Severe iatrogenic bismuth poisoning with bismuth iodoform paraffin paste treated with DMPS chelation.
BACKGROUND
Bismuth iodoform paraffin paste (BIPP) is used for the packing of wound and surgical cavities. Features of both bismuth and iodoform toxicities have been associated with the use of BIPP, but there are no previous reports of 2,3-dimercaptopropane-1-sulphonate (DMPS) chelation therapy for bismuth poisoning secondary to its use.


METHODS
A 67-year-old man presented with a pelvic tumor requiring extensive surgical resection. BIPP packing was required post-operatively for surgical wound breakdown. A few days after insertion, the patient developed neurological features of bismuth toxicity (blood and urine bismuth concentrations were 340 microg/L and 2800 microg/L, respectively), which was treated with removal of the BIPP packing and DMPS chelation [27 days of intravenous DMPS (5 mg/kg 4 times daily for 5 days, 5 mg/kg three times daily for 5 days followed by 5 mg/kg twice a day for 17 days) followed by 24 days of oral DMPS (200 mg three times a day for 10 days, followed 200 mg twice daily for 14 days)]. This resulted in improvement in his symptoms and a decline in his pre-chelation bismuth concentration of 480 microg/L to 5 microg/L following chelation. There were no adverse effects during chelation.


CONCLUSIONS
DMPS chelation appears to be a potentially effective chelating agent in bismuth toxicity.
Ovaska
Hanna
H
Guy's and St Thomas' Poisons Unit, Medical Toxicology Unit, London, United Kingdom. Hanna.Ovaska@gstt.nhs.uk
Wood
David M
DM
House
Ivan
I
Dargan
Paul I
PI
Jones
Alison L
AL
Murray
Shona
S
D000368:Aged; D000931:Antidotes / Q000008:administration & dosage / Q000627:therapeutic use; D001729:Bismuth / Q000506:poisoning* / Q000627:therapeutic use; D002614:Chelating Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D004338:Drug Combinations; D006801:Humans; D006847:Hydrocarbons, Iodinated / Q000506:poisoning* / Q000627:therapeutic use; D008297:Male; D010386:Pelvic Neoplasms / Q000601:surgery; D011183:Postoperative Complications / Q000517:prevention & control; D014494:Unithiol / Q000008:administration & dosage / Q000627:therapeutic use*; D014945:Wound Healing / Q000187:drug effects
D000931:Antidotes; D002614:Chelating Agents; D004338:Drug Combinations; D006847:Hydrocarbons, Iodinated; C045757:bismuth iodoform paraffin paste; D014494:Unithiol; D001729:Bismuth