1018 WONG A..D OTHEI.s: Boiuc Acw PoIso.m.G April 25, 1964, VOL 90 Boric Acid Poisoning: Report of 11 Cases L. C. WONG, M.D.,* M. D. HEIMBACH, M.D4 D. R. TRUSCOFI', M.D4 and B. D. DUNCAN, M.D.,§ Regina, Sask. SOMMAIRE Les auteurs rapportent 11 cas d'intoxication .i l'acide borique dans une pouponni.re et r6sultant de l'emploi accidentel ou par inadvertance d'une solution d'acide borique . 2.5% dims la pr6paration des aliments pour b.bSs. Cmq des nourrissons sont morts. A l'exception de deux, tons pr6sentaient le tableau classique de l'intoxication aiguii & 1'acide borique, soit diarrh6e, vomissement, 6ryth.me, exfoliation et desquamation de la peau et forte irritation du syst.me nerveux central. Les premi.res manifesta- tions de l'empoisonnement d6taient pas sp&ifiques et un enfant mourut avant que n'aient apparu les signes cutan.s. La dialyse intrapfriton6ale, appliqu.e dans 9 cas, s'est r6v6l.e le traitement le plus efficace. L'acide borique, dont Ia valeur th.rapeu- tique est du reste douteuse, devrait .tre enti.rement .limin6 des h.pitaux, des dis- pensaires et m6me de la pharmacop6e. Canad. Med. Ass. J. April 25, 1964, vol. 90 WONG AND (YrHERS: Bomo Acm POISONING 1019 TABLE I.-CLINxc. MANIFESTATIONS AND LABORAToRY FINDINGS IN BORIC Acm POISONING _______Clinical features ________ _________ __________ Serum electrolyte levels _______ Amount of Vomiting Oliguria Case borate and Bleed- and Sodium Potassium Chloride Bicarbonate Urea Borate No. ingested (g.) Skin diarrhea CNS ing anuria (mEq./l.) (mEq./l.) (mEq./l.) (mEq./l.) (mg.%) (mg.%) Survival 1 14.06 - ++ + - + 153 7.0 118 - 52 160 2days 2 6.25t + ++ +++ ++ + 158 4.4 112 11.4 - 40 3 days 3 9.25t +++ +++ +++ - + 176 - 122 13.3 31 100 3 days 4 4.5t +++ +++ +++ - + 153 4.9 102 20.0 - 20* 3 days 5 12.5 +++ +++ +++ + + 153 6.1 110 21.0 56 100 3days 6 4.5 ++ ++ ++ - + 155 4.8 112 20.7 29 14t 2.years+ 7 2.25 ±± ++ ++ - + 148 3.9 105 18.0 19 6t 2.,iyears+ 8 3.0 ++ ++ + - + 163 5.2 112 19.0 17 15 2.years+ 9 3.0 ++ ++ + - + 160 4.9 115 19.0 20 10 2.years+ 10 4.0 ++ ++ + - + 160 5.0 115 20.0 40 8t 2.years+ 11 2.0 - + - - - 150 4.0 111 - 8 2 2Y.years+ *T.en post mortem. tTsken after dialysis. 16, 1961, when she developed diarrhea and vomiting. The skin around the mouth, under the chin, and on the Her stools and vomitus were greenish with mucus. She abdominal wall, perineum and buttocks was markedly was very active and cried excessively. erythematous, as if she had been very close to an open Laboratory findings revealed a serum bilirubin of fire. Her respiration was rapid but deep. She tended 8.5 mg. %; serum electrolyte levels are recorded in to arch her back and to stare, was extremely irritable Table I. and had an exaggerated Moro reflex. Initially milk allergy was diagnosed and her formula Laboratory findings are recorded in Table I. was changed to Sobee. Vomiting and diarrhea persisted, Because of the striking skin lesions, boric acid and she became quite lethargic 12 hours later. Because poisoning was immediately suspected. Gastric lavage of the development of similar gastrointestinal upset in was performed and the contents of the stomach, as well two other newborn infants in the same nursery, an as a blood sample, were submitted to the provincial infectious type of gastroenteritis was considered. Stool toxicology laboratory for identification of possible culture was taken and subsequently reported negative. poison. Blood was also taken for estimation of serum About 20 hours after the onset of diarrhea and vomiting, electrolytes. An intravenous infusion of 5% glucose in she started to twitch and become drowsy. An intra- water was started. An exchange transfusion with 500 venous infusion of 5% dextrose in water was started and ml. of whole blood was performed 12 hours after the shortly thereafter her respirations ceased, 21 hours after onset of symptoms, i.e. 24 hours after initial ingestion the onset of symptoms. At no time did her skin show of boric acid. The general condition of the infant erythema or exfoliative dermatitis. At the time of death, deteriorated rapidly. The erythema of the skin became signs of boric acid poisoning became apparent in other generalized, and most of the lesions assumed the ap- infants in the same nursery; blood was therefore taken pearance of exfoliative dermatitis. A gentle touch of for determination of the boric acid concentration, the skin resulted in peeling of the whole thickness of which was 160 mg. %. Distilled water used for making epidermis. formula for this infant was then found to be 2.5% boric the The infant's eyes were bloodshot and acid solution. opisthotonus became severe. She appeared less