Severe hyperphosphatemia and hypocalcemia following the rectal administration of a phosphate-containing Fleet pediatric enema.
BACKGROUND
Toxicity secondary to rectally administered hypertonic phosphate solution in patients with normal renal function is rarely reported in the literature. We report a case of electrolyte disturbance and seizure secondary to the rectal administration of 2 Fleet pediatric enemas.


METHODS
A 4-year-old white female with spinal muscular atrophy and chronic constipation was brought to the emergency department with complaints of lethargy and difficulty breathing following the administration of 2 Fleet pediatric enemas. In the emergency department, physical examination was significant for a depressed level of consciousness and shallow respirations. A basic metabolic profile was significant for a calcium of 3.3 mg/dL, phosphate of 23 mg/dL, and sodium of 153 mEq/L. Arterial blood gases revealed a pH of 7.24, Pco2 of 38 mm Hg, Po2 of 220 mm Hg. Electrocardiogram revealed a prolonged QT interval of 340 milliseconds with a corrected QT interval of 498 milliseconds. Sixteen hours postexposure, she experienced a generalized seizure unresponsive to multiple doses of lorazepam and responsive only to 100 mg of intravenous calcium chloride. Two days after presentation, the patient experienced complete resolution of symptoms.


CONCLUSIONS
Osmotically acting hypertonic phosphate enemas can result in severe toxicity if retained. This is true even in patients without predisposing risk factors.
Marraffa
Jeanna M
JM
Central New York Poison Center, Department of Emergency Medicine, University Hospital, SUNY Upstate Medical University, Syracuse, NY 13210, USA. marraffj@upstate.edu
Hui
Alan
A
Stork
Christine M
CM
D000138:Acidosis / Q000139:chemically induced; D000285:Administration, Rectal; D002122:Calcium Chloride / Q000627:therapeutic use; D002675:Child, Preschool; D003244:Consciousness Disorders / Q000139:chemically induced; D003248:Constipation / Q000209:etiology / Q000628:therapy; D004417:Dyspnea / Q000139:chemically induced; D004733:Enema / Q000009:adverse effects*; D004829:Epilepsy, Generalized / Q000139:chemically induced; D005260:Female; D006801:Humans; D006955:Hypernatremia / Q000139:chemically induced; D006982:Hypertonic Solutions / Q000009:adverse effects*; D006996:Hypocalcemia / Q000139:chemically induced* / Q000188:drug therapy; D007408:Intestinal Absorption; D009134:Muscular Atrophy, Spinal / Q000150:complications; D010710:Phosphates / Q000008:administration & dosage / Q000009:adverse effects* / Q000097:blood* / Q000493:pharmacokinetics
D006982:Hypertonic Solutions; D010710:Phosphates; D002122:Calcium Chloride