Aluminum phosphide poisoning: Possible role of supportive measures in the absence of specific antidote

Mitotherapy with Fresh Isolated Cardiac Mitochondria Via Injection Into Blood Reduces Aluminum Phosphide-Induced Mortality and Protects Cardiac Tissue Against Oxidative Stress and Mitochondrial Damages

The hallmark of aluminum phosphide (AlP) poisoning is heart failure in victims which is associated with reactive oxygen species (ROS), mitochondrial dysfunction, oxidative stress, alteration in antioxidant defense system and depletion of ATP in cardiomyocytes. In the present study, we hypothesized that the injection of isolated mitochondria into blood or mitochondrial transplantation can likely create a primary target for phosphine released from AlP and inhibit AlP-induced mortality and cardiotoxicity in rat. Male, Wistar, healthy and adult rats were randomly divided into 5 groups as control, AlP (12.5 mg/kg, orally), AlP + mitochondria (125 µg/kg), AlP + mitochondria (250 µg/kg) and mitochondria (250 µg/kg) alone. Functional and intact mitochondria isolated from rat heart and transplantation was carried out via tail vein, 30 min after exposure to AlP. Survival rate, histopathological alterations, cardiac biochemical markers, oxidative stress and mitochondrial toxicity parameters were monitored and analyzed during 30 days. We found that injection of healthy mitochondria into blood at concentrations of 125 and 250 125 µg/ml significantly increased the survival of rats up to 40% and 56.25% respectively, during 30 days. Moreover, we observed that mitochondria injection into blood decreased histopathological damages, cardiac biochemical markers, oxidative stress and mitochondrial toxicity parameters. To our knowledge, the current study is the first report in the literature that demonstrated good therapeutic effects of mitochondrial transplantation in AlP-induced mortality and cardiotoxicity. The findings of the present study suggests that injection of exogenous mitochondria into blood could be an effective therapeutic strategy in treating AlP poisoning.

Evaluation of the Protective Effects of Lugol's Solution in Rats Poisoned with Aluminum Phosphide (Rice Tablets)

Aluminum phosphide (AlP) is the main component of rice tablets (a pesticide), which produces phosphine gas (PH3) when exposed to stomach acid. The most important symptoms of PH3 toxicity include, lethargy, tachycardia, hypotension, and cardiac shock. It was shown that Iodine can chemically react with PH3, and the purpose of this study is to investigate the protective effects of Lugol solution in poisoning with rice tablets. Five doses (12, 15, 21, 23, and 25 mg/kg) of AlP were selected, for calculating its lethal dose (LD50). Then, the rats were divided into 4 groups: AlP, Lugol, AlP + Lugol, and Almond oil (as a control). After 4 h, the blood pressure and electrocardiogram (ECG) were recorded, and blood samples were obtained for biochemical tests, then liver, lung, kidney, heart, and brain tissues were removed for histopathological examination. The results of the blood pressure showed no significant changes (P > 0.05). In ECG, the PR interval showed a significant decrease in the AlP + Lugol group (P < 0.05). In biochemical tests, LDH, Ca2+, Creatinine, ALP, Mg2+, and K+ represented significant decreases in AlP + Lugol compared to the AlP group (P < 0.05). Also, the administration of Lugol's solution to AlP-poisoned rats resulted in a significant decrease in malondialdehyde levels and a significant increase in catalase activity (P < 0.05). Histopathological evaluation indicates that Lugol improves changes in the lungs, kidneys, brain, and heart. Our results showed that the Lugol solution could reduce tissue damage and oxidative stress in AlP-poisoned rats. We assume that the positive effects of Lugol on pulmonary and cardiac tissues are due to its ability to react directly with PH3.

Modulating oxidative stress, apoptosis, and mitochondrial dysfunctions on cardiotoxicity induced by aluminum phosphide pesticide using resveratrol

