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Journal of Analytical Toxicology, Vol. 35, March 2011

Case Report A Fatal Case of Acute Sul fide Poisoning Caused by Hydrogen : Therapy for Acute Hydrogen Sul fide Poisoning

Yuji Fujita 1,2, *, Yasuhisa Fujino 3, Makoto Onodera 3, Satoshi Kikuchi 3, Tomohiro Kikkawa 3, Yoshihiro Inoue 3, Downloaded from https://academic.oup.com/jat/article/35/2/119/773132 by guest on 01 October 2021 Hisae Niitsu 4, Katsuo Takahashi 2, and Shigeatsu Endo 3 1Poisoning and Drug Laboratory Division, Critical Care and Emergency Center, Iwate Medical University Hospital, 3-16-1 Honchoudori, Morioka, Iwate 020-0015, Japan; 2Department of Pharmacy, Iwate Medical University Hospital, 19-1 Uchimaru, Morioka, Iwate 020-8505, Japan; 3Department of Emergency Medicine, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate 020-8505, Japan; and 4Department of Legal Medicine, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate 020-8505, Japan

Abstract Introduction

A patient committed with hydrogen sulfide (H S) by 2 Hydrogen sulfide (H 2S) is highly toxic, colorless, and combining two commercial products. The patient was given flammable, with a characteristic “rotten egg” scent. It exists in hydroxocobalamin as an in addition to treatment with raw and natural and volcanic , and is produced cardiopulmonary resuscitation, but died approximately 42 min through leather tanning, processes for kraft and paper , and after his arrival at the hospital. The patient’s cause of death was attributed to acute hydrogen sulfide poisoning. Serum decay of human and waste. Accidental H 2S poisoning in concentrations of sulfide before and after administration of industrial , dairy farms, and other locations has been re - hydroxocobalamin were 0.22 and 0.11 μg/mL, respectively; ported (1−4). H 2S is quickly absorbed through the and the serum concentrations of thiosulfate before and after hydroxocobalamin administration were 0.34 and 0.04 μmol/mL, respectively. Hydroxocobalamin is believed to form a complex with H 2S in detoxification pathways of H 2S. Although H 2S is rapidly metabolized and excreted, the decreased sulfide concentration may be also associated with this complex formation. The decreased sulfide concentration suggests that hydroxocobalamin therapy may be effective for acute H 2S poisoning. The decreased thiosulfate concentration seems to be associated with formation of a thiosulfate/hydroxocobalamin complex, because hydroxocobalamin can form a complex with thiosulfate. The thiosulfate concentration decreased to a greater extent than did sulfide, suggesting that hydroxocobalamin has a higher affinity for thiosulfate than for H 2S. Therefore, prompt administration of hydroxocobalamin after H 2S exposure may be effective for H 2S poisoning.

* Author to whom correspondence should be addressed: Yuji Fujita, Poisoning and Drug Laboratory Division, Critical Care and Emergency Center, Iwate Medical University Hospital, Figure 1. Main metabolic pathway of hydrogen sulfide. 3-16-1 Honchoudori, Morioka, Iwate 020-0015, Japan. Email: [email protected].

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Journal of Analytical Toxicology, Vol. 35, March 2011

