Letter to the Editor
Acute intoxication by acetonitrile
Intoxicación aguda por acetonitrilo
Roger Malo Barres, Cándido Muñoz Muñoz
, Lluis Sanchez Sitjes
Corresponding author
Departamento de Medicina Interna, Hospital General de Cataluña, Barcelona, Spain
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Currently, it is used as an organic solvent in refineries, manufacture of pesticides or pharmaceutical products, among other uses.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Acetonitrile poisoning is a rare cause of poisoning and represents a medical emergency. It usually occurs by inhalation, ingestion, or accidental skin absorption, mainly in a work context.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although there are some previously reported cases of incidental or suicidal poisoning,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> those described in the literature since its withdrawal for use by the general population are few.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 39-year-old man, a chemical industry worker, a former smoker with a history of mixed anxiety-depressive disorder who was admitted to our center due to nausea and vomiting after occupational exposure during the clean-up of a liquid ACN spill. Although he was wearing personal protective equipment, the mask was intermittently removed. During the 24 h before admission he suffered from asthenia and anorexia, but did not seek medical help. Upon arrival at our center, he was admitted to the intensive care unit, tachypnoeic at 24 bpm and with 97% baseline saturation. Regarding laboratory parameters, leukocytosis of 14.7 × 10<span class="elsevierStyleSup">3</span>, baseline arterial blood gas: pH 7.5; pCO<span class="elsevierStyleInf">2</span>: 18.3 mmHg; HCO<span class="elsevierStyleInf">3</span>: 14.4 meEq/l; excess cell bases: ↓8.2 mEq/l standard; pO<span class="elsevierStyleInf">2</span> 116 mmHg and lactic acid 52 mg/dl (4.5–14.4) stood out. Urine toxicology analysis showed thiocyanate (acetonitrile metabolite) levels of 65 mg/l (reference value < 20 mg/l in exposed people). Chest X-ray and electrocardiogram showed no abnormalities. Support measures were started with oxygen therapy and IV hydration therapy with subsequent administration of a single dose of 12.5 g of sodium thiosulfate IV and 5 g of hydroxocobalamin IV with progressive resolution of the clinical symptoms in the following 72 h.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Acetonitrile poisoning should be suspected in cases of suggestive clinical features and elevated lactate levels, as in our patient. The fact that it is a colourless, volatile liquid and non-specific symptoms do not appear until several hours after inhalation exposure may delay diagnosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> These symptoms include headache, vertigo, nausea, vomiting, breathing difficulties, and in more severe cases, seizures, or death from respiratory failure as a consequence of the liver's metabolization of acetonitrile to methyl cyanide. The first-line treatment is hydroxycobalamin.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This acts quickly and efficiently by changing the hydroxyl group for cyanide, forming cyanocobalamin (vitamin B<span class="elsevierStyleInf">12</span>). However, in massive poisoning it can be associated with sodium thiosulfate that reverses anaerobiosis and lactic acidosis caused by cyanide at the mitochondrial level, although it does so more slowly. Because the metabolization of ACN to cyanide is slower than that of other nitriles, its toxicity occurs less abruptly allowing a wider time window for neutralization and excretion by urine or exhalation without being metabolized. Our patient responded satisfactorily to treatment despite the delay in seeking medical help and taking the antidote.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Acetonitrile poisoning is a rare cause of poisoning. A quick diagnostic and therapeutic approach in the first hours after exposure can avoid a fatal outcome.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Malo Barres R, Muñoz Muñoz C, Sanchez Sitjes L. Intoxicación aguda por acetonitrilo. Med Clin (Barc). 2020;155:275.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cyanogenic aliphatic nitriles" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S.W. 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