Sevelamer overdose

Abstract

Various toxicities following suicide attempt: case report A 70-year-old man developed abdominal pain, nausea, tachycardia, anaemia, fever, hypotension, lung congestion and drug toxicity following a suicide attempt by ingestion of sevelamer at an overdose. The man presented to the emergency department with abdominal pain and nausea (current presentation). Several hours prior to the presentation, he had ingested 100 pills of sevelamer [sevelamer carbonate; dose ingested not stated] in a suicide attempt. His medical history was significant for haemodialysis (started 8 months prior) for end-stage renal disease (ESRD) due to chronic pyelonephritis, depression (under regular treatment with sulpiride), paroxysmal atrial fibrillation, history of alcohol abuse and bleeding from a gastric ulcer (6 months prior). At the time of current presentation, he was noted with tachycardia (93 /minute) without fever and BP of 75/55mm Hg. He was conscious, oriented and alert. Laboratory tests showed mild anaemia with serum haemoglobin of 101 g/L, lymphocytes of 6.4×109/L, C-reactive protein of 99.7 mg/L and potassium of 3.4 mmol/L. Chest x-rays showed no pathological changes. The man received treatment with active carbon, polyethylene-glycol and trospium-chloride. Subsequently, he underwent gastric lavage. During the gastric lavage, he developed oesophageal perforation, which was considered as a complication of the suicide attempt. After his overall status was noted as stable, he was admitted to the psychiatry department for psychosupport and evaluation after the suicide attempt. However, over the following 12 hours, his clinical condition deteriorated with worsened abdominal pain, fever and hypotension that required ICU transfer. Repeat chest x-ray showed broad mediastinum, lung congestion with marked pneumomediastinum from the base of the neck down to the diaphragm. Multi-slice CT scan showed presence of air in both anterior and posterior mediastinal compartment. Oesophageal passage was notable for extralumination of the contrast paraesophageally with free air in the mediastinal cavity. After consultation with thoracic surgeon and interventional gastroenterologist, it was decided to proceed with an endoscopy. He received empirical antimicrobial therapy with meropenem and vancomycin, total parenteral nutrition and dialysis support. Endoscopy revealed persisting defect with inadequate healing that required surgical treatment with patch plastic using the diaphragm. Thereafter, his status improved, and he was discharged in a good overall condition and regular haemodialysis treatment was continued.