gastrointestinal tract; it is eliminated through the lungs or in therapy for acute intoxication, and an accumulation of case re - feces, and its metabolites are passed in urine. H 2S has three ports would be useful for the treatment of acute intoxications in metabolic pathways: oxidation, alkylation, and reactions with the future. metallo- or -containing proteins (5). Its main metabolic pathway is the oxidation pathway; H 2S metabolizes to via thiosulfate (Figure 1) through non-enzymatic and enzymatic mechanisms. The oxidation and alkylation pathways are detox - Case History ification pathways, in which H 2S’s toxic mechanisms are reac - tions with essential proteins. In acute human H 2S poisoning In April 2008, a male in his early 20s committed suicide in cases, thiosulfate usually cannot be detected in blood of sur - a car by combining two commercial products to make H 2S vivors, but can be detected in their urine (6). In fatal cases, how - gas. He was unconscious and not breathing when his family ever, thiosulfate usually can be detected in blood, but not in found him in the car (6:40 a.m.). His family confirmed him to urine (7−9). Therefore, detection of thiosulfate in urine for have been alive at midnight (12:00 a.m.). He smelled noticeably survivors and in blood for fatal cases is useful for diagnosing of rotten eggs and had neither pulse nor spontaneous respira - H2S poisoning (6). tions when emergency workers arrived at the site (6:52 a.m.). Downloaded from https://academic.oup.com/jat/article/35/2/119/773132 by guest on 01 October 2021 H2S binds oxidase and inhibits its function, On arrival at the hospital (7:19 a.m.), his eyes showed mydri - which is the conversion of molecular to . It thus in - asis, and an electrocardiogram showed asystole. On arterial hibits generation of triphosphate, which provides blood gas analysis, his arterial carboxyhemoglobin was 1.5%, energy for many cellular functions. Most organ systems are indicating that he had not developed poi - susceptible to the effect of H 2S, particularly mucous mem - soning. He was treated with cardiopulmonary resuscitation branes and tissues that demand the most oxygen. H 2S stops cel - and received an intravenous infusion of 2.5 g of hydroxo - lular respiration at high concentrations. The mechanism of cobalamin as an antidote for H2S poisoning. However, he died of H 2S is similar to that of . Increased exposure of H2S poisoning 42 min after arrival at the hospital (8:01 concentrations of H 2S are associated with adverse effects of in - a.m.) in spite of the staff’s efforts. creased severity: conjunctival irritation occurs at about 50 ppm, irritation of the respiratory tract at 50–100 ppm, loss of smell at 100–200 ppm, at 250–500 ppm, and con - centrations greater than 500 ppm—often called the “knock Methods down concentration”—can cause respiratory arrest, collapse, and death within minutes (10). Although H 2S has a character - Analytical procedures for sulfide and thiosulfate istic “rotten egg” scent, its cannot be always identified, be - Extraction of sulfide and thiosulfate from serum and deriva - cause the exposure to > 150 ppm paralyzes olfactory nerves. tization of those were performed according to the method de - In acute H 2S poisoning, victims should be immediately trans - ferred to fresh air and cardiopulmonary resuscitation started for victims with no heartbeat. Therapy for acute H 2S poisoning is supportive care. Although effective protocols for acute H 2S poi - soning are not established, nitrate therapy, such as inhaled amyl nitrate and intravenous sodium nitrate, and hyperbaric oxygen therapy may be useful for certain patients. Nitrates detoxify H 2S poisoning by inducing the formation of methe - moglobin, which has a higher affinity for H 2S than does cy - tochrome oxidase; methemoglobin then binds H 2S, decreasing its toxicity. Truong et al. (11) recently reported that hydroxo - cobalamin (Figure 2), which is part of the antidote kit for , is useful as an antidote against H 2S poi - soning in animal experiments; a cyanide antidote kit might be useful for emergency treatment of acute H 2S poisoning. Hy - droxocobalamin is thought to detoxify H 2S poisoning by forming a complex with H 2S, which metabolizes to thiosulfate and sulfate. To help establish an effective therapy for acute H 2S poisoning, we report here on a fatal case of acute hydrogen sulfide poi - soning, and serum concentrations of sulfide and thiosulfate before and after administration of hydroxocobalamin. This pa - tient committed suicide using H 2S made from two commercial products. Recently, H 2S created from mixing two commercial products has been used as a tool for suicide in Japan (7−9,12). Figure 2. Structural formula of hydroxocobalamin. We think that case reports can offer useful information on

