Question 1 of 10

    Nitrite Poisoning

    Nitrite poisoning can occur by accidental ingestion of food and water or through recreational inhalation of amyl nitrite. Severe nausea, vomiting, fatigue, dizziness and methemoglobinemia inducing profound cyanosis are main symptoms. Rapid use of methylene blue can be life-saving, as coma and death can ensue if an early diagnosis is not made.

    The disorder is triggered by the following process: Poison.

    Presentation

    Symptoms of nitrite poisoning start within a range of 20-180 minutes, most prominent being nausea, vomiting, dizziness and fatigue [2]. Marked cyanosis caused by methemoglobinemia manifests on the lips, fingernails and skin, followed by tachycardia and loss of consciousness [21]. As the percentage of methemoglobin rises, further deterioration of clinical signs and symptoms are seen and can lead to coma and death [6].

    Entire body system
    Anemia
    • […] a long period of time, the fish’s body has no opportunity to build up a resistance to the toxin, although with both toxins, the end result is the same; oxidizing iron atoms in hemoglobin reducing oxygen supply to the blood stream and tissue; severe anemia[goldfish-emergency.com]
    • Nitrate poisoning can occur when: Forage consumed contains high levels of nitrate; The diet changes rapidly or suddenly; Parasitism or other conditions causing anemia; Livestock consume supplements of urea or high-protein feeds along with forage containing[wilkes.ces.ncsu.edu]
    • Kirsch IR & Cohen HJ (1980) Heinz-body hemolytic anemia from the use of methylene blue in neonates.[inchem.org]
  • more...
  • neurologic
    Tremor
    • Other groups showed severe toxic signs including excitement, restlessness, muscle tremor, anoxia, and coma, followed by death within 60 hours.[banglajol.info]
    • Abdominal pain Scour Weakness Muscle tremors Drooling of saliva Blue discolouration of the mouth Mouth breathing Collapse Coma Death Diagnosis The clinical signs are vague, particularly early on.[thecattlesite.com]
    • Clinical signs of nitrate/nitrite poisoning include colic, diarrhea, respiratory difficulty, weakness, muscle tremors, abnormal gait, shaking, elevated heart rate, seizures, blue to brown discoloration of the gums, and death.[equinews.com]
    • The onsets of symptoms are very rapid and include: Bluish/chocolate brown gums Rapid, difficult and noisy breathing Rapid pulse Salivation, bloat, tremors, staggering Weakness, coma, death Dark “chocolate-coloured” blood Pregnant females that survive[thevetcentrenorthland.co.nz]
    • Rapid, weak heart beat, subnormal body temperature, muscular tremors, weakness and in coordination are early signs of toxicity.[rmla.com]
  • more...
  • Skin
  • more...
  • musculoskeletal
  • more...
  • cardiovascular
    Cyanosis
    • Presentation cardiovascular Cyanosis Severe nausea, vomiting, fatigue, dizziness and methemoglobinemia inducing profound cyanosis are main symptoms.[symptoma.com]
    • On admission he had cyanosis and respiratory distress.[inchem.org]
    Tachycardia
    • [www.symptoma.com] Tachycardia Marked cyanosis caused by methemoglobinemia manifests on the lips, fingernails and skin, followed by tachycardia and loss of consciousness.[symptoma.com]
    • Tachycardia, hypotension and collapse may also occur.[inchem.org]
  • more...
  • hematological
  • more...
  • Eyes
  • more...
  • Workup

    Cyanosis that does not improve on supplemental oxygen is highly suggestive of methemoglobinemia induced by nitrites [6]. Because oxygen saturation is not a reliable diagnostic sign, one of the most prominent clinical signs is the appearance of "chocolate brown" blood when drawing samples for testing [3] [6]. The diagnosis mandates a detailed patient history and evaluation of family members, as clustered cases of accidental ingestion are the most common clinical setting [2] [6].

    Laboratory

    Serum
  • more...
  • Microbiology
  • more...
  • Treatment

    Immediate administration of 1% methylene blue is recommended, as it is able to reverse the effects of nitrite-induced methemoglobinemia [9]. It is given intravenously in doses of 1-2 mg/kg [5].

