdominal tenderness, generalized tonic-clonic convulsions, postictal coma, generalized muscle spasms, myoclonus, sinus tachycardia, and ventricular premature beats (8). Their laboratory results revealed leucocytosis, methemoglobinemia, hyperglycemia, hypokaliemia, elevated levels of serum aspartate transaminase, alanine transaminase, lactic dehydrogenase, creatine phosphokinase, and high anion gap metabolic acidosis (8).…”

“…Observed signs and symptoms in those patients included nausea, vomiting, abdominal tenderness, generalized tonic-clonic convulsions, postictal coma, generalized muscle spasms, myoclonus, sinus tachycardia, and ventricular premature beats (8). Their laboratory results revealed leucocytosis, methemoglobinemia, hyperglycemia, hypokaliemia, elevated levels of serum aspartate transaminase, alanine transaminase, lactic dehydrogenase, creatine phosphokinase, and high anion gap metabolic acidosis (8). The toxicokinetic parameters of prometryn in humans such as rate of absorption, distribution, metabolism, and elimination are not known.…”