Cyanide poisoning results from exposure to a source of cyanide ions (CN-). There are four main syndromes in animals:
Classical acute cyanide poisoning is when CN- binds to, and inhibits, the ferric (Fe3+) heme moeity form of mitochondrial cytochrome c oxidase (synonyms: aa3, complex IV, cytochrome A3, EC 126.96.36.199). This blocks the fourth step in the mitochondrial electron transport chain (reduction of O2 to H2O), resulting in the arrest of aerobic metabolism, systemic hypoxia, and death from histotoxic anoxia. Tissues that heavily depend on aerobic metabolism such as the heart and brain are particularly susceptible to these effects. Cyanide also binds to other heme-containing enzymes, such as members of the cytochrome p450 family, and to myoglobin. However, these tissue cyanide "sinks" do not provide sufficient protection from histotoxic anoxia. The acute lethal dosage of hydrogen cyanide (HCN) in most animal species is ~2 mg/kg. Plant materials containing ≥200 ppm of cyanogenic glycosides are dangerous. Cyanide poisoning is often a component of smoke inhalation poisoning Smoke Inhalation Injury in Animals Smoke inhalation injury is the damage to the body associated with breathing in superheated air or steam, other harmful gases, vapors, and particulate matter resulting from thermal combustion... read more .
Chronic cyanide poisoning-related hypothyroidism is due to disruption of iodide uptake by the follicular thyroid cell sodium-iodide symporter by thiocyanate, a metabolite in the detoxification of cyanide.
Chronic cyanide and cyanide metabolite (eg, various glutamyl beta-cyanoalanines)-associated neuropathy toxidromes, which include diseases such as sorghum cystitis ataxia syndrome in horses, as well as various cystitis ataxia syndromes in cattle, sheep, and goats
Chronic cyanogenic glycoside exposure (notably from Sorghum spp) -associated musculoskeletal teratogenesis (ankyloses or arthrogryposes) and abortion
Although cyanide levels can be determined in various biological media from poisoned animals, often the most reliable method of diagnosis is determination of cyanide (and/or cyanide glycoside and/or relevant cyanide metabolite) concentrations in food and stomach contents. Feed analysis and neurohistopathology are the gold-standard method of diagnosis of cyanide-associated neuropathy toxidromes. Likewise, feed analysis and fetal pathology are the gold-standard methods of diagnosis of chronic cyanogenic glycoside-associated teratogenic syndromes.
Etiology of Cyanide Poisoning in Animals
Various chemical forms of cyanides are found in plants, fumigants, soil sterilizers, fertilizers (eg, cyanamide), pesticides/rodenticides (eg, calcium cyanomide), and salts used in industrial processes, such as gold mining, metal cleaning and electroplating, photographic processes, and others. Hydrogen cyanide is also known as prussic acid, and cyanide salts liberate cyanide gas in the presence of acids (eg, in the stomach).
Cyanide preparations are still used as control agents for vertebrate pests, such as feral pigs, fox, Australian brush-tailed possums, and other pest or predator species in a number of countries.
Cyanide salts are still used as killing agents in entomology and (illegally) as a method of fishing and/or collection of aquarium fish species (ie, cyanide fishing). Various nitriles can be metabolized in such a way that cyanide is released.
Combustion of common polyacrylonitriles (plastics), wool, silk, keratin, polyurethane (insulation/upholstery), melamine resins (household goods), and synthetic rubber results in the release of cyanide gas.
Car fires are notorious sources of cyanide exposure, and cyanide is also a notable component of internal combustion engine exhaust and tobacco smoke. Cyanide poisoning is thus a common component of smoke inhalation toxidromes.
Toxicity can result from accidental, improper, or malicious use or exposure. However, in livestock species, the most frequent cause of acute and chronic cyanide poisoning is ingestion of plants that either constitutively contain cyanogenic glycosides or are induced to produce cyanogenic glycosides and cyanolipids as a protective response to environmental conditions (plant cyanogenesis). Plant cyanogenesis is a common process and has been documented in >3,000 different plant species distributed over ~110 different families of ferns, gymnosperms, and angiosperms. Of these plants, ~300 species are potential causes of acute and chronic cyanogenic glycoside poisoning, and there are ~75 different cyanogenic glycosides (all of which are O-beta-glycosidic derivatives of alpha-hydroxynitriles).