    Prognosis

    Poisoning by nitrites can be fatal in high concentrations and without appropriate therapy [2]. For this reason, early recognition of the disease is detrimental.

    Complications

    Bradycardia
    • Reflex tachycardia is the rule but a vasovagal reflex may induce transient bradycardia just before complete collapse (Gosselin et al., 1984; Donovan, 1990).[inchem.org]
    Hypotension
    • England journal of , 1967 - ncbi.nlm.nih.gov Antidote use in the critically ill poisoned patient - DP Betten, RB Vohra, MD Cook - Journal of intensive , 2006 - jic.sagepub.com A sudden death associated with the use of sodium nitroprusside for induction of hypotension[symptoma.com]
    • Hypotension and collapse may also occur.[inchem.org]
    Methemoglobinemia
    • Proposed mechanism of nitrite-induced methemoglobinemia.[symptoma.com]
    • However, lower doses of this substance have caused acute methemoglobinemia, particularly in infants.[earthtimes.org]
    • A recent monograph on isobutyl nitrite stated that methemoglobinemia, occurring as a result of butyl, isobutyl, and amyl nitrite inhalation, is "clinically FULL TEXT[annals.org]
    • Methemoglobinemia results in hypoxia severe enough to cause sudden death but often the fish will live until they exert themselves.[addl.purdue.edu]
    • This condition is known as methemoglobinemia and can be fatal since methemoglobin is an inefficient carrier of oxygen.[petplace.com]
  • more...
  • Etiology

    Nitrites in the form of sodium nitrite are used to preserve meat and fish products because of their antimicrobial effects, but they are also used for prevention of pipe corrosion and fertilization [6]. They are rarely found in concentrations sufficient to cause toxicity [7]. Recreational inhalation of amyl nitrite and accidental ingestion of sodium nitrite (resembling sugar and salt) are recognized modes of poisoning and between 200-500 mg are sufficient to cause severe symptoms [2] [4].

    Epidemiology

    Nitrite poisoning is rarely reported and data regarding this condition are frequently extracted from isolated reports, but the majority of cases come from China, where sodium nitrite can be easily purchased and is frequently mistaken as salt or sugar due to similar appearance [2].

    Sex distribution
    Age distribution

    Pathophysiology

    The toxic effects of nitrites in the human body are exerted by its potent conversion of oxyhemoglobin to methemoglobin, which leads to profound cyanosis and reduced oxygen saturation of tissues. The presumed mechanism is thought to be an oxido-reductive reaction that produces NO2 and renders hemoglobin unable to bind oxygen [8]. As a result, the newly converted methemoglobin is the primary cause of numerous symptoms seen in these patients [8].

    Prevention

    Although sodium nitrite is rarely found in household items, its availability on the market in countries like China presents as a significant risk for poisoning [2]. Avoiding recreational use of amyl nitrite may also be an important preventive strategy, as poisoning after inhalation has been reported [4].

    Summary

    Because of its antiseptic properties, the ability to control oxidation of lipids, but also because it gives flavor and color to meat products, nitrites (mainly in the form of sodium nitrite) are used for various industrial and agricultural purposes [1]. In high amounts, however, this substance can be highly toxic for humans and nitrite poisoning can occur through accidental ingestion of contaminated food and water, or through inhalation of amyl nitrite for recreational purposes [2] [3]. The onset of symptoms is approximately 60 minutes and include dizziness, fatigue, nausea, vomiting and profound cyanosis [2]. Methemoglobinemia, a condition in which hemoglobin is replaced by methemoglobin that is unable to bind oxygen, is the main cause of symptoms seen in nitrite poisoning and can lead to tachycardia, loss of consciousness and even coma [2] [4]. The diagnosis can be made by obtaining a detailed personal history that can reveal the source of poisoning, but rapid and profound cyanosis without an apparent cause is highly suspective of nitrite poisoning [3]. Immediate intravenous administration of methylene blue is the mainstay of therapy and the prognosis can be fatal in the setting of profound methemoglobinemia [5].

