Case Report

Fatal myocardial infarction after hydrochloric acid ingestion in a suicide attempt

Abstract

Ingestion of acid-containing household products either accidentally or for suicide attempt is a common form of intoxication. Hydrochloric acid is widely used as an antirust compound or cleaner in homes and is highly corrosive and generally causes coagulation necrosis which could lead to perforation in the gastrointestinal system. Although hydro- chloric acid ingestion is mainly harmful to the gastrointest- inal system, it may also cause metabolic acidosis, hemolysis, renal failure, and fatality as well. Cardiovascular manifesta- tions of hydrochloric acid ingestion are extremely rare, and we report a 48-year-old man who died of acute inferolateral myocardial infarction after hydrochloric acid ingestion in a suicide attempt who had no history of coronary artery disease. In conclusion, although cardiovascular manifesta- tions of hydrochloric acid ingestion are extremely rare, the ingestion may still cause myocardial infarction which could be fatal. Physicians dealing with hydrochloric acid ingestion in the ED should be aware of this possibility and always obtain serial electrocardiograms even if the patient has no cardiac complaint.

Ingestion of acid-containing household products either accidentally or for suicide attempt is a common form of intoxication. Hydrochloric acid is widely used as an antirust compound or cleaner in homes and is highly corrosive and generally causes coagulation necrosis which could lead to perforation in the gastrointestinal system. Although hydrochloric acid ingestion is mainly harmful to the gastrointestinal system, it may also cause metabolic acidosis, hemolysis, renal failure, and fatality as well [1]. Cardiovascular manifestations of hydrochloric acid inges- tion are extremely rare, and we report a case with fatal myocardial infarction after hydrochloric acid ingestion in a suicide attempt.

A 48-year-old nonsmoking man was admitted to our ED 1 hour after ingesting a domestic cleaning solution containing hydrochloric acid. He was first taken to a local hospital by his children and then transported to our clinic for further evaluation and treatment. His children stated that he had told them that he had ingested approximately half of a bottle

of a cleaning solution containing hydrochloric acid which was equivalent to 300 mL. His past medical history was unremarkable and was not on any medication. On admission to our ED, his blood pressure was 102/63 mm Hg, pulse rate was 103 beats per minute, respiration rate was 26 breaths per minute, and pulse oximetry was 86%. He was complaining of chest pain and we immediately obtained an electrocardio- gram (ECG). On ECG, there were ST-segment elevations in leads II, III, aVF, V5, and V6 accompanied by reciprocal ST- segment depressions in leads aVR, aVL, V1, V2, and V3, which was compatible with acute inferolateral myocardial infarction (Fig. 1). Immediately after ECG, ventricular fibrillation developed and after defibrillation his rhythm degenerated to asystole. The patient was intubated and resuscitated for almost 20 minutes after which his rhythm was maintained. Physical examination revealed cardiac S3, bilateral inspiratory rales in the basal parts of the lungs, and faint, filiform peripheral pulses. Chest x-ray showed no evidence of mediastinitis or subdiaphragmatic Free air, nor increased cardiothoracic ratio but compatible with pulmon- ary congestion. Arterial blood gas analysis showed metabolic acidosis, and sodium bicarbonate replacement was initiated (pH 7.16, HCO₃ 10.4 mmol/L, base excess -16.2 mmol/L, K 5.0 mmol/L). He was then quickly transferred to the coronary care unit. Five minutes after the transfer to the coronary care unit, asystole occurred. Despite resuscitation and transve- nous cardiac pacemaker implantation, the patient died 1 hour after admission to our hospital.

The present paper presents a 48-year-old man who died

of acute inferolateral myocardial infarction after hydro- chloric acid ingestion in a suicide attempt. Hydrochloric acid ingestion is mainly harmful to the gastrointestinal system but may also cause metabolic acidosis, hemolysis, renal failure, and fatality as well [1]. Cardiovascular manifestations of hydrochloric acid ingestion are extremely rare, and, to our knowledge, this is the second case in the literature in which myocardial infarction occurred after hydrochloric acid ingestion in a suicide attempt that ended with death [2].

Development of acidosis after hydrochloric acid ingestion is considered as a poor prognostic sign by some authors [3,4]. Although the reason for acidosis after hydrochloric acid ingestion is not known exactly, lactic acid accumulation is a proposed mechanism [5]. Acidosis causes increased oxygen requirement which could lead to myocardial

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634.e6 Case Report

Fig. 1 Electrocardiogram of the patient showing ST-segment elevations in leads II, III, aVF, V5, and V6 accompanied by reciprocal ST-segment depressions in leads aVR, aVL, V1, V2, and V3 which is compatible with acute inferolateral myocardial infarction.

ischemia. It may also cause decreased threshold for arrhythmias including ventricular fibrillation.

The patient in the previously presented case also died because of acute inferolateral myocardial infarction after hydrochloric acid ingestion in a suicide attempt, but he had documented coronary artery disease and had a history of stent implantation in the left anterior descending artery after an acute anteroseptal myocardial infarction [2]. Our patient had no known history of coronary artery disease, but there is a possibility that he had been experiencing the symptoms for which he did not seek treatment. Possible causes of myocardial infarction in these two cases might be (a) acidosis-induced proinflammatory and prothrombotic state which resulted in acute thrombosis of the coronary artery, (b) coronary Plaque rupture triggered by acidosis followed by thrombus formation, (c) coronary artery spasm induced by acidosis, (d) contribution of the abovementioned factors in different proportions.

In conclusion, although cardiovascular manifestations of hydrochloric acid ingestion are extremely rare, the ingestion may still cause myocardial infarction which could be fatal, and this is the second case in the literature wherein myocardial infarction occurred after hydrochloric acid ingestion in a suicide attempt that ended with death [2]. Physicians dealing with hydro- chloric acid ingestion in the ED should be aware of this possibility and always obtain serial ECGs even if the patient has no cardiac complaint.

Ibrahim Sari MD Department of Cardiology School of Medicine Gaziantep University

TR-27310 Gaziantep, Turkey E-mail address: [email protected]

Case Report 634.e7

Suat Zengin MD

Department of Emergency Medicine

School of Medicine Gaziantep University

TR-27310 Gaziantep, Turkey

Yavuz Pehlivan MD

Department of Internal Medicine

School of Medicine Gaziantep University

TR-27310 Gaziantep, Turkey

Vedat Davutoglu MD Department of Cardiology School of Medicine Gaziantep University

TR-27310 Gaziantep, Turkey E-mail address: [email protected]

Cuma Yildirim MD

Department of Emergency Medicine

School of Medicine Gaziantep University

TR-27310 Gaziantep, Turkey

doi:10.1016/j.ajem.2007.10.009

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4. Cheng YJ, Kao EL. Arterial blood gas analysis in acute caustic ingestion injuries. Surg Today 2003;33:483-5.
5. Okonek S, Bierbach H, Atzpodien W. Unexpected metabolic acidosis in severe lye poisoning. Clin Toxicol 1981;18:225-30.