title: Human fatalities from cyanobacteria: chemical and biological evidence for cyanotoxins.
abstract: An outbreak of acute liver failure occurred at a dialysis center in Caruaru, Brazil (8 degrees 17' S, 35 degrees 58' W), 134 km from Recife, the state capital of Pernambuco. At the clinic, 116 (89%) of 131 patients experienced visual disturbances, nausea, and vomiting after routine hemodialysis treatment on 13-20 February 1996. Subsequently, 100 patients developed acute liver failure, and of these 76 died. As of December 1996, 52 of the deaths could be attributed to a common syndrome now called Caruaru syndrome. Examination of phytoplankton from the dialysis clinic's water source, analyses of the clinic's water treatment system, plus serum and liver tissue of clinic patients led to the identification of two groups of cyanobacterial toxins, the hepatotoxic cyclic peptide microcystins and the hepatotoxic alkaloid cylindrospermopsin. Comparison of victims' symptoms and pathology using animal studies of these two cyanotoxins leads us to conclude that the major contributing factor to death of the dialyses patients was intravenous exposure to microcystins, specifically microcystin-YR, -LR, and -AR. From liver concentrations and exposure volumes, it was estimated that 19.5 microg/L microcystin was in the water used for dialysis treatments. This is 19.5 times the level set as a guideline for safe drinking water supplies by the World Health Organization.
authors.affiliation: Department of Biological Sciences, Wright State University, 3640 Colonel Glen Highway, Dayton, OH 45435, USA. wayne.carmichael@wright.edu
authors.forename: W W
authors.initials: WW
authors.lastname: Carmichael
authors.forename: S M
authors.initials: SM
authors.lastname: Azevedo
authors.forename: J S
authors.initials: JS
authors.lastname: An
authors.forename: R J
authors.initials: RJ
authors.lastname: Molica
authors.forename: E M
authors.initials: EM
authors.lastname: Jochimsen
authors.forename: S
authors.initials: S
authors.lastname: Lau
authors.forename: K L
authors.initials: KL
authors.lastname: Rinehart
authors.forename: G R
authors.initials: GR
authors.lastname: Shaw
authors.forename: G K
authors.initials: GK
authors.lastname: Eaglesham
mesh_terms: D000554:Ambulatory Care Facilities; D001938:Brazil / Q000453:epidemiology; D002273:Carcinogens / Q000009:adverse effects* / Q000032:analysis; D000458:Cyanobacteria / Q000737:chemistry / Q000302:isolation & purification*; D003956:Dialysis; D004196:Disease Outbreaks; D004797:Enzyme-Linked Immunosorbent Assay; D006801:Humans; D008099:Liver / Q000737:chemistry / Q000473:pathology; D017114:Liver Failure, Acute / Q000209:etiology / Q000382:microbiology*; D052998:Microcystins; D010456:Peptides, Cyclic / Q000009:adverse effects* / Q000032:analysis; D014881:Water Supply
chemical_list: D002273:Carcinogens; D052998:Microcystins; D010456:Peptides, Cyclic; C078588:microcystin