Plant species of notable veterinary importance include Sorghum spp (Johnson grass, Sudan grass, and S bicolor, the common cereal grain crop referred to as " sorghum Sorghum Poisoning in Horses Sorghum species are drought-tolerant plants with a high nutritional value related to protein, fiber, calcium, potassium, phosphorus, and antioxidant content. Unfortunately, the plants may produce... read more " or the synonyms durra, jowari, milo), Acacia greggii (guajillo), Amelanchier alnifolia (western service berry), Linum spp (linseeds and flaxes), Sambucus nigra (elderberry), Suckley suckleyana (poison suckleya), Triglochin maritima and T palustris (marsh arrow grasses), Mannihot esculentum (cassava), all members of the Prunus genus until proved otherwise (apricot, peach, chokecherry, pincherry, wild black cherry, ornamental cherry, peaches, nectarines, apricots, almonds, bird cherries, black thorn, cherry laurels [commercial orchard species are often specifically bred for low cyanide content; however, ornamental members of this genus are often highly poisonous]), Nandina domestica (heavenly or sacred bamboo), Phaseolus lunatus (lima beans), members of the Vicia genus until proved otherwise (vetches; often, pasture species have been bred for low cyanogenesis), Lotus spp (bird's-foot treefoils; often, pasture species have been bred for low cyanogenesis), Trifolium sp (clovers; often, pasture species have been bred for low cyanide content), Zea mays (corn), Eucalyptus spp (gum trees), Hydrangea spp (hydrangeas), Pteridium aquilinum (bracken fern), Bahia oppositifolia (bahia), and Chaenomales spp (flowering quince).
A number of insect species are also able to synthesize hydrogen cyanide and/or sequester hydrogen cyanide that is derived from the cyanogenic glycosides of their plant hosts (notably the USA eastern tent caterpillar Malacosoma americanum that is associated with mare reproductive loss syndrome Mare Reproductive Loss Syndrome Also see Management of Reproduction: Horses. Placenta from a mare that aborted twins. Note the large avillous area corresponding to the contact between the two placentae. Placenta from a twin... read more ; however, cyanide is not the cause of mare reproductive loss syndrome. Invertebrates such as Burnet moths (Zygaena spp) that feed on bird's-foot trefoils), as well as certain centipede and millipedes, are potentially hazardous food sources for exotic pet species.
Plant cyanogenesis in response to environmental stressors is an important part of the etiology and risk of acute cyanogenic glycoside poisoning. Within plants, amino acids that are not used for protein synthesis can be metabolized to alpha-hydroxynitriles and then to cyanogenic glycosides. Plants are protected from the potential adverse effects of cyanogenic glycosides by two features: cyanogenic glycosides are largely found within cell vacuoles, and the presence of the detoxifying enzyme beta-cyanoalanine synthase (which is responsible for production of some of the cyanide derivatives putatively involved in the chronic cyanide-associated neurologic toxidromes). Even so-called "acyanogenic" plants can become toxic under appropriate environmental circumstances.
Environmental conditions that damage relevant plant species, reduce protein synthesis, enhance the conversion of nitrate to amino acids in the presence of reduced protein synthesis, and/or inhibit beta-cyanoalanine synthase potentially increase the risk of cyanogenesis. Relevant environmental factors include crushing, wilting, freezing, high environmental temperatures, herbicide treatment, water stress, cool and moist growing conditions, nitrate fertilization, high soil nitrogen:phosphorus ratios, soil phosphorus deficiency, low soil sulfur (decreases detoxification of cyanogenic glycosides to thiocyanates within plants), insect attack, and various plant diseases. Herbicide treatment of plants is important in that it may also increase plant palatability.
Crushing and/or mastication of potentially cyanogenic plants is important in development of the acute toxidrome, because this releases cyanogenic glycosides from plant cell vacuoles and exposes them to catabolism by beta-glucosidase and hydroxynitrile lyase present in the plant cell cytosol.
Young, rapidly growing areas of plants and areas of regrowth after cutting often have high cyanogenic glycoside content. As a rough approximation, rapidly growing Sorghum spp are often hazardous until they reach ~60 cm in height; however, this is no guarantee of safety, and if there is any doubt regarding cyanogenic potential, samples of potential forage should be tested. Plant seeds and leaves typically have higher cyanogenic potential, whereas the fleshy parts of fruits generally have low levels. Drying often increases the cyanogenic potential of plants, whereas ensiling may reduce cyanide content by ~50%.
