Fatal corrosive ingestion: A study from South and South-East Delhi,India (2005

Abstract

The study presents a retrospective analysis of 64 cases of death resulting from ingestion of corrosive substances. The cases represented approximately 0.4% of all autopsies conducted and 13.6% of all fatal poisonings studied during the 10-year period from January 2005 to December 2014 at the Department of Forensic Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi. The data was analyzed with regard to age, sex, nature and source of corrosive substance used, survival period, cause and manner of death. Males (64.06%) outnumbered females (35.94%), with a male-to-female ratio of 1.78:1. The most common age group involved was 21–30 years (35.94%). Sulfuric acid (68.75%) presented as the most common corrosive substance ingested. Household cleaning substances (39.06%) were identified as a common source of such type of corrosive substance, but the exact source could not be identified in 56.26% of cases. In the majority of cases (46.88%) death was due to perforation peritonitis. Most of the victims (54.69%) succumbed to their injuries within a day of ingestion. In 87.5% of cases, the corrosive substance was consumed for suicidal purposes. A strict regulatory framework is required for the production, distribution, storage and use of corrosive substances. Preventive guidelines and creating awareness among the masses will go a long way towards curbing such unfortunate incidents.

Keywords

Fatal corrosive ingestion household cleaning substances sulfuric acid suicide

Introduction

A corrosive poison is one that corrodes and destroys the tissue by direct chemical action when it comes into contact with it.¹ The major classes of corrosives include acids (organic and inorganic), bases and dehydrating agents.² The corrosive injuries produced by acid are due to coagulation of protein, which causes denaturation of the tissue, while alkali produces liquefactive necrosis by desiccating the tissues.³ Ingestion and cutaneous contact are considered two well-known routes of exposure for such corrosives. When ingested, the corrosive substance has the potential to damage the entire gastrointestinal tract, ranging from minor injury to fulminant strictures, and eventually death. The severity of the corrosive injury also depends on a number of factors including pH, concentration, contact time, regional epidermal or mucosal properties, the physical form of the agent consumed and the manner of ingestion.^4,5 In India, there is dearth of research regarding fatal cases of corrosive poisoning. This study aimed to identify the autopsy characteristics in deaths due to corrosive substance ingestion, the nature of corrosives used and their sources, and to recommend preventive measures.

Materials and methods

The All India Institute of Medical Sciences (AIIMS) is a hospital where the medico-legal autopsies of South and South-East Delhi, India, are conducted, serving a population of 5 million. In India, two types of inquests (police and magistrate) are held. In the majority of cases, the police are the investigating officers. In unnatural and suspicious deaths, after a preliminary investigation a report is prepared regarding the apparent cause and manner of death, and postmortem examination is requested. The manner of death, i.e. accidental, suicidal, etc. is concluded by the investigating officer after thorough review of inquest papers, postmortem report and other investigation reports.

The present study was carried out on victims of corrosive ingestion brought to the Department of Forensic Medicine, AIIMS, Delhi. The cases include retrospective evaluation of autopsies from January 2005 to December 2014. The postmortem reports, available toxicology reports of viscera, inquest papers, and final opinion of the investigating officer in all cases were reviewed.

Results

The cause of death was established as “corrosive ingestion” in 64 cases amongst 470 fatal poisoning and a total of 15,746 autopsy cases. Males (64.06%) outnumbered females (35.94%), with a male-to-female ratio of 1.78:1 (Table 1). The most common age group involved was 21–30 years (35.94%), followed by older than 50 years (20.31%). Only a single case was reported in the age group of 0–10 years (Table 2). Suicidal ingestion (87.5%) was the most common manner of death followed by accidental ingestion (12.5%), with no case presenting in the homicidal category (Table 3). Household cleaning substances (39.06%) were the most common source of corrosive substance used, but the exact source of the corrosive remained uncertain in 56.26% of cases (Table 4). Sulfuric acid was the most common offending agent used, followed by phenol. Few cases were reported due to ingestion of hydrochloric acid, nitric acid and formic acid (Table 5). The survival period of the victims was divided into three categories. In 54.69% cases, death occurred within 1 day, 18.75% died between 1 day to 1 week following ingestion, and 26.56% survived more than a week (Table 6). In 67.2% cases, corrosive burn marks over the lips, angle of the mouth, teeth, oral mucosa, chin and anterior aspect of the chest were found (Figure 1). Perforation peritonitis (Figure 2) was the cause of death in 46.88% of cases; septicemia (20.31%), both perforation mediastinitis and peritonitis (18.75%), chemical pneumonitis (7.82%), acute renal failure (4.68%) and perforation mediastinitis (1.56%) (Figure 3) were other notable causes (Table 7).

Figure 1.

Corrosive burn marks over lips and peri-oral area.

Figure 2.

Perforation peritonitis.

Figure 3.

Mediastinitis due to esophageal perforation.

Table 1.

Sex distribution.

Sex	No. cases	(%)
Male	41	64.06
Female	23	35.94

Table 2.

Age distribution.

