[Left ventricular thrombus and myocarditis induced by paraphenylenediamine poisoning]

Accuracy of Rapid Emergency Medicine Score and Sequential Organ Failure Assessment Score in predicting acute paraphenylenediamine poisoning adverse outcomes

Paraphenylenediamine (PPD) is a commonly used xenobiotic in hair dying, causing deleterious outcomes in acute poisoning. Although many epidemiological studies and case reports explained their clinical presentations and fatal consequences, no studies have evaluated the early determinants of adverse outcomes. Therefore, the present study aimed to assess the initial predictors of acute PPD poisoning adverse outcomes, focusing on the discriminatory accuracy of the Rapid Emergency Medicine Score (REMS) and Sequential Organ Failure Assessment (SOFA) score. A retrospective cohort study included all acute PPD-poisoned patients admitted to three Egyptian emergency hospitals from January 2020 to January 2022. Data was gathered on admission, including demographics, toxicological, clinical, scoring systems, and laboratory investigations. Patients were categorized according to their outcomes (mortality and complications). Ninety-seven patients with acute PPD poisoning were included, with a median age of 23 years, female predominance (60.8%), and suicidal intention (95.9%). Out of all patients, 25.77% died, and 43.29% had complicated outcomes. Respiratory failure was the primary cause of fatalities (10.30%), while acute renal failure (38.14%) was a chief cause of complications. The delay time till hospitalization, abnormal electrocardiogram, initial creatine phosphokinase, bicarbonate level, REMS, and SOFA scores were the significant determinants for adverse outcomes. The REMS exhibited the highest odds ratio (OR = 1.91 [95% confidence interval (CI): 1.41-2.60], p < 0.001) and had the best discriminatory power with the area under the curve (AUC) = 0.918 and overall accuracy of 91.8% in predicting mortality. However, the SOFA score had the highest odds ratio (OR = 4.97 [95% CI: 1.16-21.21], p = 0.001) and only yielded a significant prediction for complicated sequels with AUC = 0.913 and overall accuracy of 84.7%. The REMS is a simple clinical score that accurately predicts mortality, whereas the SOFA score is more practicable for anticipating complications in acute PPD-poisoned patients.

Para-phenylenediamine deteriorates oocyte quality by impairing mitochondrial function

Several studies demonstrate that para-phenylenediamine (PPD) is often added to permanent oxidative hair dyes. Sub-chronic topical exposure to PPD in male rats damages their testicular function; however, little is known about the effects of PPD exposure on the female reproductive system, especially on oocyte quality. In this study, we found that PPD can affect the meiotic capacity of oocytes and their fertilization potential. In particular, PPD can damage the spindle/chromosome structure and prevent oocytes from developing and maturing normally. Furthermore, PPD exposure compromised the dynamics of cortical granules and their component, ovastacin. In addition to the protein level of Juno, the sperm receptors on the egg membrane, were substantially impaired in PPD-administered oocytes, thus leading to fertilization failure. Finally, we found that PPD exposure resulted in abnormal mitochondrial function, which led to oocyte degeneration, apoptosis, and increased ROS levels. Altogether, our study illustrates that mitochondrial dysfunction and redox perturbation are the major causes of the poor quality of oocytes exposed to PPD.

Hair Dye poisoning: "An early intervention"

The use of hair dye has been emerging worldwide however usage of Paraphenylenediamine (PPD) in making hair dye is generally restricted to underdeveloped and developing countries. In particular, prevalence of accidental and suicidal ingestion is more in low socioeconomic areas. The spectra of hair dye toxicity is wide, however, it presents more commonly with severe angioedema of face and neck leading to respiratory failure, rhabdomyolysis complicating into acute kidney injury, myocarditis and acute liver injury. Here we present a unique case of PPD poisoning in a young female presented with laryngeal edema and marked rhabdomyolysis. Preemptive shifting to Critical care unit and elective endotracheal intubation for air way patency obviated the need of tracheostomy and precluded its related complications. Moreover, aggressive intravenous hydration prevented from renal failure despite markedly raised Creatine phospho kinase (CPK) levels.