Beta-glucosidase and hydroxynitrile lyase are also present in the rumen microflora, and a rumen pH of ~6.5–7 favors conversion of cyanogenic glycosides to cyanide. Ruminants on high-energy grain rations are somewhat less susceptible, because their lower rumen pH (~4–6) reduces the formation of cyanide. Consumption of water before grazing on cyanogenic pastures appears to increase the risk. Monogastric animals with low stomach pH are also somewhat less susceptible to cyanogenic glycoside poisoning. However, these factors do not guarantee immunity from poisoning.
Under conditions of low-level exposure, mammals detoxify ~80% of ingested cyanide to thiocyanate via mitochondrial rhodanese. Thiocyanate is then largely excreted in urine. Often, the rate of the rhodanese pathway is limited by the availability of thiosulfate; also notably, dogs have lower overall rhodanese activity than other species. Minor, but toxicologically important, pathways of detoxification in mammals include the combination of cyanide with hydroxycobalamin (vitamin B12a) to yield cyanocobalamin (vitamin B12), and the nonenzymatic combination of cyanide with cysteine to form beta-thiocyanoalanine, which is converted to 2-iminothiazolidine-4-carboxylic acid and subsequently excreted. Small amounts of beta-thiocyanoalanine are also excreted in saliva. Dietary levels of sulfur amino acids (L-cysteine and L-methionine) strongly influence the rate of detoxification of cyanide, and low dietary intakes are associated with higher blood cyanide levels, particularly under conditions of chronic, low level exposure. Dietary sulfur and sulfur amino acid intake are known to strongly affect the neurologic toxidromes associated with chronic cyanide/cyanogenic glycoside exposure in people.
Chronic low-level cyanide/cyanogenic glycoside exposure is associated with increased exposure to the cyanide metabolite thiocyanate. Under conditions of thiocyanate overload, thiocyanate acts as a competitive inhibitor of thyroid follicular cell iodine uptake by the sodium/iodide symporter. This results in reduced iodination of tyrosine, reduced T3 synthesis, increased blood TSH, goiter, and hypothyroidism. Similar effects occur with some plant glucosinolates (goitrogenic glycosides). Selenium deficiency appears to enhance these effects.
Chronic, low-level cyanide/cyanogenic glycoside exposure (often in combination with low dietary sulfur and/or sulfur amino acid intake) is associated with neuropathy syndromes in horses and ruminants. Sorghum cystitis ataxia syndrome of horses is associated with diffuse nerve fiber degeneration in the lateral and ventral funiculi of the spinal cord and brain stem. Similar syndromes have been described in ruminants. Comparisons between these syndromes as chronic cyanogenic glycoside–associated human myeloneuropathies (such as Konzo and tropical ataxic neuropathy) have been made; however, the precise toxins and modes of action are yet to be fully defined. All of these toxidromes appear to be related to a combination of chronic cyanide/cyanogenic glycoside exposure combined with low dietary sulfur and/or sulfur amino acid intake and possibly other nutritional deficiencies. Lathyrogenic plant cyanide metabolites such as beta-cyanoalanine have been implicated as causative or at least contributory agents.
Chronic, low-level cyanogenic glycoside exposure (notably from Sorghum spp) has been associated with musculoskeletal teratogenesis (ankyloses or arthrogryposes) and abortion.
Clinical Findings of Cyanide Poisoning in Animals
Acute cyanide poisoning: Signs generally occur within 15–20 minutes to a few hours after animals consume toxic forage, and survival after onset of clinical signs is rarely >2 hours. Excitement can be displayed initially, accompanied by rapid respiration rate. Dyspnea follows shortly, with tachycardia. The classic "bitter almond" breath smell may be present; however, the ability to detect this smell is genetically determined in people, and anosmic people (a significant proportion of the population) cannot detect it. Salivation, excess lacrimation, and voiding of urine and feces may occur. Vomiting may occur, especially in pigs. Muscle fasciculation is common and progresses to generalized spasms and coma before death. Animals may stagger and struggle before collapse. In other cases, sudden unexpected death may ensue. Mucous membranes are bright red but may become cyanotic terminally. Venous blood is classically described as "cherry red" because of the presence of high venous blood pO2; however, this color rapidly changes after death. Serum ammonia and neutral and aromatic amino acids are typically increased. Cardiac arrhythmias are common due to myocardial histotoxic hypoxia. Death occurs during severe asphyxial convulsions. The heart may continue to beat for several minutes after struggling, and breathing stops. The elimination half-life of cyanide in dogs is reported to be 19 hours, so prognosis of recovery without therapeutic intervention is grave: it would take more than 4 days to eliminate >95% of the cyanide present.