The agricultural fumigant pesticide aluminum phosphide (AlP) is cardiotoxic. Water causes AlP to emit phosphine gas, a cardiac toxin that affects heart function and causes cardiogenic shock. AlP poisoning's high fatality rate is due to cardiotoxicity. This study examines how resveratrol reduces oxidative stress, mitochondrial activity, and apoptosis in human cardiac myocyte (HCM) cells. After determining the optimal doses of resveratrol using the MTT test, HCM cells were subjected to a 24-h treatment of resveratrol following exposure to AlP (2.36 μM). The levels of reactive oxygen species (ROS), superoxide dismutase (SOD) activity, mitochondrial swelling, mitochondrial cytochrome c release, and mitochondrial membrane potential (MMP) in HCM cells were investigated. Also, the expression of Bax and Bcl-2, caspace-3 activity, and apoptosis were assessed. The present investigation revealed that AlP substantially increased the level of ROS and decreased SOD activation, which were significantly modulated by resveratrol in a dose-dependent manner. Moreover, AlP induced an elevation of mitochondrial swelling, cytochrome c release, and MMP collapse. Co-administration of resveratrol significantly reduced above mitochondrial markers. AlP also significantly upregulated BAX and downregulated Bcl-2 expression, elevated caspace-3 activity, and apoptosis. Resveratrol co-administration was able to meaningfully modulate the mentioned parameters and finally reduce apoptosis. In conclusion, resveratrol, via its pleotropic properties, significantly demonstrated cytoprotective effects on HCM cytotoxicity induced by AlP.

Accidental Aluminum Phosphide Intoxication Successfully Treated with Hyperbaric Oxygen Therapy: A Case Report

The most common pesticide agents are organophosphates and phosphides, aluminum phosphide (ALP) in particular. ALP is a major cause of suicidal poisoning in many countries. In other countries, the problem of accidental, mainly occupational-related, poisoning is also real and actual. Almost two thirds of individuals in poisoning cases have died. This case report describes a case of a patient with accidental ALP intoxication. The origin of the poisoning was the fumigation of stored grain in an agricultural building adjacent to the building in which patient was temporarily housed, while both buildings were connected by an underground corridor, through which the released poison gas penetrated. The case was originally presented by the rescuers as well as healthcare professionals of the local hospital as carbon monoxide intoxication, which has a similar symptomatology as ALP intoxication. The patient was treated comprehensively, including using the HBOT method, which is very unique in the case of phosphine intoxication in human medicine, with an excellent final clinical outcome. This was the first described case of HBOT for ALP intoxication in clinical medicine, although the HBOT indication itself became a coincidence in this case. Further studies must be undertaken to demonstrate the effectiveness of HBOT in treating patients with ALP poisoning.

Gastrointestinal decontamination using oil-based solutions in patients with acute aluminum phosphide poisoning: a systematic review and meta-analysis

Some studies suggested that gastrointestinal (GIT) decontamination with oil may improve the prognosis of patients who ingested aluminum phosphide (AlP). The aim of this study is to compare the efficacy and safety of gastric lavage with oil-based solutions to any method of gastric decontamination not using oils in patients presenting with acute AlP poisoning. The literature was searched for English-published randomized controlled trials (RCTs) from inception to 16 September 2023. The searched electronic databases included MEDLINE/PubMed, Cochrane Library, Web of Science, Egyptian Knowledge Bank, Scopus, and Google Scholar. Data were extracted and pooled by calculating the risk ratio (RR) for categorical outcomes and standardized mean difference (SMD) for numerical outcomes, with 95% confidence intervals (CI). Seven RCTs were included. Paraffin oil was significantly associated with a lower risk of mortality (RR = 0.59 [95% CI: 0.45, 0.76], p < .001), intubation (RR = 0.59 [95% CI: 0.46, 0.76], p < .001) and vasopressor need (RR = 0.71 [95% CI: 0.56, 0.91], p = .006). Survival time was significantly prolonged with paraffin oil (SMD = 0.72 [95% CI: 0.32, 1.13], p < .001). Coconut oil was significantly associated with prolonged survival time (SMD = 0.83 [95% CI: 0.06, 1.59], p = .03) as well as decreased risk of requiring intubation (RR = 0.78 [95% CI: 0.62, 0.99], p = .04). Oil-based GIT decontamination using paraffin oil showed benefits over conventional lavage regarding the incidence of in-hospital mortality and endotracheal intubation, and survival time. Coconut oil showed some benefits in terms of the intubation incidence and survival time. Decontamination using paraffin oil is recommended. Future clinical trials are warranted with larger sample sizes and focusing on cost-benefit and safety.

