Paraquat is a fast acting, potent, and non-selective contact herbicide. Paraquat poisoning, resulting in serious damage to various organs, may be caused by ingestion of just one teaspoon of paraquat. Paraquat poisoning is frequently fatal.
Presentation
The amount of paraquat ingested dictates the extent of organs damage and symptoms [1]. Ingestion of more than 50 to 100 ml of 20% (w/v) liquid concentrate is very likely to cause multi-system organ failure (pulmonary, cardiac, renal, and liver) and death within a few hours to days following ingestion [2].
Immediate symptoms include pain and swelling of the mouth, throat, and upper airway. Ingestion of a small quantity of paraquat causes pulmonary and renal toxicity over a period of 2 to 6 days. Pulmonary toxicity is characterized by acute alveolitis and pulmonary edema over a period of 1 to 3 days, followed by an aggressive development of pulmonary fibrosis. Manifestations of acute renal failure (e.g., decreased urinary output, severely elevated creatine, cystatin C, and BUN levels) and/or liver toxicity (jaundice and elevated transaminases levels) are also common [3] [4].
Some degree of gastrointestinal (GI) toxicity is almost always present in those with paraquat ingestion. GI symptoms may include mucosal lesions of the mouth and tongue (‘paraquat tongue’), pharynx, esophagus, and stomach within the first several days of ingestion. Abdominal pain, nausea, vomiting, and/or diarrhea may also be present. Patients that present with mediastinitis and/or pneumomediastinum secondary to esophageal perforation have a high mortality rate [5].
Entire Body System
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Fever
A 57-year-old farmer developed breathlessness, high fever and interstitial infiltrates in the upper and middle lung fields few days after percutaneous paraquat poisoning with rapid evolution to pulmonary fibrosis. [ncbi.nlm.nih.gov]
[…] bipyridilium herbicide that has been banned in Europe), usually occurring through ingestion of the poison, and that presents with caustic injury of the oral cavity and pharynx, as well as nausea, vomiting, epigastric pain, lethargy, loss of consciousness and fever [orpha.net]
He was referred to our hospital after 5 days He had fever for 1 day with complaints of breathlessness, hematemesis, dark stools, reduced urine output, and epigastric pain. [mjdrdypu.org]
He was relatively well for several months after the surgery, when he developed fever and cough and was admitted to the hospital with impression of infected bulla and lung abscess. [ircmj.com]
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Rigor
The proposed method was rigorously evaluated against the real-life dataset in terms of accuracy, sensitivity, and specificity. Additionally, the feature selection was investigated to identify correlating factors for the risk status. [ncbi.nlm.nih.gov]
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Intravenous Drugs
Herein, we present a case of an intravenous drug abuser who injected paraquat in an effort to commit suicide. He received hemoperfusion and intravenous cyclophosphamide treatment and parenteral pulse therapy with methylprednisolone. [ncbi.nlm.nih.gov]
Gastrointestinal
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Vomiting
CONCLUSION: A large amount of ingested PQ, vomiting and age may be important variables to consider in association with the high fatality rate of PQ poisoning. [ncbi.nlm.nih.gov]
Kidney disease and age 50yrs- bad prognosis Time of ingestion Painful mouth, difficulty in swallowing, nausea, vomiting, abdominal pain Burning skin sensation Respiratory complaints-systemic poisoning 6. [slideshare.net]
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Nausea
She presented with discomfort, nausea and vomiting. She had drunk a small wine glass full of paraquat. After 18 days in the hospital, the girl developed neutropenia. This is the first reported case of paraquat poisoning-induced neutropenia. [ncbi.nlm.nih.gov]
[…] poisoning is a rare intoxication with paraquat (a non-selective bipyridilium herbicide that has been banned in Europe), usually occurring through ingestion of the poison, and that presents with caustic injury of the oral cavity and pharynx, as well as nausea [orpha.net]
