Subject: reply- caruaru's main messages

Subject: Caruaru- a dialysis tragedy in Brazil


April 27, 1996

To All : In Caruaru, a city on the northeast of Brazil, state of 

Pernambuco, 126 pts. on HD were intoxicated, several weeks ago. 

Investigations suggested the cause to be Microcystin LR, a toxic product

from Microcystis sp. blue alga ( cyanobacteria ).  Yesterday, died the 43rd.    

patient, of toxic hepatitis.

Sad Clinical Facts :

        Apparently all pts. suffered a severe form of toxic hepatitis

        Pts. continued to die many weeks after stopping dialysing in the       

	original unit and after being removed to the state capital.

        The blue algae were found in the < dam > that serves water to the

	city. There are no reports of non-uremic persons suffering from this 



	Mycrocystin LR is a cyclic heptapeptide and a potent hepatotoxic.


	Anatoxin-a is another common toxin in blue algae, but it is neurotoxic.


	The dialysis unit in focus used deionization as water treatment.

        That region of Brazil is often under severe drought and many 

	hospitals have to rely on water brought by < tank-trucks >, as it was  

	the case here.  This water is treated in the truck with chlorine and   

	analysis of the water involved indeed showed large amounts of chlorine.


Hard Biological facts : 

        Cases of hepatotoxic poisoning have been found in < every corner of the 

	world > The toxin is released only if the cell breaks or becomes old 

	and leaky, mainly during . Substances added to water to      

	impede blooming causes death of cells and release of toxins.Microcystin

	has been implicated in liver cancer in some parts of China.These       

	hepatotoxins act in a time-scale, from hours to days, by inhibiting    

	protein phosphatases in the hepatocytes.

        Anatoxin-a is an alkaloid that mimics acetylcholine, binding and       

	opening the ion channel. It cannot however be deactivated by 

	acetylcholinesterase, so the ion channel remains open, the muscle cell 

	continues to contract until it fails from exhaustion. Anatoxin-a is the 

	only natural organophosphate known. (1)

        Removal of Microcystin LR and Anatoxin-a can be difficult : 

	Chlorination is not recommended since it does not removes Ana-a and is 

	efective against Microcystin only at low pH or long residence times in 

	water systems ( over 22 Hrs. ) if pH is 7-9. 

        Other ways of removing it are: GAC and PAC ( ?? ), ozonization, 

	potassium permanganate and high dose UV-irradiation.(2)

        Microcystin has been found, for instance, in the water supply of major 

	cities such as Winnipeg, Canada. Removal of Microcystin can be 

	achieved with activated charcoal.(3)   

Questions and comments :


        Given the ubiquitous presence of these algae, we can expect other      

	catastrophic intoxications in the future, mainly in cities where water 

	treatment is poor or the water used comes from dams or .

        I could not found refs. to reverse osmosis x toxins. Ref # 2 

	mentions  as effective for Microcystin but not for     



        One can argue that chlorination in Caruaru was not effective due to pH 

	problems, and the charcoal ( activated ? ) in the filters either could

	not impede passage or became saturated. Another possibility is that    

	algae died in the sand-charcoal trap, releasing enormous amounts of    

	toxin, directly into the reservoir.

From all the above, it would be interesting if Nephrol pursue this issue       

further, consulting experts ( maybe Kim could contact site # 3, since it states 

< Health Canada will recommend guidelines for M-LR next meeting of             

Federal-Provincial Subcommitte on Drinking Water > ) to find out how can we    

impede another tragedy, not only in Brazil, but all over the world.