Age group (y)	No. cases	(%)
0–10	1	1.56
11–20	8	12.50
21–30	23	35.94
31–40	7	10.94
41–50	12	18.75
≥51	13	20.31

Table 3.

Manner of death.

Manner	No. cases	(%)
Suicidal	56	87.50
Accidental	8	12.50

Table 4.

Source of corrosive.

Source	No. cases	(%)
Household cleaning substances	25	39.06
Battery acid	2	3.12
Fly repellents	1	1.56
Not known	36	56.26

Table 5.

Nature of corrosive.

Nature	No. cases	(%)
Sulfuric acid	44	68.75
Phenol	10	15.63
Nitric acid	2	3.12
Hydrochloric acid	1	1.56
Formic acid	1	1.56
Not known	6	9.38

Table 6.

Survival period.

Survival period	No. cases	(%)
<1 day	35	54.69
1–7 days	12	18.75
>7 days	17	26.56

Table 7.

Cause of death.

Cause of death	No. cases	(%)
Perforation mediastinitis	1	1.56
Perforation peritonitis	30	46.88
Both perforation mediastinitis and peritonitis	12	18.75
Chemical pneumonitis	5	7.82
Septicemia	13	20.31
Acute renal failure	3	4.68

Discussion

Corrosive substance ingestion represents a major problem in clinical toxicology. A 2013 report from the American Center for Poisonings Control indicates that poisonings attributed to corrosive ingestion have maintained a steady incidence of about 8–9% over the years.⁶ However, a few fatal cases have been reported and the victims in such tragedies were mostly children. The epidemiological data on corrosive poisoning from various countries has been reported, but the cases for studies are limited to a few tertiary care institutions which cater to only serious cases, hence do not represent the actual burden of the problem.^7–14 According to NCRB India, 67,874 fatal poisoning cases were reported in the year 2013; however, no data is sub-classified under the ambit of corrosive poisonings.¹⁵ A few studies have been conducted, mainly highlighting therapeutic modalities used in patients, but large cohort studies regarding the incidence, fatalities and demographic profile of victims are lacking.^16–22 In our study, fatality due to corrosive poisoning represented approximately 0.4% of all autopsy cases and 13.6% of all fatal poisoning cases during the 10-year period.

In the present study, most (35.94%) victims were in the age group of 21–30 years. However, this was an autopsy-based retrospective study and only data from fatal cases was considered. Those victims who survived corrosive ingestion were not included in the study, hence the actual incidence of corrosive poisoning could not be determined. A study conducted in India at the National Poison Information Centre, New Delhi, revealed that the highest incidence of corrosive poisoning was found in the age group of 14–40 years.²³ Another study of victims of corrosive ingestion who were hospitalized and treated was conducted and suggested that the mean age of the patient was 32.9 years.²⁴ Corrosive poisonings are a serious socio-medical issue as they most commonly affect populations in their most productive period of life.

In our study, males (64.06%) outnumbered females (35.94%). This could be attributed to the higher rate of suicide among men in India. The result of the study is in accordance with a series of studies conducted in India which led to conclusion that males were affected more than females and that suicidal ideation was more common in the former category.^{16,18,19,22,23} A retrospective study conducted in Istanbul, Turkey, reported suicidal ingestion was more common in death due to corrosive ingestion, but in that study females outnumbered males.²⁵ Western data on predominately adult patients suggested that suicidal ingestion was more common in women, whereas accidental ingestion was more common among men.^{9,13,14,26,27}

In the present study, 87.5% of adult victims ingested the corrosive agent for the purpose of suicide, and the other 12.5% was due to accidental ingestion, including a 2-year-old child. In India, self-poisoning is the second most common cause of death for suicide, and insecticides are the most common modality. Corrosive ingestion is not an agent of choice for suicide; however, due to easy availability, it is used as suicidal agent. The process of death is agonizing and reflects a desperate and dire state of mind, bent upon terminating the agony of life which can no longer be borne. Accidental ingestion is also seen in adults when corrosives are stored in containers or bottles and may be mistaken as food, medicine and other consumables. Corrosive ingestion in infants, toddlers and young children are mostly accidental in nature, because this age group is inquisitive but unable to differentiate between edible liquids and toxic ones.²⁸ Fatality in accidental ingestion is not so high because the unintentional taker may spit out the corrosive immediately. We have not reported a single case of homicidal corrosive poisoning. Corrosives are generally pungent in taste and can have an immediate burning effect on the oral mucosa. The process of death is also violent. Hence, homicidal corrosive poisoning is rarely reported.

