Background: Since Bangladesh government issued a ban on the use of highly toxic WHO Class I pesticides, annual consumption of herbicides like Paraquat have been sharply increasing in the markets. Paraquat poisoning is an emerging public health threat and its high mortality rate is responsible for a significant number of deaths. Diagnostic limitations and unavailable sample at presentation have resulted in under-reporting and lack of awareness among the treating physicians, making Paraquat poisoning one of the most neglected toxicological emergencies. Herein, we present a case of Paraquat induced multi-organ failure and emphasis on pitfalls in the management. Case presentation: An 18-years-old healthy male was admitted in Sylhet M.A.G Osmani Medical College Hospital with history of attempted suicide by Paraquat ingestion. On admission, he had high serum creatinine but otherwise asymptomatic. He was discharged on day 10 when his renal functions returned to normal. But On day 15, he started having respiratory symptoms—unresponsive to any of the local treatments he received, and by day 30, he developed overt lung fibrosis. We present sequential blood picture, radiographs and CT scans demonstrating Paraquat induced kidney and lung injury over the course of 30 days. Conclusion: Paraquat poisoning can lead to death and fatal long-term consequences. All cases of Paraquat poison- ing, regardless of symptoms, must be hospitalized and observed for early detection of complications. Distribution of Paraquat should be restricted and/or banned as 38 other countries have done so, which we believe will greatly reduce poisoning related mortality. Keywords: Paraquat, Poisoning, Bangladesh, Acute kidney injury, Lung fibrosis Background Unfortunately, this compound has no effective antidote Since Bangladesh government issued a ban on WHO and rapidly causes multi-organ failure . It has high class I pesticides in 2000 , the use of herbicides have mortality even with standard care and early management been increasing in our agriculture and most toxic her- . Diagnostic limitations and unavailable sample at bicides like Paraquat entered into our market . The presentation have resulted in under-reporting and lack of annual consumption of Paraquat is sharply increasing in awareness among the treating physicians, making Para- Bangladesh , so is the incidence of Paraquat poisoning, quat poisoning one of the most neglected toxicological posing a major threat to public health. While the organo- emergencies in Bangladesh. Herein this article, we pre- phosphate (OP) poisonings still account for the majority sent a case of Paraquat poisoning complicated by renal of hospital admissions, the fatality of Paraquat poisoning failure and lung fibrosis and emphasis on pitfalls in the cases has been an emerging concern. management. Case presentation An 18-year-old healthy male was brought to the emer- *Correspondence: email@example.com gency room, Sylhet M.A.G Osmani Medical College Department of Medicine, Sylhet M.A.G Osmani Medical College Hospital, Medical College Road, Sylhet 3100, Bangladesh Hospital with a history of attempted suicide by ingestion Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Isha et al. BMC Res Notes (2018) 11:344 Page 2 of 4 of about 30 ml of an unknown poison, later revealed to Table 1 Laboratory profile after Paraquat poisoning be Paraquat 20 SL. He was initially managed at a local Investigation Day 1 Day 10 Day 30 health complex with gastric lavage, intravenous fluids, Haemoglobin 13.6 11.5 13.7 antiemetic, and H blocker, and referred to this tertiary WBC 10,600 7200 8100 hospital for further management. On admission, he had Platelets 276,000 379,000 332,000 vomiting, difficulty in opening his mouth and inability to Serum creatinine 4.32 2.1 0.84 drink or swallow. He was conscious and oriented and had Bilirubin total 2.0 – – mucosal erosion of tongue (Fig. 1), palate, and lips with ALT 36 13.7 48 some mucosal bleeding having poisoning severity score + + Na /K 138.9/3.71 136.7/4.12 132.3/4.71 (PSS) grade one. His heart rate was 78/min and regular, HCO 25.8 – – blood pressure was 100/60 mm Hg, respiratory rate was SpO 98% – 97% 20/min and temperature 98°K. Pupils were normal and Others – – Sputum for reacting to light. Oxygen saturation was 98% on room air. AFB: nega- Both lung fields were clear on auscultation. Other sys - tive temic examinations were normal. Laboratory