Aluminum phosphide intoxication mimicking ischemic heart disease led to unjustified treatment with streptokinase

Assessment of the role of N-terminal pro-B-type natriuretic peptide as a predictive biomarker of mortality in acute aluminum phosphide poisoning

BACKGROUND

In Egypt, aluminum phosphide (ALP) is a known lethal poison due to its cardiotoxicity. This study aimed to evaluate the predictive ability of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for mortality in ALP-poisoned patients.

METHODS

This prospective study was conducted on patients with ALP poisoning admitted to the Poison Control Center Ain Shams University Hospitals between July and December 2022. Upon admission, all patients were followed up and had their levels of NT-proBNP, troponin I (cTnI), and creatine kinase myocardial band (CK-MB) analyzed.

RESULTS

Thirty patients were enrolled in the study and were divided into survivors and non-survivors. The initial NT-proBNP levels were significantly higher among non-survivors in contrast to the initial cTnI and CK-MB levels. The study identified that the best cutoff point of NT-proBNP for predicting mortality was ≥72 pg/ml, with AUC (0.869).

CONCLUSION

It can be concluded that NT-proBNP can serve as an early predictor of mortality in ALP poisoning.

Pattern and predictors of death from aluminum and zinc phosphide poisoning using multi-kernel optimized relevance vector machine

The use of metal phosphides, particularly aluminum phosphide, poses a significant threat to human safety and results in high mortality rates. This study aimed to determine mortality patterns and predictive factors for acute zinc and aluminum phosphide poisoning cases that were admitted to Menoufia University Poison and Dependence Control Center from 2017 to 2021. Statistical analysis revealed that poisoning was more common among females (59.7%), aged between 10 and 20 years, and from rural regions. Most cases were students, and most poisonings were the result of suicidal intentions (78.6%). A new hybrid model named Bayesian Optimization-Relevance Vector Machine (BO-RVM) was proposed to forecast fatal poisoning. The model achieved an overall accuracy of 97%, with high positive predictive value (PPV) and negative predictive value (NPV) values of 100% and 96%, respectively. The sensitivity was 89.3%, while the specificity was 100%. The F1 score was 94.3%, indicating a good balance between precision and recall. These results suggest that the model performs well in identifying both positive and negative cases. Additionally, the BO-RVM model has a fast and accurate processing time of 379.9595 s, making it a promising tool for various applications. The study underscores the need for public health policies to restrict the availability and use of phosphides in Egypt and adopt effective treatment methods for phosphide-poisoned patients. Clinical suspicion, positive silver nitrate test for phosphine, and analysis of cholinesterase levels are useful in diagnosing metal phosphide poisoning, which can cause various symptoms.

The Molecular Mechanism of Aluminum Phosphide poisoning in Cardiovascular Disease: Pathophysiology and Diagnostic Approach

Nowadays, poisoning with metal phosphides, especially aluminum phosphide (ALP), is one of the main health threats in human societies. Patients suffer from significant complications due to this type of poisoning, and the heart is one of the main organs targeted by ALP. Therefore, in this study, we discussed the effect of phosphine on cardiac function. This study is based on data obtained from PubMed, between 2002 and 2020. The key keywords included "Aluminum phosphide," "Oxidative Stress," "Mitochondria," "Cardiovascular disease," and "Treatment." The results showed that ALP produced reactive oxygen species (ROS) due to mitochondrial dysfunction. ROS production leads to red blood cell hemolysis, decreased ATP production, and induction of apoptosis in cardiomyocytes, which eventually results in cardiovascular disease. Since ALP has the most significant effect on cardiomyocytes, the use of appropriate treatment strategies to restore cell function can increase patients' survival.

The effect of N-acetyl cysteine (NAC) on aluminum phosphide poisoning inducing cardiovascular toxicity: a case-control study

Background

Aluminum phosphide (AlP) is a very effective indoor and outdoor pesticide. We investigated the effects of N-acetyl cysteine (NAC) on the survival time, hemodynamics, and cardiac biochemical parameters at various time intervals in some cases of AlP poisoning.

Methods

This research was a case–control study to evaluate 63 AlP poisoned patients during 2010–2012. Patients with cardiovascular complications of AlP to be treated with intravenous NAC plus conventional treatment were considered as the case group and compared with patients who did not receive NAC. NAC infusion was administered to the case group at 300 mg/kg for 20 h. The data gathered included age, sex, heart rate, Systolic blood pressure (SBP), creatine phosphokinase (CPK), creatine kinase MB (CK-MB), and ECG at the admission time and 12, 18, and 24 h after admission. Analysis of repeated measures was performed to check the variability of parameters over time.

Results

The mean ages in the case and control groups were 26.65 ± 1.06 (19–37 years) and 28.39 ± 1.11 (18–37 years), respectively (P = 0.266). Most of the patients were female (56.5%). CK-MB means were significantly different between the two groups, but no differences between the other variables were observed. Also, CK-MB, CPK, heart rate, and systolic blood pressure means became significantly different over time (0, 12, 18, and 24 h) in both groups (P < 0.001). NAC prevented sharp heart rate fluctuations in AlP patients in the case group. Regarding the outcomes, 17 patients died (10 patients in the control and 7 patients in the case groups). No side-effects of NAC were observed.

Conclusion

Our patients could be managed by the positive role of NAC as the biochemical index of cardiotoxicity was found to elevate in both the case and control groups. Therefore, for the management protocol optimization, NAC evaluation should be done in further cases.

