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Eddleston M, Nagami H, Lin CY, Davis ML, Chang SS. Pesticide use, agricultural outputs, and pesticide poisoning deaths in Japan. Clin Toxicol (Phila) 2022; 60:933-941. [PMID: 35475715 DOI: 10.1080/15563650.2022.2064868] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Although pesticide poisonings occur worldwide, most high-income countries have not been severely affected. Japan is a key exception, with pesticide suicides becoming a major public health concern in the 1980s. We here report the epidemiology of lethal pesticide poisoning in Japan in relation to its pesticide regulation and agricultural output. METHODS We obtained data on pesticide registration and sales from the Japan Plant Protection Association's annual Pesticide Handbook, National Food and Agricultural Materials Inspection Center, and Food and Agriculture Organization of the United Nations. Data on deaths due to pesticide poisoning and population were obtained from Vital Statistics of Japan. We reviewed the registration status and hazard classification of pesticides in Japan and analysed the relationships between the use/sales, pesticides fatalities, and agricultural output. RESULTS Five hundred and twenty-nine pesticide active ingredients are currently registered in Japan, including four WHO hazard class IB organophosphorus and carbamate insecticides. Paraquat was registered in 1962 as a liquid SL20 formulation. In 1986, restrictions were imposed on its sale/use and a 4.3% paraquat ion/4.1% diquat ion combination product registered by ICI. There were 221 pesticide poisoning fatalities in 2019, down from 2648 in 1986, a 92% reduction over 33 years. Self-poisoning was responsible for most pesticide deaths in both 1985 (2013/2476, 81.3%) and 2019 (146/221, 66.1%). Pesticide poisoning made up 8.6% of all suicides in 1985, down to 0.7% in 2019. Unintentional pesticide poisoning deaths also all fell by 83.8%, from 463 to 75. These reductions were associated with reduced sales of both OP/carbamate insecticides and paraquat/diquat but no apparent change in agricultural output across a broad range of crops. CONCLUSIONS Reduced use of highly hazardous pesticides and lowered concentration formulations in Japan were associated with major decreases in all deaths from pesticide poisoning and the proportion of all suicides due to pesticide ingestion.
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Affiliation(s)
- Michael Eddleston
- Centre for Pesticide Suicide Prevention, and Pharmacology, Toxicology & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Hiroshi Nagami
- Institute for Prevention of Pesticide Adverse Effects on Human, Yamatokohriyama, Japan
| | - Chien-Yu Lin
- Institute of Health Behaviors and Community Sciences, and Global Health Program, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Mark L Davis
- Centre for Pesticide Suicide Prevention, and Pharmacology, Toxicology & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Shu-Sen Chang
- Institute of Health Behaviors and Community Sciences, and Global Health Program, College of Public Health, National Taiwan University, Taipei, Taiwan.,Psychiatric Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Wan X, Zhou C, Kang X, Hu D, Xue W, Li X, Bao H, Peng A. Metabolic Profiling of Amino Acids Associated with Mortality in Patients with Acute Paraquat Poisoning. Med Sci Monit 2018. [PMID: 29513648 PMCID: PMC5854108 DOI: 10.12659/msm.905843] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Paraquat is a major cause of fatal poisoning after ingestion in many parts of Asia and the Pacific nations. However, optimal prognostic indicators to evaluate patient mortality have not been unequivocally established. Following acute paraquat poisoning, a number of amino acids (AA), are abnormally expressed in metabolic pathways. However, the alterations in AA metabolite levels after paraquat poisoning remain unknown in humans. Material/Methods In the present study, 40 patients were enrolled, of whom 16 survived and 24 died. A metabolomics approach was used to assess changes in AA metabolites in plasma and its potential prognostic value following paraquat poisoning. Mass spectrometry (MS) based on metabolite identification was conducted. Results Twenty-five AA levels in plasma were abnormally expressed in non-survivor patients. Among them, creatinine, indolelactate, and 3-(4-hydroxyphenyl)lactate were found to be highly correlated with paraquat death prediction. It was noted that the intensity levels of these 3 AA metabolites in the non-survivor group were substantially higher than in the survivor group. Furthermore, we examined receiver operating characteristic (ROC) curves for clinical validation. ROC results showed that 3-(4-hydroxyphenyl)lactate had the highest AUC of 0.84, while indolelactate and creatinine had AUCs of 0.75 and 0.83, respectively, suggesting that they can be used to predict the clinical outcome (although this methodology is expensive to implement). Conclusions Metabolic profiling of AA levels could be a reliable tool to identify effective indicators for the early high precision prognosis of paraquat poisoning.