Insulin-euglycemia therapy in acute aluminum phosphide poisoning: a randomized clinical trial

Introduction: Aluminum phosphide is a pesticide that is used in developing countries. Aluminum phosphide poisoning has a high mortality rate and there is no known antidote. This study aimed to evaluate the safety and efficacy of insulin-euglycemia therapy in the management of patients with acute aluminum phosphide poisoning.Methods: This trial was prospectively registered in the Pan African Clinical Trials Registry (PACTR202008534546951). A total of 108 patients were randomly allocated to two groups. The intervention group received insulin-euglycemia therapy in addition to standard treatment (norepinephrine and supportive care); the control group received standard treatment plus placebo. The main outcome measures were survival, blood pressure, and laboratory investigations.Results: The two groups had similar baseline parameters. Insulin-euglycemia therapy was associated with a significant reduction in mortality compared with that in the control group (64.8 percent and 96.3 percent, respectively; P value <0.001). Patients randomized to insulin-euglycemia also required lower doses of vasopressors (median was 7 mg versus 26 mg in control group; P value 0.006) and fewer patients needed intubation (61.1 percent versus 81.5 percent in the control group; P value 0.019). Insulin-euglycemia therapy significantly improved blood pressure (systolic, diastolic, and mean arterial pressure) (median at 6h post-admission was 80 mmHg, 55 mmHg and 65 mmHg compared with 20 mmHg, 10 mmHg and 13 mmHg in the control group respectively; P value <0.001) and bicarbonate and lactate concentrations.Conclusion: Insulin-euglycemia therapy appears to be a safe and effective treatment option for patients with aluminum phosphide poisoning. Vasopressor only therapy was associated with very poor outcomes in acute aluminum phosphide poisoning.

Visual impairment following aluminum phosphide poisoning: A rare case

Key Clinical Message

Aluminum phosphide poisoning may cause rare visual impairment. In a case, a 31-year-old female, visual loss was linked to shock-induced hypoperfusion, causing oxygen lack and cerebral atrophy, emphasizing the need for identifying atypical symptoms.

Abstract

This case report describes the multidisciplinary evaluation of a 31-year-old female patient who suffered from visual impairment as a result of aluminum phosphide (AlP) poisoning. Phosphine, which is formed in the body when AlP reacts with water, cannot cross the blood-brain barrier; therefore, visual impairment seems unlikely to be the direct result of phosphine. To our knowledge, it is the first documented report of such impairment due to AlP.

Cardioprotective role of the coenzyme Q10 and coconut oil in acute aluminum phosphide poisoning: a randomized controlled clinical trial

Aluminum phosphide (ALP)-induced cardiotoxicity is a major cause of high mortality rates. As there is no specific antidote, restoring cardiac hemodynamics is the cornerstone for saving patients. Based on oxidative stress theory in acute ALP poisoning, we examined the cardioprotective role of coconut oil and Coenzyme Q10 (COQ10) in ALP poisoning, focusing on their antioxidant capacity. This study was a randomized, controlled, single-blind, phase II clinical trial conducted at Tanta Poison Control Center over 1 year. Eighty-four ALP poisoned patients received supportive treatment and were randomly allocated to three equal groups. Gastric lavage was performed using sodium bicarbonate 8.4% with saline in group I. Alternatively, group II received 50 ml coconut oil, and group III initially received 600 mg CoQ10 dissolved in 50 ml coconut oil; and repeated 12 hours later. In addition to patient characteristics, clinical, laboratory, electrocardiography (ECG), and total antioxidant capacity (TAC) data were recorded and repeated 12 hours later. Patient outcomes were evaluated. There was no significant difference among groups considering patient characteristics, initial cardiotoxicity severity, vital, laboratory data, ECG changes, and TAC. However, 12 hours post-admissions, group III was significantly improved in all clinical, laboratory, and ECG parameters than comparable groups. Significant correlations were observed between elevated TAC in groups II and III with hemodynamic, serum troponin, and ECG variables. Accordingly, the need for intubation, mechanical ventilation, and the total vasopressor dose was significantly decreased in group III compared with other groups. Therefore, coconut oil and COQ10 are promising cardioprotective adjuvant therapy ameliorating the ALP-induced cardiotoxicity.

Comparing the effectiveness of L-carnitine and paraffin oil in acute aluminum phosphide poisoning using predictive biomarkers and scores: A randomized controlled clinical trial

