An outbreak of aflatoxicosis and boric acid poisoning in Malaysia: A clinicopathological study

Abstract

An outbreak of food poisoning resulting in 13 deaths in children occurred in Malaysia during the Chinese Festival of the Nine-Emperor Gods in 1988. The offending food was a Chinese noodle called 'Loh See Fun' (LSF). The source was traced to a factory where a banned food preservative was added to make the LSF. The food poisoning was attributable to aflatoxins and boric acid. The clinical features included vomiting, pyrexia, diarrhoea, abdominal pain, anorexia, giddiness, seizures, and eventual coma. Initially, many presented with a Reye-like syndrome. Eleven post-mortem examinations were performed. The pathological findings included extensive coagulative necrosis of the liver with proliferative 'ductal/ductular metaplasia of the hepatocytes'. Giant cell formation, central vein sclerosis, bile stasis, and steatosis were also noted. There was presence of acute tubular necrosis, superficial upper gastrointestinal erosions, and ensuing encephalopathy. The eventual cause of death is acute hepatic and renal failure.

Medical image of the week: acute pneumonitis secondary to boric acid exposure

“…In the same incident, congestion and fatty changes were observed, and there was parenchymatous degeneration in newborn infants who ingested 505 or 765 mg boron/kg as boric acid for 3-5 days (Wong et al 1964). Coagulative necrosis of the liver, proliferative metaplasia of the hepatocytes, giant cell formation, central vein sclerosis, bile stasis, and hepatic steatosis were observed in children ingesting unknown levels of aflatoxin and boric acid in Chinese noodles (Chao et al 1991a(Chao et al , 1991b.…”

“…In two infants who ingested 9.25 g boric acid (505 mg boron/kg/day) and 14 g boric acid (765 mg boron/kg/day), degenerative changes were seen in the liver, kidney, and brain (Wong et al 1964). In a food poisoning incident in Malaysia, 13 children died after consuming Chinese noodles contaminated with boric acid (Chao et al 1991a(Chao et al , 1991b. The deaths were determined by the study authors to be caused by unknown levels of aflatoxin and boric acid in the noodles.…”

“…The subjects were hospitalized for 24-96 hours and did not develop further symptoms following release (Linden et al 1986). Food poisoning of 13 children with unknown levels of aflatoxin and boric acid (Chao et al 1991a(Chao et al , 1991b Table 3-2 Oral a The number corresponds to entries in Figure 3-2.…”

“…Degenerative changes in parenchymal cells with oliguria and albuminuria have been demonstrated in two newborn infants after ingestion of 505 and 765 mg boron/kg/day as boric acid in an evaporated milk formula over a period of 3-5 days (Wong et al 1964). Acute renal tubule necrosis was seen in children dying from ingestion of unknown levels of aflatoxin and boric acid in Chinese noodles (Chao et al 1991a(Chao et al , 1991b.…”

“…Case reports of acute oral poisonings with boric acid do not clearly identify toxicity targets and doseresponse relationships in humans, but reported effects in fatal cases include degenerative changes in the liver, kidney, and brain (Chao et al 1991a(Chao et al , 1991bWong et al 1964). In animal studies, acute-duration oral exposure to boric acid or borates has been associated with effects on the male reproductive organs (e.g., decreased testicular weight and altered sperm morphology) in Wistar rats exposed to gavage boric acid doses of 88 mg boron/kg/day for 2 weeks (Fukuda et al 2000;Kudo et al 2000) and developmentally toxic effects (including reduced fetal weight and increased skeletal variations or malformations) in CD-1 mice exposed during gestation to boric acid doses as low as 70 mg boron/kg (2 times/day) (Cherrington and Chernoff 2002) and in New Zealand rabbits exposed during gestation (days 6-19) to doses of 44 mg boron/kg/day .…”