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Affiliation(s)
- Xiuxian Wan
- Department of Nephrology and Rheumatology, Affiliated Shanghai Tenth Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu, China (mainland).,Department of Nephrology, Lianyungang Oriental Hospital, Lianyungang, Jiangsu, China (mainland)
| | - Chunyu Zhou
- Center for Nephrology and Clinical Metabolomics, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Xin Kang
- Center for Nephrology and Clinical Metabolomics, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Dayong Hu
- Center for Nephrology and Clinical Metabolomics, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Wen Xue
- Center for Nephrology and Clinical Metabolomics, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Xinhua Li
- Center for Nephrology and Clinical Metabolomics, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Hui Bao
- Department of Nephrology and Rheumatology, Affiliated Shanghai Tenth Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu, China (mainland).,Center for Nephrology and Clinical Metabolomics, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Ai Peng
- Department of Nephrology and Rheumatology, Affiliated Shanghai Tenth Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu, China (mainland).,Center for Nephrology and Clinical Metabolomics, Tongji University School of Medicine, Shanghai, China (mainland)
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Tsai JL, Chen CH, Wu MJ, Tsai SF. Paraquat Poisoning in Patients With HIV Infection: A Case Report and Literature Review. Medicine (Baltimore) 2016; 95:e3350. [PMID: 27057917 PMCID: PMC4998833 DOI: 10.1097/md.0000000000003350] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Paraquat poisoning is very severe. Most victims, including those who have ingested a small amount, will die from Paraquat poisoning. The cause of death in the majority of such cases is lung fibrosis. Paraquat poisoning in patients with positive human immunodeficiency virus (HIV) infection status has seldom been reported. Herein, we report a case of an HIV patient with Paraquat poisoning who had an excellent outcome even without standard treatment. Currently, only 3 such cases have been reported in the literature and in each case there was a good outcome, which was not expected according to predictive models. A possible mechanism may involve the relative lack of functional macrophages in HIV patients, which would tend to result in much less severe lung injury. None of the available predictive models of Paraquat poisoning appear to be appropriate for HIV patients.Paraquat poisoning in HIV patients may have better survival due to less lung injury.
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Affiliation(s)
- Jun-Li Tsai
- From the Department of Family Medicine (J-LT), Cheng Ching General Hospital; Division of Nephrology, Department of Internal Medicine (C-HC, M-JW, S-FT), Taichung Veterans General Hospital; School of Medicine (C-HC, M-JW, S-FT), China Medical University; Department of Life Science (C-HC, S-FT), Tunghai University; and Taichung; and Department of Medicine (S-FT), Nation Yang Ming University, Taipei, Taiwan
