Akbar Ghaus Arisyagaf

S1 Pendidikan Dokter 2012 (011211133045)

Formalin : The Toxicity and Treatments

Formaldehyde is a toxic gas that have characteristic water soluble,colourless,and foul

smelling that could irritate the upper way of respiratory system.the term of Formalin is a clear
solution of formaldehyde in water.it is mainly used as tissue fixative of biological specimen,
disinfectant, and antiseptic.also, formalin at room temperature is crystal clear that have same
form as normal saline.so, it can be mistaken as normal saline.formalin can enter human body
through ingestion and inhalation.the clinical symptom of formalin intoxication are severe
abdominal pain, retching, development of seizures, hypotension and difficulty of breathing.
These clinical symptom is due to biochemical, physiological and pathological changes in human
body system. (Lian and Ngeow 2000)

In biochemical changes,the formalin intoxication have same end pathway as methanol

intoxication.methanol is metabolized to formic acid with formaldehyde as intermediate
metabolite in humans.ingested formaldehyde cause severe pathological changes in
gastrointestinal tract. also,formaldehyde is metabolized rapidly to formic acid that lead to
metabolic acidosis due to accumulation of formic acid metabolite. (Lian and Ngeow 2000)

In physiological changes,formalin effect may lead to hypovolemia,vasodilation,and act as

myocadiac deppresant if ingested of 50-100 cc formalin.the patient may end with acidosis,peptic
ulceration,and circulatory shock within two hours after the ingestion.hypovolemic shock,mainly
secondary to the hemorrhage of digestive tract,has been often reported.the myocardia defect due
to formalin is another complication noted.although,formalin has been reported as oxidizing agent
to red blood cells to cause intravascular hemolysis. (Lian and Ngeow 2000)

In pathological changes,the clinical course may be marked by profund of central nervous

system depression.the kidney may be in malfunctioning that lead to renal failure and anuria.the
gastrointestinal tract such as stomach and intestinum may suffer a corrosive damage.burns of
jejunum,ileum and part of sigmoid colon have been noted in autopsy.there may be another defect
such as mucosal necrosis of oesophagus,cardiac fibrosis,hepatosplenomegaly with jaundice and
congestion of liver parenchyma,and the lung may become fibrosed which lead to insufficiency in
respiratory and eventual acute respiratory distress syndrome.the subsequent of formalin
intoxication consist of multiple organ failure and death.the fatal dose of ingested formalin is
500-1000 millilitres. (Lian and Ngeow 2000)

In other cases and evidence,formalin and formaldehyde cause a lymphohematopoetic

malignancies and brain cancer. It is mostly occur in chemical industrial workers and embalmers
which exposed routinely to formaldehyde.mortality from myeloid leukemia increase significantly
with increasing number of years of embalming (P=.020) and with increasing of formaldehyde
exposure (P=.036).compared to subjects who performed fewer than 500 of embalming, mortality
due to myeloid leukemia was elevated among those who performed embalming for more 34
years (OR=3.9, 95% CI=1.2 to 12.5,P=.024),who performed more than 3068 embalmings
(OR=3.0, 95% CI=1.0 to 9.2,P=.057),and those whose estimated cumulative exposure of
formaldehyde exceeded 9253 parts per million-hours (OR= 3.1, 95% CI=1.0 to 9.6,
P=.047).thus,duration of embaliming and related to formaldehyde or formalin exposures were
connected statistically significantly increased risk of myelod leukemia. (Hauptmann et. al 2009)

Survey and investigation was conduct in december,31th 2000.5185 were

reported,including two from sino-nasal cancer,one from nasofaringeal cancer and the case of
lung cancers were increased in mortality among those who worked with formaldehyde
.however,the relatedness of formaldehyde to sino-nasal cancer and nasopharyngeal cancer remain
unconvincing.though,the best explanation of death in this survey is lung cancer. (Coggon,D
2009)

Based on united states environmental protection agency (EPA),the effect of formalin

basicly damage the eyes and throat that feel as burning sensation,nausea,and high difficulty of
breathing if exposed at certain levels (above 0.1 part per millions).high level concentration may
cause attacks in people with asthma.also,formalin could harm nose,skin rash,and induce severe
allergic responses. ((Lian and Ngeow 2000).

There arent antidote specificly to treat the formalin intoxication.general

recommendations for reducing absorption of formalin is to evacuate the exposed individuals
from contaminated area and removing contaminated clothing,if applicable.if eyes and skin are
contaminated,they should be flushed by adequate fresh water.since formalin is very
corrosive,vomiting after oral ingestion shouldt be induced.the contaminated stomach can be
diluted by milk or water by mouth if the patients is alert and responsive,otherwise gastric lavage
may be indicated.A bolus of charcoal and isotonic saline cathartic may also be useful.( C. K.
Pandey, A. Agarwal, A. baronia, N. Singh. 2000 )

Other treatment for formalin intoxication is dialysis due to accumulation of formic

acid.this kind of dialysis are haemodialysis,peritoneal dialysis,and haemofiltration.dialysis is a
method of removing formic acid from blood by difference of diffusion rate through
semipermeabel membrane.it is effective to removing formic acid from blood due to formalin
intoxication.one more sufficient treatment is consist infusion of N-acetylsysteine (NAC) in
combination with hemodialysis.formaldehyde forms an adduct with reduced glutathione (GSH)
forming S-hydroxy-metilglutathione which is substrat for Formaldehyde dehydrogenase.GSH is
lower in acute toxicity and formaldehyde could bind to another macromolecules leading to
cellular damage.the obvious treatment is to increase GSH levels,unfortunately GSH doesnt enter
hepatocytes.hence,the exchange is NAC as substitute of glutathione,since NAC is penetrate the
hepatocytes.GSH also act as antioxidant to bind reactive oxygen species which occur in
formaldehyde metabolism.moreover,formaldehyde can bind to GSH by giving NAC and reduced
the conversion of formaldehyde to formic acid.of course this treatment will reduce metabolic
acidosis. (Lian and Ngeow 2000)
Key Word:

toxicity

treatment

Formalin

Antioxidant

Antidote

cancer

biochemical

Search Engine:

www.google.com

Reference:

Lian C.B., Ngeow W.E. 2000. The Adverse Effect of Formalin:

A warning against mishandling. Annals of Dentistry. 1(7):1-3.
Available at: http://ejum.fsktm.um.edu.my/ArticleInformation.aspx?ArticleID=441. Accessed:
February, 5th 2014.

National Toxicology Program, Department of Health and Human Service. 2011. Formaldehyde.
Report on Carcinogens. 1(12):195-206. Available at:
http://ntp.niehs.nih.gov/ntp/roc/twelfth/profiles/formaldehyde.pdf. Accessed: February, 5th 2014.

Coggon, D. 2009. Essentials of epidemiology for toxicologists. General, Applied and Systems Toxicology.
1(1):1. Available at: http://eprints.soton.ac.uk/355607/ Accessed: February, 5th 2014.

C. K. Pandey, A. Agarwal, A. baronia, N. Singh. 2000. Toxicity of ingested formalin and its management.
sage journal. 19 (6):360-366. Available at: http://het.sagepub.com/content/19/6/360.abstract .
Accessed: February, 5th 2014.