Venous thrombosis following intravenous injection of household bleach

Abstract

Sodium hypochlorite (NaClO) is used extensively as a disinfectant or bleaching agent. Most studies describe ingestion or inhalation route of this product with rare complication and fatalities. Despite global daily exposures, data about bleach injection is limited. Here we report intentional infusion of 20 mL, sodium hypochlorite 5% diluted in 500 mL normal saline 1.5 h prior admission. Clinical manifestation included local pain and edema. There were no laboratory abnormalities in the patient. Doppler sonography revealed thrombosis in superficial (antecubital and basilic) veins. Limb elevation, warm compress, and ibuprofen relived pain and edema after 3 days.

Introduction

Suicide is a significant public health problem in the world because it leads to death and disability with devastating effects on those left behind. ¹

Frequently used successful suicidal methods in descending order are hanging (48%), jumping from height (24%), poisoning (6%), and drowning (5%). Unusual ways of committing suicide are reported in the forensic literature which appears to be similar although the frequency differs from country to country. ^2,3

Venous thrombosis (VT), as the name implies, is caused by the presence of thrombus within a superficial or deep vein and the accompanying inflammatory response in the vessel wall. The inflammatory response in the vessel wall may be minimal or characterized by granulocyte infiltration, loss of endothelium, and edema.

Sodium hypochlorite is a chemical compound with formula NaClO. Sodium hypochlorite solution, commonly known as bleach, is frequently used as a disinfectant or a bleaching agent.

Some investigations in vitro and in animals have demonstrated the toxic effects of sodium hypochlorite on vital tissues. These include hemolysis, skin ulceration, ⁴ marked cell injury in endothelial cells and fibroblasts, and inhibition of neutrophil migration. ^5,6 Pashly et al. state that sodium hypochlorite can elicit severe inflammatory reactions and is cytotoxic to all cells except heavily keratinized epithelia. ⁴ Bleach as a potent oxidant has been used as a trigger for experimental lung injury. Infusion of sodium hypochlorite reduces glutathione. ⁷ This oxidative stress on pulmonary neutrophils triggers an endothelial response with increased pulmonary artery pressure that could lead to adult respiratory distress syndrome. ⁸

Ingestion is the most frequent route of bleach exposure, followed by inhalation of gases evolved by mixing sodium hypochlorite with acid or alkaline products.^9,10

In this article, we present the first case of VT due to intentional injection of household bleach (sodium hypochlorite 5%) into antecubital vein.

Case report

A 30-year-old previously physically healthy man was admitted to the emergency department (bodyweight, 75 kg). He attempted suicide by infusion of 500 mL normal saline serum containing 20 mL household bleach (sodium hypochlorite 5%) into right cubital vein with intravenous (IV) line, one and a half hours before admission. He had a history of schizophrenia since 10 years and this was his first suicide attempt.

On arrival, the patient was hemodynamically stable. Oral temperature was 37.5°C (99.5°F), pulse rate 103 beats per minute with a normal rhythm, blood pressure 135/80 mm Hg, and his respiratory rate was 18 breaths/min with no abnormal breath sounds. The abdomen was soft and flat with normal bowel sounds.

The initial oxygen saturation was 95% (in room air). He was alert, awake, and in no apparent distress. He complained of painful swelling in his right upper extremity. In clinical examination, the arm was painful and relatively swollen.

A 12-lead electrocardiogram revealed sinus tachycardia at a rate of 105 bpm, a complete blood count was normal except for a mildly elevated white blood cell count of 11.6 × 10³/μL (11.6 × 10⁹/L), hemoglobin 15.3 g/dL, hematocrit 44.5% with 46% neutrophils, 52% lymphocytes, 1% monocytes, and 1% eosinophils. His serum blood urea nitrogen, creatinine, creatinine kinase, and liver function tests were normal (sodium = 141 mEq/L, potassium = 4.8 mEq/L, calcium (total) = 10 mg/dL, magnesium = 1.7 mg/dL). Coagulation studies, including a prothrombin time and activated partial thromboplastin time, were normal. Serum glucose was 130 mg/dL. Urine analysis and arterial blood gases were in normal range. No positive toxicology screening results were detected. The color doppler sonography of right upper extremity showed thrombosis in superficial (antecubital and basilic) veins. We applied warm compresses to the affected arm and limb elevation while ibuprofen 400 mg orally every 6 hours prescribed.