Abdominal pain, nausea, vomiting, and/or diarrhea may also be present. Patients that present with mediastinitis and/or pneumomediastinum secondary to esophageal perforation have a high mortality rate. [symptoma.com]
The complications included shock (50.0%), hypoxemia (33.3%), respiratory failure (33.3%), nausea/vomiting (16.7%), abdominal pain (33.3%), hepatitis (66.7%), gastrointestinal tract bleeding (33.3%), acute renal failure (33.3%), and seizures (16.7%). [journals.lww.com]
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Abdominal Pain
He later developed abdominal pain, subcutaneous emphysema and difficulty in breathing. Following transfer to a district hospital and then to a teaching hospital, poisoning with paraquat was suspected only on day 11 of the illness. [ncbi.nlm.nih.gov]
He developed hematemesis, epigastric burning, and abdominal pain. The details of the treatment were not available. [mjdrdypu.org]
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Diarrhea
Lab evaluation General testing: Blood tests- on admission, every 6 to 12th hourly for first 48 hours, then based on clinical severity- vomiting, diarrhea, kidney injury. If prognosis is poor - palliative measures 8. Serum electrolytes- may be [slideshare.net]
Abdominal pain, nausea, vomiting, and/or diarrhea may also be present. Patients that present with mediastinitis and/or pneumomediastinum secondary to esophageal perforation have a high mortality rate. [symptoma.com]
Asymptomatic, vomiting, diarrhea, minimal hepatic, and renal lesions; decrease in pulmonary diffusion capacity, chances of complete recovery. Moderate-to-severe acute poisoning 20-30, 40-50. [mjdrdypu.org]
When ingested, paraquat poisoning results in severe gastrointestinal distress, including vomiting, diarrhea, abdominal pain, ulcers in the mouth and esophagus, etc. [petpoisonhelpline.com]
Soon after, they may experience: nausea abdominal pain vomiting diarrhea that may be bloody The gastrointestinal symptoms are often severe. They can lead to both dehydration and low blood pressure. [healthline.com]
Liver, Gall & Pancreas
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Jaundice
Case 2 (alive) showed mild liver dysfunction without jaundice. [ncbi.nlm.nih.gov]
decreased urinary output, severely elevated creatine, cystatin C, and BUN levels) and/or liver toxicity (jaundice and elevated transaminases levels) are also common. [symptoma.com]
Physical examination revealed mild jaundice and swelling and redness of the throat. Laryngoscopy showed redness and necroses of the hypopharynx, the epiglottis and the vocal cords. [bmcpharmacoltoxicol.biomedcentral.com]
Figure 1 Photograph of the patient of the described case, the oral mucosa is observed with edema, jaundice and ulcerations. [medcraveonline.com]
Cardiovascular
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Tachycardia
Immediate vomiting, diarrhea, abdominal pain, mouth and throat ulceration; within day renal, hepatic failure, hypotension, and tachycardia. Within 1 week hemoptysis, pleural effusion, pulmonary fibrosis. Most commonly leads to death in 2-3 weeks. [mjdrdypu.org]
Diagnosing toxicity from vital signs Bradycardia (PACED) Propranolol (beta-blockers), poppies (opiates), propoxyphene, physostigmine Anticholinesterase drugs, antiarrhythmics Clonidine, calcium channel blockers Ethanol or other alcohols Digoxin, digitalis Tachycardia [segwfg.nl]
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Retrosternal Chest Pain
A 15-year-old boy presented with a 1-month history of retrosternal chest pain with no obvious cause. High-resolution computed tomography showed pneumomediastinum. [ncbi.nlm.nih.gov]
Musculoskeletal
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Myopathy
The patient subsequently developed a progressive, severe, toxic myopathy with generalized weakness and inability to maintain spontaneous ventilation. [ncbi.nlm.nih.gov]
Skin
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Burning Skin Sensation
Kidney disease and age 50yrs- bad prognosis Time of ingestion Painful mouth, difficulty in swallowing, nausea, vomiting, abdominal pain Burning skin sensation Respiratory complaints-systemic poisoning 6. [slideshare.net]
