Inorganic Arsenic Poisoning Following an Intentional Overdose of Realgar-Containing Niu Huang Jie Du Pian: a Case Report and Literature Review

Background: niu huang jie du pian (nhjdp) is a widely used realgar-containing chinese medicine remedy. most brands arecomposed of eight ingredients: niuhuang (calculus bovis), xionghuang (realgar), gypsum (calcium sulphate), dahuang (radix etrhizoma rhei), huangqin (radix scutellariae), jugeng (platycodon grandiflorum), bingpian (borneol), and gancao (radixglycyrrhizae uralensis, licorice root). most users are not aware that xionghuang (realgar) contains arsenic disulphide [as2s2].inorganic arsenic poisoning after therapeutic overdoses has been reported in chinese literature, but no report of acute, intentionaloverdose of nhjdp has been published. we report a case of intentional overdose of nhjdp leading to arsenic poisoning.case presentation: a 33-year-old woman ingested approximately 100 tablets of nhjdp bought over the counter, along with her usualantidepressants. she presented with somnolence, agitation, epigastric pain and repeated vomiting, compatible with clinical toxicitiesof nhjdp reported in chinese literature. at presentation, blood and spot urine arsenic levels were 440.9 and 7,495 nmol/l,respectively. the patient’s condition improved rapidly after admission and chelation therapy was not deemed to be necessary.discussion: despite the self-limiting clinical course, the high arsenic level in the patient’s blood and urine raises safety concernsregarding the use of nhjdp in the community. inconsistencies in the sales regulation of arsenic-containing products, and a lack ofproduct label warning regarding arsenic content, may potentiate inadvertent arsenic poisoning.conclusion: clinician should be aware of the possibility of inorganic arsenic poisoning when treating patients with overdose ofchinese medicine remedies that contain xionghuang (realgar). proper product labelling may help reduce inadvertent arsenic poisoning.