A complicated case of delayed onset intermediate syndrome post organophosphorus poisoning: A rare case report

Herein, we present a case of 44-year-old male who landed in our emergency department with altered mental status with difficulty in breathing after 14 days of consumption of chlorpyrifos. Organophosphorus (OP) poisoning is one of the most common causes of poisoning encountered in rural India. There are reported cases of its acute and sub-acute atypical presentation but very few of delayed onset intermediate syndrome. By means of this case report, we want to emphasize on the delayed complications post OP poisoning and importance of treating physician’s awareness to recognize and treat such complications.

A Fatal Case of Severe Acute Organophosphorus Pesticide Poisoning Complicated with Secondary Hemophagocytic Lympho-Histiocytosis, Severe Lower Intestinal Hemorrhage and Intestinal Mucormycosis

A man in his 50’s, under influence of alcohol, accidentally ingested a pesticide, and was referred for further management and admitted to our hospital. An empty can of Curacron® was found at the site in his farm where he took the alleged pesticide. This raised the suspicion of organophosphorus pesticide poisoning and he was managed at two medical centres before getting admitted to our hospital. His hospital course was complicated with multiorgan dysfunction, shock, respiratory failure and intermediate syndrome. On day five he developed secondary hemophagocytic lymphohistiocytosis (sHLH) and had hematochezia on day six. Colonoscopy revealed multiple circumferential ulcerations in descending and sigmoid colon with luminal narrowing. Biopsy of colonic tissue showed evidence of intestinal Mucormycosis. The clinical presentation of organophosphorus pesticide poisoning in this patient was complicated with multiple issues and included sHLH, chemical gastroenteritis, hemorrhagic ulcers and intestinal zygomycosis. The organophosphorus pesticide ingested by the patient was a 50% emulsifiable concentrate of profenofos along with vegetable oil, soyabean oil and polyglycol ether alkyl aryl sulphate calcium salt 5.25% w/w as an emulsifier/spreading agent. The management of the patient is discussed. Due to the possibility of the emulsifier adhering to the gastrointestinal tract and causing mucosal injury, it is necessary to identify the drug composition and ingredients of the pesticide as soon as possible when managing organophosphorus poisoning.

Pattern and Outcome of Organophosphorus Poisoning Cases in Bheri Hospital, Nepal

BACKGROUND: Organophosphorus (OP) are frequently used as pesticides and the most common agents of poisoning in developing countries including Nepal. There is paucity of data about characteristics of organophosphorus poisoning in our localities. Therefore, we aimed to evaluate its clinical pattern and factors affecting outcome. METHODS: It was a cross-sectional study conducted in Bheri Hospital Nepalgunj between 15th July 2019 to 14th July 2020. The hospital records of patients of acute organophosphorus poisonings were collected. Data regarding age, gender, predisposing factors, duration of hospitalization and outcome of the patients were recorded. Data was analyzed using SPSS 20. RESULTS: A total of 53 patients out of which 22(41.5%) were male and 31(58.49%) were female with F:M ratio of 1.40: 1. The maximum number of the patients 25(47.16%) were in the age group of 20 to 40 years. Incidence of poisoning was more common in married patients 36(67.92%) The suicidal motive for poisoning was found in 49 cases (92.45%). The most commonly used organophosphorus poison was Dichlorvos 32(60.34%) followed by methyl parathion 14(26.41%). Domestic quarrel was the most common predisposing factor 32(60.37%). 45(84.90%) of the patients were discharged after successful treatment while there was mortality of 3 patients (5.66%). CONCLUSIONS: Organophosphorus poisoning is a common mode of suicidal attempts leading to morbidity and mortality every year. Strict policies against the free availability and sale of insecticides is required to control organophosphorus poisoning. Mental health education programme should be conducted for the prevention of suicide and poisoning.

