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Pesticide Poisoning

Pesticides Toxicity

Pesticide poisoning occurs accidentally and intentionally across the world since these products are widely used agriculturally and domestically. Pesticides commonly contain organophosphates, which cause a wide range of symptoms related to muscarinic and nicotinic effects.


Presentation

Most household and agricultural pesticides are composed of organophosphates and carbamates [1] [2]. These anticholinesterase compounds are widely available and effective. Hence, accidental and intentional poisoning with these products occurs at a high frequency, particularly in rural regions in developing countries [3].

Exposure to anticholinesterases may result in acute muscarinic and nicotinic toxicity. Muscarinic signs include diaphoresis, diarrhea, urination, miosis, bradycardia, bronchospasm, bronchorrhea, emesis, excess lacrimation, and salivation (DUMBELS). Meanwhile, nicotinic effects are comprised of muscle fasciculations, weakness, paralysis and possibly cardiovascular consequences such as tachycardia and hypertension [4].

Other severe manifestations that emerge from pesticide poisoning are mental status changes such as confusion, lethargy, agitation, anxiety, and possibly coma [3]. In cases with delayed toxicity, neuropathy may arise days to weeks post-exposure.

Complications

Sequelae such as seizure, loss of consciousness, and respiratory depression may lead to respiratory failure [5] [6]. Furthermore, other severe outcomes include myocardial infarction, liver and kidney impairment, multisystem failure, and secondary infections [7]. Additionally, cognitive deficits and extrapyramidal signs are considered as potential long-term effects.

Physical exam

The overall clinical presentation is notable for an altered mental status, fasciculations, sweating, and pinpoint pupils. Remarkable findings on an evaluation of the vital signs include hypoxia and dramatic changes in heart rate and blood pressure. Moreover, auscultation of the lungs may reveal wheezing, rhonchi, and distressed breathing while the neurology exam may demonstrate parkinsonian features and possibly paralysis.

