Phosphorus poisoning (PP) presents with different symptoms depending on the kind of exposure. Direct skin contact with white phosphorus, i.e. by manipulating ammunition or firecrackers, results in painful chemical burns, quick development of necrotic skin areas, which are typically yellow and feature a garlic-like scent. Phosphorus is highly mobile in biological tissues and will be readily absorbed. Its accumulation and toxicity mainly show in liver and kidney, sometimes in the heart. PP has been speculated to be conducive to delayed wound healing. Dry skin conditions can lead to spontaneous phosphorus reignition. Localization is possible with an ultraviolet light source [1] [2] [3].

Patients, who have been exposed to white phosphorus fumes, can show a distinct set of symptoms associated to PP, which are a burning sensation, coughs, shortness of breath, a sore throat and unconsciousness. Pulmonary edema may be observed a few hours after exposure [1].

Oral ingestion of white phosphorus is conducive to the fatal form of PP. Frequent symptoms after ingestion are nausea, vomiting, abdominal cramps, diarrhea, and hypotension. Patients typically deteriorate rapidly and enter a coma. The accepted lethal dose of white phosphorus is 1 mg/kg. Low-level intake can lead to accumulation in the feces ("smoking stool syndrome") [4] [5].

Accumulation of phosphorus after any kind of the above-mentioned ways of exposure mainly concerns the liver, the heart, and the kidneys. After oral ingestion, 70% of absorbed mineral will show in the liver shortly after intake, 12% will affect the heart, 4% will be recovered in the kidneys. Only traces can be found in the pancreas and brain [6].

• Pain

  Common symptoms were gastrointestinal: abdominal pain, diarrhea, nausea and vomiting. [thepoisonreview.com]

  Mortality rates were 23% for patients who had early symptoms of vomiting or abdominal pain; 73% for those where the first manifestation of intoxication was restlessness, irritability, drowsiness, stupor, or coma; and 47% for patients who had a combination [ncbi.nlm.nih.gov]

  Additional symptoms may include fever, headaches, fatigue, sluggishness (letheragy), vomiting, loss of appetite (anorexia), abdominal pain, constipation, joint pain, loss of recently acquired skills, incoordination, listlessness, difficulty sleeping [rarediseases.org]

  Arsenic (Ant or Rat Poisons, Weed Killers) Severe nausea, vomiting, abdominal pain, diarrhea, difficulty in swelling, urinary suppression and muscle cramps. [homoeopathyclinic.com]

  Direct skin contact with white phosphorus, i.e. by manipulating ammunition or firecrackers, results in painful chemical burns, quick development of necrotic skin areas, which are typically yellow and feature a garlic-like scent. [symptoma.com]

• Severe Pain

  Arsenic (Ant or Rat Poisons, Weed Killers) Severe nausea, vomiting, abdominal pain, diarrhea, difficulty in swelling, urinary suppression and muscle cramps. [homoeopathyclinic.com]

  INGESTION EXPOSURE : Stage 1: Feeling of warmth or burning pain in the throat and abdomen accompanied by feelings of intense thirst; nausea, vomiting (emesis), diarrhea, and severe abdominal pain; garlic odor to the breath, vomitus, and feces; vomitus [cdc.gov]

• Fatigue

  Overexposure may cause fatigue, headaches, nausea, vomiting, abdominal cramps, diarrhea, and fever. [rarediseases.org]

• Pallor

  […] cases, symptoms include headaches, vomiting, abdominal pain, lack of appetite (anorexia), constipation, slurred speech (dysarthria), changes in kidney function, unusually high amounts of protein in the blood (hyperproteinemia), and unusually pale skin (pallor [rarediseases.org]

• Chills

  In cases of chronic poisoning, weakness, muscle aches, chills, and fever may develop. The onset of symptoms in chronic arsenic poisoning is about two to eight weeks after exposure. [rarediseases.org]

• Sore Throat

  Patients, who have been exposed to white phosphorus fumes, can show a distinct set of symptoms associated to PP, which are a burning sensation, coughs, shortness of breath, a sore throat and unconsciousness. [symptoma.com]

• Vomiting

  Phase I (0 – 24 hours) Gastrointestinal effects: nausea, vomiting, diarrhea, abdominal pain. Phase II (1 – 3 days) Quiescent stage with improvement. Mild nausea, vomiting, diarrhea. [thepoisonreview.com]