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Sun IO, Shin SH, Yoon HJ, Lee KY. Predicting the probability of survival in acute paraquat poisoning. Kidney Res Clin Pract 2016; 35:102-6. [PMID: 27366665 PMCID: PMC4919560 DOI: 10.1016/j.krcp.2016.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/24/2016] [Accepted: 01/31/2016] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Paraquat (PQ) concentration-time data have been used to predict prognosis for 3 decades. The aim of this study was to find a more accurate method to predict the probability of survival. METHODS This study included 788 patients with PQ poisoning who were diagnosed using plasma PQ concentration between January 2005 and August 2012. We divided these patients into 2 groups (survivors vs. nonsurvivors), compared their clinical characteristics, and analyzed the predictors of survival. RESULTS The mean age of the included patients was 57 years (range, 14-95 years). When we compared clinical characteristics between survivors (n = 149, 19%) and nonsurvivors (n = 639, 81%), survivors were younger (47 ± 14 years vs. 59 ± 16 years) and had lower plasma PQ concentrations (1.44 ± 8.77 μg/mL vs. 80.33 ± 123.15 μg/mL) than nonsurvivors. On admission, serum creatinine was lower in survivors than in nonsurvivors (0.95 ± 0.91 mg/dL vs. 1.88 ± 1.27 mg/dL). In multivariate logistic regression analysis, age and logarithmically converted serum creatinine [ln(Cr)], [ln(time)], and [ln(PQ)] were assessed as prognostic factors to predict survival in PQ poisoning. The predicted probability of survival using significant prognostic factors was exp (logit)/[1 + exp(logit)], where logit = -1.347 + [0.212 × sex (male = 1, female = 0)] + (0.032 × age) + [1.551 × ln(Cr)] + [0.391 × ln(hours since ingestion)] + [1.076 × ln(plasma PQ μg/mL)]. With this equation, the sensitivity and specificity were 86.5% and 98.7%, respectively. CONCLUSION Age, ln(Cr), ln(time), and ln(PQ) were important prognostic factors in PQ poisoning, and our equation can be helpful to predict the survival in acute PQ poisoning patients.
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Affiliation(s)
- In O Sun
- Division of Nephrology & Toxicology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Sung Hye Shin
- Department of Biochemistry, Christian Medical Research Center, Jeonju, Korea
| | - Hyun Ju Yoon
- Division of Nephrology & Toxicology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Kwang Young Lee
- Division of Nephrology & Toxicology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea; Department of Biochemistry, Christian Medical Research Center, Jeonju, Korea
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Kim DS, Kang C, Kim DH, Kim SC, Lee SH, Jeong JH, Kang TS, Jung SM, Lee SB, Lee KW, Kim RB. External validation of the prognostic index in acute paraquat poisoning. Hum Exp Toxicol 2015; 35:366-70. [PMID: 25977258 DOI: 10.1177/0960327115586821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Some studies have evaluated the prognostic indicators associated with acute paraquat (PQ) poisoning. In this study, we externally validated the Yamaguchi index, which showed a good prognostic relevance in predicting the outcome of PQ poisoning. METHODS A retrospective analysis of 297 patients was performed. The Yamaguchi index was calculated using the following equation: Eq1 = (K(+) × HCO3(-))/(Creatinine × 0.088)(mEq/L) against time from PQ ingestion (T). The patients were divided into three groups: group A: Eq1 > 1500 - 399 × log T, group B: 930 - 399 × log T < Eq1 ≤ 1500 - 399 × log T, and group C: Eq1 ≤ 930 - 399 × log T). RESULTS The overall mortality rate was 65.3% (194 of 297). The mortality rates of the three groups stratified by the Yamaguchi index were 7.1% (2 of 28), 22.4% (15 of 67), and 87.6% (177 of 202). The area under the receiver-operating characteristic curve for predicting mortality from the external validation of the Yamaguchi index was 0.842 (95% confidence interval: 0.795-0.882). CONCLUSION The Yamaguchi index is a reliable prognostic factor and could be helpful in predicting mortality due to PQ poisoning.