investigations revealed high serum creati- nine (PSS grade 2). Complete blood count, serum ALT a high-resolution CT scan of chest was obtained, which and electrolytes were within normal limits (Table 1). revealed bilateral pulmonary fibrosis (Fig. 3). Chest radiograph was also normal (Fig. 2a). He was started on cyclophosphamide and methylpred- To rule out OP poisoning, atropine challenge test was nisolone and his condition was static. There was no fur - performed which was negative. He was managed con- ther deterioration during his stay. (Additional file 1) servatively and was soon able to swallow liquids. He was discharged on day 10 when his renal function settled (Table 1). Discussion and conclusion On day 15, he developed irregular fever, shortness of Paraquat (1,1′-Dimethyl-4,4′-bipyridinium dichloride) breath and non-productive cough and as these symptoms has the ability to generate highly reactive oxygen and progressed, he consulted with a local physician. Chest nitrite species which cause cellular damage and apoptosis radiograph revealed diffuse consolidation (Fig. 2b) and in many organs . The clinical manifestations depend he was prescribed a 14-day course of antibiotics. But his upon the quantity ingested. Ingestion of large amounts condition deteriorated and he had to get admitted to the of liquid concentrate (> 50–100 ml of 20% w/v) results in hospital on day 30. The lesions on his chest radiograph fulminant multi-organ failure and death within several showed bilateral diffuse alveolar shadowing (Fig. 2c) and hours to a few days . Ingestion of smaller quantities Fig. 1 Paraquat tongue, within 24 h of ingestion Isha et al. BMC Res Notes (2018) 11:344 Page 3 of 4 Fig. 2 Serial chest radiographs after Paraquat poisoning. a Day 1—Normal. b Day 15—Diffuse alveolar shadowing predominantly involving left mid and lower zone. c Day 30—Diffuse alveolar shadowing extending to right apical and mid zone Fig. 3 High resolution CT scan of chest demonstrating bilateral pulmonary fibrosis 30 days after Paraquat poisoning usually leads to toxicity to two key target organs, kidneys to erosion and irritation. Activated charcoal or Fuller’s and lungs, developing over days to weeks [3, 4]. earth was not used due to unavailability. An ingestion of 10–15 ml of 20% w/v Paraquat solution Irrespective of its route of administration, it is rapidly is considered lethal . The estimated amount taken by distributed in most tissues, with the highest concentra- our patient was 30 ml of 20 SL solution, which was quite tion found in the lungs and kidneys [3, 4]. It is actively high. Following ingestion, the herbicide induces a burn- taken up by the type II pneumocytes against a concen- ing sensation of the mouth and throat, gastrointestinal tration gradient. Lung damage occurs in two phases, ini- irritation, abdominal pain, nausea, vomiting, and diar- tially from destructive alveolitis over one to three days rhea . In our patient, all the initial symptoms were due followed by proliferative phase leading to fibrosis [3, 4]. Isha et al. BMC Res Notes (2018) 11:344 Page 4 of 4 Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. Centre Excretion of Paraquat is biphasic, owing to lung accumu- for Tropical Medicine and Global Health, Nuffield Department of Medicine, lation and occurs largely in the urine [4, 5]. In our patient, University of Oxford, Oxford, UK. renal failure was evident by a rise of serum creatinine to Acknowledgements 4.32 mg/dl on day 1, which subsequently normalized by Not applicable. day 30 with conservative treatment. Respiratory symp- toms appeared at the end of 2nd week and features of Competing interests The authors declare that they have no competing interests. lung fibrosis became evident within 1 month, consistent with hallmark lung findings of Paraquat poisoning . Availability of data and materials This case posed a number of diagnostic challenges to the Not applicable. medical team. Paraquat poisoning is an emerging problem Consent for publication of Bangladesh and never been reported from this region Written informed consent was obtained from the patient for publication of . Therefore, there was considerable confusion regard - this case report and any accompanying images. ing the identity of the pesticide ingested. This patient got Ethics approval and consent to participate gastric lavage (which made his condition worse) and test Not applicable. doses of atropine initially