  Aspirin (Aspirin Tablets) Nausea, vomiting, abdominal pain, tinnitus, spontaneous breathing, convulsions, uremia and coma. Induce vomiting by soda bicarbonate (one tsp. to a tumbler of Water). Strong coffee or tea may be given. [homoeopathyclinic.com]

  THALLIUM POISONING Symptoms associated with thallium poisoning include extreme drowsiness (somnolence), nausea, vomiting, abdominal pain, and bloody vomiting (hematemesis). [rarediseases.org]

  Mortality rates were 23% for patients who had early symptoms of vomiting or abdominal pain; 73% for those where the first manifestation of intoxication was restlessness, irritability, drowsiness, stupor, or coma; and 47% for patients who had a combination [ncbi.nlm.nih.gov]

  On day 2, she had intractable vomiting with altered level consciousness and irritability. She was hemodynamically unstable and developed metabolic acidosis. [ijccm.org]

• Diarrhea

  Phase I (0 – 24 hours) Gastrointestinal effects: nausea, vomiting, diarrhea, abdominal pain. Phase II (1 – 3 days) Quiescent stage with improvement. Mild nausea, vomiting, diarrhea. [thepoisonreview.com]

  Diarrhea was not a presenting complaint. Initial symptoms were referable to the gastrointestinal tract, central nervous system, or both. [ncbi.nlm.nih.gov]

  Intoxication with phosphorus from the environment is characterized initially by burning of the mouth and throat, stomach and abdominal pain, vomiting, diarrhea, jaundice, and an odor of garlic on the breath. [medicalassessmentonline.com]

  Arsenic (Ant or Rat Poisons, Weed Killers) Severe nausea, vomiting, abdominal pain, diarrhea, difficulty in swelling, urinary suppression and muscle cramps. [homoeopathyclinic.com]

  He continued to have large amounts of vomiting and diarrhea. A pralidoxime bolus of 1 g was administered IV over 15 minutes and an infusion at 500 mg/h was initiated. [calpoison.org]

• Nausea

  Phase I (0 – 24 hours) Gastrointestinal effects: nausea, vomiting, diarrhea, abdominal pain. Phase II (1 – 3 days) Quiescent stage with improvement. Mild nausea, vomiting, diarrhea. [thepoisonreview.com]

  Arsenic (Ant or Rat Poisons, Weed Killers) Severe nausea, vomiting, abdominal pain, diarrhea, difficulty in swelling, urinary suppression and muscle cramps. [homoeopathyclinic.com]

  Frequent symptoms after ingestion are nausea, vomiting, abdominal cramps, diarrhea, and hypotension. Patients typically deteriorate rapidly and enter a coma. The accepted lethal dose of white phosphorus is 1 mg/kg. [symptoma.com]

  Overexposure may cause fatigue, headaches, nausea, vomiting, abdominal cramps, diarrhea, and fever. [rarediseases.org]

  After self-limiting nausea and vomiting on the day of ingestion, he remained asymptomatic for 4 days. He observed dark-coloured urine and generalized itching on day 5 after ingestion. Pruritus was severe and disturbing his sleep. [jpharmacol.com]

• Abdominal Pain

  Common symptoms were gastrointestinal: abdominal pain, diarrhea, nausea and vomiting. [thepoisonreview.com]

  Mortality rates were 23% for patients who had early symptoms of vomiting or abdominal pain; 73% for those where the first manifestation of intoxication was restlessness, irritability, drowsiness, stupor, or coma; and 47% for patients who had a combination [ncbi.nlm.nih.gov]

  Additional symptoms may include fever, headaches, fatigue, sluggishness (letheragy), vomiting, loss of appetite (anorexia), abdominal pain, constipation, joint pain, loss of recently acquired skills, incoordination, listlessness, difficulty sleeping [rarediseases.org]

  Arsenic (Ant or Rat Poisons, Weed Killers) Severe nausea, vomiting, abdominal pain, diarrhea, difficulty in swelling, urinary suppression and muscle cramps. [homoeopathyclinic.com]

  Multiple episodes of vomiting, abdominal pain, and hematemesis were the complaints on presentation. She was provided symptomatic treatment in the form of stomach wash (gastric lavage) and antiemetics. [ijccm.org]