Aluminum phosphide (AlP) poisoning is a serious medical emergency with a high mortality rate. The absence of an exact antidote for AlP poisoning necessitates the quest for alternative treatment options. The study sought to assess the efficacy of adding L-carnitine or medicated paraffin oil to the conventional approach of treatment employed in cases of acute AlP poisoning. We conducted a 1 year, randomized, controlled, parallel-group, single-blind clinical study. 96 individuals with acute AlP poisoning were randomly assigned to one of three groups. The standard AlP therapy was administered to all groups according to the Poison Control Center guidelines at the Ain-Shams University hospitals. All patients underwent a medical history review, clinical examination, and laboratory tests. The outcomes were assessed. The participants in the study groups had mean ages ranging from 25.6 to 26.3 years. The cases analyzed were evenly distributed between genders, with the majority originating from rural areas. The average delay time varied from 2.9 to 4.2 h. All patients in the study reported ingesting AlP during suicide attempts. 12 hours after admission, many clinical and biochemical data improved in both intervention groups including cytochrome c oxidase, caspase-3, caspase-9, catalase, and superoxide dismutase. The intervention groups required significantly less mechanical ventilation and had a lower mortality rate than the control group. Decontamination with paraffin oil could be advantageous for reducing the severity of AlP poisoning, improving prognosis, and lowering the mortality rate.

Trends and Outcomes of Acute Poisoning in Felege Hiwot Comprehensive Specialized Hospital Medical Intensive Care Units: Retrospective Study

Background

Acute poisoning with agrochemicals, medicines and different environmental exposures continues to be a global health problems. However, with our search for reports about acute poisoning, there was no data regarding a change in trends and outcomes of acute poisoning in Ethiopia and its districts.

Objective

This study was to determine the burden of poison-related health hazards, identify poisoning substances, and clinical outcomes of poisoning cases admitted to Felege Hiwot Comprehensive Specialized Hospital- Medical intensive care unit (FHCSH-MICU), Bahir Dar, Ethiopia.

Methods

A retrospective hospital-based study was conducted using patient data archived from March 2019 to February 2020 at FHCSH-MICU. Collected data were analyzed using Statistical Package for Social Sciences (SPSS) software version 26 and descriptive statistics such as measures of central tendency and proportions were computed. The results were reported as text narrations, figures and tables.

Results

A total 121 poisoned patients were identified from the patient registration log books. Among the total FHCSH-MICU cases registered, acute poisoning accounted for 17.0%. Of 121 poison cases, 118 (98.3%) were due to suicide attempts with the female to male ratio being 1.5:1. The majority, 65 (54.0%), of cases were in the range of 21-30 years age. Nearly two-thirds, 75 (62.0%), of the poisoning cases died, accounting for 21.6% of all deaths in the FHCSH-MICU. The most common poisoning substance was aluminum phosphide, 92 (76%).

Conclusion and Recommendations

Aluminum phosphide became the leading poisoning substance in the study area. Nearly two-thirds of the poisoning cases died. Hence, aluminum phosphide must be placed in secured and inaccessible places and it should be replaced by less poisonous rodenticides. Health education and awareness creation about this lethal toxin are strongly advisable.

Potential role of paraffin oil gastric lavage in acute aluminum phosphide poisoning: a randomized controlled trial

Aluminum phosphide (ALP) poisoning is a true medical emergency associated with high mortality. The lack of a specific antidote for ALP poisoning mandates searching for new treatment modalities. This study aimed to evaluate the effectiveness and safety of gastric decontamination by paraffin oil in cases with acute ALP poisoning. This study was a randomized, controlled, parallel-group, single-blind, phase II clinical trial conducted over a period of 6 months. Sixty-two patients with acute ALP poisoning were randomly allocated into two equivalent groups. In both groups, the standard ALP treatment was given. Gastric decontamination in the control group was performed by saline and sodium bicarbonate 8.4%, while in the intervention group, it was done by paraffin oil and sodium bicarbonate 8.4%. All patients were subjected to history taking, clinical examination, and laboratory investigations. The outcomes were evaluated. The median age of the studied patients was 20 years. Most of the studied cases were females, single, and from rural areas. The median delay time was 1 h. All patients included in the study alleged ingestion of ALP during suicidal attempts. Twelve hours after admission, many clinical and laboratory findings were significantly better in the intervention group. The need for intubation, mechanical ventilation, and total amount of vasopressors was significantly lower, and the mortality rate was non-significantly lower in the intervention group compared to the control. The median length of hospital stay was significantly shorter in the control group. Gastric decontamination with paraffin oil and sodium bicarbonate 8.4% could be valuable in reducing ALP poisoning severity, the need for intubation, mechanical ventilation, and vasopressors.