toxic Postmortem examination revealed extensive hemor- after the exchange transfusion, and serum electrolytes rhages, congestion and edema of the lungs. The kidneys and borate level showed some improvement (Table II). were also congested microscopically and there was Oliguria developed and vomiting persisted. considerable swelling of the epithelium of the convo- Because of further deterioration, a second exchange luted tubules. The bladder mucosa was edematous and transfusion was started six hours after the first trans- showed areas of hemorrhages. The brain showed ex- fusion. Special precautions were taken to guard against tensive vascular congestion with widespread pen- hypocalcemia and cardiac arrythxnias during the pro- vascular hemorrhages and intravascular thrombosis. cedure. The infant had several episodes of convulsions and apnea, and the transfusion had to be abandoned Comment: Diarrhea, vomiting, lethargy and jaun- after 200 ml. was exchanged. Peritoneal dialysis using dice are non-specific manifestations of many dis- the modified technique described by Segar6 was started in an effort to reverse the rapidly deteriorating clinical orders in the newborn period, and the symptoma- course. Frequent convulsive and apneic episodes tology in this case provided no clue to the final per- diagnosis of boric acid poisoning. TABLE 11.-SERUM ELECTROLYTE LEVELS AFTER EXCHANGE CASE 3.-A full-term infant girl weighing 7 lb. 2 oz. TIIANSFUSTONT was born on March 13, 1961. She was fed a formula Sodium Potassium Chloride Bicarbonate of evaporated milk, and was well until the evening Case No. (mEq./l.) (mEq./L) (mEq./l.) (mEq./L) of March 16, 1961, when she developed diarrhea and 3. 145 4.0 87.5 17.2 vomiting. The stools and vomitus were greenish but 4. 152 4.6 91.3 19.0 contained no blood. 5. 153 6.1 100 .0 21.0 6. 150 40 95.0 21.0 Physical examination revealed a moderately dehy- 7. 148 3.9 97.5 17.2 drated infant with a flushed face and cherry-red lips. 10. 145 3.7 102.0 18.4 Canad. Med. Ass. 3. 1020 WONG AND OTHERS: Boiuc Acm POISONING April 25, 1964, vol. 90 sisted and she became comatose. Exfoliation of the skin Comment: This case illustrates the favourable became generalized, and desquamation was noted in consequence of peritoneal dialysis in boric acid many areas of the body. The mucous membranes and intoxication. nail beds were also involved. She remained anuric. The infant died 10 hours after the institution of pen- CASE 11.-An infant girl born on March 13, 1961, toneal dialysis. was alleged to be full-term but weighed only 4 lb. 2 Postmortem examination revealed widespread vascu- oz. Apart from the small size of the baby, physical lar congestion with fresh hemorrhages on the surface examination at birth was negative. She was started on and in the substance of the lungs, in the epicardium, Enfalac formula but regurgitated part of her feeding leptomeninges, brain substance and mucous membranes on each occasion. A stomach tube was passed and en- of the alimentary canal and urinary bladder. There countered no obstruction. was pronounced edema of the bladder mucosa and the On March 18, 1961, the colour of her emesis and lungs. Degenerative changes were seen in the paren- stools was noted to be greenish and like that found chymal cells of the liver, kidneys and adrenals, in myo- in the infants who had been accidentally poisoned. cardial fibres and in neurones of the brain. Mild regurgitation and loose bowel movements per- sisted for three days. Her skin was normal, and there Comment: This case exhibited all the classical were no abnormal neurological signs. manifestations of acute boric acid poisoning. The Laboratory findings are recorded in Table I. Blood and urine were submitted for identification of amount of boric acid ingested was believed to have borate. The plasma showed only a trace of borate far exceeded the lethal dose. which was measured as less than 2 mg. %. The possi- bility that the sample had become contaminated, be- CASE 9.-A full-term infant girl was born on March cause numerous specimens had been sent to the la- 9, 1961. She was perfectly normal, was fed an evapor- boratory within such a short period of time, was con- ated milk formula and was discharged from the nursery sidered. A second sample of blood was withdrawn six on March 15, 1961. It was the custom of the nursery hours later, and no trace of borate was found. How- to discharge a bottle-fed newborn infant home with ever, urine showed a positive tumenic paper test for a supply of that day's formula. boric acid, and urinary excretion of borate continued After discharge from hospital, she took 4 oz. of the for 17 days.