Sudden death and toxic metals following ingestion of a button battery

Excerpt

The rapidly fatal case of a 17-month-old girl who had accidentally ingested a button battery, as lucidly described in the ‘Case Report’ by Guinet et al. [1], is an important reminder that fatal outcome can occur by mechanical asphyxia due to considerable aspiration of blood into the airways, which resulted from esophageal perforation related to corrosion and dissolution of matrix alloy battery, with a diameter of 20 mm. The case report was comprehensive and detailed, and the authors presented excellent clinical photographs of case during the autopsy findings. However, we would like to make one remark. Throughout the case report, they state that no link exists between alterations in the levels of potentially toxic metals (lithium, chromium, manganese, and molybdenum) and the subsequent fatal episode. In particular, in the Discussion section, they wrote: “…their concentrations (14, 7.3, 43 and 4.6 μg/L, respectively) were non-toxic, they were nevertheless higher than usual levels for this type of biological sample: normal concentrations in whole blood are less than 1.4, 0.87, 13.3 and 0.77 μg/L for lithium, chromium, manganese and molybdenum, respectively.” [1]. It is difficult to accept the authors’ statement that a manganese level of 43 μg/L was “not-toxic” in association with the release of manganese derived from corrosion of alkaline button battery [1]. Instead, there is good evidence that a manganese concentration of 43 μg/L—in whole blood—is high enough to cause serious manganese-related adverse health effects, especially in infant and toddlers [2]. The value of whole-blood manganese [43 μg Mn per L], in the patient under discussion [1], was 4.3-fold the upper limit of normal range, which is 0.7–10 μg Mn per L [1]. In our view, the laboratory’s normal reference range for manganese in whole-blood 13.3 μg Mn per L, as reported by the authors, exceeds the recommended threshold value for manganese in humans [3]. We would like to draw attention to some findings suggesting that manganese is an essential transition metal for Streptococcus species and that elevated concentrations may affect the growth of more than a family of Streptococcus spp. [4‐6]. It is interesting to note that the child had a streptococcal infection [1]. …