Oshikoya, KA

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Response:
Accidental Potassium Bromate Poisoning Causing Acute Renal Failure 
Kazeem A. Oshikoya, Department of Pharmacology, Lagos State University College of Medicine, and Department of Paediatrics, 
Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
Address For Correspondence:
Dr Kazeem A. Oshikoya, 
Academic Division of Child Health,
University of Nottingham,
Derby Royal Children’s Hospital,
Derbyshire DE 22 3 DT, United Kingdom.
E-mail: med_modhospital@yahoo.com
Citation: Oshikoya KA. Response: Accidental Potassium Bromate Poisoning Causing Acute Renal Failure. Online J Health Allied 
Scs. 2009;8(3):19
URL: http://www.ojhas.org/issue31/2009-3-19.htm
Open Access Archives: http://cogprints.org/view/subjects/OJHAS.html and http://openmed.nic.in/view/subjects/ojhas.html
Submitted: Jul 3, 2009; Accepted: Jul 10, 2009 Published: Nov 15, 2009
Key Words: Potassium bromate, Poisoning
Response:
I have read with keen interest the case of accidental ingestion 
of  potassium  bromate  by  a  two  year  old  boy  reported 
by Adeleke and Asani.1 I sincerely congratulate them for their 
high index of suspicion of potassium bromate poisoning and 
for  successfully  managing  the  patient  amidst  inadequate 
facilities in Nigeria to manage such a case. However, I would 
like to raise a few points about the history and management of 
the patient.
Even though the body temperature was not reported, vomiting, 
diarrhoea,  abdominal  pains,  lethargy  and  hepato-
splenomegaly,  as  initially  presented  by  the  patient,  are 
symptoms  and  signs  of  malaria2 or  inflammatory 
gastroenteritis.3Perhaps  this  was  the  reason  for  the  initial 
diagnosis of acute diarrhoea with some dehydration made by 
the  authors.  The  degree  of  dehydration  of  the  patient  at 
presentation  was  not  reported,  however,  the  passage  of 
frequent and loose watery stools with weakness may indicate 
moderate  to  severe  dehydration.  Moderate  to  severe 
dehydration may result in acute renal failure.4
There is  a  high  possibility  of  the child  ingesting  potassium 
bromate  especially  when  the  mother  rinsed  his  mouth  with 
water. However, the quantity swallowed may be small and this 
may perhaps explain the  mild  symptoms  and signs  initially 
presented  by  the  child.  The  quantity  of  potassium  bromate 
ingested  by  children  from  previous  reports  was  very 
small5,6 compared to adults7,  8 and this have accounted for the 
relatively mild  symptoms  observed in  the children.  Hepato-
splenomegaly has not been reported in previous cases of acute 
potassium bromate  poisoning  but  this  may  be  caused  by  a 
massive  intravascular  haemolysis.  Massive  haemolysis  and 
thrombocytopenia  may  be  seen  in  children  with  bromate 
poisoning9 but  were  not  present  in  the  patient  reported  by 
Adeleke and Asani.1 However, mild haemolysis was reported 
as  evident  by  anaemia  (PCV-  28%).  Thus,  malaria  or 
inflammatory  gastroenteritis  may  explain  the  hepo-
splenomegaly  reported  in  the  patient.  It  might  have  been 
useful to do complete blood count, blood film morphology and 
malaria parasites study of the patient. Electrolyte and urea are 
very important in patients with moderate to severe dehydration 
which  should  have  served  as  early  pointers  to  acute  renal 
failure but unfortunately they were delayed until the 4th day of 
admission.
The  mechanism  of  bromate  toxicity  is  not  clearly 
understood9 but it has been proposed that renal failure could 
result from direct tubular toxicity due to induction of active 
oxygen  radicals10,  reduced renal  perfusion  from dehydration 
and  possibly  decreased  vasomotor  tone.7,11 Haemolytic 
anaemia  with  haemoglobinaemia  may  also  play  a 
role.12 Asymptomatic  phase  of  a  few  hours  may  follow 
bromate  poisoning  before  overt  renal  failure  develops  and 
anuria  is  usually  apparent  within  1-2  days  of  bromate 
ingestion11 similar to the onset of anuria in the patient reported 
by  Adeleke  and  Asani.1 Perhaps,  a  urethral  catheterisation 
would have been more appropriate to monitor urinary output 
rather  than  suprapubic  needle  aspiration  performed  by  the 
authors.
The authors have centred their discussion on the management 
of acute bromate poisoning with reference to animal studies 
which could  not  be extrapolated to  human and may not  be 
very relevant in the clinical management of the patient. The 
principles  of  management  of  acute  bromate  poisoning  are 
largely  empirical  and  supportive.  They  include  reducing 
bromate to less toxic bromide ion with specific antidotes. 10% 
sodium thiosulphate solution, 10- 50 ml (0.2- 1 ml/kg) i.v has 
been successfully used as a specific antidote in the treatment 
of  acute  bromate  poisoning  in  children.5-
