Attempted suicide with intravenous copper sulphate: a case report

Acute Copper Sulphate Poisoning (ACuSP) usually results from oral ingestion with suicidal purpose, rarely from parenteral exposure: only few cases of parenteral ACuSP have been reported. Case report: a 37-year-old man was admitted at ED three hours after an attempted suicide by self-injecting intravenously an unknown amount of a copper sulfate solution. The patient had a history of heroin and cocaine abuse. At the admission, he was conscious, GCS 15, T 36.5°C, RR 18 breaths/min, SpO2 96% on room air, BP 105/75 mmHg, HR 120 beats/min. He presented tremors and diffuse myalgia. Biochemical tests were normal. One day later, serum copper levels reached 263 μ/dL (normal range 70-140 μ/dL). On day 3, he was oriented and febrile (T 38°C). Physical examination revealed pallor, jaundice, brown to red urines, signs of extravasation by the antecubital area of both arms. He was complaining epigastric pain. Laboratory findings showed normochromic normocytic anaemia (Hb 7.40 g/dL) with signs of intravascular haemolysis, methaemoglobin 6.3% and rhabdomyolysis. The patient received fluids therapy, electrolyte correction, and 4 units of RBC transfusion. N-acetilcysteine (150 mg/Kg over 120 minutes + 300 mg/Kg/day) and D-penicillamine (30 mg/Kg/day per os) were started. Piperacillin/tazobactam and clindamycin were administered for peri-injection cellullitis. As critical condition was persisting, Therapeutic Plasma Exchange (TPE) was performed on day 5 and 6. On day 7 he was transferred to the ICU, then to the surgery unit for wounds toilet. On day 12 he was moved to the psychiatric unit, on day 13 D-penicillamine was discontinued due to increasing liver function tests. On day 32 he was discharged asymptomatic with normal laboratory values. ACuSP is uncommon and insidious. Clinical picture is mainly characterized by massive haemolysis associated with slight extracellular methaemoglobin. The management is symptomatic and supportive. Chelation therapy is safe and effective. Haemodialysis is indicated only in case of persistent renal failure. The TPE should be considered as an addictive measure.