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CYPERMETHRIN POISONING -AN UNCOMMON SUICIDAL COMPOUND CASE REPORT
A.N. Venkatesh1, S.B. Basavaradder2, H. Rajanna2
xApollo Hospital, Karnataka Region, India 2Apollo Hospital, Bengaluru, India
ОТРАВЛЕНИЕ ЦИПЕРМЕТРИНОМ -ОТЧЕТ О РЕДКОМ КЛИНИЧЕСКОМ СЛУЧАЕ
А.Н. Венкатеш1, С.Б. Басавараддер2, Х. Раджанна2
1Больница Апполо, Карнатака, Индия 2Больница Аполло, Бангалор, Индия
Insecticide and pesticide poisoning and ingestion are relatively common in India. Organophosphate (OP) compounds have been and still one of most common pesticide used for self harm. Introduction of various similar chemicals into the market is posing difficulties in management of patients presenting with ingestion of these chemicals to the emergency room (ER). Many times these products could have similar branding but with different chemical composition. The lack of freely available national database of these products and advice on the management in case of poisoning due to them has been a challenge which is yet to be addressed.
Learning points and objectives:
- To be aware that not all pesticides are not OP compounds.
- With newer products coming into market, we need to be read the labels carefully and make a decision regarding further management of these patients.
In the meantime we have to be cautious and aware that pesticides and insecticides have a wide chemical composition. ER physicians may have to take time and effort to get the correct chemical and review their management while attending to such cases.
Keywords: organophosphate compounds, suicide, poisoning, treatment.
Отравления инсектицидами и пестицидами относительно распространены в Индии. Фосфаторга-нические соединения (ФС) были и остаются одними из наиболее распространенных пестицидов, наносящих вред организму. Появление на рынке различных аналогичных химических веществ создает трудности для лечения пациентов, поступающих в отделение неотложной помощи с проглатыванием этих химических веществ. Эти продукты могут иметь схожую торговую марку, но с разным химическим составом. Отсутствие общедоступной национальной базы данных по таким продуктам и рекомендаций по реагированию в случае отравления ими было проблемой, которую еще предстоит решить. Цели и задачи:
- Необходимо помнить, что не все пестициды являются ФС.
- С появлением на рынке новых продуктов нам необходимо внимательно читать инструкции к подобным препаратам и принимать решение о дальнейшем лечении этих пациентов.
Между тем, мы должны проявлять осторожность и осознавать, что пестициды и инсектициды имеют широкий спектр химического состава. Врачам скорой помощи, возможно, придется потратить время и усилия, чтобы получить нужное химическое вещество и пересмотреть назначаемое лечение, оказывая помощь в таких случаях.
Ключевые слова: фосфаторганические соединения, суицид, отравление, лечение.
UDC: 616-099
Introduction
Organophosphate (OP) poisoning is one of the most common poisoning presentations to emergency departments in India. In Urban India we have seen frequent presentations with insecticide poisoning of both accidental and intentional ingestion. OP poisoning is diagnosed based on history when available, clinical presentation and the smell of OP from patient. But apart from OP there are other pesticides which have similar smell and can present with similar clinical presentations. Cypermethrin is one such compound. Cypermethrin is a class-2 Pyrethroid compound used for pesticide control. Its use has been increasing as it is relatively more toxic to pests and rodents (about 2250 times more toxic to insects than mammals).
Cypermethrin crosses the blood-brain barrier and induces neurotoxicity and motor deficits. Cypermethrin prolongs the opening of sodium channel, a major site of its action, leading to hyper-excitation of the central nervous system. In addition to sodium channel, cyper-methrin modulates chloride, voltage-gated calcium and potassium channels, alters the activity of glutamate and acetylcholine receptors and adenosine triphosphatases and induces DNA damage and oxidative stress in the neuronal cells. Cypermethrin also modulates the level of neurotransmitters, including gamma-aminobutyric acid and dopamine. At high concentration pyrethroids also act on GABA-gated chloride channel which may be responsible for seizure.