7,11 Methaemoglobinaemia  may require the use of methylene 
blue.8 In the early stage, patient can be decontaminated with 
sodium bicarbonate (baking powder) to prevent formation of 
hydrobromic acid in the stomach9; it might have been worth a 
trial  in  this  patient.  Large  recent  bromate  ingestion  may 
require  gastric  lavage  with  a  2%  sodium  bicarbonate  or 
activated charcoal.9,12 Peritoneal dialysis was performed in the 
patient  not  only  to  reverse  the  renal  failure  but  to  enhance 
bromate ion elimination since bromates are primarily excreted 
renally.9
Tinnitus  and  irreversible  sensorineural  deafness  may 
complicate bromate poisoning and may be delayed for several 
days in children or may go unnoticed.9,11,12 Thus, audiometry at 
presentation  and  follow-up  was  very  important  in  the 
management of this patient. Polyneuropathy, characterised by 
severe burning pain to the leg, is an unusual symptom seen in 
bromate  poisoning  in  adult  and  may  present  very  late; 
1
This work is licensed under a Creative 
Commons Attribution-No Derivative Works 
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Online Journal of Health and Allied Sciences
Peer Reviewed, Open Access, Free Online Journal
Published Quarterly :  Mangalore, South India : ISSN 0972-5997
Volume 8, Issue 3; Jul-Sep 2009
although it may resolve spontaneously after a month.13 Thus, a 
neurological  examination  should  have  formed  part  of  the 
follow-up evaluation of this patient.
References:
1. Adeleke  SI,  Asani  MO.  Accidental  potassium 
bromate poisoning causing acute renal failure. On-
line J Health Allied Scs. 2009;8(1):11.
2. Bhutta  ZA.  Acute  gastroenteritis  in  children.  In: 
Kliegman RM, Behrman RE, Jenson HB, Stanton 
BF, eds. Nelson Textbook of Paediatrics. 18th ed. 
Philadelphia: Saunders Elsevier, 2007: 1065-1618.
3. Molyneux  ME. Malaria-  clinical  features  in  chil-
dren. J Royal Soc Med 1989;17(Suppl):35-38.
4. Ford  DM.  Fluid,  electrolyte,  and  acid-base  dis-
orders and therapy. In Hay WW, Levin MJ, Sond-
heimer JM, Deterding RR, eds. Current diagnosis 
and treatment in pediatrics. 18th ed. USA: McGraw-
Hill, 2007: 1274-1282.
5. Warshaw BL, Carter MC, Hymes LC, Bruner BS 
Rauber AP. Bromate poisoning from hair perman-
ent preparations. Pediatrics 1985;76:975-978.
6. Kearnery TE, Redetki HM, McElwee NE. Sodium 
bromate  poisoning  in  an  infant  who  ingested  a 
home  cold  wave  neutralizing  solution. Vet  Hum 
Toxicol 1986;28:482.
7. Matsumoto I, Morizono T, Paparella NM. Hearing 
loss  following  potassium  bromate:  two  case  re-
ports. Otolaryngol  Head  Neck  Surg 1980;88:625-
629.
8. Kutom  A,  Bazilinski  NG,  Magana  L,  Dunea  G. 
Bromate  intoxication:  hairdresser’s  anuria. Am  J 
Kidney Dis 1990;15:84-85.
9. Olson KR, Anderson IB, Benowitz NL, Blanc PD, 
Clark RF, Kearney TE, Osterloh JD. Poisoning and 
overdose.  5th ed.  USA.  Mc  Graw  Hill.  2006.  pp 
128-130
10. Kurokawa Y, Maekawa A, Takahashi M, Hayashi 
Y.  Toxicity  and  carcinogenecity  of  potassium 
bromate- a new renal carcinogen. Environ Health 
Perspect1990;87:309-335.
11. Gradus D, Rhoads M, Bergstrom LB, Jordan SC. 
Acute bromate poisoning associated with renal fail-
ure and deafness presenting as haemolytic uremic 
syndrome. Am J Nephrol 1984;4:188-191.
12. De  Vriese  A,  Vanholder  R,  Lameire  N.  Severe 
acute renal failure due to bromate intoxication: re-
port  of  a  case  and  discussion  of  management 
guidelines  based  on  a  review  of  the  literat-
ure. Nephrol Dial Transplant 1997;12:204-209.
13. Wang V, Lin K Tsai C, Kao K. Bromate intoxica-
tion  with  polyneuropathy. J  Neurol  Neurosurg 
Psychiatry 1995;58:516-517.
2


Accidental potassium bromate poisoning causing acute renal failure.

Acute bromate poisoning associated with renal failure and deafness presenting as haemolytic uremic syndrome.

Acute gastroenteritis in children. In:

Bromate intoxication with polyneuropathy.

Bromate intoxication: hairdresser’s anuria.

Bromate poisoning from hair permanent preparations. Pediatrics

electrolyte, and acid-base disorders and therapy. In

Hearing loss following potassium bromate: two case reports. Otolaryngol Head Neck Surg 1980;88:625-

Malaria- clinical features in children.

Severe acute renal failure due to bromate intoxication: report of a case and discussion of management guidelines based on a review of the literature.

Sodium bromate poisoning in an infant who ingested a home cold wave neutralizing solution. Vet Hum Toxicol 1986;28:482.

Toxicity and carcinogenecity of potassium bromate- a new renal carcinogen. Environ Health Perspect1990;87:309-335.

Response: Accidental Potassium Bromate Poisoning Causing Acute Renal Failure

Kazeem A. Oshikoya

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Response: Accidental Potassium Bromate Poisoning Causing Acute Renal Failure

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