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\begin{document}

\title{Magnesium sulfate poisoning treated with hemodialysis: a case report}



\author[1]{mahdieh miri}%
\author[2]{Farhad Esmailsorkh}%
\author[1]{ehsan farhadi}%
\author[3]{Mitra Rahimi}%
\affil[1]{Saveh University of Medical Sciences}%
\affil[2]{Shaheed Beheshti University of Medical Sciences}%
\affil[3]{Shahid Beheshti University of Medical Sciences}%


\vspace{-1em}



  
  \date{March 12, 2025}


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\sloppy


\textbf{Magnesium sulfate poisoning treated with hemodialysis: a case
report}

\textbf{INTRODUCTION}

Magnesium (Mg) is the fourth most plentiful mineral in the body, having
the role of cofactor for enzymatic reactions (1-3). The normal range of
Mg concertation of serum in humans is 1.8-2.3 (4). Magnesium sulfate is
the drug of choice for the prevention and treatment, and recurrence
management of convulsions in eclampsia and pre-eclampsia and it is an
FDA-approved indication in hypomagnesemia management (5-7). Considering
the elevated use of Mg in the management of different conditions, the
safety of therapy needs more research. However, electrocardiographic
(ECG) and electrophysiological outcomes of intravenous (IV) Mg injection
have been assessed in animal research (8). We report a case of Mg
Sulfate toxicity managed with hemodialysis, with clinical improvement
and hospital discharge.

\textbf{CASE REPORT}

Case history

A 50-year-old married woman after a family struggle was referred to
Shaheed Moddares Hospital in Save. Following the struggle, the patient
got extremely agitated and the emergency medical service (EMS) reached
and checked her blood sugar (BS) by finger and her BS was 65mg/dl, so
the EMS injected two vials of 50ml Mg Sulfate 50\% (25-gram of Mg
sulfate each) instead of Dextrose 50\% to the patient by mistake.
Immediately after the injection, the patient got flushed and then she
lost consciousness, so the EMS took her to the emergency ward of Shaheed
Moddares Hospital. At the entrance to the emergency ward before any
assessment, she became pulseless, and cardiac pulmonary resuscitation
(CPR) was initiated for 10 minutes and was intubated, and her pulse came
back, and then supportive care and diagnostic processes like hydration,
ECG, and laboratory tests initiated. The patient's companion mentioned
no past medical history or kidney disease and no drug or supplement for
usual consumption. On examination, the skin was flushed, no sweating,
pupils were symmetric and dilated, heart, lung, and intestine sounds
were normal, and the deep tendon reflexes (DTR) were hypoactive. Her
blood pressure was 100/70 mmHg and her pulse rate was 110 beats per
minute.

The primary laboratory test result was BS 484mg/dl, serum sodium 128
mEq/L, serum potassium 2.2 mEq/L, calcium 9.1mg/dl, phosphorus 3.2mg/dl,
magnesium 4.9mEq/L Urea 38 mg/dl, Creatinine 1.33 mg/dl, Aspartate
transaminase (AST) 85units/liter, Alanine transaminase (ALT)
107units/liter, Lactate dehydrogenase (LDH) 528units/liter, Troponin
qualitative negative, CK-MB 21 IU/L, venous blood gas was PH: 7.14 pco2:
46.2 mmHg hco3: 15.4 mmHg.

Differential diagnosis

Internal medicine and cardiology consultation were requested in the
emergency ward considering the laboratory result and ECG, which were
hypermagnesemia, hypokalemia, and hyponatremia. the ECG rhythm was
irregular (160 bpm), the P wave was flattered, ST-depression in V2-V6,
I, and II, and ST-elevation in aVR was obvious (image 1).

Image 1- ECG before hemodialysis\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

We considered acute coronary syndrome (ACS) as one of the potential
causes of ECG issues such as ST changes. However, as the patient did not
experience any chest pain or dyspnea and had no prior history of cardiac
symptoms or risk factors for ACS, we instead suspected hypermagnesemia
as the underlying cause for the ECG changes. Additionally, the patient's
family history did not indicate any coronary cardiac problems.

