Introduction

Iron poisoning frequently occurs in children, which can be accidental or deliberate. Overdose of iron-containing products can be fatal in children(1). Over the past ten years, parent education and healthcare have led to a dramatic reduction in iron poisoning, however, the poisoning continues. The first report as the most common cause of iron-poisoning was in the mid-twentieth century(2). Iron is an essential element for the functioning of the organs in the body, but in excess quantities causes the cytotoxic and lethal effects. It affects virtually all organ systems in the body(3). The only clinical indication of iron intake is the treatment or prevention of iron deficiency anemia. Iron deficiency is predominantly seen in people with an increased need for iron. These include premature infants, children of growing age, pregnant and lactating women, and chronic renal failure. inadequate absorption can lead to iron deficiency. The most common reason for Iron deficiency in adults is bleeding and losing blood(4). Treatment with oral iron should be continued for 3 to 6 months. This will not only correct the anemia but also restore the body's iron stores(5). There are various forms of iron salts. The most prevalent iron formulations in tablets are 325 mg Ferrous sulfate (which contains 65 mg of elemental iron), 300 mg ferrous gluconate (which contains 36 mg of elemental iron), and 100 mg ferrous fumarate (which contains 33 mg of elemental iron)(6). The toxic effects of iron in doses of less than 20 mg/kg of elemental iron do not exist. Ingestion of 20 mg/kg to 60 mg/kg results in moderate hazard and more than 60 mg/kg has severe toxicity(7,8).  The clinical symptoms of iron poisoning are based on five clinical stages. Stage 1 includes nausea, vomiting, abdominal pain, and bloody diarrhea. Vomiting is the most common clinical sign of acute iron poisoning. The absence of gastrointestinal symptoms within 30 minutes and 6 hours of ingestion indicates that the iron poisoning did not occur. Stage 2 or the latent phase may seem stable. It can be seen within 6 to 24 hours after the time of consumption. During this stage, gastrointestinal symptoms disappear and intoxication may distribute to other organs. Stage 3 or shock phase is characterized by intoxication symptoms of the body. Metabolic acidosis, coagulopathy, bleeding, and shock are symptoms of this stage that appears after 6-72 hours. The liver is the first organ to react to iron, which receives a large concentration of iron. As a result, stage 4 can lead to failure of the liver that occurs 12-96 hours later. Finally, at stage 5, gastric outlet obstruction and scarring of the gastrointestinal tract develop 2-8 weeks after intoxication due to a large amount of iron that amasses there(9–11). The treatment of iron poisoning includes supportive care measures, treated with whole bowel irrigation, orogastric lavage, and the use of deferoxamine (DFO)(12,13). Patients with iron levels over 800-1000 µg/dl, GI symptoms, use of deferoxamine, shock, coma, or metabolic acidosis, should be admitted to the hospital (14,15). In this study, the prevalence of iron poisoning was determined based on age, gender, the reason for use, hospitalization time, ICU admission, clinical signs, serum iron concentration, use of antidote, coincidence with other drugs, underlying medical conditions, mortality, and the relationship between these variables. Given the lack of studies in Khuzestan province, the main purpose of this study was to further investigate the risk and complications of iron poisoning.

2. Methods

The present study is a descriptive-analytic study based on hospital information that was conducted among the patients affected with iron poisoning admitted to Razi hospital (a referral medical setting for poisoning treatment in southwest Iran) during 2014-2017. Subjects suspected of iron poisoning were excluded from the target population. Finally, 52 cases of iron poisoning admitted to Ahvaz Razi Hospital, were investigated. After studying the case files of the study population, the checklist was completed based on age, gender, the reason of use, the need for the antidote, duration of hospitalization, required hospitalization in ICU, symptom onset, time of symptom onset, co-administration with other drugs, underlying disease, and mortality. The descriptive statistics methods including graphs, frequency distribution tables, measures of central tendency, and dispersion were used in order to analyze the data. The data were analyzed using the SPSS software, version 18.0 (SPSS, Inc., Chicago, IL, US). Continuous variables are expressed as mean±SD. All data were compared by one-way analysis followed by Tukey’s Post Hoc Test. Using the Chi-square test, the relationship between variables group was performed. Statistical significance was set at p <0.05.

