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Iron Toxicity Clinical Presentation

  • Author: Clifford S Spanierman, MD; Chief Editor: Asim Tarabar, MD  more...
Updated: Dec 04, 2015


Gastrointestinal (GI) manifestations such as vomiting and diarrhea (especially when hemorrhagic) are an important feature of acute iron toxicity. Pediatric patients who are alert and not vomiting most likely did not ingest a toxic dose of iron; in adults, however, abdominal pain and vomiting may be absent. More than four episodes of vomiting suggests significant iron toxicity. Hemorrhagic gastroenteritis, even in the absence of a history of iron ingestion, should raise suspicion for iron toxicity.



Iron poisoning is often classified into five distinct stages, as follows:

  • Stage 1 - Gastrointestinal (GI)
  • Stage 2 - Latent
  • Stage 3 - Metabolic/cardiovascular
  • Stage 4 - Hepatic
  • Stage 5 - Delayed

Understanding the course of poisoning is important. In particular, the second stage may lure the physician into a false sense of security and result in premature and inappropriate discharge of a patient.

Stage 1

Features of stage 1 iron toxicity are as follows:

  • This stage usually occurs within 6 hours after exposure
  • Nausea and diarrhea, often accompanied by abdominal pain, characterize this stage
  • When the intoxication is severe, a hemorrhagic component is observed in conjunction with gastroenteritis
  • The combination of GI fluid loss and blood loss, with additional third-spacing, may result in hypovolemia or shock
  • Fatality occurs in a significant percentage of patients during this stage

Stage 2

Features of stage 2 iron toxicity are as follows:

  • GI symptoms resolve, and the patient appears to improve and recover
  • This deceptive phase usually occurs 6-12 hours after ingestion and may last as long as 24 hours.
  • Metabolic abnormalities during this phase may include hypotension, metabolic acidosis, and coagulopathy
  • Some patients skip this phase and progress directly to stage 3

Stage 3

Features of stage 3 iron toxicity are as follows:

  • Stage 3 is characterized by metabolic acidosis and cardiovascular symptoms; the acidosis may indicate failure of organs such as the heart and kidneys
  • It is hypothesized that high iron concentrations produce venous pooling and third-spacing of fluids
  • Central nervous system (CNS) symptoms, usually stupor and coma, are also characteristic of stage 3
  • Most deaths occur during this stage
  • Stage 3 can start very early (6-8 h), depending on severity of exposure, and can last up to 2 days

Stage 4

Features of stage 4 iron toxicity are as follows:

  • Elevated liver enzymes and bilirubin levels are commonly observed with coagulopathy, indicative of hepatic dysfunction
  • Hypoglycemia may accompany liver dysfunction

Stage 5

Features of stage 5 iron toxicity are as follows:

  • This stage is characterized by scarring of the healing GI tract; the stomach and/or intestines may be affected, resulting in gastric outlet or intestinal obstruction
  • This phase usually is experienced weeks after a severe poisoning
Contributor Information and Disclosures

Clifford S Spanierman, MD Consulting Staff, Departments of Emergency Medicine and Pediatrics, Lutheran General Hospital of Oak Brook, Advocate Health System

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Undersea and Hyperbaric Medical Society, Wilderness Medical Society, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

David C Lee, MD Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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