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|Fatal fluoride tablet poisoning in Austria|
Ref.: H.G. Eichler et al.: "Accidental ingestion of NaF tablets by children - report of a poison control center and one case", Int. J. Clin. Pharmacol. Ther. Toxicol. 22:7 (1982) 334-338)
From 1976 to 1981, according to the Poison Control Centre in Vienna, Austria, 108 cases of overdosing from fluoride tablets given to children for the prevention of tooth decay have been reported to that agency (but "All cases in which the amount of fluoride ingested could not be ascertained exactly by the parents or the attending physician were excluded from the study").
The majority of these cases involved 2- to 4-year-olds who developed such symptoms as vomiting, nausea and fatigue. Among the 76 children who received treatment (large doses of milk (Ca2+ donor), effervescent calcium tablets, induced emesis, or gastric lavage), 33 (45%) of them exhibited post-ingestive symptoms, and 43 (55%), "remained asymptomatic". In one case, however, the child seemed to recover but later collapsed and died.
The victim, a 3-year-old boy (12.5 kg or 27.5 lbs.) apparently consumed 200 tablets containing 1 milligram fluoride each, corresponding to an intake of 16 mg/kg body weight. Immediately following the ingestion he vomited and appeared to recover completely. Four hours later, however, he collapsed, and by the time the family physician arrived, he "was clinically dead" and had no peripheral pulse. After attempted resuscitation and intracardial injections of calcium and orciprenaline failed to revive him, the boy was taken by ambulance to a local hospital. There he was given gastric lavage, and artificial respiration and massage of the heart were continued, but he died shortly after admission, some seven hours after he ingested the tablets.
Autopsy revealed hemorrhagic tracheitis (possibly due to aspiration of gastric content after vomiting), hemorrhagic edema of the lungs associated with hypostasy and atelectasis, hemorrhagic gastritis, hemorrhagic pyelitis and cystitis, and massive cerebral edema. The samll intestine showed the signs of ileitis terminalis. Histologically, cells of the liver, heart and kidney showed cloudy swelling.
In their report concerning this case, the Vienna Control Centre authors note that, even though the total amount of fluoride ingested by the boy was less than what is ordinarily considered lethal, the symptoms and pathological findings on autopsy were at least partly explainable by the generally accepted mode of action of fluoride (formation of HF in the acidic stomach environment and corrosive action of that compound; affinity of fluoride for calcium; fluoride action on enzymes (including cholinesterase, glycolytic enzymes)).
"Estimates of the toxic and lethal dose in humans vary considerably in the literature. In addition, there seem to be wide variations in the response to a given dose among different individuals."
Postmortem analyses showed elevated fluoride concentrations in the blood (1.5 ppm), kidney (3.7 ppm), and liver (4.35 ppm).
"The fact that most symptoms and signs are characteristic of fluoride poisoning and the absence of any other obvious cause of death indicate that the child´s death was in fact a consequence of fluoride ingestion only," although certain doubts remained as no other cases of lethal fluoride intoxication with such low amounts were known to these authors then, no significant laboratory data (especially serum calcium) were available, postmortem fluoride concentrations gave "no conclusive evidence of grave fluoride intoxication", and ingestion of other drugs could not be excluded since no drug screening of serum and urine had been done.
An account of that case appeared in the "Oberösterreichische Nachrichten" of Linz, Austria, on March 14, 1978 ("Kind starb an Fluortabletten. Arzt wurde freigesprochen"; see also: "Editorial: Toxicity of fluoride", Fluoride 11 (1978) 163).
There it was reported that a 2-year-old child had died on June 29, 1976, following the ingestion of 50 -or up to 200- fluoride tablets. The attending physician, Dr. Karl Weichselbaumer of Helfenberg, was accused of negligence for not having ordered immediate hospitalization of the child.
In court, however, he was acquitted and the case dismissed because he had promptly consulted the Poison Control Centre of Vienna who had advised him that the ingestion of 50 fluoride tablets would not pose any danger to life and therefore there was no need for hospitalization. Instead, he was advised to give the boy a solution of a calcium salt, which he did. A "poison control expert" of the Centre, Dr. C. Korninger, supported Dr. Weichselbaumer´s defense and stated that, according to his perusal of the medical literature, the amount of fluoride in 50 tablets would not be lethal to a small child.