Fatigue
  • Symptoms of Heat Exhaustion Symptoms of Organophosphate/ Carbamate Poisoning Sweating Sweating Headache Headache Fatigue Fatigue Dry membranes Moist membranes Dry mouth Salivation No tears Tears No spit present Spit present in mouth Fast pulse (slow if[epa.gov]
  • Symptoms that indicate the possibility of an accidental poisoning: General: Extreme weakness and fatigue Skin: Irritation, burning sensation, excessive perspiration Eyes: Itching, burning sensation, watering, difficult or blurred vision, narrowed or widened[cropscience.bayer.in]
  • Symptoms of mild poisoning headache sweating diarrhoea irritation of nose and throat eye irritation nausea fatigue changes of mood skin irritation insomnia loss of appetite thirst weakness restlessness dizziness sore joints nervousness Symptoms of severe[health.gov.au]
  • General Symptoms Which Might Indicate Pesticide Poisoning mild poisoning moderate poisoning severe poisoning headache dizziness weakness fatigue nervousness loss of appetite thirst nausea irritation of throat and nose eye irritation constriction of pupils[www2.gov.bc.ca]
  • Headache, fatigue, soreness in joints, irritation of nose and throat. Yes. Fever, intense thirst, vomiting, muscle twitches, pinpoint pupils, unconsciousness. Yes.[articles.extension.org]
Multiple Organ Dysfunction Syndrome
  • Adjuvant treatment with crude rhubarb was associated with a significantly lower incidence of intermediate syndrome (risk ratio [RR] 0.22; 95% confidence interval [CI] 0.10-0.48), as well as multiple organ dysfunction syndrome (RR 0.34; 95% CI 0.20-0.56[ncbi.nlm.nih.gov]
Goiter
  • Early evaluation of thyroid function in anticholinesterase pesticide poisoning subjects is suggested, especially in subjects without atropine treatment, aged 40-64 years, female sex, and past history of goiter.[ncbi.nlm.nih.gov]
Exposure to Rat Poison
  • Organophosphates were implicated in 70.9% of all fatalities, with over 20% resulting from oral exposure to rat poison (RP).[ncbi.nlm.nih.gov]
Nausea
  • The result is an array of symptoms such as nausea, diarrhea, abdominal cramps, dizziness, confusion and anxiety.[web.archive.org]
  • nausea, constric- tion of throat, dizziness, nervous- ness.[psep.cce.cornell.edu]
  • Mild Poisoning or Early Symptoms of Acute Poisoning headache, fatigue, weakness, dizziness, restlessness, nervousness, perspiration, nausea, diarrhea, loss of appetite, loss of weight, thirst, moodiness, soreness in joints, skin irritation, eye irritation[articles.extension.org]
  • Nausea and diarrhea Dilated pupils Possibly small pupils Central nervous system depression Central nervous system depression Loss of coordination Loss of coordination Confusion Confusion Fainting (prompt recovery) Coma (can't waken)[epa.gov]
Abdominal Pain
  • pains and headache and convulsions and sweating Type of: intoxication, poisoning, toxic condition the physiological state produced by a poison or other toxic substance[vocabulary.com]
  • Abdominal pain usually follows. These symptoms largely mimic gastroenteritis (stomach flu) and many people ignore it. Other symptoms that also arise with pesticide ingestion are confusion, tremors and respiratory distress.[healthhype.com]
  • pain, diarrhoea Nervous system: Headache, dizziness, mental confusion, restlessness, muscle twitching, staggering gait, slurred speech, fits, and unconsciousness Respiratory system: Cough, chest pain and tightness, difficulty with breathing, wheezing[cropscience.bayer.in]
  • […] blood pressure) Bradycardia (decreased heart rate) – late (decreased heart rate) Hypotension (low blood pressure) – late (low blood pressure) Arrhythmias Dysrhythmias (prolonged QT on EKG, ventricular tachycardia) Gastrointestinal signs and symptoms Abdominal[emergency.cdc.gov]
Regurgitation
  • Syrup of ipecac is not recommended for most pesticide poisonings because of potential interference with other antidotes and regurgitation increasing exposure of the esophagus and oral area to the pesticide.Urinary alkalinisation has been used in acute[en.wikipedia.org]
Lacrimation
  • Muscarinic signs include diaphoresis, diarrhea, urination, miosis, bradycardia, bronchospasm, bronchorrhea, emesis, excess lacrimation, and salivation (DUMBELS).[symptoma.com]
  • & and vomiting Diarrhea Urinary incontinence, frequency Musculoskeletal signs and symptoms Weakness (may progress to paralysis) Fasciculations (local or generalized) Skin and mucous membrane signs and symptoms Profuse sweating (local or generalized) Lacrimation[emergency.cdc.gov]
Muscle Twitch
  • Intense muscle twitching or seizures: A seizure in anyone without a pre-existing condition could be a serious indicator of major pesticide exposure.[organicauthority.com]
  • Severe or Acute Poisoning fever, intense thirst, increased rate of breathing, vomiting, uncontrollable muscle twitches, pinpoint pupils, convulsions, inability to breathe, unconsciousness.[articles.extension.org]
  • twitching, staggering gait, slurred speech, fits, and unconsciousness Respiratory system: Cough, chest pain and tightness, difficulty with breathing, wheezing Do’s and Don’t’s in case of poisoning Maintain adequate respiration.[cropscience.bayer.in]
  • Injure liver, kidney, and nervous system Prompt vomit- ing, burning sensation in stomach, dia- rrhea, muscle twitching Moderately irritating to eyes, skin, and lungs Do not remain in body; passed out within hours or days Paraquat and Diquat Herbicides[psep.cce.cornell.edu]
Headache
  • Blisters and redness on the skin Liver damage, weight loss, and jaundice Carbon disulfide Fumigants Injury to nervous system Headache, dizzi- ness, nausea, and disorientation Irritates eyes, nose, and throat.[psep.cce.cornell.edu]
  • Headache, fatigue, soreness in joints, irritation of nose and throat. Yes. Fever, intense thirst, vomiting, muscle twitches, pinpoint pupils, unconsciousness. Yes.[articles.extension.org]
  • Symptoms of Heat Exhaustion Symptoms of Organophosphate/ Carbamate Poisoning Sweating Sweating Headache Headache Fatigue Fatigue Dry membranes Moist membranes Dry mouth Salivation No tears Tears No spit present Spit present in mouth Fast pulse (slow if[epa.gov]
  • Sudden but persistent headache: If you're not one to regularly experience headaches and your routine hasn't changed recently, you may have eaten or inhaled a hefty dose of a pesticide.[organicauthority.com]
Confusion
  • Confusion Fainting (prompt recovery) Coma (can't waken)[epa.gov]
  • Other symptoms that also arise with pesticide ingestion are confusion, tremors and respiratory distress. Once seizures or a coma occurs, the outcome may be very poor.[healthhype.com]
  • The result is an array of symptoms such as nausea, diarrhea, abdominal cramps, dizziness, confusion and anxiety.[web.archive.org]
  • Other severe manifestations that emerge from pesticide poisoning are mental status changes such as confusion, lethargy, agitation, anxiety, and possibly coma. In cases with delayed toxicity, neuropathy may arise days to weeks post-exposure.[symptoma.com]
Altered Mental Status
  • Physical exam The overall clinical presentation is notable for an altered mental status, fasciculations, sweating, and pinpoint pupils.[symptoma.com]
  • Excess acetylcholine produces a predictable cholinergic syndrome consisting of copious respiratory and oral secretions, diarrhea and vomiting, sweating, altered mental status, autonomic instability, and generalized weakness that can progress to paralysis[emergency.cdc.gov]
Peripheral Neuropathy
  • This is different from a potentially permanent peripheral neuropathy. Expert advice Expert advice may be sought from PHE which has helplines for Chemicals 0844 8920555 and Poisons 0844 892 0111.[patient.info]
Generalized Seizure
  • CONCLUSION: The clinical manifestations of amitraz (impaired consciousness, drowsiness, vomiting, disorientation, miosis, mydriasis, hypotension, bradycardia, respiratory depression, hypothermia, generalized seizures, hyperglycemia and glycosuria) can[ncbi.nlm.nih.gov]