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scribed by Kage et al. (13,14). Sulfide was detected as bis(pentafluorobenzyl)sulfide. A serum sample (0.2 mL) was added to the mixture solution: 0.8 mL of 5 mM tetradecyl-dimethyl-benzyl chloride solution in oxygen-free water saturated with sodium tetraborate, 0.5 mL of 20 mM pentafluorobenzyl bromide (PFBBr) solution in ethyl acetate, and 2.0 mL of internal standard (IS) solution (10 μM 1,3,5-tribromobenzene (TBB) in ethyl acetate). The preparation was vortex mixed for 1 min, and about 0.1 g of potas - sium dihydrogen phosphate was added. The preparation was again vortex mixed for 10 s and centrifuged at 2500 rpm for Downloaded from https://academic.oup.com/jat/article/35/2/119/773132 by guest on 01 October 2021 10 min. An aliquot of the organic phase was injected onto a gas chromatograph – mass spectrometer (GC –MS). Thiosulfate was detected as bis(penta- fluorobenzyl)disulfide. A serum sample (0.2 mL) was added to the mixture solu - tion: 0.05 mL of 200 mM L-ascorbic acid solution, 0.05 mL of 5% sodium chlo - ride, and 0.5 mL of 20 mM PFBBr solu - tion in . The preparation was vortex mixed for 1 min; 2.0 mL of 25 mM solution in ethyl acetate and 0.5 mL of IS solution (40 μM TBB in Figure 3. Selected -monitoring chromatograms (SIM) of sulfide and thiosulfate in serum. Sulfide and ethyl acetate) were added. The prepara - thiosulfate were detected as bis(pentafluorobenzyl)sulfide and bis(pentafluorobenzyl)disulfide, respec - tion was again vortex mixed for 30 s, tively. The mass-to-charge ratios of the monitored of sulfide, thiosulfate, and internal standard were centrifuged at 2500 rpm for 15 min, and m/z 393.9, m/z 425.8, and m/z 313.7, respectively. SIM chromatogram of sulfide in spiked serum (0.29 μg/mL) (A); SIM chromatogram of sulfide in patient’s serum before administration of hydroxocobalamin left to stand for 1 h. An aliquot of the or - (B); SIM chromatogram of thiosulfate in spiked serum (0.50 μmol/mL) (C); and SIM chromatogram of thio - ganic phase was injected onto a GC –MS. sulfate in patient’s serum before administration of hydroxocobalamin (D). The serum samples were stored at –80°C until analysis.

Instrumentation and Table I. Blood Concentrations of Sulfide and Thiosulfate in Fatal Cases of Acute operating parameters Hydrogen Sulfide Poisoning A PerkinElmer AutoSystem XL GC and Turbomass MS (Waltham, MA) were used Number SA for GC –MS analysis. GC was performed Report of Sulfide Thiosulfate with an Agilent J&W DB-5MS column (30 (Reference) Cases (µg/mL) (µmol/mL) Remarks m × 0.25-mm i.d., 0.25- μm film thick - ness, Agilent Technologies, Santa Clara, Kage et al. (2) 4 0.32 –9.36 0.11 –0.23 Accidental poisoning CA); column oven temperature was main - at a dye works tained at 60°C for 4 min and then pro - Igawa et al. (7) 4 0.57 –3.67 0.055 –0.124 Suicide, H 2S produced from grammed to 300°C at 20°C/min. Carrier two commercial products gas was helium (1 mL/min). Injection Kobayashi et al. (9) 1 0.66 0.14 Suicide, H 2S produced from port and ion source temperatures were two commercial products kept at 250°C and 200°C, respectively; MS Sasaki et al. (12) 13 0.06 –14.13 0.05 Suicide, H 2S produced from was performed in electron impact ioniza - two commercial products tion mode at ionization energy of 70 eV.

Present case 1 0.22* 0.34* Suicide, H 2S produced from Measurements were taken in selected ion 0.11 † 0.04 † two commercial products monitoring mode. The mass-to-charge ra - tios of monitored ions of sulfide, thiosul - * Before hydroxocobalamin administration. † After hydroxocobalamin administration. fate, and IS were m/z 393.9, m/z 425.8, and m/z 313.7, respectively.