Chronic cyanide poisoning: Chronic cyanogenic glycoside hypothyroidism will present as hypothyroidism Hypothyroidism in Animals Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features such as lethargy, weight gain, obesity, haircoat changes, and low serum thyroid hormone concentrations. Management... read more with or without goiter. Cystitis ataxia toxidromes are typically associated with posterior ataxia or incoordination that may progress to irreversible flaccid paralysis, cystitis secondary to urinary incontinence, and hindlimb urine scalding and alopecia Alopecia in Animals Alopecia is the partial or complete lack of hairs in areas where they are normally present. It can be congenital or acquired. Congenital alopecias are noninflammatory and are the result of hair... read more . Death, although uncommon, is often associated with pyelonephritis. Late-term abortion and musculoskeletal teratogenesis may also occur.
Acute cyanide poisoning: Necropsy personnel may require appropriate personal protective equipment, including respirators with suitable cartridges. Venous blood is classically described as being "bright cherry red"; however, this color rapidly fades after death or if the blood is exposed to the atmosphere. Whole blood clotting may be slow or not occur. Mucous membranes may also be pink initially, then become cyanotic after respiration ceases. The rumen may be distended with gas; in some cases the odor of “bitter almonds” may be detected after opening. Rumen contents may provide a positive sodium picrate paper test (or positive results on other rapid cyanide test strip systems). Rumen gases may provide positive results in cyanide Draeger tube rapid test systems. Agonal hemorrhages of the heart may be seen. Liver, serosal surfaces, tracheal mucosa, and lungs may be congested or hemorrhagic; some froth may be seen in respiratory passages. Cyanide also binds to iron (both Fe2+ and Fe3+) present in myoglobin (although this occurs more slowly than the binding to cytochrome c oxidase and, hence, is not protective); this may result in a generalized dark coloration of skeletal muscle. Neither gross nor histologic lesions are consistently seen.
Multiple foci of degeneration or necrosis may be seen in the CNS of dogs chronically exposed to sublethal amounts of cyanide. These lesions have not been reported in livestock.
Chronic cyanide poisoning: Goiter may be present. Cystitis ataxia toxidromes are characterized by opportunistic bacterial cystitis with or without pyelonephritis and diffuse nerve fiber degeneration in the lateral and ventral funiculi of the spinal cord and brain stem. Hindlimb urine scalding and alopecia may be present.
Diagnosis of Cyanide Poisoning in Animals
Determination of cyanide (and/or cyanide glycoside and/or relevant cyanide metabolite) concentrations in food and stomach contents
For cyanide-associated neuropathy syndromes: feed analysis and neurohistopathology
For chronic cyanogenic glycoside-associated teratogenic syndromes, Feed analysis and fetal pathologies
Appropriate history, clinical signs, postmortem findings, and demonstration of HCN in rumen (stomach) contents or other diagnostic specimens support a diagnosis of cyanide poisoning. Veterinarians should be aware of the possible need to use appropriate personal protective equipment, including a respirator, when collecting samples that may liberate cyanide gas (eg, rumen contents and rumen gas cap).
A rapid qualitative and presumptive diagnosis can be made by testing representative plant samples or stomach contents using the picric acid paper test or by collecting rumen gas cap samples by trocarization and testing with a Draeger cyanide gas detection tube or other cyanide gas detection system. Negative results with such rapid presumptive tests do not completely exclude the possibility of cyanide poisoning.