• Abdominal Cramps

  Frequent symptoms after ingestion are nausea, vomiting, abdominal cramps, diarrhea, and hypotension. Patients typically deteriorate rapidly and enter a coma. The accepted lethal dose of white phosphorus is 1 mg/kg. [symptoma.com]

  Overexposure may cause fatigue, headaches, nausea, vomiting, abdominal cramps, diarrhea, and fever. [rarediseases.org]

• Hypotension

  Our patient manifested with hypotension, tachycardia and acute pulmonary edema as a consequence of LV failure. [casereports.in]

  Frequent symptoms after ingestion are nausea, vomiting, abdominal cramps, diarrhea, and hypotension. Patients typically deteriorate rapidly and enter a coma. The accepted lethal dose of white phosphorus is 1 mg/kg. [symptoma.com]

  Signs and Symptoms Muscarinic signs (SLUDGE) salivation, lacrimation, urination, diaphoresis, gastrointestinal upset, emesis and progressing to bronchospasm, bronchorrhea, blurred vision, bradycardia or tachycardia, hypotension, confusion, and shock. [openanesthesia.org]

  Other symptoms include breakdown of the hemoglobin of red blood cells (hemolysis), a low level of iron in the red blood cells (anemia), and low blood pressure (hypotension). [rarediseases.org]

  MEDICAL TREATMENT : Hypotension should be treated with IV fluids. Seizures should be treated with benzodiazepines. [cdc.gov]

• Irregular Heart Rhythm

  Individuals with severe inorganic arsenic poisoning may experience heart problems (cardiomyopathy); accumulation of acid in the tubes of the kidneys (renal tubular acidosis); breakdown of the hemoglobin of red blood cells (hemolysis); irregular heart [rarediseases.org]

• Jaundice

  After being detected to have jaundice, by his local physician, he was referred to our institute on day 8 for further investigation. Examination revealed clinical jaundice with excoriation marks all over the body secondary to severe pruritus. [jpharmacol.com]

  Intoxication with phosphorus from the environment is characterized initially by burning of the mouth and throat, stomach and abdominal pain, vomiting, diarrhea, jaundice, and an odor of garlic on the breath. [medicalassessmentonline.com]

  On evaluation, the patient had jaundice on the second day of admission. There was no evidence of hepatic encephalopathy. Serology for hepatitis B surface antigen, hepatitis C virus, dengue, Leptospira, and hepatitis was negative. [ijccm.org]

  Later symptoms Jaundice, enlargement of liver, skin eruptions, pulse weak, heart weak and convulsions. [homoeopathyclinic.com]

  […] breakdown of the hemoglobin of red blood cells (hemolysis); irregular heart rhythms (ventricular arrhythmias); coma; seizures; bleeding within the intestines (intestinal hemorrhage); and yellowing of the skin, mucous membranes, and whites of the eyes (jaundice [rarediseases.org]

• Hepatomegaly

  Abdominal sonography done on day 2 showed mild hepatomegaly and diffuse gallbladder (GB) wall edema [Figure 2]. [ijccm.org]

• Liver Dysfunction

  Zinc overexposure may cause the flu-like symptoms of metal fume fever; stomach and intestinal disturbances; and/or liver dysfunction. [rarediseases.org]

• Flushing

  However, the US has now admitted its forces also used white phosphorus rounds to a lesser extent to flush enemy forces out of covered positions, allowing them to be targeted with high explosives. [news.bbc.co.uk]

  "Both patients were sweating, only partially conscious, had mucus in their airways, a rapid pulse, flushed skin, and had narrow pupils. [israelnationalnews.com]

• Skin Rash

  Overexposure to gold (as in treatment of rheumatoid arthritis) may cause skin rashes; bone marrow depression; stomach and intestinal bleeding; headaches; vomiting; focal or generalized continuous fine vibrating muscle movements (myokymia); and yellowing [rarediseases.org]

• Eruptions

  Later symptoms Jaundice, enlargement of liver, skin eruptions, pulse weak, heart weak and convulsions. [homoeopathyclinic.com]

• Seizure

  Overexposure may cause headaches, drowsiness, confusion, seizures, and life-threatening complications. [rarediseases.org]

  Intubation may be necessary in cases of respiratory distress due to laryngospasm, bronchospasm, bronchorrhea, or seizures. Immediate aggressive use of atropine may eliminate the need for intubation. [openanesthesia.org]

