Bromide intoxication by the combination of bromide-containing over-the-counter drug and dextromethorphan hydrobromide

Abstract

A 30-year old woman was presented to the emergency room with marked lethargy and fever. Her physical examination showed an acneiform eruption on the face. Blood biochemistry showed a high chloride level and a negative anion gap. High blood bromide level measurements on an ion-selective electrode was noted later to cause spurious hyperchloremia with a negative anion gap. After receiving saline hydration and diuretic treatment, her serum chloride returned to normal range on hospital day nine. Slow resolution of her mental status occurred over 2 months. Her skin lesions disappeared about 5 months later. In conclusion, in face of an unusual high chloride level and a negative anion gap in a patient of long-term use of over-the-counter (OTC) agents, bromide intoxication should be included in the differential diagnosis.

Keywords

Bromide intoxication negative anion gap over-thecounter agents spurious hyperchloremia

References

Trump DL , Hochberg MC . Bromide intoxication . Johns Hopkins Med J 1976; 38: 119–123 .

Rothenberg DM , Berns AS , Barkin R , Glantz RH . Bromide intoxication secondary to pyridostigmine bromide therapy . JAMA 1991; 263: 1121–1122 .

Wenk RE , Lustgarten JA , Pappas NJ . Serum chloride analysis, bromide detection, and the diagnosis of bromism . Am J Clin Pathol 1976; 65: 49–57 .

Vasuyattakul S , Lertpattanasuwan N , Vareesangthip K , Nimmannit S , Nilwarangkur S . A negative anion gap as a clue to diagnose bromide intoxication . Nephron 1995; 69: 311–313 .

Ng YY , Lin WL , Chen TW , Lin BC , Tsai SH , Chang CC , Huang TP . Spurious hyperchloremia and decreased anion gap in a patient with dextromethorphan bromide . Am J Nephrol 1992; 12: 268–270 .

Battin DG , Varkey TA . Neuropsychiatric manifestations of bromide intoxication . Postgrad Med J 1982; 58: 523–525 .

Kunze U . Chronic bromide intoxication with a severe neurological deficit . J Neurol 1976; 213: 149–152 .

Raskind MA , Kitchell M , Alvarez C . Bromide intoxication in the elderly . J Am Geriatr Soc 1978; 26: 222–224 .

Elin D , Robertson EA , Johnson E . Bromide interferes with determination of chloride by each of four methods . Clin Chem 1990; 36: 1470–1473 .

10.

Emancipator K , Kroll MH . Bromide interference: Is less really better? Clin Chem 1990; 36: 1470–1473 .

11.

Adamson JS Jr , Flanigan WJ , Ackerman GL . Treatment of bromide intoxication with ethacrynic acid and mannitol diuresis . Ann Intern Med 1966; 65: 749–752 .

12.

Heckerling PS , Ammar KA . Bromide intoxication due to propantheline bromide . Am J Nephrol 1996; 16: 537–539 .

13.

Wieth JO , Funder J . Treatment of bromide poisoning: comparison of forced halogen turnover and hemodialysis . Lancet 1963; 2: 327–329 .