Workup

Suspicion for organophosphate pesticide toxicity should be high for patients with altered mental status, miosis, excessive diaphoresis, fasciculations and difficulty with respiration. Since this is a clinical diagnosis, the patient's history, exposure risk, and characteristic findings on physical exam are significant components of the workup. Furthermore, assessment of the cholinesterase activity is important for confirmation of the diagnosis.

Laboratory tests

Organophosphate pesticides act as cholinesterase inhibitors, which explains why the measurement of cholinesterase activity is used as the confirmatory study [4]. Moreover, both red blood cell cholinesterase (RBC AChE) and plasma or pseudo cholinesterase (PChE) can be tested. However, RBC AChE is a more accurate biomarker.

In contrast to time-consuming assays, there is a portable field test known as Test-mate ChE that yields RBC AChE and PChE results within 4 minutes. This has been reported as an effective tool for the measurement of cholinesterase levels in patients with acute organophosphate pesticide poisoning [8]. The use of enzyme assays and confirmation of toxicity is paramount in the monitoring of organophosphates in occupational and military settings [9].

Administration of atropine reverses or improves the anti-muscarinic manifestations and thereby serves as a diagnostic and therapeutic measure.

Further evaluation is necessary to understand the comprehensive picture. For example, a complete blood count (CBC) exhibits leukocytosis while a complete metabolic panel (CMP) demonstrates hyperglycemia, hypokalemia, hypomagnesemia, increased liver function tests (LFTs) and elevated amylase. Additionally, cardiac enzyme studies may be notable for elevated troponin levels due to myocardial injury [10]. Very importantly, an arterial blood gas is likely to show metabolic and/or respiratory acidosis.

Other

Electrocardiography (EKG) reveals the presence of arrhythmias and ischemic changes.

Glycosuria
  • CONCLUSION: The clinical manifestations of amitraz (impaired consciousness, drowsiness, vomiting, disorientation, miosis, mydriasis, hypotension, bradycardia, respiratory depression, hypothermia, generalized seizures, hyperglycemia and glycosuria) can[ncbi.nlm.nih.gov]
Pseudomonas
  • Stepanov and Brian Iken, Isolation and molecular characterization of a novel pseudomonas putida strain capable of degrading organophosphate and aromatic compounds, Advances in Biological Chemistry, 03, 06, (564), (2013).[doi.org]
Ischemic Changes
  • Other Electrocardiography (EKG) reveals the presence of arrhythmias and ischemic changes.[symptoma.com]

Treatment

  • […] by a high-volume physician can reduce LOS and treatment cost.[ncbi.nlm.nih.gov]
  • Interventions included oral N-acetylcysteine (600 mg three times daily for 3 days) as an added treatment to the conventional measures versus only the conventional treatment.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To summarize the beneficial effects of adjuvant treatment with crude rhubarb in patients with AOPP by conducting a meta-analysis.[ncbi.nlm.nih.gov]
  • In this article we discuss some recent developments and treatment dilemmas, illustrated by cases from our clinic, followed by a review of the current recommendations in the treatment of organophosphate poisoning.[ncbi.nlm.nih.gov]
  • Further understanding may also lead to improvements in diagnosis and treatment. 4. The few effective treatments are not being recommended or delivered in an optimal and timely fashion to poisoned patients.[ncbi.nlm.nih.gov]

