Conclusion
After an extensive literature review, this appears to be the first case documenting bromide toxicity in a patient exposed to the product called Cordial de Monell, which contains potassium bromide. We have identified this product on store shelves in areas of New York City. We believe this child suffered from excess therapeutic sedative exposure due to her size, age, and repeated exposure. Bromism is not nearly as common as it once was, but several forms of bromide are still readily available. This diagnosis should be included in the differential diagnosis of patients who present with sedative-hypnotic-type intoxication. Elevations in the reported serum chloride levels and a negative anion gap are helpful findings if present, but our case and others before confirm that the lack of these features do not rule out this poisoning. This case further illustrates the need for clinicians to be diligent in obtaining thorough medication, dietary, herbal supplement, social, occupational, and cultural histories from their patients. Aggressive hydration with chloride-containing solutions is the cornerstone of treatment, and in severe cases dialysis may be considered. Bromides are not gone, and bromism should not be forgotten.
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References
Sourkes TL. Early clinical neurochemistry of CNS-active drugs. Bromides.Mol Chem Neuropathol 1991;14(2):131–142.
Hung YM. Bromide intoxication by the combination of bromide-containing over-the-counter drug and dextro- methorphan hydrobromide.Hum Exp Toxicol 2003;22(8): 459–461.
Horowitz BZ. Bromism from excessive cola consumption.J Toxicol/Clin Toxicol 1997;35(3):315–320.
Raskind MA, Kitchell M, Alvarez C. Bromide intoxication in the elderly.J Am Geriatr Soc 1978;26(5):222–224.
Cummins JA. Untoward effects of bromide medication.Can Med Assoc J 1942;47(3):259–260.
Adamson JS, Flanigan WJ, Ackerman GL. Treatment of bromide intoxication with ethacrynic acid and mannitol diuresis.Ann Intern Med 1966;65(4):749–752.
Mangurten HH, Kaye CI. Neonatal bromism secondary to maternal exposure in a photographic laboratory.J Pediatr 1982;100(4):596–598.
Gutschmidt KP, Haefliger G, Zilker T. Outbreak or Neurological Illness of Unknown Etiology in Cacuaco Municipality, Angola. 2008, World Health Organization.
Hsieh PF, Tsan YT, Hung DZ, et al. Bromism caused by mix-formulated analgesic injectables.Hum Exp Toxicol 2007;26(12):971–973.
Frances C, Hoizey G, Lamiable D, et al. Bromism from daily over intake of bromide salt.J Toxicol/Clin Toxicol 2003;41(2):181–183.
De Keyser J, Maes V, Malfait R, et al. Bromism after pro- longed use of carbromal.Acta Neurol Belg 1984;84(2):69–74.
Wang YT, Yang SY, Wu VC, et al. Pseudohyperchloraemia due to bromvalerylurea abuse.Nephrol Dial Transplant 2005;20(8):1767–8.
Ng YY, Lin WL, Chen TW, et al. Spurious hyperchloremia and decreased anion gap in a patient with dextromethorphan bromide.Am J Nephrol 1992;12(4):268–270.
Rothenberg DM, Berns AS, Barkin R, et al. Bromide intoxication secondary to pyridostigmine bromide therapy.JAMA 1990;263(8):1121–1122.
Jih, DM, Khanna V, Somach SC. Bromoderma after excessive ingestion of Ruby Red Squirt.N Engl J Med 2003;348(19):1932–1934.
James LP, Farrar HC, Griebel ML, et al. Bromism: intoxication from a rare anticonvulsant therapy.Pediatr Emerg Care 1997;13(4):268–270.
Maes V, Huyghens L, Dekeyser J, et al. Acute and chronic intoxication with carbromal preparations.J Toxicol/Clin Toxicol 1985;23(4–6):341–346.
Lin JN, Lin HL, Huang CK, et al. Myoclonic jerks due to acute bromovalerylurea intoxication.Clin Toxicol (Phila) 2008;46(9):861–863.
Battin DG, Varkey TA. Neuropsychiatric manifestations of bromide ingestion.Postgrad Med J 1982;58(682):523–524.
Hafiji, J, Majmudar V, Mathews S, et al. A case of bromoderma and bromism.Br J Dermatol 2008;158(2):427–429.
Heckerling PS. Ethylene glycol poisoning with a normal anion gap due to occult bromide intoxication.Ann Emerg Med 1987;16(12):1384–1386.
Caraccio TR, McGuigan M. Over-the-counter products. In: Dart RC, ed. Medical Toxicology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2004:1051–1052.
Lee D. Sedative-hypnotics. In: Goldfrank LR, Floenbaum NE, Lewin NA, Howland MA, Hoffman RS, Nelson LS, eds. Goldfrank’s Toxicologic Emergencies. 8th ed. New York: McGraw-Hill, 2006:1105–1106.
Elin RJ, Robertson EA, Johnson E. Bromide interferes with determination of chloride by each of four methods.Clin Chem 1981;27(5):778–779.
Danel VC, Saviuc PF, Hardy GA, et al. Bromide intoxication and pseudohyperchloremia.Ann Pharmacother 2001;35(3):386–387.
Vasuyattakul S, Lertpattanasuwan N, Vareesangthip K, et al. A negative anion gap as a clue to diagnose bromide intoxication.Nephron 1995;69(3):311–313.
Kraut JA, Madias NE. Serum anion gap: its uses and limitations in clinical medicine.Clin J Am Soc Nephrol 2007;2(1):162–174.
Sood MM, Richardson R. Negative anion gap and elevated osmolar gap due to lithium overdose.CMAJ 2007;176(7):921–923.
Blume RS, MacLowry JD, Wolff SM. Limitations of chloride determination in the diagnosis of bromism.N Engl J Med 1968:279(11):593–595.
Morrison G. Serum chloride. In: Walker HK, Hurst JW, eds. Clinical Methods: The History, Physical, and Laboratory Examinations. Stoneham: Butterworth Publishers, 1990:890–891.
Heckerling PS, Ammar KA. Bromide intoxication due to propantheline bromide.Am J Nephrol 1996;16(6):537–539.
Wieth JO, Funder J. Treatment of Bromide Poisoning: Comparison of Forced Halogen Turnover and Haemodialysis.Lancet 1963;2(7303):327–329.
Yeung GT. Skin eruption in newborn due to bromism derived from mother’s milk.BMJ 1950;1:769.
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Lugassy, D.M., Nelson, L.S. Case files of the medical toxicology fellowship at the New York City Poison Control: Bromism: Forgotten, but not gone. J. Med. Toxicol. 5, 151–157 (2009). https://doi.org/10.1007/BF03161228
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DOI: https://doi.org/10.1007/BF03161228