Bismuth-containing drugs are used in the treatment of Heliobacter-pylori-associated peptic ulcers (Pedersen et al, 2003).

Bismuth is normally in our environment. The normal daily intake in untreated people is 5 to 20 mcg/day (Hamilton et al, 1972, 1973; (Woolrich, 1973).

A "normal" background blood level in untreated subjects is 1 to 15 (+/-12) mcg/L (Conso et al, 1975; Dekker et al, 1986; pp 293-296).

"Normal" background urinary excretion of bismuth in non-treated subjects is 8.2 to 22 mcg/L (Conso et al, 1975; Dekker & Reisma, 1979).

One study of 6 patients who ingested 227 grams/day for 3 weeks showed no detectable blood levels 24 hours after cessation of therapy and no symptoms (Ericsson et al, 1980). Plasma levels of salicylate approximating those following an analgesic dose were found in 6 volunteers given a dose of an OTC product containing bismuth subsalicylate (Anon, 1980; Pickering et al, 1981).

A 45-year-old man with AIDS was found lethargic and dysarthric, with myoclonic jerks of his facial and axial muscles on the seventh day after beginning acyclovir and bismuth subsalicylate 5.2 to 9.4 grams daily in divided doses for treatment of severe diarrhea.

CASE REPORT: A 17-year-old girl presented to the emergency department with nausea, vomiting and anuria, 7 days after intentionally ingesting 25 tablets of 300 mg (7.5 g) bismuth subcitrate. Lab findings included: blood urea nitrogen (BUN) 71 mg/dL, serum creatinine 12.3 mg/dL, uric acid 8.5 mg/dL, serum glutamic-oxaloacetic transaminase (SGOT) 85 U/L and lactic dehydrogenase 2,371 U/L. Renal biopsy revealed signs of acute tubular necrosis in the proximal tubule epithelium. Hemodialysis was performed 6 times. The patient recovered and was discharged with normal BUN and creatinine levels (Sarikaya et al, 2002).

CASE REPORT: A 22-year-old woman developed renal failure and proximal tubular dysfunction (Fanconi's syndrome) after intentionally ingesting 5.4 grams of colloidal bismuth subcitrate. On presentation, the patient was oliguric (<500 mL/24 hours) progressing to anuria. Over the next 48 hours, laboratory data indicated serum creatinine and BUN levels of 7.8 mg/dL and 38.4 mg/dL, respectively. Treatment included intravenous chelation therapy with unithiol and 9 hemodialysis sessions. The patient gradually recovered with diuresis occurring 10 days post-admission, and serum creatinine levels continuously decreasing from hospital day 18. The patient's renal function normalized with no signs of tubular dysfunction on follow-up 6 and 12 weeks post-intoxication (Hruz et al, 2002).

CASE REPORT/CHILD: A 2-year-old boy developed acute renal failure after ingesting 28 tablets (8.4 g) of colloidal bismuth subcitrate. Two days post-ingestion, the patient was somnolent and lethargic and had developed oliguria (urine output 140 mL/day). Laboratory data revealed a plasma BUN concentration of 36 mg/dL and a serum creatinine concentration of 1.5 mg/dL. Despite administration of IV fluids and furosemide, urine output continued to decrease to 50 mL/day and his BUN and creatinine concentrations increased to a peak of 75 mg/dL and 4 mg/dL, respectively, by day 4. Peritoneal dialysis was initiated and continued for a total of 16 days (automated peritoneal dialysis for 6 days and daytime ambulatory peritoneal dialysis for 10 days), resulting in a decrease in BUN and serum creatinine concentrations of 14 mg/dL and 0.7 mg/dL, respectively. The patient continued to improve clinically and was discharged approximately 20 days post-ingestion (Islek et al, 2001).

Acute toxic symptoms have occurred with as little as 5.2 milligrams intramuscularly over 26 hours in a 21-month-old to 30 grams over 8 days in a 7.5-year-old. A summary of the onset of symptoms in a number of subacute cases ranged from 4 hours to 7 weeks (Gryboski & Gotoff, 1961).

CASE REPORT: A 16-year-old girl presented to the hospital with a 4- to 5-day history of nausea, vomiting, dizziness, and a 2-day history of oliguria. The patient had ingested 10 to 15 tablets of tripotassium dicitrato bismuthate (3 to 4.5 g) 1 week prior to presentation. Laboratory data, obtained at admission, revealed a BUN of 146 mg/dL and a serum creatinine of 17.9 mg/dL. A renal biopsy showed necrosis and prominent regeneration primarily in the proximal tubule epithelium and moderate cell infiltration in the interstitium, minimal edema, congestion, and narrowing of the Bowman's capsular space in the glomeruli, leading to a diagnosis of acute tubular necrosis. With supportive care, including hemodialysis, the patient gradually recovered (Akpolat et al, 1996).

TEEL-0: The threshold concentration below which most people will experience no adverse health effects.

TEEL-1: The airborne concentration (expressed as ppm [parts per million] or mg/m(3) [milligrams per cubic meter]) of a substance above which it is predicted that the general population, including susceptible individuals, could experience notable discomfort, irritation, or certain asymptomatic, nonsensory effects. However, these effects are not disabling and are transient and reversible upon cessation of exposure.

TEEL-2: The airborne concentration (expressed as ppm or mg/m(3)) of a substance above which it is predicted that the general population, including susceptible individuals, could experience irreversible or other serious, long-lasting, adverse health effects or an impaired ability to escape.

TEEL-3: The airborne concentration (expressed as ppm or mg/m(3)) of a substance above which it is predicted that the general population, including susceptible individuals, could experience life-threatening adverse health effects or death.