- Email: [email protected]
Acute cyanide poisoning following administration of Laetrile enemas
CLINICAL NOTES
Articles in this section are limited to 400 words or less, J illustration or I short table, and up to 4 references. These articles' are subject to the same critical peer review and editing as articles appearing in other sections of THE JOURNAL.
Acute cyanide poisoning following administration of Laetrile enemas It has been estimated that during 1977, 50,000 patients with cancer were treated with Laetrile in one form or another. ' Of the hazardous side effects of Laetrile, cyanide poisoning,' acute and chronic, is probably the most significant. These complications have been observed in patients taking the drug orally. The exarnpie reported here :s abc u: a c;;::d who developed acu te cyanide poisoning following administration of the parenteral form of Laetrile as an enema. CASE REPORT Patient S.T. was first admitted at the age of 210/ " years with a two-month history of constipation and back pain. Physical examination revealed a hard, non tender spherical mass in the right upper quadrant of the abdomen. Initial evaluation revealed a normal complete blood count, urinalysis, chest radiograph, skeletal survey, bone, liver and spleen scans, and bone marrow. An intravenous pyelogram revealed an extrarenal calcified mass in the right flank close to the kidney . Abdominal exploration resulted in the excision of a tumor immediately below the hilum of the right kidney. Pathologic examination revealed neuroblastoma with invasion of the capsule and regional lymph nodes. Ten days after surgery, chemotherapy consisting of vincristine, cyclophosphamide, and dimethyl trianzeno imidazole carboxamide was initiated . However, after receiving three doses of the latter and one dose of cyclophosphamide, the patient was lost to follow-up . It was subsequently learned that the patient was receiving treatment with Laetrile, 500 mg daily by mouth and 3.5 gm intravenously, daily. Because of increasing technical diffl cuhy in administration of the drug intravenously, the mother was advised to use the parenteral form of Laetrile as an enema . Following administration of the second daily enema of 3.5 p,m Laetrile in 10 rnl, the patient developed vomiting and diarrhea which persisted into the third day of treatment. Shortly after receiving the third Laetrile enema, the patient, who previously had been irritable, became progressively lethargic and unresponsive, tachypneic, and cyanotic. He was then taken to a local hospital where 0, therapy and intravenous hydration were rapidly initiated. Supported in pari by Gran! CA 02649 from the United Slates Public Health Servic e. Department of Health. Education and Welfare.
0022-3476/78/121059+01$00.10/0 e 1978 The C. V. Mosby Co.
Because of the history of Laetrile administration, the possibil-
ity of cyanide poisoning was suggested and, five hours after admission, cyanide blood concentration levels were obtained and reported as 214 pg/d!. (The lethal range is 260 to 3,000 pg/d/.) The child recovered slowly over the next 12 hours. Subsequent evaluation revealed recurrence of in tra-abdominal disease with several bone metastases. DISCL'SSroN Laetrile, which is a glycoside, contains cyanide, a respiratory poison by virtue of its tight a!!i~ity fer cytochrome oxidase, a key respiratory enzyme. The resulting tissue hypoxia produces nausea, vomiting, hypotension, cyanosis , shock, stupor, coma, respiratory failure, and death . The release of cyanide from amygdalin occurs in the presence of hydrolyzing ,a-glucosidase enzymes, which are contained in many fruits and vegetables. Ingestion of Laetrile with any of these in an uncooked state can result in the release of cyanide. All examples of Laetrile-induced cyanide poisoning reported in tile United States, including two fatal episodes," have been associated with ingestion of the oral form of the compound, with the exception of one case which resulted from ingestion of the parenteral form. In the child reported here, the administration of the parenteral form as an enema resulted in acute cyanide poisoning. This can be explained by the hydrolysis of Laetrile within the intestinal mucosa, where the p-glucosidases occur as lysosomal enzymes.' Jorge A. Ortega, M.D. James E. Creek. l\.f,D. Division of Hematology-Oncology Children; Hospital of Los Angeles 4 65~ Sunset BJ~d Los Angeles, CA 90027 enzy~e
REFERENCES 1. Moertel CO: A trial of Laetrile now, N Engl J Med 298:218, 1978. 2. Humbert JR, Tress JH, Braico KT : Fatal cyanide poisoning: Accidental ingestion of amygdalin, JAMA 238:482, 1911. 3. Smith FP, Butler TP, Cohan S, Schein PS: Laetrile toxicity: A report of two cases, JAMA 238:1361,1977. 4. Toxicity of Laetrile, FDA Drug Bull 7:26, 1977. The Journal ofPED1 ATR I CS Val 93. No 6. pp 1059-/067
1059
Articles in this section are limited to 400 words or less, J illustration or I short table, and up to 4 references. These articles' are subject to the same critical peer review and editing as articles appearing in other sections of THE JOURNAL.
