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Context. Bamboo shoots contain cyanogenic glycosides named taxiphyllin. Cyanide poisoning from cyanogenic glycosides commonly
occurs following ingestion. However, toxicity caused by inhalation of hydrogen cyanide gas (HCN) produced from pickled shoots has
never been reported. Objective. To describe cyanide poisoning in eight victims who were exposed to HCN produced in a well containing
pickling bamboo shoots. Materials and methods. Due to a series of botched rescue attempts, a total of eight patients entered into a
27 m3 well containing pickled bamboo shoots and immediately lost consciousness. After rescue, two patients developed cardiac arrest,
metabolic acidosis and died. Four other patients suffered metabolic acidosis, but recovered after supportive care. The remaining two
regained consciousness and recovered soon after the event. Ambient air study and cyanide content of bamboo shoots helped confirm the
diagnosis. Results. All patients had high anion gap metabolic acidosis with normal oxygenation. Blood cyanide levels ranged from 2.66
to 3.30 mcg/ml (taken after about 18 h of incident). Ambient air study (21 h after incident) revealed oxygen 20.9%, and sulfur dioxide
19.4 ppm. The instrument was unfortunately not equipped to detect HCN. A simulation study revealed HCN and sulfur dioxide in the
ambient air at 10 ppm and 7.5 ppm, respectively. Cyanide content in the bamboo shoots ranged from 39 to 434 mg/kg in the wet shoots.
Discussion. This series of patients developed sudden onset of alteration of consciousness and metabolic acidosis upon exposure, and
cyanide was confirmed in all victims. The simulation study confirmed the presence of HCN in the ambient air of the well containing
bamboo shoots. Conclusion. We have reported mass acute cyanide poisoning with two fatalities. The source of HCN was unusual as it was
produced from pickling bamboo shoot.
Keywords Metabolic; Heart; CNS/ Psychological
Introduction
Bamboo shoots are an ingredient of various popular traditional Thai and Asian cuisines. There are 30 kinds of bamboo
in Thailand, but the shoots of Dendrocalamus aspe, Bambusa
nutans, Bambusa mulfiplex, and Thyrsostachys siamensis are
commonly selected for food.1 The demand for consuming
bamboo shoots occurs year round, but shoots are harvested
only in the early rainy season in Thailand. Therefore, the Thai
people have developed various methods to preserve bamboo
shoots so that they are available for consumption year round.
One of the methods is salt pickling of sliced bamboo shoots.
In the past, pickling bamboo shoots was a home-based industry. The salt pickling process commences by taking fresh
bamboo shoots which are peeled and then sliced into small
thin pieces. The thin pieces are then washed and mixed with
salt and kept in closed containers for at least 30 days before
being ready to eat. Nowadays, demand is increasing and
hence pickled bamboo shoot production is carried out on an
industrial scale. Bamboo shoots are harvested from the forest
Received 23 April 2011; accepted 24 August 2011.
Case Series
Fig. 1. Chemical biotransformation of taxiphyllin in bamboo shoots to generate hydrogen cyanide during the preparation.
836
P. Sang-A-Gad et al.
Table 1. Summary of clinical features and clinical course of the eight patients.
Initial manifestation
at emergency room (1st Day)
2nd Day
3rd Day
29
Recovered
Discharged
20
Less agitated
Drowsy
26
Conscious
Recovered
Discharged
47
Died 13 hr after
admission
35
Able to wean
the respirator
Discharged
57
He was able
to wean the
ventilator
Discharged
30
Coma
Coma
Died 30 hr
after
admission
34
He regained consciousness
and was supported with a
mechanical ventilator.
He was able
to wean the
ventilator.
Discharged
4th Day
Discharged on
5th day
GCS, Glasgow Coma Scale; E, Best eye response; M, Best motor response; V, Best verbal response; E1, No eye open; E4, Eye open spontaneously; M1, No motor
response; V1, No verbal response; V5, Oriented; CPR, Cardiopulmonary resuscitation.
also normal. Both chest X-ray and ABG suggested that the
patients ventilation was not the major cause of the illness.
