Portal de Periódicos da CAPES

Ingestion of a dietary supplement resulting in selenium toxicity

2010; Elsevier BV; Volume: 63; Issue: 1 Linguagem: Inglês

10.1016/j.jaad.2009.03.045

1097-6787

Rafael E. Lopez, Alfred L. Knable, Joyti B. Burruss,

Selenium in Biological Systems

To the Editor: In April 2008, the US Food and Drug Administration warned consumers not to ingest certain flavors of the nutritional supplements "Total Body Formula" and "Total Body Mega Formula" because they contained more than 200 times the 200 μg of selenium indicated on the label.1Centers for Disease Control and Prevention. CDC alert on adverse effects associated with consuming "Total Body Formula" and "Total Body Mega Formula." April 14, 2008. Available at:http://www2a.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00274. Accessed June 27, 2008.Google Scholar, 2Total Body Essential Nutrition, Inc. Total Body Formula: supplement facts. Available at: http://www.totalbodyteam.com/product_info. Accessed October 26, 2008.Google Scholar Elevated levels of chromium were also discovered—up to 17 times the amount stated on the label. The distributor of the vitamins voluntarily recalled the products.3US Food and Drug Administration. FDA warns consumers about "Total Body Formula" and "Total Body Mega Formula." March 27, 2008. Available at: http://www.fda.gov/bbs/topics/NEWS/2008/NEW01812.html. Accessed June 27, 2008.Google Scholar We describe two patients who developed signs consistent with selenium poisoning after consuming the "Total Body Formula" dietary supplement. Patient 1 was a 45-year-old woman who presented with a 4-week history of a diffuse erythematous, pruritic, exfoliative eruption of the scalp with progressive hair loss. She reported discoloration of the nails, dizziness, fatigue, amenorrhea, and dental caries. The patient stated that the hair loss and scalp problems appeared 7 days after she began ingesting the "Total Body Formula" nutritional supplement. The patient did not associate the development of these medical problems with the supplement, and continued to consume the product for approximately 30 consecutive days, nearly completing a 0.95-L container. She presented to our clinic approximately 2 days after completing her last dose of the supplement. Selenium toxicity was not suspected until her following examination, approximately 25 days later. The physical examination revealed seborrhea-like scaling with some acneiform papules on the scalp. Hair loss was noted, with pulled hairs being predominantly in the anagen phase. Most of her fingernails possessed a grayish-white discoloration in transverse bands approximately 2- to 4-mm distal to the cuticle (Fig 1). Serum and urine levels analyzed for selenium 5 weeks after last ingestion of the product were within normal limits. A selenium hair test, performed 6 weeks after last dose of the supplement, revealed an elevated selenium level at 3.2 μg/g (reference range, 0.4-1.4 μg/g). Before the hair analysis, the ingredients of the shampoos the patient used during the previous 2 months were tested, and we determined that they contained no selenium sulfide. Pertinent demographic and clinical information about patient 2 is presented in Table 1. Figure 2 illustrates patient 2's diffuse alopecia. The clinical manifestations of selenium toxicity vary greatly, including cramping, nausea, vomiting, diarrhea, joint pain, and fatigue.4Centers for Disease Control and Prevention. Toxic levels of selenium in dietary supplements. April 17, 2008. Available at: http://emergency.cdc.gov/agent/selenium/supplements2008.asp. Accessed June 27, 2008.Google Scholar Additional possible symptoms include blistering skin lesions, nail changes, hair loss, and possible dental caries.4Centers for Disease Control and Prevention. Toxic levels of selenium in dietary supplements. April 17, 2008. Available at: http://emergency.cdc.gov/agent/selenium/supplements2008.asp. Accessed June 27, 2008.Google Scholar, 5Yang G.Q. Wang S.Z. Zhou R.H. Sun S.Z. Endemic selenium intoxication of humans in China.Am J Clin Nutr. 1983; 37: 872-881PubMed Scopus (630) Google ScholarTable 1Demographic and clinical information for patients 1 and 2Patient 1Patient 2Duration of ingestion1 month3.5 monthsClinical presentation45-year-old woman with a 4-week history of a diffuse erythematous, pruritic, exfoliative eruption of the scalp and hair loss; discoloration of nails, dizziness, fatigue, amenorrhea, and numerous dental carries; last dose of supplement just before presentation56-year-old woman with a 3-month history of hair loss; discoloration of nails, metatarsal cramping, fatigue, and malaise; last dose of the supplement just before presentationPhysical examinationScalp: patchy, seborrhea-like scaling with acneiform papules; hair: alopecia and pulled hairs of anagen phase; nails: most nails possessed a grayish-white discoloration in transverse bands 2 to 4 mm distal to the cuticleHair: diffuse alopecia and pulled hairs of anagen phase; nails: all nails had 3 mm of normal nail at the base but were distally thickened and yellow (nail changes were not noted until 49 days after initial presentation)Discovery of selenium toxicity25 days after the initial examination49 days after the initial examinationLaboratory valuesSerum and urine selenium levels were normal—tests were performed 5 weeks after last ingestion; selenium hair test: 3.2 μg/g (reference range, 0.4-1.4 μg/g)—performed 6 weeks after last ingestionSerum selenium: 166 μg/L (reference range, 110-160 μg/L)—performed 7 weeks after last ingestion; hair was unattainable for testingResolution of symptomsHair loss and nails began to improve 5 weeks after the last dose, and the majority of symptoms completely resolved 6 months after the last doseHair loss and nails began to improve 2 months after the last dose; hair and nail growth were completely normal 7 months after the last dose Open table in a new tab Although patient 1 exhibited numerous physical signs of selenium poisoning, her serum selenium and urine levels were normal, likely because the laboratory values were assessed 5 weeks after the last dose of the supplement. The element had therefore already been metabolized and excreted. However, a hair analysis did reveal significantly elevated selenium levels. There is no proven treatment for selenium poisoning. Symptoms associated with this condition as a rule gradually improve over time with supportive care.4Centers for Disease Control and Prevention. Toxic levels of selenium in dietary supplements. April 17, 2008. Available at: http://emergency.cdc.gov/agent/selenium/supplements2008.asp. Accessed June 27, 2008.Google Scholar Patient 1's hair loss and nail discoloration began to improve approximately 5 weeks after consuming her last dose of the product, and by 6 months later most of her symptoms had resolved. We report two cases of selenium toxicity that occurred after ingestion of the "Total Body Formula" dietary supplement.1Centers for Disease Control and Prevention. CDC alert on adverse effects associated with consuming "Total Body Formula" and "Total Body Mega Formula." April 14, 2008. Available at:http://www2a.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00274. Accessed June 27, 2008.Google Scholar Physicians should be familiar with the symptoms of selenium poisoning in order to recognize this diagnosis.