- Can cause Vin-rose urine due to the treatment of iron toxicity with
- Iron overdose is one of the leading causes of death from toxicologic
agents in children younger than 6 years.
- Iron is most often available in ferrous sulfate tablets containing 20%
- Other formulations include ferrous gluconate with 12% elemental iron and
ferrous fumarate with 33% elemental iron.
- ingestions <20 mg/kg are often asymptomatic and do not require treatment.
- Doses of 20-60 mg/kg cause moderate symptoms.
- Ingestions of >60 mg/kg produce severe toxicity and are often lethal
- Serum iron levels should be measured at least 4 hours after the ingestion.
- Levels obtained more than 6 hours after ingestion may lead to an
underestimation of the toxicity because of the binding and redistribution of
- Mild-to-moderate toxicity generally manifests at levels of 350-500 mcg/dL.
- Hepatotoxicity is usually observed at levels >500 mcg/dL, and levels >800
mcg/dL are associated with severe toxicity.
- The clinical course of patients with iron toxicity is often described in 4
phases, though patients rarely progress through all of these stages.
- Phase I occurs within the first 6 hours of ingestion and is due to the
acute corrosive effects of iron. This phase is characterized by GI symptoms,
such as nausea, vomiting, and diarrhea, with hematemesis and hematochezia in
some patients. Blood loss accompanied by third-space effects leads to
hypotension and shock, with their concomitant risk of mortality.
- In phase II, patients often appear to improve, and their vital signs
normalize until approximately 12-48 hours after the ingestion.
- During phase III, patients often begin to have dramatic systemic effects,
including lethargy, coma, hypotension, anion-gap metabolic acidosis, acute
renal failure, and coagulopathy. Rarely, approximately 2-5 days after
ingestion, patients may have acute hepatic failure, a delayed complication of
phase III characterized by jaundice, encephalopathy, coagulopathy, elevated
transaminase levels, and hypoglycemia.
- Finally, phase IV leads to long-term complications from the corrosive
effects of iron on the intestinal mucosa. Scarring, stricture formation, and
gastric outlet obstruction are observed 2-6 weeks after ingestion.
- Although vomiting might be induced with syrup of ipecac if the ingestion
is known to have occurred within 2 hours of presentation, this modality of
decontamination, as well as gastric lavage and use of activated charcoal, is
Whole-bowel irrigation, and potentially surgery for refractory cases, should
be considered if iron tablets or a clump of iron is noted on plain
- The specific antidote for most moderate-to-severe cases is
deferoxamine, a chelator that
binds the ferric ion and promotes the elimination of iron by forming
ferrioxamine, a water-soluble compound that is excreted in the urine.
- Indications for its use are based on clinical and laboratory parameters
and include shock, altered mental status, persistent GI symptoms, metabolic
acidosis, iron pills visible on radiographs, serum iron level >500 mcg/dL, or
estimated dose >60 mg elemental iron per kilogram of body weight.
- Chelation therapy should be started if a serum iron level is not available
or if it is deemed unreliable and the patient has symptoms.
Vin rose urine
- Excretion of the deferoxamine-iron complex results in pink-red urine that
is classically called vin-rose urine.
- The urine collected in the tubes demonstrates progression of the color
change over 16 hours in the child in this case, who was treated with
intravenous deferoxamine 15 mg/kg/h given over this period.
- despite having toxic serum levels of iron, 30% of patients do not
demonstrate the classic vin-rose urine.
- Before deferoxamine treatment is started, one must obtain a baseline
urine sample for comparison. A change to pink-red is considered a positive
Endpoint for cessation of therapy
- is clinically significant resolution of the patient's shock and/or
acidosis (usually in 8-12 h and <24 h).
- is when the color of the patient's urine returns to normal.
- Prolonged treatment with deferoxamine has been associated with adult
respiratory distress syndrome, but this usually occurs only if the agent is
administrated for >24 hours.
- Therefore, consultation with a pharmacologist and a regional poison center
(see American Association of Poison Control Centers) are advised to obtain
- Patients should be observed for the recurrence of toxicity 2-3 hours after
deferoxamine therapy is stopped.
Clark K. Toxicity, iron. eMedicine Journal [serial online]. 2005. Available at:
Spanierman C. Toxicity, iron. eMedicine Journal [serial online]. 2005. Available