  Other reported toxic effects include gastrointestinal symptoms, renal failure, arrhythmias, seizures, coma, bone marrow suppression, and cardiovascular collapse. [8] Clinical features of acute poisoning with YP have been classically divided into 3 stages [jpharmacol.com]

  The short term effects of YP intoxication include gastrointestinal symptoms, liver changes, renal failure, arrhythmias, seizures, coma, and cardiovascular collapse. 5 Published data recommend that decontamination is started within two to five hours after [emj.bmj.com]

  Seizures should be treated with benzodiazepines. [cdc.gov]

PP diagnosis relies on a clinical examination and the determination of serum calcium, magnesium, phosphorus as well as urine phosphate concentrations. There is no specific method to determine PP, so diagnosis is mainly built based on observed symptoms and direct observation of phosphorus using UV light in the case of skin contact [1].

A major task in PP occurring by contact is skin decontamination by placing water-soaked pads or a moist gauze on the area of exposure [7]. It is imperative to keep the skin moist to avoid spontaneous phosphorus reignition. Ingestion-caused PP may be countered with a swift gastric lavage procedure to avoid the accumulation of this chemical in the liver. Phosphorus will cause macrovesicular and microvesicular vacuolization in hepatocytes. The contaminated liver tissue is not necrotic but hepatic functions will diminish [5].

Experimental treatment with copper sulfate and silver nitrate is speculated to provide limited recovery perspectives after a PP diagnosis [1]. PP fatality is highly likely for patients who present with hepatorenal failure and a cardiovascular collapse. PP has a mortality rate of 20-50% [6] [8].

• Hypoglycemia

  This group also showed hepatorenal failure, hypoglycemia and severe effect on the heart function. 3. Groups II and III recorded no mortality, but their patients showed an effect on the liver, which was severe in group II and mild in group III. [ncbi.nlm.nih.gov]

  […] been seen to result in death. [7] Indicators for poor outcome included early elevation of liver transaminases and alkaline phosphatase, more than 10-fold increase in alanine aminotransferase, derangement in prothrombin time, metabolic acidosis, and hypoglycemia [cmijournal.org]

  There was no hypoglycemia (blood glucose 108 mg/dl). Arterial blood gases revealed pH - 7.11, PCO 2 -20.6, PO 2 -75.4, and HCO 3 -6.3 suggesting metabolic acidosis. No cardiac dysrhythmias or electrocardiography changes were demonstrated. [ijccm.org]

  Evaluate for low blood sugar (hypoglycemia), electrolyte disturbances, and low oxygen levels (hypoxia). If evidence of shock or low blood pressure (hypotension) is observed, begin intravenous (IV) fluid administration. [cdc.gov]

• Hyperglycemia

  Sympathetic stimulation may result in hyperglycemia, leukocytosis and urinary retention. Cardiopulmonary effects are also common with severe poisonings from cholinesterase inhibitors. [calpoison.org]

• Leukocytosis

  Sympathetic stimulation may result in hyperglycemia, leukocytosis and urinary retention. Cardiopulmonary effects are also common with severe poisonings from cholinesterase inhibitors. [calpoison.org]

Early use of intravenous N-acetylcysteine in treatment of acute yellow phosphorus poisoning. Curr Med Issues 2017;15:136-8 How to cite this URL: Kharkongor MA, Mishra AK, Ninan K F, Iyadurai R. [cmijournal.org]

The only definitive treatment for acute liver failure due to the ingestion of YP is liver transplantation because no antidote or medical treatment is available to reverse the toxic effects on the liver. [4] Here, we present a case of acute YP poisoning [ijccm.org]

Treatment Termination of the exposure including removing all soiled clothing. Gently cleanse with soap and water to hydrolyze organophosphate solutions. Airway control and adequate oxygenation. [openanesthesia.org]

335 Chapter 22 Medical Education visàvis Medical Practice 346 Chapter 23 Medical Negligence 361 Chapter 24 Consent to and Refusal of Treatment 370 Medical Social Ethical and Legal Implications 376 Chapter 26 Abortion and Delivery 380 Chapter 27 Impotence [books.google.de]

Experimental treatment with copper sulfate and silver nitrate is speculated to provide limited recovery perspectives after a PP diagnosis. PP fatality is highly likely for patients who present with hepatorenal failure and a cardiovascular collapse. [symptoma.com]

