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Iron Toxicity

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

Background

Iron overdose has been one of the leading causes of poisoning deaths in children younger than 6 years. Iron is used in pediatric or prenatal vitamin and mineral supplements and for treatment of anemia. Iron tablets are particularly tempting to young children because they look like candy.

Iron overload may develop chronically as well, especially in patients requiring multiple transfusions of red blood cells. This condition develops in patients with sickle cell disease, thalassemia, and myelodysplastic syndromes.

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Pathophysiology

Iron toxicity can be classified as corrosive or cellular. Ingested iron can have an extremely corrosive effect on the gastrointestinal (GI) mucosa, which can manifest as nausea, vomiting, abdominal pain, hematemesis, and diarrhea; patients may become hypovolemic because of significant fluid and blood loss.

Cellular toxicity occurs with the absorption of excessive quantities of ingested iron. Severe overdose causes impaired oxidative phosphorylation and mitochondrial dysfunction, which can result in cellular death. The liver is one of the organs most affected by cellular iron toxicity, but other organs such as the heart, kidneys, lungs, and the hematologic systems also may be impaired. With chronic iron overload, the deposit of iron into the heart may cause death due to myocardial siderosis.

With both corrosive and cellular toxicity, the end result is significant metabolic acidosis, due to several factors. Hypoperfusion due to significant volume loss, vasodilatation, and negative inotropic effect of iron will result in lactic acidosis. Inhibition of oxidative phosphorylation will promote anaerobic metabolism.

Individuals demonstrate signs of GI toxicity after ingestion of more than 20 mg/kg. Moderate intoxication occurs when ingestion of elemental iron exceeds 40 mg/kg. Ingestions exceeding 60 mg/kg can cause severe toxicity and may be lethal.[1]

Suggested iron doses are based on calculation of the amount of elemental iron. Different iron preparations (salts) contain different amounts of elemental iron, as follows:

  • Fumarate - 33%
  • Sulfate - 20%
  • Gluconate - 12%
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Epidemiology

United States

The 2014 Annual Report of the American Association of Poison Control Centers' (AAPCC) National Poison Data System reported 4024 single exposures to iron or iron salts, with one major outcome and one death. In addition, the AAPCC reported 11,180 single exposures to multiple vitamins containing iron, with one major outcome and no deaths. Overall, 75% of cases were in children younger than 6 years.[2]

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Contributor Information and Disclosures
Author

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.

References
  1. McGuigan MA. Acute iron poisoning. Pediatr Ann. 1996 Jan. 25(1):33-8. [Medline].

  2. Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila). 2015 Dec. 53 (10):962-1147. [Medline]. [Full Text].

  3. [Guideline] Höjer J, Troutman WG, Hoppu K, Erdman A, Benson BE, Mégarbane B, et al. Position paper update: ipecac syrup for gastrointestinal decontamination. Clin Toxicol (Phila). 2013 Mar. 51(3):134-9. [Medline].

  4. Tenenbein M. Benefits of parenteral deferoxamine for acute iron poisoning. J Toxicol Clin Toxicol. 1996. 34(5):485-9. [Medline].

  5. Sankar J, Shukla A, Khurana R, Dubey N. Near fatal iron intoxication managed conservatively. BMJ Case Rep. 2013 Jan 31. 2013:[Medline].

  6. Carlsson M, Cortes D, Jepson S, Kansstrup T. Severe iron intoxication treated with exchange transfusion. Arch Dis Child. April 2008. 93(4):321-2. [Medline].

  7. Gumber MR, Kute VB, Shah PR, et al. Successful Treatment of Severe Iron Intoxication with Gastrointestinal Decontamination, Deferoxamine, and Hemodialysis. Ren Fail. 2013 May 1. [Medline].

  8. Ng HW, Tse ML, Lau FL, Chu W. Endoscopic removal of iron bezoar following acute overdose. Clin Toxicol (Phila). 2008 Nov. 46(9):913-5. [Medline].

  9. Haider F, De Carli C, Dhanani S, Sweeny B. Emergency laparoscopic-assisted gastrotomy for the treatment of an iron bezoar. J Laparoendosc Adv Surg Tech A. April 2009. 19 Suppl 1:S141-3. [Medline].

  10. Cerezo A, Costan G Gonzale A, Galvez C , Garcia V, Iglesias E, Reye A, et al. Severe esophagitis due to overload of iron tablets. Gastroenterol Hepatol. Oct 2008. 31(8):551-2. [Medline].

  11. Valentine K, Mastropietro C, Sarnaik AP. Infantile iron poisonings: challenges in diagnosis and management. Pediatr Crit Care Med. May 2009. 10 (3):e31-33. [Medline].

  12. Atiq M, Dang S, Olden KW, Aduli F. Early endoscopic gastric lavage for acute iron overdose: a novel approach to accidental pill ingestions. Acta Gastroenterol Belg. 2008 Jul-Sep. 71(3):345-6. [Medline].

 
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