Toxicity to humans due to pyrethroid can be of two types. Type I can manifest as hypersensitivity reaction, like anaphylaxis, reflex hyper excitability and fine tremors. Type II produces watery diarrhoea, coarse tremor, reflex hyper excitability, choreoathetosis, and seizure. On ingestion it produces throat and epigastric pain, nausea, vomiting, salivation, dysphagia, dizziness, headache, and fatigue. Burning or tingling sensation, numbness, pa-raesthesias, lacrimation, photophobia, conjuc-tival congestion, and bronchospasm are the other manifestations due to direct or dermal
exposure. In our case, most of the symptoms were present. Ingestion of large doses may produce neurotoxicity like, tremors, fascicu-lation, convulsion, coma, pulmonary edema, respiratory failure and cardiac conduction disturbances.
The toxic oral dose in mammals is greater than 100-1000 mg/kg, and the potentially lethal acute oral dose is 10-100 g.
With both the compounds being freely available over the counter, both the compounds being used for similar purposes and both of them having similar clinical presentations it is relevant and important to try and establish the cause as Treatment of both is different. Cypermethrin do not have any antidote. Their management is mainly symptomatic. They also have clearance levels hence can be expected to have faster recovery. On the other hand OP poisoning may need more aggressive management and can be given Pralidoxime as an antidote.
Learning points and objectives
To be aware that not all pesticides are not OP compounds.
With newer products coming into market, we need to be read the labels carefully and make a decision regarding further management of these patients.
Case presentation
A 36 year old female brought to Emergency Room (ER) with complaints of multiple episodes of vomiting, burning sensation in the chest and excessive salivation. Her symptoms had been progressively been getting worse. She also gave history of having consumed a bottle of pesticide - Metacid about 100 ml to kill herself about two hours before presentation. Her family became aware of this and had brought her to Emergency department for further management. She had history of previous suicidal attempts. Currently she seemed quite and hesitant to interact.
She was noted to have a heart rate of 82 beats/min, blood pressure of 120/70, respiratory rate of 16/min, temp of 98.6. Her pupils
A.N. Venkatesh, S.B. Basavaradder, H. Rajanna
were bilaterally 3 mm and reactive. She was noted to have increased oral secretions. Her chest was clear. Rest of examination was unremarkable.
With above history she was diagnosed to have consumed OP poison and was planned to be treated as such. In view on ongoing nausea and vomiting and smell of OP from patient, stomach was with ryle's tube was initiated. As patient was noted to have increased salivation she was also give atropine 0.6 mg bolus twice in ER. Up on further discussion with family, they had brought the container from which she had consumed the poison. The container was labeled - Metacid which is a relatively brand name for OP compound methyl parathion. But on reading fully it had mentioned under the name as Cypermethrin. This made us re-think if we are really dealing with OP compound. Patient was stable and was not having in marked features of OP poisoning and with her presenting symptoms settling, we admitted patient to ICU for further observation. We looked up on further management of cypermethrin poisoning and learnt that it was symptomatic management. She continued to stay asymptomatic for next 24 hours in ICU and did not need any further medications. She was reviewed by Psychiatry team and discharged from hospital in stable and symptom Free State.
Conclusion
It is important to go through the chemical contents of ingested substance when dealing with poisoning. The labeling, branding and familiarity may lead to bias and incorrect interpretation of ingested substance and hence can affect the treatment. Thought the presentation
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Container used by patient.
with OP and cypermethrin can be similar there are some difference in their management. It is important to try and establish the compound to be able to tailor the care appropriately. This will help avoid atropinisation in cases where they are not needed and limit to symptomatic management. There are some similarities in treatment, like the use of stomach wash. We can use the time of initial treatment being administered to establish the ingested compound. Pralidoxime can be given in undifferentiated cases, as early administration of PAM has beneficial effects in OP poisoning and has not been noted to cause harm by its administration cypermethrin poisoning. It is the use of atropine which need to be monitored. Use of atropine should be stopped on confirmation of cypermethrin poisoning. Current and recent advice is to treat cypermethrin poisoning cases symptomatically.
