Fatal overdose of iron tablets in adults
A 25-year-old lady allegedly consumed 200 tablets of ferrous sulphate with suicidal intent. The total dose amounted to 13.5 g of elemental iron (270 mg/kg). She had abdominal pain with vomiting and was given gastric lavage along with supportive care at a primary health center. She was referred to our hospital after 24 h of ingestion for further management. At presentation, she was hemodynamically stable with a normal pulse rate and blood pressure. Complete blood count (CBC) showed hemoglobin-14.1 g/dl, total white blood cell (WBC) count-19,300/cu mm (90% neutrophils) and platelet count-283,000/cu mm. Serum iron level as measured by spectrophotometric analysis was 73 μg/dl (normal range 40-145 μg/dl) and the total iron binding capacity was 350 g/dl (normal range 250-350 μg/dl). Liver function tests (LFT) showed marked elevation in liver enzymes (serum glutamic oxaloacetic transaminase [SGOT]-11,000 U/L and serum glutamic pyruvic transaminase [SGPT]-11,420 U/L), total bilirubin (2.6 mg%), direct bilirubin (1.1 mg%), protein (4.6 g%), albumin (2.8 g%) and alkaline phosphatase (161 U/L). Serum creatinine was 1.9 mg%, bicarbonate was 15 mmol/l and blood sugar level was 81 mg/dl. Chelation therapy with desferrioxamine was started as an intravenous infusion of 15 mg/kg/h and increased to 25 mg/kg/h. 24 h after admission, she developed severe gastro-intestinal (GI) bleeding and went into a state of circulatory shock. Hemoglobin dropped from 14.1 to 7 gm%. Activated partial thromboplastin time (aPTT) was 71.3 s and prothrombin time (PT) was 24.5 with an international normalized ratio (INR) of 1.9. Arterial blood gas analysis showed severe metabolic acidosis with a pH of 6.96. She became progressively drowsy with un-recordable blood pressure, for which she was intubated and ventilated and supported with multiple inotropes. Aggressive blood product supports were given and hemodialysis was initiated for metabolic acidosis. Despite these measures, she continued to deteriorate and died within 36 h of admission due to multi-organ failure.