Psychiatrical
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Denial
After all likely causes of pneumomediastinum were eliminated, the diagnosis of occult paraquat poisoning was made when serum paraquat concentration was revealed at 467.40 ng/mL, despite the patient's denial of ingestion or contact. [ncbi.nlm.nih.gov]
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Dysthymic Disorder
CONCLUSIONS: Awareness of comorbid psychiatric illnesses, especially dysthymic disorder, is vital in the prevention and treatment of suicide by paraquat poisoning. [ncbi.nlm.nih.gov]
Urogenital
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Oliguria
Clinical features of paraquat toxicity Mild overdose: Nausea and vomiting Diarrhoea Intestinal hemorrhage Haemoptysis Oliguria Minimal renal dysfunction Moderate overdose: Renal failure (ATN within 12-24hours) Pulmonary oedema Hepatotoxicity Pulmonary [derangedphysiology.com]
Renal system Paraquat is eliminated mainly by the urinary tract, renal failure being oliguria and anuric acid main complication. [medcraveonline.com]
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Anuria
Increase in serum Cr to 200% to 300% ( 2 to 3-fold) from baseline 0.5 mL/kg/h for more than 12 h Stage 3 Increase in serum Cr to 300% (3-fold) from baseline (or serum Cr of 4.0 mg/dL with an acute increase of at least 0.5 mg/dL 0.3 mL/kg/h for 24 h or anuria [journals.plos.org]
Workup
Clinicians should first obtain a thorough history that includes the patient's comorbidities, the strength and quantity of paraquat ingested, and the time of ingestion [6] [7]. The physical exam includes an inspection of the patient's skin and eyes for signs of topical contact, the mouth and pharynx for irritation or ulcerations, auscultation of the chest for crackles which may indicate alveolitis, and the palpation of the abdomen.
The patient's vital signs should be continuously monitored, including respiratory rate and oxygen saturation levels given the high likelihood of pulmonary injury. An arterial blood gas test may be used to evaluate resultant lung injury. A low PaCO2 with concurrent tachypnea indicates the progression of hypoxia. PaO2 steadily declines as paraquat-induced lung injury proceeds; a PaO2 less than 60 mmHg has been associated with a significant rise in mortality [8].
Laboratory tests
Quantitative serum and urine paraquat levels should be obtained to ascertain the degree of intoxication [9]. The concentration of paraquat in the body relative to the time of paraquat ingestion predicts the likelihood of death [10]. The dithionite urine test becomes positive for paraquat about six hours following a large ingestion [11]. The serum level usually peaks one hour after ingestion, followed by a rapid decline as it is redistributed to other compartments in the body.
Imaging tests
A chest radiography may be performed in patients with symptoms indicative of acute lung injury, hypoxia, hyperventilation, and/or crackles on admission, but it has weak sensitivity. A high-resolution computed tomography of the chest could be performed to ascertain the extent of lung injury, about one week after ingestion [12] [13] [14].
Other Pathologies
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Gliosis
Examination of the brain by electron microscopy showed oedema and destruction of myelin with abundant myelin breakdown products, and astrocytic fibrous gliosis. [ncbi.nlm.nih.gov]
Biopsy
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Liver Biopsy
We have examined liver biopsy specimens from two cases of paraquat poisoning. Case 1 (fatal) presented severe intrahepatic jaundice, and liver biopsy showed centrilobular cholestasis with extensive bile duct loss. [ncbi.nlm.nih.gov]
Treatment
RESULTS: Seventy-five, 65, and 43 underwent conservative treatment only (conservative treatment group), conservative treatment HP (HP group), and conservative treatment HP CVVH (HP CVVH group), respectively. [ncbi.nlm.nih.gov]
Prognosis
OBJECTIVE: To examine the utility of arterial blood gas analysis (ABG) in early evaluation of prognosis in paraquat poisoning. [ncbi.nlm.nih.gov]
Etiology
