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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].

Splenomegaly
  • Detailed examination failed to show any stigma of underlying chronic liver disease, splenomegaly, or ascites. Cardiovascular and nervous system examination was observed normal and there were no bleeding diathesis.[jpharmacol.com]
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]
  • Delirium Diarrhea Blood Pressure Drop In the oral cavity, the mouth of the patient, the mouth and the stomach have burning pain, and nausea, vomiting, abdominal pain, diarrhea, vomit and feces are garlic smelly, half an hour or so after a period of half[healthfrom.com]
  • On day 2, she had intractable vomiting with altered level consciousness and irritability. She was hemodynamically unstable and developed metabolic acidosis.[ijccm.org]
  • 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]
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]
  • Delirium Diarrhea Blood Pressure Drop In the oral cavity, the mouth of the patient, the mouth and the stomach have burning pain, and nausea, vomiting, abdominal pain, diarrhea, vomit and feces are garlic smelly, half an hour or so after a period of half[healthfrom.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]
  • 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]
  • 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]
  • Symptom Symptoms of Phosphorus Poisoning Symptoms Symptom Blurred Coma Breathing Dizziness Gastrointestinal Symptoms Nausea Central Nerve Inhibitors ...[healthfrom.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]
  • Fulminant poisoning results from ingestion of more than 1 to 2 g. [5] In our patient, 2 h following the ingestion of YP, she complained of nausea and repeated vomiting, for which she admitted to our hospital.[ijccm.org]
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 and diarrhea, some patients can be in 1 to 3 days after the symptoms improved after the symptoms of poisoning, re-spit, diarrhea, abdominal pain, spit, diarrhea can be bloody, Liver enlargement, jaundice, epistaxis and subcutaneous hemorrhage, severe[healthfrom.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]
  • pain occurring within 24 hours, with normal laboratory tests.[jpharmacol.com]
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]
  • […] and hypoxemia that may result from coma and convulsions, nicotinic effects on skeletal muscles (weakness and paralysis) and muscarinic effects on the cardiovascular and pulmonary system (bronchospasm, bronchorrhea, aspiration, bradydysrhythmias, or hypotension[calpoison.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]
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]
  • (Such as zinc phosphide, etc.), in addition to gastrointestinal symptoms, the rapid occurrence of pulmonary edema, jaundice, etc., may have neurological symptoms such as dizziness, general numbness, convulsions, confusion, coma and circulation System[healthfrom.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]
  • 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]
Hepatomegaly
  • Abdominal sonography done on day 2 showed mild hepatomegaly and diffuse gallbladder (GB) wall edema [Figure 2] .[ijccm.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]
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]
  • Besides decreasing the incidence of seizure and resulting CNS damage, there is data to support improved respiratory function and outcome when benzodiazepines are used in conjunction with oximes in severe cases.[calpoison.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]
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].

Right Pleural Effusion
  • Chest X-ray revealed mild right pleural effusion [Figure 1] . Abdominal sonography done on day 2 showed mild hepatomegaly and diffuse gallbladder (GB) wall edema [Figure 2] .[ijccm.org]
Prolonged PR Interval
  • Bradycardia with a prolonged PR interval and atrioventricular blocks of various degrees occur as toxicity becomes more severe. QT interval prolongation has been reported in severe cases.[calpoison.org]

Treatment

  • Treatment Summary of Treatment of Phosphorus Poisoning Department of Internal Medicine: Department of Internal Medicine, Department of Internal Medicine, Department of Internal Medicine Treatment: drug treatment supportive treatment Treatment cycle: 30[healthfrom.com]
  • Early use of intravenous N-acetylcysteine in treatment of acute yellow phosphorus poisoning. Curr Med Issues [serial online] 2017 [cited 2018 Nov 25];15:136-8.[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]
  • 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]

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]

Etiology

  • Etiology The cause of phosphorus poisoning Yellow phosphorus toxicity is very small, the minimum lethal dose of adults is about 60 100mg, zinc lethal dose of about 40mg / kg.[healthfrom.com]

Epidemiology

  • 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]
  • 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

Pathophysiology

  • 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]

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]
  • Prevention Prevention of phosphorus poisoning Prevention of poisoning is the key to try not to use yellow phosphorus as raw materials to red phosphorus or other chemical substances to replace; pay attention to safe production, strengthen the protection[healthfrom.com]
  • 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