Suitable specimens for more sophisticated testing include the suspected food source, rumen/stomach contents, samples of the rumen gas cap, heparinized whole blood, liver, and muscle. Antemortem whole blood is preferred; other specimens should be collected as soon as possible after death, preferably within 4 hours. Specimens should be sealed in an airtight container, refrigerated or frozen, and submitted to the laboratory without delay. When cold storage is unavailable, immersion of specimens in 1%–3% mercuric chloride has been satisfactory. The rationale for using liver as a diagnostic sample is that cyanide binds to the Fe3+ form of cytochrome p450 and other heme-containing metabolic enzymes. The rationale for using skeletal muscle is that cyanide will bind to the iron moiety in myoglobin.
Measurement of the urinary metabolite of cyanide, thiocyanate, may reveal increased concentrations after cyanide poisoning.
Hay, green chop, silage, or growing plants containing >220 ppm cyanide as HCN on a wet-weight (as is) basis are very dangerous as animal feed. Forage containing <100 ppm HCN, wet weight, is usually safe to pasture. Analyses performed on a dry-weight basis have the following criteria: >750 ppm HCN is hazardous, 500–750 ppm HCN is suspect, and <500 ppm HCN is considered safe.
Normally expected cyanide concentrations in blood of most animal species are usually <0.5 mcg/mL. Minimal lethal blood concentrations are ~3 mcg/mL or less. Cyanide concentrations in muscle are similar to those in blood, but concentrations in liver are generally lower than those in blood. In dogs, whole blood cyanide concentrations may be 4–5 times greater than serum concentrations because of binding to ferric ions and sequestration in RBCs.
Differential diagnoses include poisonings by:
nitrate or nitrite
chlorinated hydrocarbon pesticides Overview of Insecticide and Acaricide (Organic) Toxicosis in Animals Insecticides are any substance or a mixture of substances intended to prevent, destroy, repel, or mitigate insects. Similarly, acaricides are substances that can destroy mites. A chemical can... read more
toxic gases ( carbon monoxide Carbon Monoxide as a Veterinary Workplace Hazard Carbon monoxide (CO) will most commonly be encountered by veterinarians working in enclosed spaces (eg, intensive animal production facilities) being heated by combustion sources (eg, gas space... read more and hydrogen sulfide Hydrogen Sulfide as a Veterinary Workplace Hazard Veterinarians are most likely to encounter hydrogen sulfide emanating from concentrated decaying organic matter (eg, septic/sewage ponds/manure handling facilities in intensive animal production... read more )
as well as infectious or noninfectious diseases and other toxidromes that cause sudden death
Treatment, Control, and Prevention of Cyanide Poisoning in Animals
Immediate treatment with hydroxocobalamin and oxygen
Methylene blue if diagnosis is in doubt (signs are similar to those of nitrate poisoning)
Removal from the source of exposure
In cases of acute cyanide poisoning, immediate treatment is necessary. Activated charcoal is ineffective, and its use is not recommended. Hydroxocobalamin (vitamin B12a ) is the gold-standard antidote for cyanide because of its effectiveness and low toxicity. It has a great advantage of not further compromising tissue oxygenation and not inducing hypotension. Hydroxocobalamin detoxifies cyanide by binding to it and forming cyanocobalamin (ie, a decoy receptor approach), which is then excreted in urine. The suggested dosage is 70 mg/kg, infused IV over 15 minutes, repeated as necessary. Hydroxocobalamin produces chromaturia (which may result in false urinalysis results), as well as infusion site reactions, GI upset, pruritus, and dysphagia. Hydroxocobalamin is costly, which may limit its use in herd and flock animals.
When available, oxygen should be used to supplement antidotal therapy, especially in small animals. Hyperbaric oxygen therapy (100% oxygen breathed intermittently at a pressure >1 atmosphere absolute) causes an above-normal partial pressure of oxygen (pO2) in arterial blood and markedly increases the amount of oxygen dissolved in plasma. Oxygen-dependent cellular metabolic processes benefit from heightened oxygen tension in capillaries and enhanced oxygen diffusion from capillaries to critical tissues.