In the septic etiology the presence of a microbial infection is detected by mononuclear phagocytes (monocytes, tissue macrophages) and by mast cells. [medcraveonline.com]
Epidemiology
China. 3 Emergency Department, The First Affiliated hospital of Zhengzhou University, Zhengzhou 450052, China. 4 Institute of Medical Information, Chinese Academy of Medical Sciences &Peking Union Medical College, Beijing 100020, China. 5 Department of Epidemiology [ncbi.nlm.nih.gov]
Investigate the epidemiology of acute paraquat poisoning in Fiji 2. Assist in the development of a treatment protocol specific to the needs and clinical resources of Fiji 3. [globalhealth.uic.edu]
الصفحة 69 - Epidemiology is defined as the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to control of health problems. [books.google.com]
He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. [lifeinthefastlane.com]
The Epidemiology of Paraquat Intoxications in Surinam. - Abstract - Europe PMC [Internet]. Available at: . Accessed September 23, 2016. [33]. University of California, Riverside, U.S.A. Academic Press, Krieger R. [journals.lww.com]
Pathophysiology
The management is discussed in the light of the histological observations, and the pathophysiology of the condition. [ncbi.nlm.nih.gov]
Certain topics are discussed in depth either because of their clinical importance or because recent data have become available concerning pathophysiology or treatment. [books.google.com]
However, other causes such as pancreatitis, burns, major surgery, cirrhosis, intoxication, trauma and ischemia-reperfusion syndrome have allowed to unify the pathophysiology of multiple organ failure due to the different hemodynamic, microvascular and [medcraveonline.com]
Prevention
In order to prevent pulmonary fibrosis, we employed radiotherapy of both lungs in a 23-year-old patient with severe paraquat poisoning; however, it failed to prevent the fatal outcome. [ncbi.nlm.nih.gov]
References
- Bismuth C, Hall AH. Paraquat Poisoning: Mechanisms, Prevention, Treatment. New York: Marcel Dekker Inc; 1995.
- Proudfoot AT, Vale JA. Pesticides. In: Weatherall DJ, Ledingham JGG, Warrell DA, editors. Oxford Textbook of Medicine. 3rd edn. Oxford: Oxford University Press.1996;1120–1124.
- Scherrmann JM, Houze P, Bismuth C, Bourdon R. Prognostic value of plasma and urine paraquat concentration. Hum Toxicol. 1987;6:91–93.
- Roberts DM, Wilks MF, Roberts MS, et al. Changes in the concentrations of creatinine, cystatin C and NGAL in patients with acute paraquat self-poisoning. Toxicol Lett. 2011;202:69–74.
- Zhou CY, Kang X, Li CB, et al. Pneumomediastinum predicts early mortality in acute paraquat poisoning. Clin Toxicol. 2015; 53:551-556.
- Wilks MF, Tomenson JA, Fernando R, et al. Formulation changes and time trends in outcome following paraquat ingestion in Sri Lanka. Clin Toxicol. 2011; 49:21-28.
- Kim JH, Gil HW, Yang JO, et al. Serum uric acid level as a marker for mortality and acute kidney injury in patients acute paraquat intoxication. Nephrol Dial Transplant. 2011; 26:1846-1852.
- Lee KH, Gil HW, Kim YT, Yang JO, Lee EY, Hong SY. Marked recovery from paraquat-induced lung injury during long-term follow-up. Korean J Intern Med. 2009;24:95–100.
- Seok S, Kim YH, Gil HW, Song HY, Hong SY. The time between paraquat ingestion and a negative dithionite urine test in an independent risk factor for death and organ failure in acute paraquat intoxication. J Korean Med Sci. 2012;27:993–998.
- Senarathna L, Eddleston M, Wilks MF, et al. Prediction of outcome after paraquat poisoning by measurement of the plasma paraquat concentration. QJM. 2009; 102:251-259.
- Koo JR, Joon YW, Han SJ, et al. Rapid analysis of plasma paraquat using sodium dithionite as a predictor of outcome in acute paraquat poisoning. Am J Med Sci. 2009; 338:373.
- Lee SH, Lee KS, Ahn JM, Kim SH, Hong SY. Paraquat poisoning of the lung: thin-section CT findings. Radiology. 1995;195:271–274.
- Im JG, Lee KS, Han MC, Kim SJ, Kim IO. Paraquat poisoning: findings on chest radiography and CT in 42 patients. AJR Am J Roentgenol. 1991;157:697–701.
- Zhang H, Liu P, Qiao P, et al. CT imaging as a prognostic indicator for patients with pulmonary injury from acute paraquat poisoning. Br J Radiol. 2013;86:20130035.