Hydroxocobalamin treatment of acute cyanide poisoning from apricot kernels

Abstract

BACKGROUNDCyanide, a mitochondrial toxin is one among the most rapidly acting lethal poisons known to man. If untreated, exposure to cyanide can kill within minutes. Current treatment of cyanide poisoning includes the intravenous administration of hydroxocobalamin. This case report describes unusual cyanide poisoning due to ingestion of large quantities of apricot kernels containing amygdalin, a compound which forms hydrogen cyanide when metabolised in the intestine and thus induces typical symptoms observed with cyanide poisoning. CASE PRESENTATIONA 35-year-old mentally ill woman was admitted while conscious to our emergency department and clinical toxicology unit. The patient's parents reported that they found their daughter in the living room, surrounded by apricots from which she had extracted and eaten the cores. Further investigation revealed that the woman had swallowed 20-30 apricot kernels, with extrapolation from the remaining uneaten kernels suggesting that this equated to a total kernel consumption of 10-15 g. The approximate time of consumption was 30 min prior to admission, and on arrival, the patient was uncooperative and appeared asymptomatic. INVESTIGATIONSThe following measurements were taken: blood pressure 120/70 mm Hg, pulse rate 120 beats/min, respiratory rate 26 breaths/min, temperature 37.5°C and SpO 2 on room air 98%. Arterial blood gas analysis also revealed slight metabolic acidosis (pH 7.33, pO 2 90 mm Hg, pCO 2 35.5 mm Hg, and HCO 3− 20 mmol/l). The anion gap at admission was 19 mEq/l. Lactate and cyanide levels were not measured and no signifi cant ECG changes were noted. TREATMENTAfter consultation with the clinical toxicology unit, she was subjected to a gastric lavage. One hundred grams of activated charcoal and 30 g of magnesium sulphate were administered, followed by hydration therapy (1000 ml of normal saline) and ECG monitoring. Approximately 70 min postingestion, the patient experienced headache, nausea and dyspnoea. Her vital signs were: blood pressure 75/50 mm Hg, pulse rate 145 beats/min, respiratory rate 30 breaths/min and SpO 2 93% (with supplementary oxygen mask: 3l/min). Arterial blood gas analysis revealed metabolic acidosis (pH 7.20, pO 2 75 mm Hg, pCO 2 34.2 mm Hg and HCO 3− 16 mmol/l). The anion gap was now 23 mEq/l. Two 1 ml phials of 5% amyl nitrite via inhalation, and intravenous infusion of 50 ml of 25% sodium thiosulphate in 1000 ml of 5% glucose solution (infusion rate 5 ml/min) were subsequently administered as recommended by the toxicologist. Following this therapy, the patient's methaemoglobin level was 10%, prompting the administration of oxygen via a facemask. Electrolytic solution (1000 ml) was then administered. This slightly improved her vital signs and her blood pressure rose to 80/60 mm Hg. SummaryClinical experience with hydroxocobalamin in acute cyanide poisoning via ingestion remains limited. This case concerns a 35-year-old mentally ill woman who consumed more than 20 apricot kernels. Published literature suggests each kernel would have conta...

Hong Kong poison information centre: Annual report 2020

“…They are known to contain a higher amygdalin content when compared with sweet almonds or other Prunus species kernel. Accidental poisonings were well‐reported in the literature and ingestion of 5–10 raw bitter almonds can result in severe toxicity in young children 15–18 . Early clinical features of cyanide poisoning are non‐specific and may include gastrointestinal disturbances, dizziness, headache and weakness.…”

“…Accidental poisonings were well-reported in the literature and ingestion of 5-10 raw bitter almonds can result in severe toxicity in young children. [15][16][17][18] Early clinical features of cyanide poisoning are non-specific and may include gastrointestinal disturbances, dizziness, headache and weakness. Severe poisoning will progress to coma, seizures, cardiovascular collapse and severe lactic acidosis.…”

Amygdalin content of seeds, kernels and food products commercially-available in the UK

“…The amygdalin content of stone fruit seeds could produce cyanide in the range of 0.01 -1.1 mg cyanide equivalents/g; this value is relatively high. Thus, ingestion of the kernels either intentionally or accidentally could result in acute or sub-acute health problems (Akyildiz, Kurtoğlu, Kondolot, & Tunç, 2010;Cigolini, Ricci, Zannoni, Codogni, Luca, Perfetti, & Giampaolo, 2011) especially if taking place over prolong periods of time.…”

Awareness, among primary health care physicians, of acute cyanide poisoning being a possible consequence of fire accidents

“…CVS involvement is manifested as hemodynamic instability [23]. Early administration of one of the antidotes holds the key to treatment [24].…”