Reasons for under-reporting of paraquat poisoning in India

Background Paraquat is an inexpensive herbicide used in agriculture because it is easily available and the cost of labour for manual clearance of weeds is prohibitive. Paraquat is toxic to human beings and is also used for committing suicide. We studied the reasons for under-reporting of paraquat poisoning including those related to the training of doctors. Methods In this mixed-methods study, we describe a series of patients with paraquat poisoning. We recorded their demographic data, clinical features, treatment and outcome with an intention to explore the reason for an initial misdiagnosis. We also explored whether deficiencies in curricula contributed to the misdiagnosis. Results The patients of paraquat poisoning (n=28) were mostly young illiterate men driven by impulsive behaviour rather than chronic depression. Paraquat was consumed by patients from non-agricultural background as well, implying easy access to the poison. Many patients could not name the agent and so initial treatment was directed at organophosphorus poisoning. The diagnostic signs included paraquat tongue, renal failure and jaundice. Most of the casualty medical officers and residents were unfamiliar with the symptoms and signs of paraquat poisoning as was evident by their answers to the questionnaire. Knowledge of medical students about paraquat poisoning was not assessed in the theory examinations and viva. Conclusion Factors contributing to the limitation in establishing the diagnosis are illiteracy and ignorance of the patients, lack of specific signs and lack of training of medical officers in treating patients with paraquat poisoning.

A STUDY OF HYPOKALEMIA IN ORGANOPHOSPHORUS POISONING IN DAHOD GUJARAT

Organophosphorus compounds (OPCs) are common pesticides used in agriculture in India. In this study, totally 24 patients had hypokalemia. Of 39 male patients,20 patients (51.3%) had hypokalemia. Of 11 female patients, 4 patients(36.4%)had hypokalemia. Of 50 patients totally, 14 had hyponatremia(<135 meq/dl) which constitutes 28%. Of this 6 patients had hypokalemia which accounts for 42.9%of hyponatremia.Of 24 patients with hypokalemia this 6 cases of hyponatremia accounts for 25%. Hypokalemia increases both morbidity and mortality in organophosphorus compound poisoning significantly.Hypokalemia can be used as a reliable and a cost effective marker of morbidity and mortality in organophosphorus compound poisoning

Impact of Serum Amylase Level in the Outcome of Acute Organophosphorus Poisoning: 2-Year Cross-Sectional Study at Rural Teaching Hospital

Introduction Prompt recognition and aggressive management of acute intoxication due to organophosphorus poisoning are essential to minimize the morbidity and mortality. The present study was undertaken to know the prognosis and outcome of organophosphorus poisoning patients with the estimation of low-cost enzymes like the serum amylase level in a population with financial constraints. Method In this cross-sectional study, we had enrolled 100 cases that had a history of exposure to organophosphorus compounds, and the serum amylase level was measured in all the patients. We assessed the outcome of all the patients in the form of discharge, need of ventilators, intensive care unit stay, and death. Results The mean serum amylase level in discharge patients was 335.40 ± 192.45, and in the patients who died it was 843.37 ± 22.60. It was significant to predict the outcome (t-value 7.07, p-value 0.0001, statistically significant). Conclusion Serum amylase level shows significant correlation with clinical outcomes in organophosphorus poisoning.

Significance of Serum Potassium Level at Admission in Organophosphorus Poisoning and Impact on Outcome - A Hospital Based Study from North East India

BACKGROUND Organophosphorus (OP) pesticides are one of the most common cause of morbidity and mortality due to poisoning worldwide especially in agrarian countries like India. Hence it is prudent to undertake a detailed study of clinico-pathological evaluation of OP poisoning and assess the role of serum potassium as an alternative, easy and convenient prognostic indicator in estimating the severity of OP poisoning. This study was undertaken to assess serum potassium levels in patients of acute organophosphorus poisoning and determine association between serum potassium level and outcome in cases of acute organophosphorus poisoning. METHODS This was a prospective observational study conducted in Department of General Medicine, Silchar Medical College & Hospital for one year from 1st June 2019 to 31st May 2020 with a sample size of 100 after satisfying the inclusion and exclusion criteria. Peradeniya organophosphorus poisoning (POP) scale was used for categorizing study population according to severity. RESULTS Among patients who were admitted with organophosphorus poisoning, 72 % of the patients discharged were having normal serum potassium levels on admission, whereas 22 % (n = 22) patients who died had hypokalaemia at the time of admission. The chi-square value for the association between serum potassium and outcome is statistically significant [P value is 0.001 (P < 0.05)]. CONCLUSIONS The serum potassium level on the day of admission was significantly correlated with the severity of the acute organophosphate poisoning as determined by Peradeniya OP poisoning scale. The cases that had lower serum potassium levels on admission had poor outcome. Reduced serum potassium levels also had significant association with the need for ventilator support. Therefore, serum potassium can be used as a predictive marker of severity in organophosphorus poisoning. This can help in early triage of patients and will be helpful in reducing mortality and morbidity. KEYWORDS Organophosphorus Compound Poisoning, Serum Potassium, POP Scale