PEANUT BUTTER AND FATAL FLUORIDE POISONING - A CASE OF MISTAKEN IDENTITY

We report here a case of an adult seeking a late night peanut butter snack who mistook for peanut butter a fluoride containing glass etching compound. The glass etching compound was of a color and consistency similar to peanut butter and was packaged in a similar appearing container. The decedent survived for six hours after the fluoride ingestion. He was admitted to the emergency room in stable condition with severe gastrointestinal symptoms. His condition deteriorated rapidly prior to death with abrupt cardiac arrest and profound hypocalcemia (5.5 mg/dl). Autopsy showed only gastric hyperemia and discoloration with a postmortem blood fluoride level of 19 mg/L.