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Affiliation(s)
- D S Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - C Kang
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - D H Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - S C Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - S H Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - J H Jeong
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - T S Kang
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - S M Jung
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - S B Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju, Republic of Korea
| | - K W Lee
- Department of Emergency Medicine, Catholic University of Daegu, Daegu, Republic of Korea
| | - R B Kim
- Department of Preventive Medicine, Dong-A University, Busan, Republic of Korea
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The volume ratio of ground glass opacity in early lung CT predicts mortality in acute paraquat poisoning. PLoS One 2015; 10:e0121691. [PMID: 25830638 PMCID: PMC4382148 DOI: 10.1371/journal.pone.0121691] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 02/14/2015] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Pulmonary injury is the main cause of death in acute paraquat (PQ) poisoning. However, whether quantitative lung computed tomography (CT) can be useful in predicting the outcome of PQ poisoning remains unknown. We aimed to identify early findings of quantitative lung CT as predictors of outcome in acute PQ poisoning. METHODS Lung CT scanning (64-slide) and quantitative CT lesions were prospectively measured for patients after PQ intoxication within 5 days. The study outcome was mortality during 90 days follow-up. Survival curves were derived by the Kaplan-Meier method, and mortality risk factors were analyzed by the forward stepwise Cox regression analysis. RESULTS Of 97 patients, 41 (42.3%) died. Among the eight different types of lung CT findings which appeared in the first 5-day of PQ intoxication, four ones discriminated between survivors and non-survivors including ground glass opacity (GGO), consolidation, pneumomediastinum and "no obvious lesion". With a cutoff value of 10.8%, sensitivity of 85.4% and specificity of 89.3%, GGO volume ratio is better than adopted outcome indicators in predicting mortality, such as estimated amount of PQ ingestion, plasma or urine PQ concentration, acute physiology and chronic health evaluation (APACHE) II and sequential organ failure assessment (SOFA) scores. GGO volume ratios above 10.8% were associated with increased mortality (hazard ratio, 5.82; 95% confidence interval, 4.77-7.09; P < 0.001). CONCLUSIONS The volume ratio of GGO exceeding 10.8% is a novel, reliable and independent predictors of outcome in acute PQ poisoning.
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Seok S, Kim YH, Gil HW, Song HY, Hong SY. The time between paraquat ingestion and a negative dithionite urine test in an independent risk factor for death and organ failure in acute paraquat intoxication. J Korean Med Sci 2012; 27:993-8. [PMID: 22969243 PMCID: PMC3429840 DOI: 10.3346/jkms.2012.27.9.993] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 06/07/2012] [Indexed: 11/20/2022] Open
Abstract
To identify a prognostic marker that is less sensitive to variations in the elapsed time since paraquat ingestion, we assessed the time between paraquat ingestion and a negative dithionite urine test as a prognostic parameter in patients with acute paraquat intoxication. Forty-one patients with acute paraquat intoxication were enrolled in this study and analyzed to verify significant determinants of mortality and organ dysfunction. The amount of paraquat ingested, paraquat plasma levels, and the time to a negative urine dithionite test were significant independent risk factors predicting mortality. The amount of paraquat ingestion, and the time to a negative urine dithionite test were independent risk factors predicting organ dysfunction. With a cut-off value of 34.5 hr for the time to negative conversion of the urine dithionite test, the sensitivity and specificity for mortality were 71.4% and 75.0%, respectively. The incidence of acute kidney injury and respiratory failure above 34.5 hr were 100% and 85.0%, respectively. In conclusion, the time to a negative urine dithionite test is the reliable marker for predicting mortality and/or essential organ failure in patients with acute paraquat intoxication, who survive 72 hr.
