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CASE SNIPPET
Year : 2013  |  Volume : 59  |  Issue : 2  |  Page : 152-153

Heartburn literally: Cardiac injury due to corrosive ingestion


Department of Medicine, University College of Medical Sciences (University of Delhi) and Guru Teg Bahadur Hospital, Delhi, India

Date of Web Publication21-Jun-2013

Correspondence Address:
V Sharma
Department of Medicine, University College of Medical Sciences (University of Delhi) and Guru Teg Bahadur Hospital, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.113837

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How to cite this article:
Aggarwal A, Bansal A, Dixit A, Sharma V. Heartburn literally: Cardiac injury due to corrosive ingestion. J Postgrad Med 2013;59:152-3

How to cite this URL:
Aggarwal A, Bansal A, Dixit A, Sharma V. Heartburn literally: Cardiac injury due to corrosive ingestion. J Postgrad Med [serial online] 2013 [cited 2019 Jun 19];59:152-3. Available from: http://www.jpgmonline.com/text.asp?2013/59/2/152/113837


A 15-year-old boy presented with a history of accidental ingestion of about 50 ml of toilet cleaner (diluted 8% sulfuric acid) around 8 h back. Immediately after ingestion, he developed a sensation of local irritation and burning sensation in his oral cavity. There were no respiratory complaints or hemodynamic instability. Our patient did not have any known cardiac or other vascular disease. At presentation, his pulse rate was 110/min, respiratory rate of 20/min, and blood pressure was 100/70 mmHg. Examination of the oral cavity revealed mild erythema on the inner cheeks and the posterior pharyngeal wall. The abdomen was soft to palpation with mild tenderness in the epigastrium. The rest of the general and systemic examination was unremarkable. His arterial blood gas analysis and chest and abdominal roentgenogram were normal. However, his electrocardiogram (ECG) showed "T" wave inversions in leads II, III, aVF, V 1 -V 4 [Figure 1]. His troponin T level was elevated (1.9 ng/mL, normal <0.1 ng/mL) and creatine kinase isoenzyme MB was also raised (48 U/L, normal <25 U/L). His liver and kidney function tests were normal. Serum potassium was normal (4.2 meq/L). The patient was managed with injectable proton pump inhibitors and intravenous fluids. Endoscopy revealed esophagus injury with multiple deep ulcers and scattered necrotic areas (Grade 3a) throughout the esophagus and gastric injury in the form of deep circumferential ulcerations (Grade 2b). His ECG changes persisted for more than a week, but cardiac enzymes returned to normal levels on 7 th day with troponin at 0.08 ng/mL (<0.1 ng/mL) and CK-MB at 12 U/L. His echocardiograms done on 7 th and 12 th day after presentation were absolutely normal.
Figure 1: ECG showing diffuse ST-T changes

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Sulfuric acid is a commonly used chemical in households for cleansing toilet bowl. [1] It acts as a corrosive agent and results in local irritation and mucosal injury and, therefore, causes esophageal and gastric injury. [1],[2],[3] Sulfuric acid at 8-10% concentration is used as a toilet bowl cleaner and is a common accidental poison in India. It can cause injury of variable severity to the esophageal and gastric mucosa. [1],[3],[4] This may manifest endoscopically as mucosal edema, erythema, ulcerations, necrosis, bleeding, and even perforation. The site and severity of injury depends on a number of factors including dosage of the agent, its concentration, nature (acidic or alkaline) of corrosive, and whether the patient was empty stomach. Delayed complications include stricture formation resulting in dysphagia or gastric outlet obstruction. Most patients report mild to severe oropharyngeal, esophageal, and gastrointestinal damage. Heavy ingestion of concentrated (52-100%) sulfuric acid can also lead to hypotension, metabolic acidosis, and disseminated intravascular coagulation. [5] In such patients, death can occur from cardiovascular collapse or shock secondary to chemical peritonitis due to gastrointestinal tract perforation. [5]

This, to the best of our knowledge, is the first report of cardiac manifestations following corrosive ingestion. Such changes can occur if corrosive ingestion leads to hypotension resulting in cardiac necrosis and then causing elevation of myocardial enzymes and ECG changes. However, our patient did not have any episode of hypotension. We believe that the trans-mural spread of inflammation across the esophageal wall into the mediastinum and then injuring the myo-pericardium might have been responsible for these manifestations.

 
 :: References Top

1.Lahoti D, Broor SL. Corrosive injury to the upper gastrointestinal tract. Indian J Gastroenterol 1993;12:135-41.  Back to cited text no. 1
    
2.Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK. Ingestion of corrosive acids. Spectrum of injury to upper gastrointestinal tract and natural history. Gastroenterology 1989;97:702-7.  Back to cited text no. 2
    
3.Dilawari JB, Singh S, Rao PN, Anand BS. Corrosive acid ingestion in man-a clinical and endoscopic study. Gut 1984;25:183-7.  Back to cited text no. 3
    
4.Mills SW, Okoye MI. Sulfuric acid poisoning. Am J Forensic Med Pathol 1987;8:252-5.  Back to cited text no. 4
    
5.Matshes EW, Taylor KA, Rao VJ. Sulfuric acid injury. Am J Forensic Med Pathol 2008;29:340-5.  Back to cited text no. 5
    


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