Correspondence

Aluminum Toxicity Due to Intravenous Injection of Boiled Methadone

N Engl J Med 2006; 354:1210-1211March 16, 2006

Article

To the Editor:

A 42-year-old man who was in rehabilitation for intravenous substance abuse presented with a three-month history of seizures and incoordination. Other symptoms included dysarthria, a hesitant pattern of speech, myoclonic jerks, postural tremor, emotional lability, and fluctuating short-term memory. On questioning he admitted that for four years he had been concentrating his methadone preparation, which was diluted with a grape-flavored drink, by heating it in an uncoated aluminum pot. He would then reconstitute the residue for intravenous injection. His serum aluminum level was 6650 nmol per liter (reference interval, <400). The patient reported that he did not use antacids, had had no occupational exposure to aluminum, and did not use the aluminum pot for cooking.

Chelation therapy with a continuous intravenous infusion of desferrioxamine was initiated at a rate of 50 mg per hour. Chelation was interrupted on several occasions because of renal dysfunction; however, renal function improved with supportive measures and adjustment of the continuous infusion rate (Figure 1Figure 1Relationship among the Patient's Creatinine Clearance Rate, Serum Aluminum Level, and Desferrioxamine Infusion Rate during the First Two Months of Hospitalization.). The infusion was maintained for seven months, followed by weekly intermittent intravenous desferrioxamine for another two months, at the end of which he refused further treatment. The serum aluminum level at this time was 2390 nmol per liter (a 64 percent reduction), and he was able to speak comprehensibly, write legibly, and walk with a walker.

Parenteral exposure to aluminum was first documented in patients undergoing hemodialysis who were exposed to dialysate derived from aluminum-treated water.1 Parenteral exposure can also occur through contaminated intravenous-feeding solutions.2 Concentrating an oral methadone solution by heating it and redissolving the residue allows the drug user to avoid injecting large volumes of fluid intravenously. We think that the citric acid in the methadone preparation reacted with the aluminum oxide of the pot, resulting in water-soluble aluminum species.3

Our patient demonstrated the characteristic encephalopathy of aluminum toxicity, first described by Alfrey et al. in 1976.4 Other manifestations include microcytic anemia, adynamic bone disease, and osteomalacia. Desferrioxamine is the only aluminum-chelating agent that is used routinely in patients undergoing dialysis. There is only one other reported case of treatment with desferrioxamine for hyperaluminemia without concurrent hemodialysis,5 probably because of the rarity of hyperaluminemia outside the setting of end-stage renal disease. On the basis of our experience with the use of desferrioxamine for iron chelation in patients with thalassemia, a protocol for aluminum chelation in a patient with preserved renal function was used with encouraging results.

We conclude that exposure to aluminum can occur through intravenous substance use. Desferrioxamine should be considered for the treatment of chronic aluminum toxicity in patients who are not undergoing hemodialysis.

Raymund L. Yong, M.D.
Daniel T. Holmes, M.D.
Gayatri M. Sreenivasan, M.D.
University of British Columbia, Vancouver, BC V5Z 4E3, Canada
raymund.yong@vch.ca

5 References

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Citing Articles (3)

Citing Articles

1. 1

   Guido Crisponi, Valeria M. Nurchi, Gavino Faa, Maurizio Remelli. (2011) Human diseases related to aluminium overload. Monatshefte für Chemie - Chemical Monthly 142:4, 331-340
   CrossRef

2. 2

   Robert A. Yokel, Clair L. Hicks, Rebecca L. Florence. (2008) Aluminum bioavailability from basic sodium aluminum phosphate, an approved food additive emulsifying agent, incorporated in cheese. Food and Chemical Toxicology 46:6, 2261-2266
   CrossRef

3. 3

   Christopher Exley, Usman Ahmed, Anthony Polwart, Roger N. Bloor. (2007) Elevated urinary aluminium in current and past users of illicit heroin. Addiction Biology 12:2, 197-199
   CrossRef