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Calibration curves for sul fide and thiosulfate in serum sulfate (11). Although H2S is rapidly metabolized and excreted, In GC –MS analysis, calibration curves for sulfide and thio - decreased serum concentration of sulfide may be also associ - sulfate in serum were obtained by plotting the peak-area ratio ated with this complex formation. Hydroxocobalamin has also of each relative to an internal standard. The calibra - sufficient potential for forming a complex with thiosulfate in tion curve setting range for sulfide was 0.036–0.36 μg/mL; for vivo because hydroxocobalamin forms such a complex in vitro thiosulfate, the calibration curve range was 0.025–0.50 (17). Therefore, the formation of a thiosulfate/hydroxocobal - μmol/mL. To examine the precision, three different concen - amin complex seems associated with rapid decrease of serum trations of sulfide and thiosulfate were spiked in reference concentration of thiosulfate. sera. Serum concentrations of sulfide were 0.072, 0.14, and In acute H2S poisoning, thiosulfate can be detected in the 0.29 μg/mL; serum concentrations of thiosulfate were 0.05, urine of the survivors (6), but it cannot be detected in the 0.25, and 0.40 μmol/mL. These samples were analyzed five urine of the fatal cases (7−9), indicating that thiosulfate is not times in one day for intraday precision, and they were analyzed excreted in urine in fatal cases; apparently thiosulfate cannot three times each on five separate days for interday precision. be excreted in urine in the short period between exposure and death. Therefore, it seems unlikely that the thiosulfate of this patient was excreted in urine. Serum concentration of thio - sulfate decreased to a greater extent than did sulfide in this Downloaded from https://academic.oup.com/jat/article/35/2/119/773132 by guest on 01 October 2021 Results and Discussion case. Given the findings, this result suggests that hydroxo - cobalamin has a higher affinity for thiosulfate than for H2S. This patient committed suicide using hydrogen sulfide. Sim - In conclusion, this patient was given hydroxocobalamin as ilar H 2S poisonings have been recently reported in Japan an antidote for H2S poisoning, but it was ineffective in this (7−9,12), combining two commercial products, such as toilet case. The patient would have succumbed regardless of treat - bowl cleaner and liquid bath additive, to make H2S gas in ment because he was in cardiopulmonary arrest upon arrival at sealed small spaces. The toilet cleaners and the liquid bath the hospital. However, the decreased serum concentration of additives contain hydrochloric acid and polysulfide, respec - H2S after administration of hydroxocobalamin suggests that tively. Kobayashi and Fukushima (9) reported that mixing 120 this therapy may be effective for acute H2S poisoning. Given mL of each of these products can produce approximately 1000 the finding that hydroxocobalamin has a higher affinity for ppm of hydrogen sulfide, for example, in an ordinary motor - H2S’s metabolite thiosulfate than for H2S itself, it seems likely hicle with a volume of 3300 L. Because this reaction happens that administration of hydroxocobalamin immediately after immediately after mixing, the production of lethal concentra - H2S exposure, when trace amounts of thiosulfate appear, is tions (over 500 ppm) of hydrogen sulfide is not very difficult in effective for H2S poisoning. Further case studies may elucidate these cases. this therapeutic effect of hydroxocobalamin against H2S poi - Sulfide and thiosulfate were detected in serum using GC –MS soning. analysis (Figure 3). Serum concentrations of sulfide before and after administration of hydroxocobalamin were 0.22 and 0.11 μg/mL, respectively; serum concentrations of thiosulfate before and after hydroxocobalamin administration were 0.34 References and 0.04 μmol/mL, respectively (Table I). For the intraday and interday precision of the method, the relative standard devia - 1. S. Kage, S. Kashimura, H. Ikeda, K. Kudo, and N. Ikeda. Fatal and tions (RSDs) of each concentration of sulfide and thiosulfate in nonfatal poisoning by hydrogen sulfide at an industrial waste the intraday were below 10%, and the RSDs of those in the in - site. J. Forensic Sci. 47: 652−655 (2002). terday were below 15%. The overall precision of the method 2. S. Kage, H. Ikeda, N. Ikeda, A. Tsujita, and K. Kudo. Fatal hy - drogen sulfide poisoning at a dye works. Leg. Med. (Tokyo) 6: was acceptable. Reportedly, blood concentrations of sulfide 182−186 (2004). and thiosulfate are lower than 0.05 μg/mL (15) and 0.003 3. G. Gerasimon, S. Bennett, J. Musser, and J. Rinard. Acute hy - μmol/mL (14,16), respectively, in humans who are not ex - drogen sulfide poisoning in a dairy farmer. Clin. Toxicol. 45: 420−423 (2007). posed to H2S. On the other hand, in acute H2S poisoning fa - talities, blood concentrations of sulfide and thiosulfate are 4. M. Ago, K. Ago, and M. Ogata. Two fatalities by hydrogen sulfide poisoning: variation of pathological and toxicological findings. 0.06–14.13 μg/mL and 0.05–3.02 μmol/mL, respectively (Table Leg. Med. (Tokyo) 10: 148−152 (2008). I). Serum concentrations of sulfide and thiosulfate in this case 5. R.O. Beauchamp, Jr ., J.S. Bus, J.A. Popp, C.J. Boreiko, and were similar to reported concentrations in fatal cases of acute D.A. Andjelkovich. A critical review of the literature on hydrogen sulfide toxicity. Crit. Rev. Toxicol. 13: 25−97 (1984). H2S poisoning, and higher than concentrations of those in blood of humans who were not exposed to H S. This result 6. S. Kage, K. Takekawa, K. Kurosaki, T. Imamura, and K. Kudo. The 2 usefulness of thiosulfate as an indicator of hydrogen sulfide poi - shows that the patient’s cause of death was acute hydrogen sul - soning: three cases. Int. J. Legal Med. 110: 220−222 (1997). fide poisoning. 7. Y. Igawa and S. Kage. Fatal cases of hydrogen sulfide poisoning Serum concentrations of sulfide and thiosulfate in this case caused by a liquid bath additive containing polysulfide. Pro - were less after administering hydroxocobalamin than before its ceedings of 13th Annual Meeting of Japanese Association of administration. In the detoxification of H S in the presence of and Technology. Tokyo, Japan, 2007, p 61 (in 2 Japanese). hydroxocobalamin, hydroxocobalamin is thought to form a 8. K. Hatake, Y. Morimura, R. Kudo, A. Ishitani, M. Kusatani, complex with H2S; H2S is then metabolized to thiosulfate and A. Fukudome, and S. Kasuda. An autopsy case of death due to

