J Forensic Sci, 2019

doi: 10.1111/1556-4029.14017
CASE REPORT Available online at: onlinelibrary.wiley.com

TOXICOLOGY

Ping Lu,1 Ph.D.; Jin-Qi Ma,1 A.P.; Fan Li,1 M.D.; Guo-Hui Xu,1 M.M.; Wan Guo,1 Ph.D.; and
Hai-Mei Zhou,1 Ph.D.

A Fatal Case of Acute Arsenic Poisoning

ABSTRACT: This manuscript reported a case of fatal arsenic poisoning. A woman with schizophrenia took arsenic-containing “pills,” which
consisted of arsenic trioxide and realgar (arsenic (II) sulfide) and wrapped with gauze. The victim consumed 1.09 and 0.819 g arsenic on two
occasions, respectively, with the interval between the two doses of 3 days. The woman died on the sixth day after the first dose without any
treatment. In this case, pathological examination revealed fat degeneration of the liver rather than hepatomegaly, a rare finding in acute arsenic
poisoning. Arsenic in tissue samples was measured, the total arsenic and inorganic arsenic in blood, liver, and gastric wall was 10.2 lg/mL
(9.61 lg/mL), 23.1 lg/g (20.7 lg/g), and 32.3 lg/g (28.6 lg/g), respectively.

KEYWORDS: forensic science, forensic toxicology, arsenic trioxide, realgar, tissue concentration, fatality

Arsenic is one of the earliest frequently used poisons. Known
as the “king of poisons,” arsenic has been a common means of
homicide and suicide for centuries (1). In 1247, Song Ci recorded
the symptoms of arsenic poisoning in the book “Collected Cases
of Injustice Rectified” (2,3). However, arsenic is also one of the
oldest known drugs and has been used for medicinal purposes in
traditional Chinese and Western medicine for more than
2000 years (4). Studies have shown that arsenic trioxide has ther-
apeutic effects on cancer and acute promyelocytic leukemia (4,5).
Some traditional Chinese medicine preparations containing
arsenic as a raw material, such as “Niu Huang Jie Du Pian,” have
been proven safe for use in humans and are still in use, although
the dose and dosage form are strictly regulated (6,7). However,
in China, folk remedies containing arsenic are sometimes used to
treat miscellaneous diseases in remote areas or by persons with
little knowledge. Highly impure arsenic is often found at lethal
doses in these privately made preparations.
This article describes a case of acute poisoning in a woman
with schizophrenia after taking two large doses of arsenic-con-
taining “pills.” The woman survived for 6 days after taking the
pills, which contained two inorganic forms of arsenic, arsenic tri-
oxide, and realgar (arsenic (II) sulfide). Owing to vomiting and
diarrhea, and the poor solubility and low bioavailability of real-
gar, the time of death was delayed.
prescribed contained realgar, arsenic trioxide, and mung bean
flour and were wrapped with gauze into pills (~1 g per pill;
Fig. 1). According to the description of the illegal medical prac-
titioner, the proportion of the three components was approxi-
mately 1:1:1. According to her husband, the first dose of four
pills was taken between 5:00 and 6:00 PM. Approximately 10 h
later, the woman suffered from gastrointestinal symptoms such
as vomiting and diarrhea. On the third day after the first dose,
the woman took three more pills. Three days after the second
dose, the woman died.
Materials and Methods
Medical Records
One week of nausea, vomiting, and diarrhea, no urine output
for 2 days was the chief complaints at the time of admission.
Additionally, the patient had a 2–3-year documented history of
schizophrenia. After oral administration of the pills at her home,
the woman showed oral ulcerations, strawberry tongue, poor skin
elasticity, light coma, severe dehydration, and electrolyte distur-
bance. Electrocardiogram showed myocardial injury. The bio-
chemical indexes of liver and kidney were abnormal. The patient
was pronounced dead 2.5 h after admission.

