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Paraquat Poisoning

Paraquat Toxicity %2F Parquat Lung

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].

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]
  • There were no history of abdominal pain, diarrhoea, seizure or fever. Past medical history included depression.[ispub.com]
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]
  • The detection method was rigorously evaluated against a real-world data set to determine its accuracy, sensitivity and specificity.[ncbi.nlm.nih.gov]
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]
  • 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]
  • We report the case of a 28-year-old man admitted to the casualty department at Ngwelezana Hospital, Empangeni, KwaZulu-Natal, South Africa, with a history of vomiting and abdominal pain after ingestion of 100 mL of an unknown substance, later identified[ncbi.nlm.nih.gov]
  • A 9-year-old boy was admitted to a peripheral hospital with a history of diarrhoea and vomiting. He later developed abdominal pain, subcutaneous emphysema and difficulty in breathing.[ncbi.nlm.nih.gov]
  • 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%).[ncbi.nlm.nih.gov]
Abdominal Pain
  • We report the case of a 28-year-old man admitted to the casualty department at Ngwelezana Hospital, Empangeni, KwaZulu-Natal, South Africa, with a history of vomiting and abdominal pain after ingestion of 100 mL of an unknown substance, later identified[ncbi.nlm.nih.gov]
  • 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]
  • Abdominal computed tomography of the seven cases showed no evidence of pancreatitis, and significant abdominal pain was not observed.[ncbi.nlm.nih.gov]
  • 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%).[ncbi.nlm.nih.gov]
  • 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]
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]
  • 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%).[ncbi.nlm.nih.gov]
  • 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]
  • […] 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]
Diarrhea
  • 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]
  • 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]
  • 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]
  • The next signs of illness following ingestion are gastrointestinal (digestive tract) symptoms, such as nausea, vomiting, abdominal pain, and diarrhea (which may become bloody).[emergency.cdc.gov]
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]
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]
  • Smaller doses (greater than or equal to 4 mg/kg of paraquat base) may cause respiratory distress, renal dysfunction or, occasionally, jaundice or adrenal cortical necrosis.[ajhp.org]
  • 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]
Myopathy
  • The patient subsequently developed a progressive, severe, toxic myopathy with generalized weakness and inability to maintain spontaneous ventilation.[ncbi.nlm.nih.gov]
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]
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]

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].

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]
  • The treatment of PQ poisoning has always been difficult, and there is currently no definite effective treatment.[ncbi.nlm.nih.gov]
  • ), and 37.9% (combined treatment group).[ncbi.nlm.nih.gov]
  • Vital organ function, survival time within 28 days and adverse events during the treatment were reviewed.[ncbi.nlm.nih.gov]
  • Out of 138 patients, 60 were treated with pulse treatment (15 mg kg day MP for 3 days) and 78 were treated with prolonged MP therapy after pulse treatment (15 mg kg day MP for 3 days; afterward, the dosage was reduced in half every 2 days, and the MP[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]
  • The early identification of toxic paraquat (PQ) poisoning in patients is critical to ensure timely and accurate prognosis.[ncbi.nlm.nih.gov]
  • ADVANCES IN KNOWLEDGE: Chest CT scan can be used 2-3 days following acute PQ poisoning to determine prognosis.[ncbi.nlm.nih.gov]
  • Abstract Many prognostic indictors have been studied to evaluate the prognosis of paraquat poisoning. However, the optimal indicator remains unclear.[ncbi.nlm.nih.gov]
  • The long-term prognosis of paraquat poisoning was not optimistic. The plasma paraquat level could be a significant factor in predicting the prognosis.[ncbi.nlm.nih.gov]

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]
  • Aetiological aspects on primary liver cancer with special regard to alcohol, organic solvents and acute intermittent porphyria — An epidemiological investigation. ‎ Pagina 283 - Bressac, B., Kew, M., Wands, J., and Ozturk, M. 1991.[books.google.ro]
Sex distribution
Age distribution

Pathophysiology

  • In light of the apparently irreversible pathophysiology of paraquat poisoning with plasma levels as low as 3 mg/L, prevention and early intervention are the best treatments.[ncbi.nlm.nih.gov]
  • 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]
  • Abstract The pathophysiology, symptoms and treatment of paraquat intoxication, primarily from oral ingestion, and the pharmacology and pharmacokinetics of paraquat are reviewed.[ajhp.org]
  • From basic science and pathophysiology to clinical best practices, Brenner & Rector’s The Kidney is your go-to resource for any stage of your career.[books.google.com]

Prevention

  • However, our clinical experience and data concerning paraquat concentration in body and dialysis fluids suggest a therapeutic approach aimed at preventing early and progressive tissue damage.[ncbi.nlm.nih.gov]
  • In conclusion, prophylactic CVVH after HP prevented early death caused by circulatory collapse and prolonged survival time.[ncbi.nlm.nih.gov]
  • 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]
  • Postmortem concentration of paraquat in different tissues reveals that treatment in this case could not prevent lethal tissue accumulation. Although accumulation was more pronounced in renal tissue, lung toxicity caused death.[ncbi.nlm.nih.gov]
  • In light of the apparently irreversible pathophysiology of paraquat poisoning with plasma levels as low as 3 mg/L, prevention and early intervention are the best treatments.[ncbi.nlm.nih.gov]

References

Article

  1. Bismuth C, Hall AH. Paraquat Poisoning: Mechanisms, Prevention, Treatment. New York: Marcel Dekker Inc; 1995.
  2. 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.
  3. Scherrmann JM, Houze P, Bismuth C, Bourdon R. Prognostic value of plasma and urine paraquat concentration. Hum Toxicol. 1987;6:91–93.
  4. 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.
  5. Zhou CY, Kang X, Li CB, et al. Pneumomediastinum predicts early mortality in acute paraquat poisoning. Clin Toxicol. 2015; 53:551-556.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. Lee SH, Lee KS, Ahn JM, Kim SH, Hong SY. Paraquat poisoning of the lung: thin-section CT findings. Radiology. 1995;195:271–274.
  13. 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.
  14. 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.

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Last updated: 2018-06-22 05:47