title: An autopsy case of death due to metabolic acidosis after citric acid ingestion.
abstract: A man in his 40s was found unconscious on a sofa in a communal residence for people with various disabilities. He appeared to have drunk 800 ml of undiluted citric acid from a commercial plastic bottle. The instructions on the label of the beverage specified that the beverage be diluted 20- to 30-fold before consumption. The patient was admitted to an emergency hospital with severe metabolic acidosis (pH, 6.70; HCO3(-), 3.6 mEq/L) and a low ionized calcium level (0.73 mmol/L). Although ionized calcium and catecholamines were continuously administered intravenously to correct the acidosis, the state of acidemia and low blood pressure did not improve, and he died 20 h later. Citric acid concentrations in the patient's serum drawn shortly after treatment in the hospital and from the heart at autopsy were 80.6 mg/ml and 39.8 mg/dl, respectively (normal range: 1.3-2.6 mg/dl). Autopsy revealed black discoloration of the mucosal surface of the esophagus. Microscopically, degenerated epithelium and neutrophilic infiltration in the muscle layer were observed. In daily life, drinking a large amount of concentrated citric acid beverage is rare as a cause of lethal poisoning. However, persons with mental disorders such as dementia may mistakenly drink detergent or concentrated fluids, as in our case. Family members or facility staff in the home or nursing facility must bear in mind that they should not leave such bottles in places where they are easily accessible to mentally handicapped persons.
authors.affiliation: Department of Forensic Medicine, School of Medicine, Tohoku University, Sendai, Japan. Electronic address: ikeda@forensic.med.tohoku.ac.jp.
authors.forename: Tomoya
authors.initials: T
authors.lastname: Ikeda
authors.affiliation: Department of Diagnostic Image Analysis, School of Medicine, Tohoku University, Sendai, Japan.
authors.forename: Akihito
authors.initials: A
authors.lastname: Usui
authors.affiliation: Osaki Citizen Hospital, Osaki, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Matsumura
authors.affiliation: Department of Forensic Medicine, School of Medicine, Tohoku University, Sendai, Japan.
authors.forename: Tomomi
authors.initials: T
authors.lastname: Aramaki
authors.affiliation: Department of Forensic Medicine, School of Medicine, Tohoku University, Sendai, Japan.
authors.forename: Tadashi
authors.initials: T
authors.lastname: Hosoya
authors.affiliation: Department of Forensic Medicine, School of Medicine, Tohoku University, Sendai, Japan.
authors.forename: Yui
authors.initials: Y
authors.lastname: Igari
authors.affiliation: Department of Forensic Medicine, School of Medicine, Tohoku University, Sendai, Japan.
authors.forename: Tsukasa
authors.initials: T
authors.lastname: Ohuchi
authors.affiliation: Department of Forensic Medicine, School of Medicine, Tohoku University, Sendai, Japan.
authors.forename: Yoshie
authors.initials: Y
authors.lastname: Hayashizaki
authors.affiliation: Department of Forensic Medicine, School of Medicine, Tohoku University, Sendai, Japan.
authors.forename: Kiyotaka
authors.initials: K
authors.lastname: Usui
authors.affiliation: Department of Forensic Medicine, School of Medicine, Tohoku University, Sendai, Japan.
authors.forename: Masato
authors.initials: M
authors.lastname: Funayama
mesh_terms: D000138:Acidosis / Q000209:etiology*; D000328:Adult; D001344:Autopsy; D001628:Beverages / Q000506:poisoning*; D019343:Citric Acid / Q000097:blood / Q000506:poisoning*; D004947:Esophagus / Q000473:pathology; D017809:Fatal Outcome; D006801:Humans; D008297:Male
chemical_list: D019343:Citric Acid
keywords: Calcium; Citric acid beverage; Metabolic acidosis; Oral ingestion