3. Results

Table 1 indicates the demographic and clinical characteristics of persons with iron poisoning. All the target variables include gender, age group, the intention of poisoning, symptom after ingestion, ICU admission, time admit, use of deferoxamine, serum level of iron, underlying disease, use with other drugs, and mortality were reviewed. In this report, the number of iron-poisoned patients admitted to Razi Hospital from the beginning of 2014 to the end of 2017 was 52. Almost the majority of the subjects were female. Of the female patients, 5 were pregnant., The highest number of patients was reported in the age range of 15 to 25 years in people. As shown in table 2, gastrointestinal symptoms such as nausea and vomiting were the main clinical symptom in patients. Most of the symptom onset in patients appeared in the first 6 hours after poisoning. In all, 16 patients were admitted to ICU. Based on the results, among admitted patients due to poisoning with iron, the maximum duration of admission was 6-24 hours and the least amount was less than 6 hours. The serum iron level was not measured in 28 patients (53.8%) and was not included in the file. According to the study, serum iron level in most of the patients was 95-150 μg/dL. In this study population, there were underlying diseases included mental illness, thyroid disease, and diabetes. The results indicated that a large majority of patients attempted suicide by overdosing on drugs. In the examination of the coincidence of iron poisoning with other drugs: 13 patients (25%) took vitamin supplement, including folic acid, B12, etc. 8 patients (15.4%) took antidepressants, 6 patients (11.5%) antipsychotics, and 11 cases with other drugs such as acetaminophen, antibiotics, cardiovascular drugs, and cold tablets. 14 cases (26.9%) took only tablets of ferrous sulfate. Moreover, mortality was reported in one case, that was co-administered with other drugs (antidepressants). Based on the results, there were no significant differences between the two variables of age and cause of iron poisoning, age, and serum iron concentration, symptom onset and gender, symptom onset and time of symptom onset, duration of hospitalization and time of symptom onset, and serum iron concentration and time of symptom onset in patients. Based on the result of the evaluation, the p-value was greater than 0.05. Among the cases of the relationship between variables, significant differences found only between the time of symptom onset, and the use of antidote, the value of the p-value is 0.05. The results were reported in the following Tables 3.

4. Discussion

According to the results obtained from the study, the following can be deduced: The most common gender in the poisoning of iron is female (94.2%). In a study conducted in Loghman Hakim's hospital about adult poisoning, 62.7% of patients were female(16). In a study done by Scott Kroeker (17), 80% of the patients were female, which was consistent with the results of our study. In our research, 5 women patients (9.6%) were pregnant. According to a study by W Rayburn (18), the most commonly used drugs during pregnancy were analgesics (acetaminophen), vitamins, iron, antibiotics, and antihistamines, Which justifies the prevalence of pregnant mothers in this study. In our survey, suicide (96.2%) was the most common cause of iron poisoning. It would appear to be justifiable, due to the fact that the patients were all over the age of 15 years. The most affected age group was between 15-25 years old (69.2%). In a study in India, there was a significant outbreak of accidental poisoning with iron in the pre-school age group(19). In studies conducted in the United States, accidental iron poisoning in children under 6 years old is common(20), Which is in agreement with the results obtained in our study. The most common clinical symptom in this study was nausea and vomiting (50%). In a study done by PA Chyka and colleagues(21), the most common symptom was gastrointestinal symptoms (47.8%). 32.6% of patients had central nervous system changes, and 13% of patients had no symptoms. In our study, 69.3% of patients had gastrointestinal symptoms (diarrhea, abdominal pain, nausea, and vomiting). 21.2% had lethargy, headache, dizziness, and drowsiness. In a study conducted in Loghman Hakim Hospital (16), there was one case with a change in the level of consciousness(1.3%). Out of 78 cases with iron poisoning, 77 patients were alert and conscious. One patient was in the first stage of unconsciousness. The results of this experiment are consistent with the results of our study. In the current study, 5 patients (9.6%) received deferoxamine. In the study done by WF Westlin (22), out of 172 patients, only 4 patients received deferoxamine. Table 3 indicates that, of the 31 patients whose symptoms started less than 6 hours, only 5 patients (16.1%) received the antidote. Of the 21 patients whose symptoms began between 6-24 hours after the poisoning, none of whom had received the antidote. Considering that the value of the p-value is 0.05, there is a significant relationship between the two variables of time of symptom onset and the use of the antidote. This point is notable because all patients who received the antidote had symptom onset less than 6 hours. Clinically, these patients were well qualified to take deferoxamine. In our study, 16 patients (30.8%) were admitted to ICU. In a study, which was done in India among 21 children, 18 patients were admitted to PICU(23). Serum iron concentrations in our study did not measure in 28 patients (53.8%), so there is no record in the file. Serum iron level in 18 patients (34.6%) was between 95-150 μg/dL, 3 patients (5.8%) was between 151-300 μg/dL, and 3 patients (5.8%) had serum iron concentrations above 300 μg/dL. In a study by KK Burkhart and colleagues(24), 6 adults ingested 20 mg/kg of elemental iron. All 6 cases had symptomatic gastrointestinal toxicity. 4 patients needed IV fluids. The maximum serum iron concentration in these patients was 300 μg/dL 2-4 hours after the ingestion of iron. Other findings in this study (the symptoms of iron poisoning, underlying disease, and co-administration with other drugs) were not comparable due to the limited resources and lack of adequate information on iron poisoning in Iran. In the present study, the prevalence of iron poisoning has been examined in the Khuzestan region of southwestern Iran. Iron-drug interactions may occur in many cases. Most studies have been examined the mortality rates in children and few studies have been conducted on adult iron toxicity. One mortality was reported in our study, which had been simultaneous with antidepressants. From the available data, it can be concluded that adults have lower mortality rates than children. However, iron poisoning is more common in the young age group (96.2% suicides). Analysis of data significantly affects the community. Hence, further studies in psychological, social, and behavioral issues are needed for suicide prevention and obtain reliable prevalence rates.

Acknowledgments:

This research was supported by the Deputy of Research of Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.