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Affiliation(s)
- Sujin Seok
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Young-hee Kim
- Department of Immunology, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Hyo-wook Gil
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Ho-yeon Song
- Department of Immunology, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Sae-yong Hong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
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Lee Y, Lee JH, Seong AJ, Hong CK, Lee HJ, Shin DH, Hwang SY. Arterial lactate as a predictor of mortality in emergency department patients with paraquat intoxication. Clin Toxicol (Phila) 2011; 50:52-6. [DOI: 10.3109/15563650.2011.639716] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Huang C, Zhang X. Prognostic significance of arterial blood gas analysis in the early evaluation of Paraquat poisoning patients. Clin Toxicol (Phila) 2011; 49:734-8. [DOI: 10.3109/15563650.2011.607459] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Rapid analysis of plasma paraquat using sodium dithionite as a predictor of outcome in acute paraquat poisoning. Am J Med Sci 2009; 338:373-7. [PMID: 19826241 DOI: 10.1097/maj.0b013e3181b4deee] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Paraquat poisoning can be lethal, and aggressive treatments might have little or no effect on severely poisoned patients. Accordingly, a convenient prognostic test is necessary to guide therapy for acute paraquat poisoning. Sodium dithionite reduces paraquat to a blue radical form in alkaline plasma with a paraquat detection sensitivity of 2.0 mg/L, which is a 100% lethal concentration at 10 to 12 hours postingestion. The prognostic utility of this simple reaction was examined prospectively. METHODS Of 233 paraquat-poisoned patients, who were taken to the hospital within 12 hours after ingestion, the plasma samples obtained on arrival were tested using the sodium dithionite reaction. Standard saline containing 2.0 mg/L paraquat was used as the positive control. The test result was interpreted as being positive when the plasma test yielded a blue color darker than that of the positive control. The effects of aggressive treatment, including cyclophosphamide pulse and continuous venovenous hemofiltration, were evaluated retrospectively. RESULTS The discharge survival rate was 41.6% (97 of 233). Ninety-seven of 142 patients with negative or equivocal plasma dithionite test survived. However, all 91 patients with positive plasma dithionite test died of multiorgan failure. Cyclophosphamide and/or continuous venovenous hemofiltration could not improve survival. CONCLUSIONS In this single-center study, a positive plasma dithionite test was associated with 100% mortality, despite aggressive treatment. In contrast, negative or equivocal tests were associated with a 68% survival rate. It is believed that after further verification, this test can be used to guide therapy and predict the outcomes of patients suffering acute paraquat poisoning.
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Hypokalemia and hypothermia are associated with 30-day mortality in patients with acute paraquat poisoning. Am J Med Sci 2008; 335:451-6. [PMID: 18552575 DOI: 10.1097/maj.0b013e318157cb6d] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Clinical predictors associated with acute paraquat (PQ) poisoning have not been systematically studied. OBJECTIVE To identify independent predictors of death in patients with acute PQ poisoning. METHODS This is a retrospective study executed in the emergency department of a university hospital. One hundred three consecutive patients poisoned with PQ between January 1999 and December 2004 were enrolled. Urine PQ concentration, electrolyte and renal function, detailed history, and Acute Physiology and Chronic Health Evaluation II were extracted from medical records. The outcome measure was 30-day mortality. Multivariate analysis was done by Cox-proportional hazard regression model. Receiver operating characteristics area under the curve was calculated for selected predictors. RESULTS The crude 30-day mortality was 67.9% (70 of 103). Independent predictors of death were acute renal failure (hazard ratio, 3.53; 95% confidence interval, 1.97-6.32), hypokalemia (2.07, 1.21-3.51), hypothermia (2.91, 1.67-5.07), suicide (2.11, 1.04-4.29), and self-reported ingested dose (2.06, 1.38-3.06). The receiver operating characteristics area under the curve of serum potassium concentrations, maximal urine PQ concentrations, and Acute Physiology and Chronic Health Evaluation II scores were 0.75 (95% confidence interval, 0.60-0.81), 0.71 (0.66-0.84), and 0.80 (0.71-0.88), respectively. Under the cutoff value of 3.6 mEq/L, hypokalemia had a sensitivity of 75% and specificity of 54% in predicting mortality. CONCLUSION The identified risk factors may allow better identification of those at greater mortality risk. Future development of a tailored clinical scoring system incorporating the identified risk factors for acute PQ poisoning may be of great help.
