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Phosphorus Poisoning

Phosphorus poisoning (PP) occurs after accidental exposure to white (also synonymously termed yellow) phosphorus. This compound can have mild effects like affecting the skin upon direct contact or the eyes in case of white phosphorus gas. Further possibilities include inhalation of white phosphorus and its accidental ingestion. 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.


Presentation

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].

Rigor
  • ASPECTS MEDICOLEGAL IMPORTANCES metal muscles neck negligence occurs oedema offence oxalic acid patient person physician poisoning police postmortem pregnancy present preserved produced pubic symphysis punishment putrefaction rape respiration respiratory rigor[books.google.de]
Vomiting
  • 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]
  • 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]
  • 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]
  • 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]
  • He had no further episodes of vomiting and was otherwise asymptomatic. On examination, he was conscious, oriented and in no apparent distress. General and systemic examinations were normal.[cmijournal.org]
Diarrhea
  • Diarrhea was not a presenting complaint. Initial symptoms were referable to the gastrointestinal tract, central nervous system, or both.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • 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]
Abdominal Pain
  • 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]
  • Common symptoms were gastrointestinal: abdominal pain, diarrhea, nausea and vomiting.[thepoisonreview.com]
  • pain occurring within 24 hours, with normal laboratory tests.[jpharmacol.com]
  • Gastrointestinal symptoms include a flu-like illness (gastroenteritis) that is characterized by vomiting; abdominal pain; fever; and diarrhea, which, in some cases, may be bloody.[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]
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]
  • 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]
  • 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]
  • Arsenic (Ant or Rat Poisons, Weed Killers) Severe nausea, vomiting, abdominal pain, diarrhea, difficulty in swelling, urinary suppression and muscle cramps.[homoeopathyclinic.com]
  • Overexposure may cause fatigue, headaches, nausea, vomiting, abdominal cramps, diarrhea, and fever.[rarediseases.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
  • 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]
  • Our patient manifested with hypotension, tachycardia and acute pulmonary edema as a consequence of LV failure.[casereports.in]
  • 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]
  • Most patients have bradycardia and, if poisoning is severe, hypotension. CNS toxicity is common, sometimes with seizures and excitability and often with lethargy and coma.[gii.co.jp]
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]
  • There were no bleeding manifestations, jaundice, or other signs of liver failure.[cmijournal.org]
  • 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]
  • 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]
Flushing
  • "Both patients were sweating, only partially conscious, had mucus in their airways, a rapid pulse, flushed skin, and had narrow pupils.[israelnationalnews.com]
  • 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]
Dry Skin
  • Dry skin conditions can lead to spontaneous phosphorus reignition. Localization is possible with an ultraviolet light source.[symptoma.com]
Delayed Wound Healing
  • 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.[symptoma.com]
Seizure
  • Overexposure may cause headaches, drowsiness, confusion, seizures, and life-threatening complications.[rarediseases.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]
  • 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]
  • 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]
  • CNS toxicity is common, sometimes with seizures and excitability and often with lethargy and coma. Pancreatitis is possible, and organophosphates may cause arrhythmias such as heart block and QTc interval prolongation.[gii.co.jp]
Neglect
  • Chapter 9 Starvation and Neglect 173 Chapter 10 Death by Electrocution 175 Chapter 11 Deaths Associated with Surgery Anaesthesia and Blood Transfusion 183 Chapter 12 Custody Related Torture andor Death 191 Medicolegal Considerations and Types 197 Chapter[books.google.de]

Workup

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].

Treatment

  • Early use of intravenous N-acetylcysteine in treatment of acute yellow phosphorus poisoning. Curr Med Issues [serial online] 2017 [cited 2019 May 13];15:136-8.[cmijournal.org]
  • 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]
  • 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]
  • […] police postmortem pregnancy present preserved produced pubic symphysis punishment putrefaction rape respiration respiratory rigor mortis sexual intercourse signs and symptoms skin skull staining strangulation suicidal surface teeth tion tissue toxic treatment[books.google.de]
  • Evaluation of corticosteroid and exchange-transfusion treatment of acute yellow-phosphorus intoxication. N Engl J Med 1971;284:125-8. 11. Akman SA, Cakir M, Baran M, Arikan C, Yuksekkaya HA, Tumgor G, et al.[jpharmacol.com]

Prognosis

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

Epidemiology

  • 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]
  • Adult Blood Lead Epidemiology and Surveillance --- United States, 2002. CDC MMWR [On-line information]. Available online at . Harold E. Hoffman, MD, FRCPC, FACOEM. Occupational & Environmental Medicine. Edmonton, Alberta, Canada. Thomas P.[labtestsonline.it]
  • 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]
Sex distribution
Age distribution

Prevention

  • 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]
  • Anything that’s stuck to the plant leaves doesn’t get incorporated with the soil, and that does things like prevent mineralization of the glyphosate.” That means the half-life of glyphosate goes up significantly, Spiese says.[sustainablepulse.com]
  • (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]

References

Article

  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.

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Last updated: 2018-06-22 03:05