Fatal 3-Nitropropionic Acid Poisoning after Consuming Coconut Water

A 69-year old Caucasian man was admitted to Aarhus University Hospital, Aarhus, Denmark, in a state of reduced consciousness and Glasgow Coma Scale (GCS) score of 13-14.Approximately 4.5 hours before admission, the patient had consumed coconut water directly from a coconut using a straw.Because the water had a foul taste, he swallowed only a small amount.Afterward, he opened the nut and described to his wife that the interior was slimy and looked rotten.The coconut was preshaved, with visible endosperm (coconut meat) at the top for easy access to the carpels (holes) and the coconut water.A straw was included and used for puncturing the coconut at the time of consumption (Figure).Recommended storage was at 4°C-5°C in the refrigerator, but the coconut had been kept on the kitchen table for 1 month after purchase.Approximately 3 hours after drinking the coconut water, the patient developed sweating, nausea, and vomiting.Ambulance attendants found the patient in distress with pale and clammy skin, reduced mental state with confusion, dystonia, and poor balance but normal strength in the extremities.The patient was able to answer questions with delay and had no local neurologic deficits.At the emergency department, the patient's consciousness level descended to GCS 3. A computed tomography angiography of the cerebrum, thorax, abdomen, and pelvis was performed and showed no abnormalities.Blood pressure was 200/110 mm Hg; pupils were small and reactive to light.The physical exam, including the abdomen, was unremarkable.An electrocardiogram showed sinus tachycardia of 130 beats/min with new right bundle branch block, which had not been present on an electrocardiogram 7 months earlier.Body temperature was 37.5°C.Arterial blood gas analysis revealed metabolic acidosis with a pH of 7.29, PaCO 2 of 2.1 kPa (reference 9.6-13.7 kPa), base excess -18.3 mmol/L (reference -1.5 to -3.0 mmol/L), lactate level of 10.9 mmol/L (reference 0.5-2.5 mmol/L), and unremarkable strong ion difference.Elevated 3-hydroxybutyrate level of 2.2 mmol/L (reference <0.3 mmol/L) and slightly elevated blood glucose of 9.5 mmol/L (reference 4.2-7.8mmol/L) were found.Other initial blood samples were unremarkable.Carbon monoxide was not detected.The patient was brought to the intensive care unit 2 hours after his arrival at the hospital.At this point he had pronation and jerks of the forearms and calves and his body temperature had increased to 39.7°C.The patient was intubated and actively cooled to 37.5°C.Treatment for meningitis and encephalitis (penicillin, ceftriaxone, and acyclovir) was initiated and insulin was administered, keeping blood glucose at 5-10 mmol/L.Pinpoint pupils were noted; to rule out opioid intoxication, naloxone was administered, with no response.The patient had stable hemodynamics at the intensive care unit.High diuresis of <450 mL/hour was noticed.