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Eddleston M, Wilks MF, Buckley NA. Prospects for treatment of paraquat-induced lung fibrosis with immunosuppressive drugs and the need for better prediction of outcome: a systematic review. QJM 2003; 96:809-24. [PMID: 14566036 PMCID: PMC1948029 DOI: 10.1093/qjmed/hcg137] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Acute paraquat self-poisoning is a significant problem in parts of Asia, the Pacific and the Caribbean. Ingestion of large amounts of paraquat results in rapid death, but smaller doses often cause a delayed lung fibrosis that is usually fatal. Anti-neutrophil ('immunosuppressive') treatment has been recommended to prevent lung fibrosis, but there is no consensus on efficacy. AIM To review the evidence for the use of immunosuppression in paraquat poisoning, and to identify validated prognostic systems that would allow the use of data from historical control studies and the future identification of patients who might benefit from immunosuppression. DESIGN Systematic review. METHODS We searched PubMed, Embase and Cochrane databases for 'paraquat' together with 'poisoning' or 'overdose'. We cross-checked references and contacted experts, and searched on [www.google.com] and [www.yahoo.com] using 'paraquat', 'cyclophosphamide', 'methylprednisolone' and 'prognosis'. RESULTS We found ten clinical studies of immunosuppression in paraquat poisoning. One was a randomized controlled trial (RCT). Seven used historical controls only; the other two were small (n = 1 and n = 4). Mortality in controls and patients varied markedly between studies. Three of the seven non-RCT controlled studies measured plasma paraquat; analysis using Proudfoot's or Hart's nomograms did not suggest that immunosuppression increased survival in these studies. Of 16 prognostic systems for paraquat poisoning, none has been independently validated in a large cohort. DISCUSSION The authors of the RCT have performed valuable and difficult research, but their results are hypothesis-forming rather than conclusive; elsewhere, the use of historical controls is problematic. In the absence of a validated prognostic marker, a large RCT of immunosuppression using death as the primary outcome is required. This RCT should also prospectively test and validate the available prognostic methods, so that future patients can be selected for this and other therapies on admission.
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Affiliation(s)
- M Eddleston
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, UK.
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Abstract
Acute paraquat poisoning is often fatal. Many studies have investigated successful treatment modalities, but no standard treatment yet exists. The purpose of this study was to determine the predictors of survival after acute paraquat poisoning in 602 patients. The paraquat exposure was assessed based on the amount of ingested paraquat and a semiquantitative measure of the urine level of paraquat. Initial clinical parameters including vital signs, hemoglobin, white-blood-cell count, pH, PaCO2, PaO2, blood urea nitrogen, creatinine, aspartate aminotransferase, alanine aminotransferase, total bilirubin, amylase, and glucose were obtained at the time of arrival at the emergency room. Outcomes after acute paraquat poisoning were categorized as survivors and nonsurvivors. Multiple logistic regression analysis was applied to assess the predictors of survival after acute paraquat poisoning. Some patients (55.5%) survived after oral ingestion of paraquat, whereas all those exposed to paraquat percutaneous or inhalational route survived. The amount of paraquat (24.5% concentrate of 1,1'-dimethyl-4,4'-bipyridium dichloride) ingested was 45.6 +/- 74.1 mL (mean +/- SD). In addition to degree of paraquat exposure, survival after acute paraquat poisoning was associated with age, respiratory rate, pH, PaCO2, hemoglobin, white-blood-cell count, blood urea nitrogen, amylase, and the number of failed organs in multiple logistic regression analysis. In conclusion, young age, percutaneous or inhalational route, exposure to less paraquat, and lesser degrees of leukocytosis, acidosis, and renal, hepatic, and pancreatic failures on admission are good prognostic factors of survival after acute paraquat poisoning.
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Affiliation(s)
- Eun-Young Lee
- Department of Internal Medicine, College of Medicine, Soonchunhyang University, Chonan, Chungnam, Korea
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Hong SY, Yang DH, Hwang KY. Associations between laboratory parameters and outcome of paraquat poisoning. Toxicol Lett 2000; 118:53-9. [PMID: 11137309 DOI: 10.1016/s0378-4274(00)00264-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Paraquat, a non-selective herbicide, is a known fatal substance in humans, and intentional ingestion of paraquat is increasing among Korean suicides. In 1999, 147 subjects admitted to the Institute of Pesticide Poisoning, Soonchunhyang Chunan Hospital, Korea ingested paraquat. Initial routine laboratory tests were conducted and the outcome of paraquat poisoning was categorized as survivor and fatality. Mean amount (S.D.) of ingestion was 54.5 (104.9) ml, and the overall fatality rate was 44.2%. Abnormal liver function (GOT and GPT), renal dysfunction (BUN and creatinine), metabolic acidosis (pH and PaCO(2)), and abnormal urine analysis (RBC, WBC, and protein) had significant odds ratios (ORs) for paraquat fatality (P<0.05). In multiple logistic regression, subjects with liver or renal dysfunction or metabolic acidosis had significant risks of the fatality. Our results determined that initial routine laboratory parameters could be used to predict the outcome of paraquat poisoning and recommended that evaluation of acid-base status and renal and liver function should be conducted and evaluated before intensive therapy.
