Correspondence

Bromoderma after Excessive Ingestion of Ruby Red Squirt

N Engl J Med 2003; 348:1932-1934May 8, 2003

Article

To the Editor:

We report a case of bromoderma from excessive ingestion of a soft drink. A 63-year-old man presented with a two-week history of tender, ulcerated, erythematous nodules on his hands and fingers (Figure 1Figure 1Ulcerated Erythematous Nodules on the Dorsal Aspect of the Hands and Fingers.). There was no history of recent travel or trauma. Skin biopsy revealed epidermal hyperplasia with sheets of intraepidermal and dermal neutrophils. Tissue culture was negative for microorganisms. The patient reported that he had been drinking 8 liters of Ruby Red Squirt daily for several months. This soft drink contains brominated vegetable oil. The patient's serum bromine level was 0.96 mg per deciliter (normal level, <0.5 mg per deciliter), and a diagnosis of bromoderma was made. Review of the patient's medications and additional history did not reveal other sources of bromine exposure. Because colchicine is thought to be antineutrophilic, treatment with colchicine was started. Discontinuation of consumption of the brominated soft drink and treatment with colchicine were followed by resolution of the skin lesions within four months. There was no recurrence after discontinuation of treatment with colchicine.

Bromoderma is a rare cutaneous hypersensitivity reaction to bromine exposure. Patients typically present with exudative plaques, fungating nodules, necrotic ulcers, and acneiform eruptions. Bromine intoxication can occur in 1 to 10 percent of exposed patients.1 Treatment includes avoidance of the source of bromine, wound care, and the administration of topical or systemic corticosteroids. To increase renal excretion of bromine, diuretics and sodium chloride can be used. Although our patient appeared to have a good response to colchicine treatment, we are unable to rule out spontaneous resolution due to the cessation of bromine ingestion.

Bromine intoxication from cola ingestion has been described,2 but we are unaware of other reports of bromoderma caused by soft-drink ingestion. Brominated vegetable oil is an emulsifier and flavor carrier commonly added to citrus-flavored drinks. Food and Drug Administration guidelines indicate that it cannot exceed a concentration of 15 ppm. Most reported cases of bromoderma have occurred after the ingestion of bromine-containing sedatives.3 Such sedatives are no longer available, but many bromine-containing medications are still available, including ipratropium bromide and dextromethorphan hydrobromide. Other reports of bromoderma cite the pesticide methyl bromide4 and a brominated pool disinfectant5 as sources of bromine exposure. Additional sources of bromine include flame retardants, photographic films and papers, and permanent hair-waving solution.

Debra M. Jih, M.D.
MetroHealth Medical Center, Cleveland, OH 44109
debbiejih@yahoo.com

Vikram Khanna, M.D.
Northwestern University Medical School, Chicago, IL 60611

Stephen C. Somach, M.D.
MetroHealth Medical Center, Cleveland, OH 44109

5 References

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Citing Articles (7)

Citing Articles

1. 1

   Paul Bendig, Lisa Maier, Walter Vetter. (2012) Brominated vegetable oil in soft drinks – an underrated source of human organobromine intake. Food Chemistry
   CrossRef

2. 2

   S. Perbet, M. Salavert, S. Amarger, J.- M. Constantin, M. D'Incan, J.- E. Bazin. (2011) Fluoroderma after exposure to sevoflurane. British Journal of Anaesthesia 107:1, 106-107
   CrossRef

3. 3

   Shin Nabatame, Yoshiaki Saito, Hiroshi Sakuma, Hirofumi Komaki, Eiji Nakagawa, Kenji Sugai, Masayuki Sasaki, Kentaro Uchiyama, Maki Kosaka. (2010) Bromoderma in a patient with migrating partial seizures in infancy. Epilepsy Research 91:2-3, 283-288
   CrossRef

4. 4

   Daniel M. Lugassy, Lewis S. Nelson. (2009) Case files of the medical toxicology fellowship at the New York City Poison Control: Bromism: Forgotten, but not gone. Journal of Medical Toxicology 5:3, 151-157
   CrossRef

5. 5

   Laura Maffeis, Maria Carmela Musolino, Stefano Cambiaghi. (2008) Single-plaque vegetating bromoderma. Journal of the American Academy of Dermatology 58:4, 682-684
   CrossRef

6. 6

   J. Hafiji, V. Majmudar, S. Mathews, A. Green, E. Rytina, N.P. Burrows. (2008) A case of bromoderma and bromism. British Journal of Dermatology 158:2, 427-429
   CrossRef

7. 7

   Angela Ehling, Sigrid Karrer, Frank Klebl, Andreas Schffler, Ulf Mller-Ladner. (2004) Therapeutic management of pyoderma gangrenosum. Arthritis & Rheumatism 50:10, 3076-3084
   CrossRef