References
1. Aggarwal P., Jamshed N., Ekka M., Imran A. Suicidal poisoning with cypermethrin: A clinical dilemma in the emergency department. J Emerg Trauma Shock. 2015; 8(2):123-125. doi:10.4103/0974-2700.145424
2. Junquera P. Cypermethrin: Safety Summary for Veterinary Use. Parasitepedia.net, WHO
Acute Hazard classification: Class II, moderately hazardous. Dec 15 2017.
3. Singh A.K., Tiwari M.N., Prakash O., Singh M.P. A current review of cypermethrin-induced neurotoxicity and nigrostriatal dopaminergic neurodegeneration. Curr Neurophar-macol. 2012; 10(1):64-71. doi:10.2174/ 157015912799362779
4. Cypermethrin, INCHEM, url:inchem.org/do-cuments/pims/chemical/pim163.htm
ЦИПЕРМЕТРИН БИЛАН ЗАХДРЛАНИШ -КАМ УЧРАЙДИГАН КЛИНИК ХОЛАТ БУЙИЧА МАЪЛУМОТ
А.Н. Венкатеш1, С.Б. Басавараддер2, Х. Раджанна2
хАпполо касалхонаси, Карнатака, Хиндистон 2Апполо касалхонаси, Бангалор, Хиндистон
Хиндистонда инсектицид ва пестицидлар билан зах,арланиш нисбатан куп учраб туради. Фосфат-органик бирикма (ФБ)лар организмга зарар курсатувчи энг куп тарцалган пестицидлардан бири булиб цолмоцда. Шунга ухшаш кимёвий моддаларнинг турли хил аналогларининг сотувда пайдо булиши шошилинч тиббий ёрдам булимларига бундай моддаларни ютиб юборганлиги сабабли му-рожаат цилаётган беморларни даволашда цийинчиликлар тугдирмоцда. Ушбу кимёвий воситалар бир-бирига ухшаш савдо белгисига эга булгани х,олда, кимёвий таркиби купинча турли хил булади. Бу каби моддалар буйича барча учун очиц булган маълумотлар базаси ва ушбу моддалар билан зах,арланганда куриладиган чораларга доир тавсиялар йуцлиги муаммоси очицлигича цолмоцда. Мацсад ва вазифалар:
- Пестицидларнинг барчаси х,ам ФБ эмаслигини ёдда тутиш зарур.
- Сотувда янги воситалар пайдо булганда уларга тегишли маълумотномаларни диццат билан уциб чициб, ушбу моддалар билан зах,арланган беморларни даволаш буйича царор цабул цилиш зарур. Шу билан бир цаторда, пестицидлар ва инсектицидлар кенг спектрдаги кимёвий таркибга эга экан-лигини тушунган х,олда, эх,тиёт чораларини ишлаб чицишимиз зарур. Шошилинч тиббий ёрдам булимлари шифокорлари ушбу моддалар билан зах,арланган беморларга ёрдам курсатишда улар-нинг кимёвий таркибини аницлаштиришга ва буюрилган даво чораларига тегишли узгартиришлар киритишлари учун маълум бир вацт ва х,аракатларни сарфлашларига тугри келади.
Калит сузлар: фосфаторганик бирикмалар, суицид, зацарланиш, даволаш.
Information about authors:
Dr. A.N. Venkatesh - b Senior Consultant & Head, Emergency Medicine, Apollo Hospitals, Karnataka Region, India.
Dr. S.B. Basavaradder - Associate consultant Emergency Medicine, Apollo Hospital, Bengaluru, India.
Dr. H. Rajanna - Consultant Emergency Medicine, Apollo Hospital, Bengaluru, India.
Сведения об авторах:
А.Н. Венкатеш - старший консультант и руководитель отделения экстренной медицины, больница Аполло - Карнатака, Индия С.Б. Басавараддер - младший консультант по экстренной медицинской помощи, больница Аполло, Бангалор, Индия. Х. Раджанна - консультант по экстренной медицинской помощи, больница Аполло, Бангалор, Индия.
Поступила в редакцию 02.01.2021