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Affiliation(s)
- S Y Hong
- Department of Internal Medicine, School of Medicine, Soonchunhyang University, Chunan, South Korea
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Ernouf D, Boussa N, Legras A, Dutertre-Catella H. Acute paraquat poisoning: increased toxicity in one case with high alcohol intake. Hum Exp Toxicol 1998; 17:182-4. [PMID: 9587788 DOI: 10.1177/096032719801700310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Human paraquat poisoning from accidental or intentional ingestion is very often fatal. According to the amount of paraquat involved, death can occur within hours or weeks following ingestion. The inefficacy of the various treatments undertaken have led to determine prognostic factors based upon the evolution of plasma and urine paraquat concentrations or of usual biochemical parameters. We report one case of acute poisoning which, although the ingested dose of paraquat was not massive (< 50 mg/kg-1) and the severity indices were in favour of a delayed fatal outcome, has ended in an early death. The high blood alcohol level of the patient (3.34 g l-1) seems to be the main cause of the precocity of this death (86th hour).
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Affiliation(s)
- D Ernouf
- Laboratoire de Toxicologie, Faculté de Pharmacie, Tours, France
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Abstract
From 1987 to 1994, 31 cases of acute paraquat poisoning were managed in the CHRU of Pointe à Pitre (FWI). Eighteen patients died, 13 survived. Biological indexes accurately predicted patient's outcome in all cases out of one. In the last case biological parameters were misleading: the corresponding patient survived despite consistent clinical and biological prognosis of death. The unexpected survivor was West Indian, male, agricultural worker of 26 years who alleged drunk about 300 ml of gramoxone (20% v/v paraquat) in a suicide attempt. The patient was HIV-infected (Elisa+, Western-Blot+) and presented an AIDS syndrome (CD4 count inferior to 200 cells/mm2) established since 10 months and treated by AZT. We could not identify any other distinguishing features among the unexpected survivor and the rest of the patients. This observation suggests that the immunological status of the patient could explain this protection from paraquat toxicity.
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Affiliation(s)
- C Ragoucy-Sengler
- Laboratoire de Biochimie-Pharmacologie-Toxicologie, Centre Hospitalier Regional et Universitaire, Pointe à Pitre, Guadeloupe FWI
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Ragoucy-Sengler C, Pileire B. A biological index to predict patient outcome in paraquat poisoning. Hum Exp Toxicol 1996; 15:265-8. [PMID: 8839218 DOI: 10.1177/096032719601500315] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
1. In humans, the accidental or voluntary ingestion of paraquat, a non selective contact herbicide, is often lethal. Paraquat induces renal failure amongst other effects. 2. In this study we test the value of an index of the rate of increase in plasma creatinine over a 5 h period (dCreat/dt) to predict the outcome in intoxicated patients. These results are compared to previously published indices of severity of the paraquat poisoning. The proposed index is reliable, within the capability of any laboratory and will indicate the prognosis for poisoned patients within 6 h of admission to hospital.
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Affiliation(s)
- C Ragoucy-Sengler
- Laboratoire de Biochimie, Centre Hospitalier Régional et Universitaire, Pointe à Pitre, Guadeloupe
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Floersheim GL. Influence of ethanol on toxicity of paraquat and Amanita phalloides. Lancet 1992; 339:437. [PMID: 1346705 DOI: 10.1016/0140-6736(92)90130-u] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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