Reducing the risk of death induced by aluminum phosphide poisoning: The new therapies

Numerous people suffer from accidental or deliberate exposure to different pesticides when poisoning with aluminum phosphate (AlP) is increasing in the eastern countries. Aluminum phosphate is a conventional insecticide that quickly reacts with water or the moistures in the atmosphere and produces fatal phosphine gas, which absorbs quickly by the body. Oral consumption or inhalation of AlP leads to excessive reaction of the body such as fatigue, vomiting, fever, palpitation, vasodilatory shock, increasing blood pressure, cardiac dysfunction, pulmonary congestion, shortness of breath, and death. The garlic smell from the patient's mouth or exhale is one of the methods to recognize the positioning. Due to the lack of individual antidotes, several supportive treatments are required. The present study focused on the available and new therapies that help reduce the effect of AlP poisoning and the mortality rate. The therapies are divided into the antioxidant-related agent and the other agents. The impacts of each agent on the experimental cases are reported.

HEPATIC DYSFUNCTION IN MEDICAL INTENSIVE CAREUNIT PATIENTS PREDICTS POOR OUTCOME

BACKGROUND

A large number of patients admitted to the medical intensive care unit (MICU) have abnormal liver function tests (LFT). This includes patients with critical illness with or without preexisting liver disease and patients with acute primary liver injury. There are very few studies which have investigated the spectrum of liver disease, clinical profile and outcome in patients admitted to the MICU.

OBJECTIVE

To evaluate the occurrence, etiology, clinical profile, laboratory profile and outcome of hepatic dysfunction in patients admitted to the MICU. To evaluate the utility of model for end-stage liver disease (MELD) score on admission as a predictor of adverse short term outcome in patients with hepatic dysfunction admitted in MICU.

METHODS

It was a prospective observational study, conducted from December 2017 to December 2018 in a tertiary care hospital. Two hundred and two patients admitted to the MICU with LFTs as per the inclusion criteria were analyzed and their short-term outcome at 7 days was studied in relation to various parameters.

RESULTS

LFT abnormalities were present in 202/1126 (17.9%) of the patients admitted to MICU. Critical illness associated liver dysfunction was found in 172 (85.2%) patients, chronic liver disease in 11 (5.4%) patients and acute viral hepatitis in 19 (9.4%) patients. Most common symptom was fever (68.3%) followed by vomiting (48.0%). Among LFT abnormalities, elevated transaminases, raised international normalized ratio and high MELD score on admission correlated with poor short-term outcome. Requirement for inotropes and mechanical ventilation correlated with poor short-term outcome. Mortality did not differ significantly between patients with chronic liver disease, patients with acute viral hepatitis and patients with critical illness associated hepatic dysfunction. Hepatic dysfunction in MICU was associated with poor outcome and a high short-term mortality of 56.4% (114/202).

CONCLUSION

Liver function abnormality is common in patients who are admitted to the MICU and its presence is an indicator of poor short-term outcome.

The Role of Echocardiographic Findings in Estimating Survival Probability of Intensive Care Unit Admitted Aluminum Phosphide Poisoned Patients

INTRODUCTION

Cardiotoxicity represents the primary cause of death in acute aluminum phosphide (AlP) poisoning. Prompt supportive care can improve patient survival. This study assessed the role of echocardiography in estimating the survival probability of AlP-poisoned patients admitted to the intensive care unit.

METHODS

A prospective cohort study of symptomatic acute AlP poisoned patients was conducted between September 2019 and December 2020. Patients were subjected to history taking, clinical examination, To be included, patient evaluation needed to include electrocardiographic (ECG) and echocardiographic studies. The statistical analysis assessed the association between patient survival and relevant factors. Survival analysis was performed using the Kaplan-Meier survival curve and Cox proportional hazard regression.

RESULTS

A total of 90 patients met inclusion criteria. Electrocardiographic abnormalities were detected in 38.1% of survivors and 82.6% of non-survivors (p < 0.001). Survivors had a higher mean left ventricle ejection fraction (LVEF) (50.86 ± 6.30% vs. 26.52 ± 7.64%, respectively, p < 0.001) and a lower percentage of global LV hypokinesia (4.8% vs. 94.2%, p < 0.001). The mean survival time was higher among patients with LVEF ≥ 50% than those with LVEF = 41-49% and ≤ 40% (p = 0.014 and 0.001, respectively). The hazard of death was 4.42 and 5.40 times greater in patients with LVEF ≤ 40% or with global LV hypokinesia, respectively. Regression revealed that the global LV hypokinesia, ECG abnormalities, and decreased LVEF and oxygen saturation were significantly associated with the risk of death (hazard ratios: 4.382, 3.348, 0.957, and 0.971, respectively).

CONCLUSIONS

Echocardiography represents a valuable diagnostic tool to assess cardiac function in acute AlP poisoning. Both LVEF and global LV hypokinesia significantly impact the survival of AlP-poisoned patients. Echocardiography was superior to ECG changes in terms of accuracy for the prediction of mortality.

