Introduction: 2,4-Dinitrophenol (DNP) is a mitochondrial oxidative phosphorylation uncoupler, once marketed for weight loss but banned due to a narrow therapeutic index and high fatality risk. Toxicity manifests as severe hyperthermia, metabolic acidosis, multiorgan failure, disseminated intravascular coagulation, and rapid death. Despite prohibition, unregulated online sales have led to rising overdoses, often in bodybuilders. Reported survival from intentional lethal doses is extremely rare. Description: A 20-year-old male ingested 6 g of DNP over two days (~75 mg/kg/day) with suicidal intent, presenting 7 hours after the last dose. Initial vitals showed normothermia and tachycardia. Anticipating rapid deterioration, he was intubated promptly and the team initiated active cooling before hyperthermia onset. He paralysed, and commenced on high-minute ventilation (18–20 L/min) to manage severe CO2 production, noting an end-tidal CO2 peak of 114mmHg. Cooling methods included cold intravenous fluids, fanning, Arctic Sun™ pads, and ice-packed high-flux continuous veno-venous haemodiafiltration (CVVHDF) initiated within 3 hours. Peak temperature was 39.9 °C, reduced to normothermia within 4 h of CVVHDF commencement. Vasopressors were weaned by day 2; CVVHDF ceased at 48 hours. Extubated on day 5, he recovered without irreversible organ injury and was discharged to the ward on day 8 with mental health follow-up. Discussion: This case represents, to our knowledge, the first modern survival from a deliberate DNP ingestion exceeding twice the previously reported highest survivable dose. Survival was attributed to rapid recognition, pre-emptive initiation of aggressive multimodal cooling, and high-volume ventilation to counteract hypercapnia. CVVHDF proved the most effective cooling method, with temperature rising nearly 1 °C during a 30-min interruption, underscoring its importance. In DNP overdoses, there is a high likelihood of severe symptoms, therefore aggressive cooling therapies should be commenced early. This case adds valuable insights to the literature on DNP toxicity management.
Yee et al. (Sun,) studied this question.