The absence of any specific antidote is an important factor for poor prognosis among those who consume this poison. [cmijournal.org]

In this condition, the chemcial can accumulate in liver and kidney leading to liver failure and to a fatal prognosis, if more than 1 mg/kg have been absorbed. [symptoma.com]

Pesticide Exposures andDevelopmental Outcomes: The Epidemiological Evidence.Journal of Toxicology and Environmental Healt. Part B.2007;10:41-80. Vale J A. Toxicokinetic and Toxicodynamic Aspects of OrganophosphorousInsecticide Poisoning. [revistas.unimilitar.edu.co]

Acute pesticide poisoning in Ecuador: a short epidemiological report. J Public Health. 2010;18:437-442. Simon FA, Pickering LK. Acute yellow phosphorous poisoning “Smoking stool syndrome”. JAMA. 1976;235:1343-1344. [casereports.in]

Adult Blood Lead Epidemiology and Surveillance --- United States, 2002. CDC MMWR [On-line information]. Available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5326a2.htm. Harold E. Hoffman, MD, FRCPC, FACOEM. [labtestsonline.it]

Epidemiology In 2007, Californians reported over 700 exposures to OP and carbamate pesticides to the CPCS. Nationally, more than 15,000 poisonings with these chemicals are reported to poison control centers each year, with five or six fatalities. [calpoison.org]

Pathophysiology Acetylcholine (ACh) is a neurotransmitter found at both parasympathetic and sympathetic ganglia, skeletal neuromuscular junctions, terminal junctions of all postganglionic parasympathetic nerves, post-ganglionic sympathetic fibers to most [calpoison.org]

The safest method of managing poisoning from this highly toxic substance is prevention. Two of the patients had a history of previous medicine overdose. [ncbi.nlm.nih.gov]

CDC Childhood Lead Poisoning Prevention Program, CDC Recommendations for Lead Poisoning Prevention in Newly Arrived Refugee Children. [labtestsonline.it]

(common chickweed) will help prevent kidney damage/stress. [tldp.com]

Chief Editor Zygmunt F Dembek, PhD, MPH, MS, LHD Associate Professor, Department of Military and Emergency Medicine, Adjunct Assistant Professor, Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, F [emedicine.medscape.com]

In order to prevent future deficiencies, you'll need to continue to add organic matter periodically. Home grown green manures are a good source of organic matter and if you have the space you cal so grow your own straw. [plantprobs.net]

1. Agency for Toxic Substances and Disease Registry (ATSDR). U.S. Department of Health and Human Services, Public Health Service. Toxicological Profile for White Phosphorus. 1997.
   https://www.atsdr.cdc.gov/toxprofiles/tp103.pdf. Accessed May 3, 2017.
2. Skaik S, Abu-Shaban N, Abu-Shaban N, et al. Metals detected by ICP/MS in wound tissue of war injuries without fragments in Gaza. BMC Int Health Hum Rights. 2010; 10:17.
3. Frank M, Schmucker U, Nowotny T, Ekkernkamp A, Hinz P. Not all that glistens is gold: civilian white phosphorus burn injuries. Am J Emerg Med. 2008; 26(8):974.e3-5.
4. Yilmaz R, Yilmaz E, Ozdemir V, et al. An evaluation of childhood deaths in Turkey due to yellow phosphorus in firecrackers. J Forensic Sci. 2015; 60(3):648-652.
5. Türkmen Şamdanci E, Çakir E, Şahin N, Elmali C, Sayin S. Clinical and Pathological Findings on Intoxication by Yellow Phosphorus After Ingesting Firework Cracker: A Rare Case of Autopsy. Turk Patoloji Derg. 2016; 32(1):51-53.
6. McCarron MM, Gaddis GP, Trotter AT. Acute yellow phosphorus poisoning from pesticide pastes. Clin Toxicol. 1981; 18:693-711.
7. Witkowski W, Surowiecka-Pastewka A, Biesaga M, Gierczak T. Experimental Comparison of Efficiency of First Aid Dressings in Burning White Phosphorus on Bacon Model. Med Sci Monit. 2015; 21:2361-2366.
8. Santos O, Restrepo JC, Velásquez l, et al. Acute liver failure due to white phosphorus ingestion. Ann Hepatol. 2009; 8:162-165.