The older (and less expensive—making it likely more practical for grazing animals) approach to the treatment of acute cyanide poisoning is to break the cyanide-cytochrome c oxidase bond and reestablish the mitochondrial electron transport chain. One way to accomplish this is by using Fe3+ in hemoglobin (ie, inducing methemoglobinemia), which then acts as a high-affinity decoy chemical receptor for cyanide and forms cyanmethemoglobin. Classically, various nitrites have been used for this purpose; eg, inhaled amyl nitrite followed by IV injection of a nitrite salt (typically sodium nitrite) has been used to rapidly induce methemoglobinemia. Cyanide bound to methemoglobin can then be detoxified by rhodanese to thiocyanate. Because the rhodanese-mediated detoxification of cyanide to thiocyanate is usually capacity and rate limited by the availability of sulfur donors, treatment with nitrites is usually followed up by injection of sodium thiosulfate. Oral dosing with sodium thiosulfate into the rumen and/or stomach has also been suggested because the reaction between thiosulfate and cyanide can also occur nonenzymatically, and this may reduce any ongoing production of cyanide in the rumen/stomach environments.
If possible, the contents of one 0.3-mL vial of amyl nitrite should be inhaled by the animal as soon as possible after exposure, followed by an IV infusion of sodium nitrite (10 g/100 mL of distilled water or isotonic saline; 20 mg/kg body weight) over 3–4 minutes. Nitrite treatment is then followed by a slow IV injection of sodium thiosulfate (20% w/w) at ≥500 mg/kg. Thiosulfate is generally well tolerated; however, vomiting and hypotension can occur. The thiosulfate injection can be repeated if necessary. Oral administration of thiosulfate can also be considered in an attempt to convert any cyanide in the stomach/rumen into thiocyanate. Sodium nitrite therapy may be carefully repeated at 10 mg/kg, every 2–4 hours or as needed. Ideally, decisions regarding repeated treatment with nitrites should consider the degree of methemoglobinemia present.
Notably, thiosulfate treatment alone (sodium thiosulfate at ≥500 mg/kg, IV, plus 30 g/cow orally for ruminants, with the objective of facilitating the detoxification of any remaining HCN in the rumen) has been successful in some cases. However, thiosulfate treatment should ideally be preceded by nitrite induction of methemoglobinemia in cases of confirmed cyanide poisoning. However, because thiosulfate is generally well tolerated, it is often administered alone in situations when cyanide exposure is likely but unconfirmed (eg, smoke inhalation or exposure to fires).
The best preventive step is to test suspect feed and/or pastures before allowing consumption. Pasture and forage sorghums Sorghum Poisoning (eg, Sudan grass and sorghum-Sudan grass hybrids) should not be grazed until they are >60 cm tall or have been proved by testing to have acceptable cyanide levels, to reduce danger from prussic acid poisoning. Animals should be fed before first turning out to pasture; hungry animals may consume forage too rapidly to detoxify HCN released in the rumen. Animals should be turned out to new pasture later in the day; potential for prussic acid release is reported to be highest during early morning hours. Free-choice salt and mineral with added sulfur may help protect against prussic acid toxicity. Grazing should be monitored closely during periods of environmental stress, eg, drought or frost. Abundant regrowth of sorghum can be dangerous; these shoots should be frozen and wilted before grazing.
Green chop forces livestock to eat both stems and leaves, thereby reducing problems caused by selective grazing. Cutting height can be raised to minimize inclusion of regrowth.
Sorghum hay and silage usually lose ≥50% of prussic acid content during curing and ensiling processes. Free cyanide is released by enzyme activity and escapes as a gas. Although a rare occurrence, hazardous concentrations of prussic acid may still remain in the final product, especially if the forage had an extremely high cyanide content before cutting. Hay has been dried at oven temperatures for up to 4 days with no significant loss of cyanide potential. These feeds should be analyzed before use whenever high prussic acid concentrations are suspected. Potentially toxic feed should be diluted or mixed with grain or forage that is low in prussic acid content to achieve safe concentrations in the final product. At least in theory, the risk of chronic cyanide poisoning syndromes may be reduced by iodine supplementation in the case of hypothyroidism and by sulfur-containing amino acids in the case of chronic neurologic toxidromes. Great care must be taken when providing supplemental elemental sulfur sources in ruminants because of the possible risk of polioencephalomalacia Polioencephalomalacia .
Manage grazing and feed conditions for environmental stress to minimize risk, and analyze feed before allowing consumption.
Hydroxocobalamin plus 100% oxygen should be administered as soon as possible after suspected cyanide poisoning.
Treatment should not be delayed for diagnostic confirmation.
Removal from the source of exposure is the main clinical priority in chronic cyanide-associated toxidromes.
Prognosis for cases of chronic cyanide poisoning other than those associated with thyroid syndromes is guarded.