title: [Thioridazine intoxication of therapeutic error as the cause of death of a three-year girl].
abstract: Intoxication with drugs and xenobiotics in children, particularly under the age of 7 years, represents a serious diagnostic and therapeutic challenge considering the relatively immature enzymatic detoxication systems, greater susceptibility to organ lesions, easily destabilized homeostasis (including water-electrolyte balance) and limited compensatory mechanisms in acidosis or alkalosis. We present the case of a 3-year-old girl, who died 30 hours after admission to hospital, with suspicion of ingestion of two or three 100-mg tablets of thioridazine. The medical documentation and results of autopsy are in favor of acute cardiopulmonary failure caused by extensive cerebral and pulmonary edema as a complication of "water poisoning" i.e. acute hypotonic overhydration of the child.
authors.affiliation: Zakładu Medycyny Sadowej Pomorskiej Akademii Medycznej.
authors.forename: Danuta
authors.initials: D
authors.lastname: Deboa
authors.forename: Krzysztof S
authors.initials: KS
authors.lastname: Borowiak
authors.forename: Kazimierz
authors.initials: K
authors.lastname: Ciechanowski
authors.forename: Małgorzata
authors.initials: M
authors.lastname: Kurzejamska-Parafiniuk
mesh_terms: D000208:Acute Disease; D014150:Antipsychotic Agents / Q000506:poisoning*; D001344:Autopsy; D001929:Brain Edema / Q000139:chemically induced; D002675:Child, Preschool; D002983:Clinical Competence; D003937:Diagnosis, Differential; D004638:Emergency Treatment / Q000009:adverse effects*; D017809:Fatal Outcome; D005260:Female; D005440:Fluid Therapy / Q000009:adverse effects*; D006323:Heart Arrest / Q000209:etiology; D006801:Humans; D019300:Medical Errors; D011654:Pulmonary Edema / Q000139:chemically induced; D013881:Thioridazine / Q000506:poisoning*; D013997:Time Factors; D014869:Water Intoxication / Q000150:complications* / Q000209:etiology
chemical_list: D014150:Antipsychotic Agents; D013881:Thioridazine