Inorganic Arsenic Poisoning Following An Intentional Overdose Of Realgar-Containing Niu Huang Jie Du Pian: A Case report and Literature Review

Authors

  • Ella Chan Accident and Emergency Department, Pamela Youde Nethersole Eastern Hospital, Hospital Authority, Hong Kong Special Administrative Region, China
  • Joe Kai Shing Leung Department of Accident and Emergency, Pamela Youde Nethersole Eastern Hospital, Hospital Authority, Hong Kong Special Administrative Region, China
  • Man Li Tse Hong Kong Poison Information Centre, Hospital Authority, Hong Kong Special Administrative Region, China
  • Rex Pui Kin LAM Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong
  • Zhi Xiu Lin School of Chinese Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
Abstract:

Background: Niu Huang Jie Du Pian (NHJDP) is a widely used realgar-containing Chinese medicine remedy. Most brands are composed of eight ingredients: Niuhuang (Calculus Bovis), Xionghuang (realgar), gypsum (calcium sulphate), Dahuang (Radix et Rhizoma Rhei), Huangqin (Radix Scutellariae), Jugeng (Platycodon grandiflorum), Bingpian (borneol), and Gancao (Radix Glycyrrhizae uralensis, licorice root). Most users are not aware that Xionghuang (realgar) contains arsenic disulphide [As2S2]. Inorganic arsenic poisoning after therapeutic overdoses has been reported in Chinese literature, but no report of acute, intentional overdose of NHJDP has been published. We report a case of intentional overdose of NHJDP leading to arsenic poisoning. Case Presentation: A 33-year-old woman ingested approximately 100 tablets of NHJDP bought over the counter, along with her usual antidepressants. She presented with somnolence, agitation, epigastric pain and repeated vomiting, compatible with clinical toxicities of NHJDP reported in Chinese literature. At presentation, blood and spot urine arsenic levels were 440.9 and 7,495 nmol/L, respectively. The patient’s condition improved rapidly after admission and chelation therapy was not deemed to be necessary. Discussion: Despite the self-limiting clinical course, the high arsenic level in the patient’s blood and urine raises safety concerns regarding the use of NHJDP in the community. Inconsistencies in the sales regulation of arsenic-containing products, and a lack of product label warning regarding arsenic content, may potentiate inadvertent arsenic poisoning.  Conclusion: Clinician should be aware of the possibility of inorganic arsenic poisoning when treating patients with overdose of Chinese medicine remedies that contain Xionghuang (realgar). Proper product labelling may help reduce inadvertent arsenic poisoning.

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volume 7  issue 4

pages  107- 110

publication date 2018-12-01

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