Aakash Desai, MD
Resident Physician
MetroHealth Medical Center/Case Western Reserve University
Cleveland, Ohio
Aakash Desai, MD1, Patrick Twohig, MD, MPH2, Dalbir S. Sandhu, MD3
1MetroHealth Hospital, Case Western Reserve University, Cleveland, OH; 2MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; 3Case Western Reserve University / MetroHealth Medical Center, Cleveland, OH
Introduction: In adults, iron overdose is usually associated with suicide attempts. Unfortunately, a majority of acute iron toxicity cases are fatal given the rapid progression to multi-organ failure. Literature on management of acute iron toxicity is scant with most of current available information reported in pediatric population. Here in, we report a case of acute iron toxicity in an adult.
Case Description/Methods: A 58-year-old African American woman with a history of depression, prior suicide attempt and post-traumatic stress disorder presented to the emergency room with a 3-day history of coffee-ground emesis and abdominal pain. She was found to be hypotensive (74/45 mm Hg), and tachycardic (124 beats per minute). Laboratory investigation revealed a markedly elevated AST/ALT at 10518/5430 IU/L, alkaline phosphatase 260 IU/L, direct bilirubin 2.9 mg/dL, total bilirubin 4.9 mg/dL, INR 1.47, PT 16.8 sec, sodium 127 mmol/L, bicarbonate 14 mmol/L, BUN 45 mg/dL, Cr 5.92 mg/dL, anion gap 29 and lactate of 3.1 mmol/L. Additional comprehensive workup for acute liver injury was negative. She was fluid resuscitated with 5 liters of 0.9% normal saline. CT abdomen and pelvis with contrast revealed multiple radiopaque objects in the proximal ileum. Serum iron level was > 500, iron saturation > 273, TIBC 183, Transferrin 131 and Ferritin level of 867. She was started on a deferoxamine infusion at 5 mg/kg/hour and whole bowel irrigation with Colyte at 200 cc/hour. She was also started on continuous venovenous hemofiltration (CVVH) for anuric acute kidney injury. Deferoxamine was discontinued 24 hours after initiation, as her urine was clear and iron level was less than 350. Colyte was discontinued once stool output was clear. Her hospital course was complicated by small bowel obstruction, which resolved with bowel rest and non-operative supportive care. Psychiatry was consulted for a suicide risk assessment however, patient consistently denied any suicide attempt and collateral information from family was reassuring. The idea of accidental ingestion was entertained, however, the patient denied being on iron supplementation. Her iron levels, LFTs, and urine output were back to baseline 1-week post-discharge.
Discussion: Acute iron toxicity in adults can rapidly progressive to multiorgan failure and death. Deferoxamine should be initiated early in severe cases. Clinicians should be aware of other adjunctive measures like WBI and CVVH; they should be employed early in the treatment course to improve survival outcomes.
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Citation: Aakash Desai, MD; Patrick Twohig, MD, MPH; Dalbir S. Sandhu, MD. P1598 - ACUTE IRON TOXICITY IN AN ADULT: INTENTIONAL OR ACCIDENTAL?. Program No. P1598. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.