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hydrogen sulfide poisoning. Hoigaku No Jissai To Kenkyu 50: 13. S. Kage, T. Nagata, K. Kimura, and K. Kudo. Extractive alkylation 171−174 (2007) (in Japanese with English abstract). and gas chromatographic analysis of sulfide. J. Forensic Sci. 33: 9. K. Kobayashi and H. Fukushima. A suicidal poisoning due to hy - 217−222 (1988). drogen sulfide produced by mixing a liquid bath essence con - 14. S. Kage, T. Nagata, and K. Kudo. Determination of thiosulfate in taining and a toilet bowl cleaner containing hydrochloric body fluids by GC and GC/MS. J. Anal. Toxicol. 15: 148−150 acid. Chudoku Kenkyu 21: 183−188 (2008) (in Japanese with En - (1991). glish abstract). 15. B.H. McAnalley, W.T. Lowry, R.D. Oliver, and J.C. Garriott. De - 10. R.J. Reiffenstein, W.C. Hulbert, and S.H. Roth. Toxicology of hy - termination of inorganic sulfide and cyanide in blood using spe - drogen sulfide. Annu. Rev. Pharmacol. Toxicol. 32: 109−134 cific ion electrodes: application to the investigation of hydrogen (1992). sulfide and cyanide poisoning. J. Anal. Toxicol. 3: 111−114 (1979). 11. D.H. Truong, A. Mihajlovic, P. Gunness, W. Hindmarsh, and 16. T. Kawanishi, T. Togawa, A. Ishigami, S. Tanabe, and T. Imanari. P.J. O’Brien. Prevention of hydrogen sulfide (H 2S)-induced mouse Determination of thiosulfate in human urine and plasma by high lethality and cytotoxicity by hydroxocobalamin ( B(12a)). performance liquid chromatography with a dual electrochem - Toxicology 242: 16−22 (2007). ical detector. Bunseki Kagaku 33: E295−E300 (1984). 12. C. Sasaki, T. Shinozuka, W. Irie, K. Yoshimura, C. Murakami, 17. C.L. Evans. Cobalt compounds as for hydrocyanic acid. N. Nakamaru, M. Kobayashi, K. Maeda, T. Kaneko, B. Wada, S. Br. J. Pharmacol. 23: 455−475 (1964). Nakamura, M. Furukawa, and K. Kurihara. Fifteen fatal cases by hydrogen sulfide poisoning. Proceedings of 28th Annual Meeting of Japanese Association of Forensic Toxicology, Kanazawa, Japan, Manuscript received May 1, 2010; Downloaded from https://academic.oup.com/jat/article/35/2/119/773132 by guest on 01 October 2021 2009, pp 100−101 (in Japanese with English abstract). revision received July 20, 2010.

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