Acute cyanide poisoning following administration of Laetrile enemas It has been estimated that during 1977, 50,000 patients with cancer were treated with Laetrile in one form or another. ' Of the hazardous side effects of Laetrile, cyanide poisoning,' acute and chronic, is probably the most significant. These complications have been observed in patients taking the drug orally. The exarnpie reported here :s abc u: a c;;::d who developed acu te cyanide poisoning following administration of the parenteral form of Laetrile as an enema. CASE REPORT Patient S.T. was first admitted at the age of 210/ " years with a two-month history of constipation and back pain. Physical examination revealed a hard, non tender spherical mass in the right upper quadrant of the abdomen. Initial evaluation revealed a normal complete blood count, urinalysis, chest radiograph, skeletal survey, bone, liver and spleen scans, and bone marrow. An intravenous pyelogram revealed an extrarenal calcified mass in the right flank close to the kidney . Abdominal exploration resulted in the excision of a tumor immediately below the hilum of the right kidney. Pathologic examination revealed neuroblastoma with invasion of the capsule and regional lymph nodes. Ten days after surgery, chemotherapy consisting of vincristine, cyclophosphamide, and dimethyl trianzeno imidazole carboxamide was initiated . However, after receiving three doses of the latter and one dose of cyclophosphamide, the patient was lost to follow-up . It was subsequently learned that the patient was receiving treatment with Laetrile, 500 mg daily by mouth and 3.5 gm intravenously, daily. Because of increasing technical diffl cuhy in administration of the drug intravenously, the mother was advised to use the parenteral form of Laetrile as an enema . Following administration of the second daily enema of 3.5 p,m Laetrile in 10 rnl, the patient developed vomiting and diarrhea which persisted into the third day of treatment. Shortly after receiving the third Laetrile enema, the patient, who previously had been irritable, became progressively lethargic and unresponsive, tachypneic, and cyanotic. He was then taken to a local hospital where 0, therapy and intravenous hydration were rapidly initiated. Supported in pari by Gran! CA 02649 from the United Slates Public Health Servic e. Department of Health. Education and Welfare.
0022-3476/78/121059+01$00.10/0 e 1978 The C. V. Mosby Co.
Because of the history of Laetrile administration, the possibil-
ity of cyanide poisoning was suggested and, five hours after admission, cyanide blood concentration levels were obtained and reported as 214 pg/d!. (The lethal range is 260 to 3,000 pg/d/.) The child recovered slowly over the next 12 hours. Subsequent evaluation revealed recurrence of in tra-abdominal disease with several bone metastases. DISCL'SSroN Laetrile, which is a glycoside, contains cyanide, a respiratory poison by virtue of its tight a!!i~ity fer cytochrome oxidase, a key respiratory enzyme. The resulting tissue hypoxia produces nausea, vomiting, hypotension, cyanosis , shock, stupor, coma, respiratory failure, and death . The release of cyanide from amygdalin occurs in the presence of hydrolyzing ,a-glucosidase enzymes, which are contained in many fruits and vegetables. Ingestion of Laetrile with any of these in an uncooked state can result in the release of cyanide. All examples of Laetrile-induced cyanide poisoning reported in tile United States, including two fatal episodes," have been associated with ingestion of the oral form of the compound, with the exception of one case which resulted from ingestion of the parenteral form. In the child reported here, the administration of the parenteral form as an enema resulted in acute cyanide poisoning. This can be explained by the hydrolysis of Laetrile within the intestinal mucosa, where the p-glucosidases occur as lysosomal enzymes.' Jorge A. Ortega, M.D. James E. Creek. l\.f,D. Division of Hematology-Oncology Children; Hospital of Los Angeles 4 65~ Sunset BJ~d Los Angeles, CA 90027 enzy~e
REFERENCES 1. Moertel CO: A trial of Laetrile now, N Engl J Med 298:218, 1978. 2. Humbert JR, Tress JH, Braico KT : Fatal cyanide poisoning: Accidental ingestion of amygdalin, JAMA 238:482, 1911. 3. Smith FP, Butler TP, Cohan S, Schein PS: Laetrile toxicity: A report of two cases, JAMA 238:1361,1977. 4. Toxicity of Laetrile, FDA Drug Bull 7:26, 1977. The Journal ofPED1 ATR I CS Val 93. No 6. pp 1059-/067
1059