jose roberto c. rocha



 3- Philip Orr comments - Caruaru

DR. CARMICHAEL'S FIRST REPLY ( APRIL 4, 1996 ) Dr Rocha, Below is a reply sent to me from Prof Wayne Carmichael reagrding the matter. >Ben: Since we are involved in the analysis of microcystins for the human >poisonings in Caruraru, Brazil i can provide some clarification as we >currently understand it: >1) Most of the details as Dr. Daugiradas provides it are correct. HD patients >suffered most because they received the water i.v. While there are other >reports of gastroenteritis from persons using the water for drinking non >of these persons report acute toxicity or are they hospitalized. >2) Initial reports using HPLC did find microcystin in the water source and >in the clinics (there are two involved) including the carbon filters for >the inhouse water system. The reference to microcystin-LR is due to the fact >that it was the only standard available and hence by co-elution on HPLC was >the toxin identified--others are certainly present as well. >3) Our analysis of liver and serum from persons who had died and/or been >hospitalized (only serum from patients still alive) using ELISA and PPIA >confirm microcystins at levels which we associate with acute or lethal >toxicites. >4) Much remains to be done however. Since the source water couold have other >toxic orgainics including pesticides it is to soon to conlude that microcystins >were the prime toxins involved. Since we have not data base of human symptoms >we cannot make direct comparisons with the symptoms found in these patients >and microcystin acute/lethal symptoms. Therefore at this point we can sa= y >microcysins are present and are certainly a factor but perhaps not the main >factor. Both our lab, CDC in Atlanta and the Brazilian labs are still >analyzing. If it is microcystin that is the prime toxin involved it will >be a first-a very significant first. > >Wayne Carmichael >Professor >Dept. Biol. Sci. >Wright State Univ. >Dayton, Ohio 45435

PHILIP ORR'S COMMENTS ( APRIL 30, 1996 ): The original post is both tragic and potentially very significant. If microcystin is shown rather than just implicated it will be the first confirmed human fatalites from microcystin poisoning. >Comments:- Was microcystin actually measured in the water or just implicated? Were Post Mortems carried out on the victims to determine if liver breakdown and internal haemhorraging had occurred? If microcystinis the cause, it is likely that the chlorination process killed the cells, releasing the toxins into the water. Chlorination may have not been sufficiently strong to deactivate the toxin (oxidation of the diene in the ADDA residue). If the dialysis did not size exclude microcystin, then direct entry into the bloodstream would almost certainly enhance its uptake into the liver compared to its normal route through ingestion via the bile transport pathway. Microcystin has accute (death by liver damage) and chronic (as a tumor promoter but NOT a carcinogen) effects. Accute effects occur at much higher dose levels. The chronic effects are observed through exposure to very low doses for lengthy periods of time. In Australia, safe recommeded levels of microcystin-LR in drinking water is 1nM (~1=microg/L). Microcystin-LR has a mouse I.P. injection LD100 of 50-60=microg/kg. ------------------------------------------------------------------------- Philip Orr E-mail CSIRO Division of Water Resources, FINGER for PGP Public Key Locked Bag No3. Phone +61 69 62 5604 (Home) Griffith NSW 2680 Phone +61 69 60 1555 (Work) Australia FAX +61 69 60 1600 (Work) TALK *** There is no greater fury than a vested *** *** interest masquerading as a moral principle *** (C) Copyright 1996. -------------------------------------------------------------------------

FALCONER,HUMPAGE'S COMMENTS ( MAY 1, 1996 ) Comments on the deaths of dialysis patients in Brazil reported by Dr. Jose Roberto Rocha. This case shows a similarity to the report from Dr. Filomena Araujo of Evora, Portugal, on deaths of dialysis patients in which the water supply to the unit was drawn from a river heavily contaminated with Microcystis aeruginosa. A perfectly functioning reverse osmosis filter will not allow microcysins to cross, however filter defects happen. The alkaloid toxins from cyanobacteria are more likely to cross the filter than the cyclic peptides. Activated carbon filters become saturated. Adding chlorine to a water tanker of cyanobacterial bloom can be expected to liberate toxins very effectively into the water. A number of questions can usefully be answered before any conclusions are possible: - What species of cyanobacterium was present? - Was it toxic? - Were any samples taken for chemical or other toxin tests? - Was the remaining renal function of the patients further damaged? - Was the post mortem histopathology of the liver examined? If we can be of any assistance, we can easily be contacted at the following email address: Ian Falconer, Andrew Humpage. Dept. of Clinical and Experimental Pharmacology, University of Adelaide Medical School, Australia.

