Osteonecrosis of Femoral Head, An Overlooked Long-Term Complication after Paraquat Intoxication: A Retrospective Cohort Study

Paraquat ingestion in an adult with cystic fibrosis (CF): Diagnostic and management dilemmas

N,N'-dimethyl-4,4'bipyridinium dichloride (Paraquat) is a potent herbicide used widely in agriculture. We report the effects of an ingestion of paraquat by a 28 year old male with cystic fibrosis and the diagnostic and management challenges this posed in both the acute and longer term setting. We describe the effects of direct paraquat toxicity on the lung tissue secondary to aspiration and review the long-term sequelae of paraquat, namely osteonecrosis. Our case is the first to describe osteonecrosis of the knee in the context of paraquat toxicity. Survival following ingestion remains poor with a high associated mortality. However, timely treatment with NAC and immunosuppression may impact on survival. In those patients who do survive the acute phase post ingestion, follow-up over years may be required to detect the long-term effects of paraquat on bone health.

A Case of Multi-focal Osteonecrosis in the Context of Liver Transplant Following Ingestion of Amanita phalloides Mushroom Toxin

We present the case of a 44-year-old female who presented with atraumatic avascular necrosis (AVN) of the patella and hips bilaterally, following ingestion of the deadly fungus Amanita phalloides or ‘death cap’ and subsequent liver transplant. Upon presentation, in the hours following ingestion, our patient required a liver transplant and ICU admission. She was treated by a multidisciplinary team, with input from various specialities. Our patient required steroids in the months following this event. Six months after the liver transplant and subsequent ICU admission, our patient developed hip pain, thus limiting her mobility, ability to engage in physiotherapy and rehabilitation. X-rays were performed that excluded any acute pathology. She was still receiving high-dose steroids at this time. When the pain did not resolve with analgesia, MRI of pelvis and knee was performed and the patient was found to have polyarticular AVN. Acute bilateral total hip replacement was performed and within weeks, the patient returned to physiotherapy and to full rehabilitation. Conservative management of the patella was favoured. Over two years later, the patient can now mobilise independently.

The role of acute total hip replacement is evident in this case, and how in performing this surgery, the overall conditioning and health of our patient improved drastically. Currently, cases reporting A. phalloides ingestion are few and we wish to use this case to highlight the differential diagnosis in a patient presenting with joint pain in this context of fungus ingestion, organ transplant or prolonged steroid use.