Paraphenylenediamine Containing Hair Dye: An Emerging Household Poisoning

Paraphenylenediamine poisoning is among one of the emerging causes of poisoning in Asian countries, because it is a constituent of hair dye formulations and is easily available in market at low cost. Hair dyes are rampantly used in Asian households compared with the western world. Locally, hair dye constituents may have allergic adverse effects, and acute systemic poisoning presents with characteristic angioedema, upper airway obstruction, rhabdomyolysis, methemoglobinemia, myoglobinuria, and acute renal failure. This study reports about the death of a 24-year-old Indian housewife who committed suicide by taking hair dye emulsion. She had an argument with her husband, and because of fit of rage, took a bowlful (80 mL) of hair dye emulsion kept prepared for the use by husband. She developed angioedema, cervical swelling, and rhabdomyolysis and died of acute renal failure within 24 hours. Toxicological analysis of viscera and blood revealed varying levels of paraphenylenediamine. Histopathological samples of kidney showed features of acute tubular necrosis and myoglobin casts in renal tubules. The aim of the study is to create awareness about the adverse effects of the hair dye, its poisoning outcome, and possible preventive measures.

Clinical profile of acute paraphenylenediamine intoxication in Egypt

Orientation to paraphenylenediamine (PPD) acute systemic intoxication in Egypt has been increased over the last decade. The aim of this study was to provide more insight into the clinical profile of acute PPD intoxication with reviewing the possible underlying mechanisms. Our study was retrospective. It was conducted over 7 years (2001—2008) on 25 cases with acute PPD intoxication admitted to the Poison Control Center Ain Shams University Hospitals, Cairo, Egypt. The mean age of the cases was 35.34 ± 10.5 years; the male to female ratio was 18:7. Cervicofacial and laryngeal edema was the dominating presenting manifestation in 72% of the cases, 100% of the cases developed rhabdomyolysis, 80% had impaired renal functions, elevated liver transaminases were detected in 76% of cases, 75% showed hyperkalemia and 16% died due to ventricular arrhythmia. In conclusion, PPD causes serious multisystem toxicity and its selling to the public should be officially restricted.

Myocardial lysis in a fetus induced by maternal paraphenylenediamine poisoning following an intentional ingestion to induce abortion

The acute toxicity of paraphenylenediamine (PPD) has been associated with several histopathological changes. In humans, acute PPD poisoning is known to cause rhabdomyolisis and particularly myocardial lysis. However, its toxicity for the fetus has never been reported in the literature. We report a case of myocardial lysis in a fetus expelled by a 22-year-old mother after apparent ingestion of an unknown amount of PPD. The patient was admitted to our intensive care unit with acute onset of respiratory distress and rhabdomyolysis. The pelvic ultrasonography on admission showed a normally progressing pregnancy of 23-24 weeks. On day 9 post-ingestion, the patient spontaneously expelled a non-viable fetus. The fetal examination did not show any external or macroscopic abnormalities. However, the histopathological exam showed an important heart and lung congestion. There was also some interstitial edema and inflammation at the base of the lingua, in addition to a chorionic villus thrombosis and abruptio placentae. The histopathology of the myocardium showed lysis of the cardiac muscle. This observation suggests that the PPD was most likely responsible for the myocardial injury in the fetus.

Acute myocarditis and myocardial infarction induced by Paraphenylenediamine poisoning. Interest of angiocoronarography

We present 2 cases of myocardial damage induced by Paraphenylenediamine (PPD) poisoning in young patients without any history of cardiovascular disease. ECG findings revealed the presence of localized ST segment elevation in precordial leads (V1-V4) in the first case and (V3-V6) in the second associated to an increase of the serum troponine T level at 23 ng/ml (case 1) and 29.7 ng/ml (case 2). The transthoracic echocardiography was in favour of diffuse myocarditis in the first case and of localized myocarditis or septo-apical myocardial infarction in the second. The angiocoronarography performed for the first time in the second case conclude on a septo-apical hypokinesia of the left ventricular resulting of a coronary spasm of the anterior interventricular artery.