If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Requests for reprints should be addressed to William J. Stone, MD, Department of Internal Medicine, Vanderbilt University, 1310 24th Ave. S, #111A, Nashville TN 37212-2637
Bromide salt is an effective antiepileptic and sedative in small doses and was once a common ingredient of many medicines and patent tonics such as Dr. Miles' Nervine and Bromo-Seltzer.
Unfortunately, the long 10-12 day half-life of bromide results in an intolerably narrow therapeutic window. Bromide toxicity or “bromism” accounted for over 2% of admissions to psychiatric hospitals before the removal of bromide salts from most US medications in 1975.
We report a case of bromide toxicity after the consumption of Dead Sea salt obtained over the Internet.
A 57-year-old man with Asperger syndrome presented complaining of diffuse pain and generalized malaise. Mentally, he was impaired, with disjointed thoughts, labile mood, and disorganized, slurred speech. He denied taking any over-the-counter or herbal medications, and his history was otherwise uninformative. A screening basic metabolic panel returned with a chloride level of “>175 mEq/L” (normal 95-110), yielding an anion gap of −55 mEq/L. To rule out laboratory error, a repeat basic metabolic panel was performed and confirmed the initial value. Such marked hyperchloremia prompted a measurement of the patient's serum bromide, which was found to be 2540 mg/L (32 mEq/L).
Upon further questioning, the patient reported consuming 3-4 tablespoons of Dead Sea salt daily for several months. He stated that he purchased the Dead Sea salt due to websites' claims of its holistic, calming effects and health benefits. The Dead Sea has the highest bromide concentration of any large body of water in the world, with a bromide concentration of approximately 5 g/L.
Our patient's bromide level was impressive by these criteria.
The most common manifestations of bromism are psychiatric and dermatologic. Patients present with weakness, slurred speech, emotional instability, agitation, hallucinations, seizures, and coma.
Bromoderma occurs in approximately 35% of cases and is characterized by acneiform eruptions or, less commonly, granulomatous plaques, ulcers, or bullae, usually on the face and trunk.
The finding of hyperchloremia was instrumental in establishing the diagnosis. On many laboratory assays, bromide causes a false hyperchloremia sufficient to yield a negative anion gap. Assays register an additional 3-4 mEq of Cl− per mEq of Br− due to the greater affinity of bromide for the silver or mercury species used in measuring chloride levels.
Bromism should be considered whenever new-onset psychiatric symptoms accompany an elevated chloride level, especially in the setting of a negative anion gap.
A case of bromism can be missed if hyperchloremia is dismissed as laboratory error.
Awareness of this diagnosis is important because the symptoms of bromism are usually completely reversible with cessation of bromide ingestion. Bromide is renally excreted, and its 10-12 day half-life can be shortened to <1 day with saline loading and diuresis.
Our patient was successfully treated with saline and furosemide over 5 days and discharged with improved mental status and the recommendation to avoid consuming Dead Sea salt. (Figure).
FigureElectrolyte concentrations over time. Patient's admission electrolytes on day 1 were: Na+ 144, K+ 3.6, Cl− 175, HCO3− 25, Ca2+ 8.3 (reported in mEq/L). The patient was seen several months earlier in outpatient appointment and as reflected in day −195, had normal chloride levels. Saline diuresis was initiated on day 2. Bromide and chloride levels over the next 5 days show a decrease in both values over time. Normal range of chloride and sodium levels are denoted by dashed blue (95-110 mEq) and red (135-145 mEq) lines, respectively. Toxic bromide levels are denoted by dashed black line (5 mEq).
Funding: There are no funding sources to disclose.
Conflict of Interest: The authors have no conflicts of interest to disclose. Ethics Committee approval was not required.
Authorship: Dr Brent R. Taylor and Dr Romina Sosa researched and wrote the article and are the medical student and resident who took care of the patient. Dr William J. Stone advised Dr Taylor and Dr Sosa during the writing of this manuscript and was the attending on the case.
00954-1&id=gr1.jpg){kind=link}