Case Report Autopsy Findings

A 24-year-old female (155 cm tall) who had suffered with
schizophrenia for 2–3 years sought medical treatment from an
illegal medical practitioner in a nearby village. The drugs
1
School of Forensic Science, Henan University of Science and Technol-
ogy, Luoyang, 471023, China.
Corresponding author: Hai-Mei Zhou, Ph.D.
E-mail: lyzhouhm@haust.edu.cn
Received 28 Sept. 2018; and in revised form 18 Jan. 2019; accepted 18
Jan. 2019.
The postmortem interval between death and autopsy was esti-
mated to be approximately 94 h. No external injuries were pre-
sent at autopsy, and the body was mildly putrefied. The
postmortem examination revealed a small amount of thin reddish
fluid in the thoracic and abdominal cavities. Brown liquid was
found in the trachea and bronchi, and a small amount of thin
light yellow liquid was found in the pericardium. A
1.5 9 1.5 cm yellowish-brown area was found in the anterior
lobe of the left lung, and the outer surface and cut surface of the

© 2019 American Academy of Forensic Sciences 1

2 JOURNAL OF FORENSIC SCIENCES
FIG. 1––Arsenic-containing pills made by the illegal practitioner.
liver were an orange-yellow color. The gastric contents were
150 mL brown liquid and no bleeding in gastric mucosa.
Histological examination revealed myocardial edema, broken
cardiac muscle fibers, vasodilatation, submembrane adipose infil-
tration of the right ventricle, pulmonary vascular congestion,
some damaged alveolar septa, diffuse fatty degeneration and
autolysis of hepatocytes, anemia of the hepatic sinus, degenera-
tion and autolysis of renal tube epithelial cells, and brain and
meningeal edema. Vascular dilatation and anemia were found in
the heart, lung, liver, spleen, kidney, pancreas, brain, stomach,
and intestines. These results were consistent with high-dose
arsenic poisoning. Arsenic is known to directly damage and
dilate capillaries, causing plasma and red blood cells to exude
fluid, which leads to hydrothorax and celiac effusion, partial
organ hemorrhage, and tissue anemia (2).
Toxicological Analyses
Sample Collection—The remaining pills were obtained from
the home of the deceased, and the raw powder used to prepare
the pills was obtained from the home of the illegal practitioner.
The remaining pills were weighed separately. Specimens of liver
and gastric wall tissue were obtained, and the surfaces of the
specimens were immediately washed with normal saline and
wiped dry with clean gauze. Cardiac blood was collected using a
clean disposable syringe.
Chemicals—Standard solutions of arsenic (1000 lg/mL) were
purchased from the National Institute of Metrology (Beijing,
China) and diluted with distilled water to prepare 0–120 ng/mL
solutions for calibration curves. Other chemicals were of analyti-
cal reagent grade.
Measurement of Arsenic in Biological Samples—An analytical
method described by the National Standards of the People’s
Republic of China (GB/T 5009.11-2003) was followed. Briefly,
0.2 g of each organ or 0.2 mL blood was weighed separately
using an electronic analytical balance (Ohaus Discovery, Parsi-
mony, NJ, USA), placed in a container, and 4 mL of 6 mmol/L
hydrochloric acid was added and the container placed in a 60°C
water bath for 18 h. The extraction solution was filtered by absor-
bent cotton into a 10 mL volumetric flask after cooling, 1 mL
potassium iodide-thiourea and 3 drops of n-octanol were added
and diluted to scale with distilled water. The solution was prepared
for detecting inorganic arsenic in samples.
Additional samples prepared as above were digested with
4 mL HNO3 (65–68.5%) and 1 mL H2O2 (30%), respectively,
and decomposed using a WX-4000 microwave digestion instru-
ment (Preekem Scientific Instruments Co., Ltd., Shanghai,
China) with the following parameters: initial temperature of
150°C and initial pressure of 15 atm, increased to 180°C and
25 atm 4 min later, and maintained for 5 min. The clarified and
transparent solution obtained was placed into a 25 mL volumet-
ric flask, and 2 mL thiourea and ascorbic acid solution was
added. The solution was diluted with distilled water to scale and
prepared for the determination of total arsenic.
The solution of processed samples was introduced into an
AFS-8320 Atomic Fluorescence Spectrometer (Beijing Titan
Instruments Co., Ltd., Beijing, China) to measure the contents of
arsenic. The instrument detection conditions were as follows:
photomultiplier tube negative high pressure, 270 V; atomizer
height, 8 mm; lamp current, 60 mA; carrier gas flow rate,
300 mL/min; shielding gas flow rate, 800 mL/min; carrier, 5%
hydrochloric acid; reductant, 2% potassium hydroborate dis-
solved in 0.5% potassium hydroxide; measurement mode, fluo-
rescence intensity; reading mode, peak area.
Measurement of Arsenic in the Pills—Following GB/T
5009.11-2003 protocols, the powder in the pills was weighed,
dissolved in 10 mL 10% NaOH, mixed with 25 mL 6% H2SO4,
and diluted with distilled water to 100 mL. The contents of
arsenic in the pills were analyzed using spectrophotometric
methods with a silver-diethyldithiocarbamate (Ag-DDC) complex
on a TU-1901 double beam UV-VIS spectrophotometer (Beijing
Purkinje General Instrument Co., Ltd., Beijing, China). The
absorbance of the red-colored complex of arsenic and Ag-DDC
in chloroform was measured at 520 nm.
Screening for Alcohol and Volatile Drugs—Gastric wall,
blood, and liver tissues were tested for alcohols and other vola-
tile organics using a gas chromatography-mass spectrometry
(GC-MS) instrument (Agilent Technologies 6890 GC-5973
MSD, USA) in accordance with the relevant industry standards
of the Ministry of Public Security of China.
Results
No alcohol and other volatile organic compounds were
detected in the above biological samples by GC-MS.
The average weight of the pills was found to be
0.732  0.118 g (n = 9) per pill. The arsenic content of the pills
was 0.372 g/g. The deceased patient originally took four pills,
corresponding to 1.09 g arsenic. Three days later, the patient
took three additional pills, corresponding to 0.819 g arsenic.
The arsenic concentrations in the biological samples are
shown in Table 1. As shown in Table 1, the total content of
arsenic in the blood was lower than that in the liver or gastric
wall tissues, which is similar to the previous reports (5,8,9). In
acute ingestions of arsenic, gastric contents and gastric wall are
particularly high in arsenic concentrations. As ingestion in this
case took place approximately 3 days after the last known dos-
ing, expected concentrations in these specimen types would be
lower than a rapid fatality after administration. Nevertheless, the
arsenic concentration in gastric wall tissue was still relatively
high compared to the other specimens tested. Furthermore, the
proportion of inorganic arsenic to total arsenic in the three

