Agatha Christie is an English crime novelist who frequently used poisons in her books to murder the victims. In her book, Murder is Easy, Ms. Christie uses arsenic/arsenic trioxide to kill several characters.

 

Primary source of arsenic in general population is contaminated food, water and soil. Arsenic exists in several forms: elemental, gaseous (arsine), organic and inorganic (trivalent or pentavalent).

 

Arsenic trioxide has also been used to treat acute promyelocytic leukemia in China; it’s use in other leukemia, lymphoma, and other solid tumors are currently being investigated.

 

Arsenic primarily inhibits the pyruvate dehydrogenase complex and multiple other enzymes involved in the citric cycle/oxidative phosphorylation, resulting in mitochondrial dysfunction.

 

Acute toxicity of arsenic after ingestion

1. GI symptoms (minutes to several hours) – nausea, vomiting, abdominal pain and cholera like diarrhea.
2. Cardiovascular: QT prolongation/torsade de pointes, orthostatic hypotension, ventricular dysrhythmias, myocardial dysfunction and shock.
3. CNS (days): encephalopathy, delirium, coma, and seizure due to cerebral edema and microhemorrhages.
4. Respiratory: ARDS, respiratory failure,
5. Others: AKI, leukemoid reaction, hemolytic anemia, and hepatitis.

 

 Management

1. Chelation: dimercaptrol (BAL) or succimer
2. Whole bowel irrigation if radiopaque material is present (abdominal XR)
3. Electrolyte and fluid management
4. Cardiac monitoring and pressor support in hypotension