Prognosis

  • […] and neutrophil-lymphocyte and platelet-lymphocyte ratios (p CONCLUSION: Leukocyte counts, neutrophil counts, and neutrophil-lymphocyte ratios measured within the first 24 h after admission to the ED are useful and easy-to-use parameters for estimating prognosis[ncbi.nlm.nih.gov]
  • The teenagers’ prognosis depends on the duration of exposure and how much they breathed in, Dr.[people.com]
  • “I would say the prognosis, at best, is guarded,” said Panettieri, who has not personally treated the family. “As we know the victims have been off ventilators and they’ve been improved.[fox6now.com]
  • There is little evidence of risk to healthcare workers from managing OP poisoned patients as long as universal precautions are followed see refs 5, 6 below Prognosis Varies markedly. Above all, it will depend on the specific OP and amount ingested.[aic.cuhk.edu.hk]
  • RBC cholinesterase level correlates better with severity and prognosis or a mixed cholinesterase ratio is best for determining if sufficient pralidoxime is being given.[patient.info]

Epidemiology

  • KEYWORDS: Epidemiology; Mood disorders; Organophosphate poisoning; Review; Toxicology[ncbi.nlm.nih.gov]
  • Schwartz, MPH j, Michelle Lackovic, MPH k a Division of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, OH b Environmental and Injury Epidemiology[doi.org]
  • OBJECTIVES: To determine the epidemiological profile and risk factors of voluntary poisoning by pesticides.[ncbi.nlm.nih.gov]
  • INTRODUCTION: Understanding the epidemiologic profile of a particular disease is key to undertake health actions.[ncbi.nlm.nih.gov]
  • However, there is paucity of research on the epidemiology of pesticides poisoning in Nepal.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • A review of the literature and consideration of three illustrative cases shows misunderstandings in the pathophysiology of the enzyme and in procedures for effective testing and monitoring of AChE levels.[ncbi.nlm.nih.gov]

Prevention

  • Disease Control and Prevention, Yixing, Jiangsu Province, China. 5 Injury Prevention Research Institute, School of Public Health, Southeast University, Nanjing, Jiangsu Province, China. 6 Nanchang Center for Disease Control and Prevention, Nanchang, Jiangsu[ncbi.nlm.nih.gov]
  • Author information 1 Department of Preventive Medicine, College of Medicine, Korea University, Seoul, South Korea. 2 Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, South Korea; Institute of Health Policy and Management[ncbi.nlm.nih.gov]
  • Government agencies together with scientists should focus their efforts on the prevention of potential threats to vulnerable groups such as the elderly, women, and children.[ncbi.nlm.nih.gov]
  • The increasing resistance of these arthropods to the safest pesticides may lead to greater use of more toxic, alternative pesticides to control infestations and to prevent institutional outbreaks.[ncbi.nlm.nih.gov]
  • More detailed research is required to identify aspects of these deaths amenable to prevention, but measures such as bans on the most toxic pesticides and changes in storage practice would appear to be sensible initial approaches.[ncbi.nlm.nih.gov]

References

Article

  1. Casida JE, Durkin KA. Anticholinesterase insecticide retrospective. Chem Biol Interact 2013; 203(1):221–225.
  2. Lim YP, Lin CL, Hung DZ, et al. Increased risk of deep vein thrombosis and pulmonary thromboembolism in patients with organophosphate intoxication: a nationwide prospective cohort study. Medicine (Baltimore). 2015; 94(1):e341.
  3. Eddleston M, Buckley NA, Eyer P, et al. Management of acute organophosphorus pesticide poisoning. Lancet. 2008; 371(9612):597–607.
  4. Lotti M. Clinical toxicology of anticholinesterase agents in humans. In: Krieger R, editor. Handbook of pesticide toxicology. Volume 2. Agents. 2 ed. Academic Press; San Diego: 2001. pp. 1043–1085.
  5. Okumura T, Takasu N, Ishimatsu S, et al. Report on 640 victims of the Tokyo subway sarin attack. Ann Emerg Med. 1996;28(2):129–135.
  6. Tsao TCY, Juang YC, Lan RS, Shieh WB, Lee CH. Respiratory failure of acute organophosphate and carbamate poisoning. Chest. 1990;98(3):631–636.
  7. Katan M, Morgenthaler N, Widmer I, et al. Copeptin, a stable peptide derived from the vasopressin precursor, correlates with the individual stress level. Neuro Endocrinol Lett. 2008;29(3):341–346.
  8. Rajapakse BN, Thiermann H, Eyer P, et al. Evaluation of the Test-mate ChE (cholinesterase) field kit in acute organophosphorus poisoning. Ann Emerg Med. 2011; 58(6):559-564.e6.
  9. Jalady AM, Dorandeu F. Interest of the cholinesterase assay during organophosphate poisonings. Ann Fr Anesth Reanim. 2013;32(12):856-862. [Article in French]
  10. Cha YS, Kim H, Go J, et al. Features of myocardial injury in severe organophosphate poisoning. Clin Toxicol (Phila). 2014; 52(8):873-879.

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Last updated: 2019-06-28 11:24