The patient was observed for 6 h and discharged after psychiatric consultation for outpatient follow-up. His symptoms improved after 3 days without further sequels.

Discussion

The factors that predispose to VT were initially described by Virchow in 1856 and include stasis, vascular damage, and hypercoagulability. Accordingly, a variety of clinical situations are associated with increased risk of VT. Of these risk factors, relative hypercoagulability appears most important in most cases of spontaneous VT, whereas stasis and endothelial damage likely play a greater role in secondary VT. VT could be a result of any IV injection and subsequent endothelial damage, particularly by a nonmedical person.

Household bleach sold for use in laundering clothes is a 3–6% solution of sodium hypochlorite. This makes the solution very hypertonic (∼2800 mOsm/kg). There are some fatal reports of hypernatremia and hyperchloremic metabolic acidosis due to ingestion; although most of them ingest concentrated large-volume products. ¹¹ Household bleach is a well known to be relatively nontoxic when ingested in small amounts. ¹² There are reports of parenteral injection of sodium hypochlorite, but these are usually inadvertent intramucosal injections into soft tissue during dental procedures and produce only local edema and pain ^13,14 or as a disinfectant by IV drug abusers which manifest by transient left-sided chest pain and vomiting. ¹⁵

Sodium hypochlorite has a pH of approximately 11–12. At this pH, the mechanism of injury from undiluted liquid chlorine bleach is primarily oxidation of proteins. Ingestion is the most frequent route of exposure, followed by inhalation of gases evolved by mixing sodium hypochlorite bleach with acid or alkaline products which produce chlorine and irritate particularly pulmonary mucous membranes. ¹⁰

Froner et al. in 1987 reported case of the IV injection of a small amount of bleach. ¹⁶ This patient injected 0.3 mL and ingested 60 mL of sodium hypochlorite (5.25%). He had normal laboratory values except for the urine toxicology screen, which was positive for benzodiazepine, methamphetamine, and amphetamine. He was treated with ipecac and activated charcoal and did well.

Marrion and Menichetti in 1991 reported a case of the IV injection of bleach involving a much larger amount. ¹⁷ A 69-year-old man hospitalized for meningitis in Italy inadvertently received 150 mL of 1% sodium hypochlorite IV over 1 h. He experienced mild hypotension and bradycardia that lasted 3 days and then had permanent lower limb paralysis. The author did not believe the paralysis was caused by the sodium hypochlorite but thought that the bradycardia was due to the direct toxic effect on the cardiac tissues and recommended forced diuresis and hydration.

A woman with chronic renal failure inadvertently received a large amount of 5.25% sodium hypochlorite (which was used in cleaning the dialysis machine) in her dialysate. ¹⁸ Although her blood was in contact with the bleach through the dialysis membrane for less than 2 min, she had an immediate cardiac arrest. Fortunately, she was resuscitated successfully. It was believed that the bleach caused massive hemolysis that lead to hyperkalemia and cardiac arrest.

Dennis et al. in 2008 reported a case of diffuse alveolar hemorrhage following the ingestion and IV injection of bleach. ¹⁹

Our reported patient suffered from no serious complications after the IV injection of a small amount of sodium hypochlorite, which is consistent with the other reported case of a relatively small amount of bleach. Also this case highlights a rare cause of VT.

We hypothesize that thrombosis may be triggered by direct damage of endothelial response resulted from potent oxidant effects of sodium hypochlorite. Based on this theory, storage and depletion of glutathione has an important role to demonstrate the amount of endothelial response following this oxidative stress. Administration of antioxidant glutathione in severe cases might be beneficial.