Treatment

The patient had no clinical changes, her Glasgow Coma scale (GCS) score
was 4/15. After receiving supportive care with intravenous isotonic
fluids and calcium gluconate to prevent cardiac complications, it was
decided to do hemodialysis for the patient. The decision to undergo
hemodialysis was based on Micromedex toxicology reference, which
recommends hemodialysis for severe magnesium toxicity. Then, after 4
hours of hemodialysis, serum Mg concentration became 3.1 mEq/L, calcium
6 mg/dl, and phosphorus 0.6 mg/dl, and her consciousness became better
with a GCS score of 7/15. The patient's condition significantly
improved, as evidenced by clinical observations, laboratory tests, and
ECG, after spending 24 hours in the intensive care unit (ICU) in
intubated condition. The day after, the patient was extubated, and she
had normal respiratory rate and O2 saturation (image 2) (table 1).

Image 2 -- ECG after hemodialysis\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Two doses of 10ml of calcium gluconate 10\% three times a day due to her
hypocalcemia, tab phosphate Sandoz 500mg three times a day due to her
hypophosphatemia, heparin 5000-unit ampules twice a day, ampule
pantoprazole 40 mg daily, and serum normal saline 0.9\% 2 liters daily
were given during ICU admission. After 4 days of admission, she was
discharged with a normal laboratory and clinical situation.

Table 1- laboratory result\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
\begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Time after admission/ Lab test\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Upon arrival\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
7 hour\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
9 hour\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
15 hour\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
21 hour\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
24 hour\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
48 hour\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
PH\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7.14\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7.21\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7.34\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7.36\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7.42\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
PCO2 (mmHg)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
46.2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
54.3\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
35.2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
42.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
33.2\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
HCO3 (mmHg)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
15.4\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
21.2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
18.7\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
23.5\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
22.5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Blood sugar(mg/dl)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
484\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
122\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
111\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
UREA (mg/dl)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
38\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
21\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
37\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
43\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Creatinine(mg/dl)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1.33\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1.04\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
1.01\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.87\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.93\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Magnesium(mEq/L)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4.9\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3.1\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2.4\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2.7\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2.5\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Calcium(mg/dl)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
9.1\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7.5\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
6.7\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7.9\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
7.9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Phosphorus(mg/dl)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3.2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
0.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2.2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2.1\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2.1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Sodium(mEq/L)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
128\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
137\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
141\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
142\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
140\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
142\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
138\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Potassium(mEq/L)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
2.2\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
3.1\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4.4\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
4\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
White blood count(103/mm\textsuperscript{3})\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
28.1\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
15.6\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
10.5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Hemoglobin(g/dl)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
12.5\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8.9\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
8.2\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Platelet(10\textsuperscript{3}/mm\textsuperscript{3})\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
166\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
131\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
110\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
AST (SGOT) (U/L)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
85\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
ALT (SGPT) (U/L)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
107\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Alkaline phosphatase (U/L)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
142\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Lactate dehydrogenase(U/L)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
526\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Creatine kinase(U/L)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
80\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Ck-mb (U/L)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
28\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Troponin(Qualitative)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
negative\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
Uric acid (mg/dl)\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
6.7\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.10\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{DISCUSSION}

Magnesium sulfate is frequently utilized to treat eclampsia and
pre-eclampsia during pregnancy as an anticonvulsant {[}9{]}. Magnesium
sulfate extensively influences heart, lung, and brain function
{[}10-12{]}. Predominantly hypermagnesemia occurs when renal function
decreases or a large quantity of magnesium is loaded {[}13,14{]}.
Clinical presentation of hypermagnesemia is associated with the serum
magnesium concentration. Nausea, vomiting, bradycardia, and hypotension
take place at the magnesium serum level of 4-7 mEq/L, moreover, loss of
deep tendon reflexes and increased QT interval duration take place at
the serum level of 8-10 mEq/L. Also, comatose, muscle paralysis,
complete AV block, and cardiac arrest take place at serum levels greater
than 12 mEq/L {[}15,16{]}.