TABLE 1––Arsenic concentrations in biological specimens and pills.
Arsenic concentration
Total arsenic Inorganic arsenic Inorganic
Sample (lg/g or lg/mL) (lg/g or lg/mL) arsenic/Total arsenic
Gastric wall 32.3 28.6 88.5%
Blood 10.2 9.61 94.2%
Liver 23.1 20.7 89.6%
tissues showed little difference, this may indicate that all the
arsenic determined in the tissues examined was almost entirely
inorganic arsenic, with the remainder most likely organic
metabolites.
Discussion
In this case study, the source of poisoning was clear, and the
vomiting, diarrhea, reduced urine output, lack of yellow color,
myocardial defects, abnormal liver and kidney functioning, and
other clinical symptoms were indicative of acute arsenic poison-
ing. It is worth noting that pathological examination revealed fat
degeneration of the liver rather than hepatomegaly, which is a
rare finding in acute arsenic poisoning, and a similar case has
been previous reported (9). Another noteworthy finding from
this case study was that, despite the high dose of ingested
arsenic, gastrointestinal symptoms did not appear until 10 h after
ingestion and not within 30 min as previously reported (9),
which may have contributed to the longer survival time.
The total amount of arsenic ingested by the deceased patient
was 1.91 mg, including 1.09 g in the first dose and 0.819 g in
the second dose. Each of these doses is much higher than the
known lethal dose (100–300 mg) (5,8). However, we found the
contents of arsenic in body tissues were within the range of fatal
concentration of arsenic (8.9–202 lg/g in liver and 0.16–41 lg/
mL in blood) (10).
The woman did not die immediately and survived for 6 days
without any treatment. This may be related to vomiting and diar-
rhea, but is more likely due to the low solubility of realgar in
LU ET AL. . ACUTE ARSENIC POISONING 3
the pill (6,11,12). And, in this case, the pill actually appears to
be material in a small gauze sack, which may account for
decreased bioavailability.
In this case, the victim took an illegally prepared compounded
product comprised of large amounts of arsenic trioxide and
arsenic (II) sulfide resulting in her death. The latter substance
has low solubility, thus mitigating its bioavailability. This case
demonstrates the differential absorption of arsenic and that cau-
tion must be taken in relating total arsenic ingestion versus
resulting tissue concentrations.
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