Poisoning and suicide by cyanide jewelry cleaner in the US Hmong community: A case series

Abstract

Over 200 000 persons of Hmong ethnicity live in the United States. The majority of this Southeast Asian ethnic group live in California, Minnesota and Wisconsin. Tradition plays a strong role in the Hmong population, and difficulty in assimilation into "Western ways" has been reported to result in depression and suicide attempts. Some products sold at Southeast Asian ethnic markets are well-known within the Hmong community to be lethal but are essentially unknown to the outside community. We describe eight cases in which cyanide-containing products were ingested by Hmong patients. Seven cases were suicide attempts involving the ingestion of a locally-purchased substance intended for cleaning metal, coins, or jewelry. One case involved the fatal ingestion of a cyanide-containing "herbal" cure. In the majority of the cases, cyanide was not initially suspected, and treatment was delayed due to lack of information regarding the product ingested. In the two patients who survived, the cyanide antidote kit (sodium nitrite, amyl nitrite, and sodium thiosulfate) was administered early. Clinicians should be aware that unusual and potentially lethal products are easily available at ethnic markets. Cyanide toxicity should be suspected, and empiric antidote therapy initiated early, in patients of Hmong or Southeast Asian descent who present with sudden and unexplained cardiovascular collapse and metabolic acidosis, especially in the setting of a suspected suicidal ingestion.

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“…Hypotension typically appears in cases where the pH is less than 7.1 and/or the serum bicarbonate is less than 10 [64-66, 70, 74-79]. Although we have found several cases where significant acidosis in cyanide poisoning occurred in the absence of hypotension, we have not been able to identify a case in which the pH was less than 7.00 [68,69,71,74,80]. Therefore, our impression that hypotension would be expected if cyanide was the etiology in our case appears to be accurate.…”

“…Many patients poisoned with cyanide do not manifest hypotension despite having a depressed level of consciousness or coma [63,[68][69][70][71][72][73][74][75][76]. However, hypotension generally occurs in more severely poisoned patients and appears to correlate with a lower serum pH [64-66, 70, 74-79].…”

“…In multiple case reports, the presence of an elevated venous oxygen content, either from centrally or peripherally drawn blood and often done simultaneously with analysis of arterial blood oxygen content, has been used as a surrogate marker for cyanide poisoning [63,74,79,80,[82][83][84][85][86][87]. Serial measurement of venous oxygenation has also been described to monitor the need for additional antidotal treatment [87], and analysis of venous oxygen content has been used in animal studies evaluating the efficacy of cyanide antidotes [88].…”

“…They suggest that when using the venous blood as a surrogate for cyanide poisoning, it should ideally be drawn from central blood, but as in their case, peripherally drawn blood may potentially be helpful [82]. Multiple subsequent case reports have detailed central venous oxygen saturations greater than 90 % in cyanide poisoning [74,79,[83][84][85]87].…”

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“…Interestingly, there were 20 cases (5.8%) with capillary blood glucose concentration higher than 200 mg/dL, two of which received insulin. Hyperglycemia has been reported with cyanide poisoning, and some previously reported cases demonstrated spontaneous resolution without insulin administration [19,20]. The mechanism of hyperglycemia in cyanide poisoning might be related to increased glycogenolysis and insulin resistance [21,22].…”