PROF. CARMICHAEL'S 2ND REPLY (MAY 2, 1996 ) Dear Dr. Carmichael : Last saturday I posted on Nephrol ( a Net list for nephrologist )the Caruaru tragedy, mainly to inform all colleagues of what happened and to collect impressions and suggestions to avoid further tragedies in the dialysis community. Dr. Daugirdas then promplty forwarded my message to Mr Long who in turn informed you and also kindly sent me some informations on microcystins as well as your address. Mr Long now forwards me your message on the studies you are doing on Caruaru pts. and I would like to request your permission to post your response to Nephrol. ********** While much is still unknown -you have my permission to post the summary of my response. I Will be in Brazil next week and hopefully have more information upon my return. We nephrologist are both scared and curious about microcystins, a subject we literally know nothing. We became painfully aware of these cyanobacterias only after Caruaru. Many dialysis units exist around the world where water could well be contaminated by cyanobact and we don't really know what to do to avoid intoxications. As you point out in your poster, this may well be the first known severe intoxication in man, and possibly only the first one.... We need your help to dismiss our fears, and at this moment I would like to ask you some of the questions that go thru my mind : *********** Many of the following questions are answered in a resource manual that I helped publish by the American Water works Research Foundation- titled--"Cyanobacterial (blue-green algal) Toxins: A resource Guide". 1995---American Water Works Association--Denver, Colorado--contact Ann Scarritt--telephone:(303)794-7711----FAX(303)730-0851. *********** - Are microcystins a contaminant of treated city waters? - The usual treatment of municipal water is enough to kill the bacteria or to neutralize the toxin ? - Charcoal-sand ( deionization ) filters utilized in thousands of dialysis units around the world are safe enough if there is no massive contamination ? - Does reverse osmosis treatment impede the passage of the toxins ? - Is culturing and identification of the organism a very difficult technique ? - Pts. on dialysis often show unexplained alterations in liver enzymes, that cannot be attributed to known viruses. Could this be the result of chronic, low level microcystin intoxication ? As you can see, we have so many questions that I feel somewhat ashamed of my ignorance. Unfortunately, however, this is now another important point to be clarified, for the safety of our pts. and we all would like to have your opinions on this matter. Again, if you agree, I would like to spread your comments to the nephrology community. Thank you very much jose roberto c. rocha,md *****I hope this helps--Wayne Carmichael, Professor.

SECOND MESSAGE May 4 1996 FROM JRCRocha To all : After my message on "Caruaru, a dialysis tragedy" I received several private mails, besides the ones posted here. I'll try to summarize things for you. Many thanks to Drs. Solez and Daugirdas and to Mr. Ben Long who helped a lot : 1- The 3 doctors who owned the unit were indicted by the state gov. for . 2- A parlament comission indicated the doctors, the state health and the municipal health secretaries as responsible for the events. 3- The message was posted at a CYANO-TOX discussion group (htt:/ ) 4- Philip Orr, Div. of Water Resources, Au wanted to know if microcystins were really involved. If so 5- Prof. Wayne Carmichael, Dayton, Ohio (Biol. Sc.) is actually studying this tragedy.He authorized me to post this : < HPLC did find microcystin in the water source and the in the clinics, including the carbon filter....Other microcystins, besides LR are certainly involved... Analys is of liver and serum from pts. ( dead or alive ) with ELISA and PPIA confirm micro at levels we associate with acute or lethal toxicities...It is too soon to conclude Micro were the prime toxins since the water could have others...including pesticides. Our lab, CDC and brazilian labs are working on it... If microcystin is the prime toxin, it will be a first- a very significant first... > 6- From Adelaide Med. School, Falconer and Humpage comment: < similarity with report from Dr. Filomena Araujo, Evora, Portugal, on deaths of HD pts. in wich water supply to the unit, from a river, was heavily contaminated with Microcystis aeruginosa... A perfectly functioning RO filter will not allow Micro to cross, however filter defects happens...Activated carbon filters become saturated. Adding chlorine to water tanker of cyanobact. bloom can be expected to liberate toxins very effectively into the water.> 7- Dr. Carmichael will be back in Brasil next week to look for more answers.

Those that wish to have the full text of any of these messages please feel free to contact me ( ) Do you feel this should be posted further or should we stop here ??