title: Severe iatrogenic bismuth poisoning with bismuth iodoform paraffin paste treated with DMPS chelation.
abstract: 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.
authors.affiliation: Guy's and St Thomas' Poisons Unit, Medical Toxicology Unit, London, United Kingdom. Hanna.Ovaska@gstt.nhs.uk
authors.forename: Hanna
authors.initials: H
authors.lastname: Ovaska
authors.forename: David M
authors.initials: DM
authors.lastname: Wood
authors.forename: Ivan
authors.initials: I
authors.lastname: House
authors.forename: Paul I
authors.initials: PI
authors.lastname: Dargan
authors.forename: Alison L
authors.initials: AL
authors.lastname: Jones
authors.forename: Shona
authors.initials: S
authors.lastname: Murray
mesh_terms: 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
chemical_list: D000931:Antidotes; D002614:Chelating Agents; D004338:Drug Combinations; D006847:Hydrocarbons, Iodinated; C045757:bismuth iodoform paraffin paste; D014494:Unithiol; D001729:Bismuth