title: Fatal manganese intoxication due to an error in the elaboration of Epsom salts for a liver cleansing diet.
abstract: We describe the case of a 50-year-old man with a fatal intoxication after accidental massive oral ingestion of manganese. The patient presented with lethargy, diffuse abdominal pain, vomiting, and profuse diarrhea after ingesting Epsom salts (magnesium sulfate heptahydrate) during a liver cleansing diet. Despite intensive care management with intubation, prone position ventilation, continuous venovenous hemofiltration, and multiple transfusions, he progressed to refractory shock with multiple organ dysfunction resulting in death within 72 h. Similar patients arrived at several hospitals with identical epidemiology (all had ingested the same salt obtained in the same place). Clinical and forensic investigations (X-ray diffraction) discovered that the supplier had mistakenly prepared the salts with hydrated manganese sulfate instead of magnesium sulfate heptahydrate. The results enabled the other patients to be successfully treated for hydrated manganese sulfate intoxication with life support in the intensive care unit and chelation therapy (EDTA). We describe the clinical presentation of acute manganese poisoning and alert professionals to the risk of an increasingly popular diet. This case demonstrates the importance of collaboration between clinicians, pathologists, and forensic scientists to resolve a difficult-to-diagnose case.
authors.affiliation: Intensive Care Department, Hospital Mútua de Terrassa, Universidad de Barcelona, Plaza Dr. Robert 5, CP: 08221, Terrassa, Barcelona, Spain. balsango@yahoo.es
authors.forename: Baltasar
authors.initials: B
authors.lastname: Sánchez
authors.forename: Jaume
authors.initials: J
authors.lastname: Casalots-Casado
authors.forename: Salvador
authors.initials: S
authors.lastname: Quintana
authors.forename: Amparo
authors.initials: A
authors.lastname: Arroyo
authors.forename: Carles
authors.initials: C
authors.lastname: Martín-Fumadó
authors.forename: Ignasi
authors.initials: I
authors.lastname: Galtés
mesh_terms: D000059:Accidents; D000284:Administration, Oral; D049429:Forensic Pathology; D053593:Forensic Toxicology; D006470:Hemorrhage / Q000473:pathology; D006801:Humans; D008099:Liver / Q000473:pathology; D008297:Male; D017895:Manganese Compounds / Q000032:analysis / Q000493:pharmacokinetics; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000139:chemically induced; D009336:Necrosis; D010179:Pancreas / Q000473:pathology; D012769:Shock / Q000139:chemically induced; D013054:Spectrophotometry, Atomic; D013431:Sulfates / Q000032:analysis / Q000493:pharmacokinetics / Q000506:poisoning*; D014018:Tissue Distribution; D014961:X-Ray Diffraction
chemical_list: D017895:Manganese Compounds; D013431:Sulfates; C039798:manganese sulfate