and might have looked upon as Funding OP poisoning. Later he was confirmed as a case of Para - Not applicable. quat poisoning after examining the container. Secondly, the initial clinical features were nonspecific. Initial symp - Publisher’s Note toms of vomiting and mucosal ulceration mislead to other Springer Nature remains neutral with regard to jurisdictional claims in pub- corrosive agents. Thirdly, failure to anticipate the com - lished maps and institutional affiliations. plications led to an early discharge of the patient. Subse- Received: 26 October 2017 Accepted: 10 May 2018 quently, he developed overt lung fibrosis within 30 days. Methylprednisolone and cyclophosphamide therapy was not given initially (started later), which was a major pitfall in the management of our patient. Early initiation of these References therapies might reduce the accumulation into lung . 1. Chowdhury FR, Dewan G, Verma VR, Knipe DW, Isha IT, Faiz MA, et al. Bans of WHO class I pesticides in Bangladesh—suicide prevention without Up to date, 38 countries have issued a ban on Paraquat hampering agricultural output. Int J Epidemiol. 2018;47(1):175–84. https including the European Union, Sri Lanka, Vietnam and ://doi.org/10.1093/ije/dyx15 7. South Korea [8–11]. Bans of W.H.O class I pesticides is 2. Pesticides use. http://www.fao.org/faost at/en/#data/RP. Accessed 15 Apr proved to significantly lower the suicide rates in Bangla - 3. Gawarammana IB, Buckley NA. Medical management of paraquat desh . Therefore it is the high time to implement such ingestion. Br J Clin Pharmacol. 2011;72(5):745–57. https ://doi.org/10.111 regulation on Paraquat also. 1/j.1365-2125.2011.04026 .x. 4. Wunnapuk K, Mohammed F, Gawarammana I, Liu X, Verbeeck RK, Buckley Paraquat poisoning can lead to death and fatal long- NA, et al. Prediction of paraquat exposure and toxicity in clinically term consequences. Unfortunately, there is no avail- ill poisoned patients: a model based approach. Br J Clin Pharmacol. able antidote, which makes it more hazardous. All 2014;78(4):855–66. https ://doi.org/10.1111/bcp.12389 . 5. Houze P, Baud FJ, Mouy R, Bismuth C, Bourdon R, Scherrmann JM. Toxi- cases, regardless of symptoms, must be hospitalized and cokinetics of paraquat in humans. Hum Exp Toxicol. 1990;9:5–12. observed for early detection of complications. We recom- 6. Lee SH, Lee KS, Ahn JM, Kim SH, Hong SY. Paraquat poisoning of the lung: mend the government should look into the problem at thin-section CT findings. Radiology. 1995;195:271–4. 7. Bari MS, Chakraborty SR, Alam MMJ, Qayyum JA, Hassan N, Chowdhury large and issue a ban on Paraquat which will effectively FR. Four-year study on acute poisoning cases admitted to a tertiary hos- lower the poisoning death-rates. pital in Bangladesh: emerging trend of poisoning in commuters. Asia Pac J Med Toxicol. 2014;3(4):152–6. https ://doi.org/10.22038 /apjmt .2014.3485. Additional files 8. EU Court Reimposes Ban on Paraquat Weed killer. http://www.reute rs.com/artic le/envir onmen t-eu-paraq uat-dc/eu-court -reimp oses-ban- on-paraq uat-weedk iller -idUSL 11666 80020 07071 1. Accessed 12 Oct 2017. Additional file 1. Timeline of clinical events. 9. Pearson M, Zwi AB, Buckley NA, Manuweera G, Fernando R, Dawson AH, et al. Policymaking ‘under the radar’: a case study of pesticide regula- tion to prevent intentional poisoning in Sri Lanka. Health Policy Plan. Abbreviations 2015;30(1):56–67. https ://doi.org/10.1093/heapo l/czt09 6. PSS: poisoning severity score; AFB: acid fast bacilli; ALT: alanine transaminase; 10. Cha ES, Chang SS, Gunnell D, Eddleston M, Khang Y-H, Lee WJ. Impact OP: organophosphate. of paraquat regulation on suicide in South Korea. Int J Epidemiol. 2016;45:470–9. https ://doi.org/10.1093/ije/dyv30 4. Authors’ contributions 11. PAN Vietnam Welcomes the Ban of Paraquat and 2,4-d . http://panap ITI, ZNA, BKS, MZJB and MSB diagnosed the case, collected data, supervised .net/2017/02/pan-vietn am-welco mes-the-ban-of-paraq uat-and-24-d/. the management and followed-up the patient. ITI and FRC drafted the manu- Accessed 12 Oct 2017. script. All authors read and approved the final manuscript. Author details Department of Medicine, Sylhet M.A.G Osmani Medical College Hospital, Medical College Road, Sylhet 3100, Bangladesh. Department of Medicine,
BMC Research Notes – Springer Journals
Published: May 30, 2018
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