    Patient Information

    Nitrites are compounds used for preservation of certain food products, such as meat and fish, primarily because of their antimicrobial properties. They are rarely found in concentrations high enough to cause toxicity, but accidental ingestion of water or food containing very high amounts of this inorganic substance is the most frequent mode of poisoning. Namely, nitrites induce conversion of hemoglobin to methemoglobin, which is unable to bind oxygen, resulting in the appearance of severe and life-threatening symptoms. Nausea, vomiting, dizziness and extreme fatigue develop within three hours after nitrites are introduced into the body, followed by the onset of profound cyanosis - marked bluish-to-purple discoloration of lips, fingers and nails due to absence of oxygen. In severe cases, lack of oxygen in tissues can cause coma and even death. For this reason, prompt recognition of the disease is mandatory. Nitrite poisoning is distinguished by the appearance of cyanosis that is not improving after supplementation with oxygen and by observing a brown to chocolate color of blood when drawing samples for testing. Treatment includes immediate intravenous administration of methylene blue, which enables conversion of methemoglobin back to hemoglobin.

    Self-assessment

    Ask Question


    5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.

    References

    1. Sindelar JJ, Milkowski AL. Human safety controversies surrounding nitrate and nitrite in the diet. Nitric Oxide. 2012;26(4):259-266.
    2. Wang R, Teng C, Zhang N, Zhang J, Conway G. A family cluster of nitrite poisoning, Suzhou City, Jiangsu Province, China, 2013. Western Pacific Surveillance and Response Journal : Western Pac Surveill Response J. 2013;4(3):33-36.
    3. Aagaard NK. Amyl nitrite poisoning [Article in Danish]. Ugeskr Laeger. 1998;160(25):3740-3741.
    4. Lin CH, Fang CC, Lee CC, Ko PC, Chen WJ. Near-fatal methemoglobinemia after recreational inhalation of amyl nitrite aerosolized with a compressed gas blower. J Formos Med Assoc. 2005;104(11):856-859.
    5. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
    6. Centers for Disease Control and Prevention (CDC). Methemoglobinemia following unintentional ingestion of sodium nitrite--New York, 2002. MMWR Morb Mortal Wkly Rep. 2002;51(29):639-642.
    7. Fang Y, Liu Q, Zhang B. Investigation of food poison caused by cool food contaminated with sodium nitrite. Chinese Journal of Public Health Management. 2012;28:218.
    8. Titov VY, Petrenko YM. Proposed mechanism of nitrite-induced methemoglobinemia. Biochemistry (Mosc). 2005;70(4):473-83.
    9. Modarai B, Kapadia YK, Kerins M, Terris J. Methylene blue: a treatment for severe methaemoglobinaemia secondary to misuse of amyl nitrite. Emerg Med J. 2002;19(3):270-1.

    • Acquired methemoglobinemia: a retrospective series of 138 cases at 2 teaching hospitals - R Ash-Bernal, R Wise, SM Wright - Medicine, 2004 - journals.lww.com
    • Brief recording: sausage cyanosis--acquired methemoglobinemic nitrite poisoning. - SP Bakshi, JL Fahey, LE Pierce - The New England journal of , 1967 - ncbi.nlm.nih.gov
    • Accidental poisoning of two laboratory technologists with sodium nitrite. - JJ Aquanno, KM Chan, DN Dietzler - Clinical Chemistry, 1981 - Am Assoc Clin Chem
    • A sudden death associated with the use of sodium nitroprusside for induction of hypotension during anaesthesia - DW Davies, D Kadar, DJ Steward, IR Munro - Canadian Journal of , 1975 - Springer
    • Current concepts about the treatment of selected poisonings: nitrite, cyanide, sulfide, barium, and quinidine - RP Smith, RE Gosselin - Annual review of pharmacology and , 1976 - annualreviews.org
    • Antidote use in the critically ill poisoned patient - DP Betten, RB Vohra, MD Cook - Journal of intensive , 2006 - jic.sagepub.com

    Languages

    Self-assessment