The management of patients with hypermagnesemia would be needed to
eliminate magnesium through renal excretion by high-volume normal saline
infusion and loop diuretic consumption, Because of the specificity of
the loop diuretics which inhibits tubular reabsorption of magnesium in
the thick ascending part of Henle's loop. For patients with impaired
kidneys or who have the clinical symptoms of hypermagnesemia,
hemodialysis should be considered. In patients with symptoms of
hypermagnesemia, it should be managed with calcium to prevent the
neuromuscular and cardiovascular adverse effects of hypermagnesemia
{[}17{]}.

a large number of cases of hypermagnesemia were reported in Japan due to
magnesium oxide (MgO) prescription as a laxative in elderly patients
with constipation, most of whom had chronic kidney disease (CKD). In
addition, some of the cases had dementia or cerebrovascular events and
couldn't express their symptoms, and the magnesium serum concentration
was not examined. All of the cases were treated with fluid infusion
(normal saline) and diuretics except one case that was managed by
continuous hemodiafiltration (CHDF) and after 4 days died at the
hospital {[}18-23{]}.

In Akbar MIA \emph{et al's} study, they reported 19 Mg intoxication
patients in preeclampsia with severe features in women treated with
magnesium sulfate and it was significantly associated with prenatal
death and low Apgar score at 1 and 5 minutes. All of the Mg
intoxications were treated with calcium gluconate immediately in line
with Indonesian national protocol. 3 patients died, whereas, it was not
due to hypermagnesemia events {[}24{]}.

Another case was reported in 2021, a 34-year-old man reached the
emergency ward after he was found unresponsive in a restaurant, and an
empty bottle of magnesium supplement and ibuprofen was with him. He was
hypotensive and hypothermic. His serum magnesium concentration was 11.7
mEq/L. he was admitted to the intensive care unit and intubated and
intravenous calcium was initiated. Continuous renal replacement therapy
(CRRT) was started for him and serum magnesium level lowered. His
complications in the hospital were extensive. despite various
vasopressors utilized, he was in shock. Abdominal compartment syndrome
needed for bedside laparotomy, aspiration pneumonia, acute respiratory
distress, and disseminated intravascular coagulation (DIC) led to his
family's decision to transmit him to comfort care, and he died on the
4\textsuperscript{th} day {[}25{]}.

Our case was an iatrogenic and EMS mistake magnesium sulfate overdose
which was performed continuously for 4 hours of hemodialysis. calcium
gluconate was administrated to protect against cardiac complications.
After hemodialysis, the patients recovered and then extubated. during
treatment in the hospital, she showed hypocalcemia, hypophosphatemia,
and hypokalemia which were managed appropriately.

\textbf{CONCLUSION}

Mg serum concentration is not measured routinely in every country so
most patients come to the emergency ward due to their clinical symptoms.
Magnesium toxicity is an uncommon but life-threatening issue that
exhibits itself by clinical symptoms and changing consciousness levels.
Utilizing intensive procedures like hemodialysis can be effective and
save the patient's life.

\textbf{ETHICAL STATEMENT}

This study was conducted by the Declaration of Helsinki of the World
Medical Association for Experiments involving Humans.

\textbf{CONFLICT OF INTEREST}

The authors declare that they have no competing interests.

\textbf{FUNDING INFORMATION}

No funds, grants, or other support were received from any organization.

\textbf{CONSENT}

Written informed consent was obtained from the patient to publish this
report by the journal's patient consent policy.

\textbf{ACKNOWLEDGMENT}

The authors would like to thank the Toxicological Research Center of
Loqhman Hakim Hospital, Shaheed Beheshti University of Medical Science
for their assistance.

\textbf{AUTHOR CONTRIBUTIONS}

\textbf{Mahdie Miri:} Data curation, Project
administration.\textbf{Farhad Esmailsorkh:} Writing -- original draft,
Conceptualization, Investigation. \textbf{Ehsan Farhadi:} Data curation,
Project administration. \textbf{Mitra Rahimi:} Supervision, Writing --
review \& editing, Validation.

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