Ingestion of corrosive substances results in extensive damage to the mucosa of the respiratory and gastrointestinal tract. The eschar formed in acid ingestion helps to inhibit penetration into deeper muscle layers of the gastrointestinal tract. The esophagus is slightly alkaline, and the epithelium is resistant to acid, so esophageal burn occurs in only 6–20% of acid ingestion. In our study, fatal perforation of the esophagus resulting in mediastinitis occurred in 20.31% of cases. The antrum of the stomach is the most sensitive to acids.²⁹ Prolonged contact produces extensive coagulative necrosis of the mucosal epithelium and chronic inflammatory infiltrate and congestion in the sub-epithelium (Figure 4). The gross autopsy findings included corrosive burns of the oral cavity, with erosive digestion of the esophagus, complete digestion of the cardia and fundus of the stomach with perforation of the pylorus. External autopsy findings such as corrosive burn marks over lips, angle of the mouth, teeth, oral mucosa, chin and anterior aspect of the chest were found in 67.2% of cases, while internal findings such as erosion of esophageal, stomach, and intestinal mucosa were found in 100% of cases in the present study. The damage to the respiratory and gastrointestinal tract can cause the death of the patient acutely, or due to subsequent complications at a later date. In the case of ingestion of a corrosive substance, the cause of death may be esophageal or gastric perforation, extensive upper gastrointestinal bleeding from the ulceration site, acute renal failure, laryngeal spasm, chemical pneumonitis, septicemia or, in the long term, the production of strictures or carcinoma. Perforation of the stomach is usually seen within 24 hours of acid ingestion, and is a common internal autopsy finding when an adult has consumed large quantities of acid for suicidal purposes.³⁰ Ingestion of sulfuric acid invariably leads to death by rapid cardiovascular collapse or shock secondary to gastrointestinal tract rupture leading to chemical peritonitis.³¹ Perforation peritonitis (46.88%) was the leading cause of death in the present study. Perforation of the stomach was also reported in 47.8% cases in a retrospective study in Turkey. Research regarding mortality due to corrosive ingestion is lacking in India. Death due to aspiration pneumonia is rare, as the individual is conscious at the time of the incident, and if it occurs, the likelihood of death increases. ³² In the present study, in 7.82% cases death occurred due to chemical pneumonitis resulting from aspiration of the corrosive. Expensive diagnostic and therapeutic procedures in the management of corrosive poisoning, as well as a long duration of hospital stay, are considered as an economic burden to society. Data in the present study revealed that in 26.56% cases, the victim survived more than 1 week in hospital, while in 54.69% of cases the victim died within the first 24 hours.

Figure 4.

Microphotograph shows coagulative necrosis of mucosal epithelium and sub-epithelium shows mild chronic inflammatory infiltrate and congestion (H&E, 100×).

A recent study conducted in India also reported that the highest incidence of poisoning was due to household agents, which include corrosive substances.²⁴ The findings of the present study are consistent with this previous study. The growing number of cases of suicide by ingestion of household cleaning agents such as sulfuric acid and phenyl is due to the easy availability of these agents in the form of toilet cleaner in every modern Indian household. The type of corrosive agent most commonly implicated in poisoning varies from country to country. In our study, all cases were due to corrosive acid ingestion; the corrosive was sulfuric acid in 68.75% of cases, and the exact nature of the corrosive could not be ascertained in 9.38% of cases. It is one of the most common chemicals to cause corrosive burns in developing countries.¹ Indian data from different studies is consistent with our result that the majority of ingestions are due to acids, as compared with reports from developed countries showing that alkaline agents were more commonly involved in corrosive poisoning.^7–11,33,34 A report from the American Association of Poison Control Center in 2008 concluded that sodium hypochlorite was the most commonly implicated alkaline agent in corrosive poisoning, which includes bleaches followed by toilet bowl cleaners, drain cleaners and household disinfectants.³⁵ In our study, in 39.06% of cases the source of corrosive was found to be household cleaning substances, but in 56.26% cases the exact source of such substances was not known. Sulfuric acid is also utilized in storage batteries (battery acid) as an electrolyte; 3.2% of victims used battery acid to commit suicide, which is easily accessible to the general public in India.

In all corrosive poisoning cases except carbolic acid, stomach with contents, pieces of small intestine with contents, and parts of liver, kidney and corroded areas of skin should be preserved in rectified spirit for toxicological analysis. For histopathology, corroded skin, esophagus, stomach, intestines, liver, lung and kidney can be preserved. The clothes of the deceased must be preserved. During autopsy, the forensic pathologist can sustain corrosive burns at the site of contact and inhalational injuries due to fumes of some corrosives while handling such cases.² Hence precautionary measures, such as wearing protective gear, must be taken in all suspected cases.

Conclusion

Corrosive ingestion is an important and often neglected cause of morbidity and mortality in developing countries. In spite of being a hazardous chemical, sulfuric acid is freely available over the counter at many retail outlets in India. Hence, strict regulation of its sale is required. Reducing the concentration of household corrosive, especially toilet cleaner, to a level which is effective against microbial and less harmful to humans is an important remedial measure to prevent fatal poisoning. Accidental ingestion can also be prevented by creating awareness among parents of the importance of keeping household corrosives safely away from children. Household corrosive chemicals should not be stored in bottles used for food and drink, which would be helpful in reducing the incidence of accidental ingestion.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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Fatal corrosive ingestion: A study from South and South-East Delhi,India (2005–2014)

Abstract

Keywords

Introduction

Materials and methods

Results

Discussion

Conclusion

Footnotes

Declaration of conflicting interests

Funding

References