However, the ABG and electrolytes did show metabolic
acidosis with high anion gap. The elevated anion gap predicted the clinical course for the more severely ill patients.
Asphyxia and anoxia were included in the differential diagnosis. Metabolic acidosis did not resolve soon after oxygen
therapy, suggesting systemic asphyxia rather than simple
asphyxia. According to these lines of evidence, cyanide poisoning was suspected. Blood samples were collected from
29
20
3
4
26
47
5
6
7
35
57
30
34
Chest radiography
Normal
Pulmonary edema without
pleural effusion
Normal
Infiltration of both right
lower and upper lobes,
possible aspiration
pneumonitis
Normal
Normal
Basal lung infiltration with
plate atelectasis
Normal
pH
pCO2
(mmHg)
HCO3
(mEq/l)
pO2
(mmHg)
O2 sat.
(%)
Anion
gap**
Whole blood
cyanide level**
(mcg/ml)
C
VR
7.38
7.02
40
41
24
10
222
93
100
93
25.9
33.0
2.66
3.54
C
VR
7.36
7.11
47
36
26
11
186
263
99
100
22.3
30.0
2.93
NA
BR
BR
BR
7.48
7.29
7.24
20
21
39
15
10
16
393
386
180
100
100
99
28.7
33.8
30.4
2.80
3.15
3.30
BR
7.49
24
18
417
100
27.2
3.02
Mode of O2
delivery*
Environmental study
As soon as the incident occurred, the provincial Surveillance
and Rapid Response Team (SRRT) was notified and the team
immediately reached the scene for investigation on the same
day. They found that there were 10 concrete wells in the
factory. Each was 27 m3, 3x3x3 m in size and partially filled
with sliced bamboo shoots. These wells were in a poorly ventilated plant. Though all wells were equipped with exhaust fans,
they were turned off during the incident. The SRRT found that
the ambient air had a bitter odour and was irritative to noses
and eyes. The team came back with an air analysis instrument
21 h after the incident, and found that the odour was reduced.
The instrument found oxygen 20.9%, carbon dioxide 6 ppm,
sulfur dioxide (SO2) 19.4 ppm, but hydrogen sulfide (H2S) was
not found. Unfortunately, no instrument equipped to detect
HCN was available. The team tested the ambient air toxicity in
the well by putting a chick (Gallus gallus domesticus) into the
well (1.5 m down from the upper edge) and observed seizures
in the chick within 2 to 3 min.
The sliced bamboo shoots and pickling juice in the well
were collected for cyanide (CN) and sulfur dioxide determination. The determination of CN liberated from the bamboo
Fig. 2. Scatters plot between whole blood cyanide levels and anion gap of 7 patients (see colour version of this figure online).
Copyright Informa Healthcare USA, Inc. 2011
838
P. Sang-A-Gad et al.
Samples
Fresh, unprocessed bamboo shoots
Fresh sliced bamboo shoots
Sliced pickled bamboo shoots left over
for 1 night
Sliced pickled bamboo shoots left over
for 2 nights
266434
248299
39196
141
Discussion
When a group illness occurs, it suggests that the patients may
have been exposed to a causative agent such as a poison.
Table 4. Gas contents of the ambient air in the well at various
conditions.
Hydrogen
cyanide
(ppm)
Sulfur
dioxide
(ppm)
Oxygen
(%)
10
7.5
3.55
6.8
7.9
0.6
20.5
20.5
20.5
Acknowledgement
The authors wish to express sincere thanks to Professor
Amnuay Thithapandha and Dr. Frank J Gonzalez for their
help with the English editing of this article.
Declaration of interest
The authors have no conflicts of interests.
Copyright Informa Healthcare USA, Inc. 2011
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