A review of aluminium phosphide poisoning and a flowchart to treat it

The use of pesticides such as aluminium phosphide (AlP) has increased in the recent years and improved the quantity and quality of agricultural products in a number of developing countries. The downside is that AlP causes severe chronic and acute health effects that have reached major proportions in countries such as India, Iran, Bangladesh, and Jordan. Nearly 300,000 people die due to pesticide poisoning in the world every year. Poisoning with AlP accounts for many of these deaths. Unfortunately, at the same time, there is no standard treatment for it. The aim of this article is to give a brief review of AlP poisoning and propose a treatment flowchart based on the knowledge gained so far. For this purpose we reviewed all articles on the management of AlP poisoning published from 2000 till now. Using a modified Delphi design, we have designed a handy flowchart that could be used as a guide for AlP poisoning management of patients in emergency centres.

N-acetylcysteine, Ascorbic Acid, and Methylene Blue for the Treatment of Aluminium Phosphide Poisoning: Still Beneficial?

Objectives:

Intentional and accidental intoxication with aluminium phosphide (ALP) remains a clinical problem, especially in the Middle East region. Considering the high mortality rate besides lack of any recommended first option drug for its treatment, this study was aimed to compare the therapeutic effects of N-acetylcysteine (NAC), vitamin C (Vit C), and methylene blue; both in isolate and also in combination, for the treatment of ALP intoxication in a rat model.

Materials and Methods:

In this experimental animal study, 80 male Wistar rats in eight groups were intoxicated with ALP (12.5 mg/kg) and treated with a single dose of NAC (100 mg/kg) or Vit C (500–1,000 mg/kg) or methylene blue (1 mg/kg/5 min, 0.1%) or two of these agents or all three of them (controls were not treated). Rats were monitored regarding the parameters of drug efficacy as increased survival time and reduced morbidity and mortality rate for 3 consecutive days to ensure toxin neutralization. Macroscopic changes were recorded and biopsy sections were taken from brain, cerebellum, kidney, liver, and heart for microscopic evaluation regarding cellular hypoxia.

Results:

The mean survival times of rats exposed to ALP and treated with VitC + NAC was 210.55±236.22 minutes. In analysis of survival times, there was a significant difference between Group 5 which received VitC + NAC and the other groups (P < 0.01). Serum magnesium levels after death were higher than normal (P = 0.01).

Conclusions:

Despite the higher survival rate of antioxidant-treated rats compared with controls, this difference was not statistically significant.

Electrocardiographic findings and cardiac manifestations in acute aluminum phosphide poisoning

Aluminium phosphide (AlP) poisoning has a high mortality due to cardiovascular involvement. In this study, we evaluated the frequency of cardiac manifestations and electrocardiographic (ECG) findings in 20 patients with acute AlP poisoning, who were admitted to the intensive care unit (ICU) in Tehran, Iran, over a period of 6 months (between October 2008 and April 2009). The sex, age, cause and manner of ingestion, number of ingested AlP tablets, cardiac and ECG manifestations, creatine phosphokinase (CPK), CPK-myocardial band (CPK-mb) and troponin-T (TnT) were extracted from the patients' files. All data were analysed with Statistical Package for the Social Sciences (SPSS) software. The majority (60%) of patients were male. The mean age was 27 ± 8.7 years. The mortality rate was 40%. In all of the patients, the cause of poisoning was intentional suicide and ingestion was the route of exposure. The mean number of ingested AlP tablets per patient was 2.2 ± 1.1. The average time interval between admission and cardiovascular manifestations or ECG findings was 168.8 ± 116.2 min. The range of systolic (SBP) and diastolic blood pressure was 60-130 mmHg and 40-70 mmHg, respectively. Dysrhythmia was observed in nine (45%) cases. Elevation of the ST segment was seen in nine cases (45%). Seven patients (35%) had prolonged QTc intervals. Bundle branch block (BBB) was observed in four (20%) patients. In nine (45%) patients, the serum cardiac TnT qualitative assay was positive. There were no significant differences between normal and abnormal ECG groups according to sex, age, number and manner of ingested AlP tablets and SBP. There was a significant correlation between cardiac manifestations and ECG findings and TnT-positive results with mortality in acute AlP poisoning.

Clinical Toxicology of Insecticides

Some insects compete for our food, some damage construction materials and some are important disease vectors in humans and animals. Hence, it is not surprising that chemicals (insecticides) have been developed that kill insects and other arthropods. More recently introduced insecticides, such as the neonicotinoids, have been produced with the intent that humans and animals will not be harmed by their appropriate use. This chapter reviews the clinical features and management of exposure to organophosphorus (OP) and carbamate insecticides, neonicotinoids, phosphides and pyrethroids. In the developing world where the ambient temperature is often high and personal protection equipment often not worn, poisoning particularly from OP and carbamate insecticides is common in an occupational setting, though more severe cases are due to deliberate ingestion of these pesticides. Both of these insecticides produce the cholinergic syndrome. The neonicotinoids, a major new class of insecticide, were introduced on the basis that they were highly specific for subtypes of nicotinic receptors that occur only in insect tissues. However, deliberate ingestion of substantial amounts of a neonicotinoid has resulted in features similar to those found in nicotine (and OP and carbamate) poisoning, though the solvent in some formulations may have contributed to their toxicity. Phosphides interact with moisture in air (or with water or acid) to liberate phosphine, which is the active pesticide. Inhalation of phosphine, however, is a much less frequent cause of human poisoning than ingestion of a metal phosphide, though the toxicity by the oral route is also due to phosphine liberated by contact of the phosphide with gut fluids. It is then absorbed through the alimentary mucosa and distributed to tissues where it depresses mitochondrial respiration by inhibiting cytochrome c oxidase and other enzymes. Dermal exposure to pyrethroids may result in paraesthesiae, but systemic toxicity usually only occurs after ingestion, when irritation of the gastrointestinal tract and CNS toxicity, predominantly coma and convulsions, result.