Importance of pesticides for lethal poisoning in India during 1999 to 2018: a systematic review

BACKGROUND

Poisoning is a major problem in India. However, there is little systematic information on the key poisons responsible for most deaths by geographical area and over time. We aimed to review the literature to identify the poison classes causing the greatest number of deaths in India over the last 20 years.

METHODS

We performed a systematic literature review in Medline, Embase and Google Scholar (1999-2018), and Indian online medical journals, to find papers that reported deaths from all forms of poisoning in India, with last search 20 April 2020. We included epidemiological studies, observational studies, randomised trials, interventional studies, and case series published from 1999 to 2018 that showed the number of deaths and autopsy studies indicating the specific poisons or poison classes. Studies providing the case fatality for specific poisons or classes, which enabled calculation of the number of deaths, were also included. We excluded deaths due to animal bites and stings, ethanol or methanol poisoning, and gas inhalation as well as papers reporting a single death (case study of single patient). We grouped the papers into 5-year intervals and identified the two most common poison classes in each paper. We used descriptive statistics to summarise the findings over time based on the causative poison and the location of the study.

RESULTS

We identified 186 papers reporting 16,659 poisoning deaths between 1999 and 2018. The number of publications per 5-year interval showed no clear trend over the period (48, 38, 67, and 36 for consecutive periods). Half of the deaths (n = 8338, 50.0%) were reported during the first 5 years of the study (1999-2003), the number of deaths declining thereafter (to n = 1714 in 2014-2018). Deaths due to pesticide poisoning (94.5%) were dominant across the study period compared to other classes of poison [hair dye paraphenylenediamine poisoning (2.6%), medicine overdose (1.4%) or plant poisoning (1.0%)]. Among the pesticides, aluminium phosphide was the most important lethal poison during the first 10 years before declining markedly; organophosphorus insecticides were important throughout the period, becoming dominant in the last decade as aluminium phosphide cases declined. Unfortunately, few papers identified the specific organophosphorus insecticide responsible for deaths.

CONCLUSION

Use of the published literature to better understand the epidemiology of lethal poisoning in India has clear limitations, including secular variation in publishing practices and interest in poisoning. Unfortunately, there are no long-term detailed, combination hospital and community studies from India to provide this information. In their absence, our review indicates that pesticides are the most important poison in India, with organophosphorus insecticides replacing aluminium phosphide as the key lethal poison after government regulatory changes in 2001 reduced the latter's lethality. Plant and hair dye poisoning and medicines overdose caused few deaths. Aluminium phosphide deaths mostly occurred in northern Indian states, whereas deaths from organophosphorus insecticide poisoning occurred throughout India. Paraquat poisoning has become a clinical problem in the last 10 years. Lethal pesticide poisoning remains alarmingly common, emphasising the need for additional regulatory interventions to curtail the burden of pesticide poisoning deaths in India. More detailed reporting about the specific pesticide involved in lethal poisoning will be helpful to guide regulatory decisions.

Development of detection methods for the diagnosis and analysis of highly toxic metal phosphides: A comprehensive and critical review

Metal phosphides, especially aluminum phosphide, and phosphine (PH₃ ) are widely used as insecticides and rodenticides for protection of grains during process of storage and transportation. The main reason of poisoning with this compound is related to the conscious ingestion of salts or accidental inhalation of PH₃ . So the early and accurate diagnosis of poisoning can significantly help to the effective clinical treatment or recognition of death cause. PH₃ is somewhat unstable due to reaction with oxygen or hemoglobin leading to formation of oxy-acids phosphorous. Here, we critically reviewed the literature introducing the quantitative and qualitative methods for the detection of metal phosphides, PH₃ , and its products. This study obviously demonstrates that during past years, different diagnosis methods have been remarkably progressed. Head-space gas chromatography and confirmatory colorimetric methods have been as the most popular techniques. Also, the gas sensors are a promising method that must be more progressed.

Survival after Aluminum Phosphide Poisoning in Pregnancy

Intoxication and drug overdose as suicidal attempt are rare in pregnancy. We report here the case of aluminum phosphide poisoning in a pregnant lady through oral and intravaginal administration which was managed with aggressive supportive measures without resorting to extracorporeal life support.

Suspected alimentary poisoning by aluminium phosphide in horses – a case report

In November 2018, a horse owner from the Czech Republic experienced the loss of two of his stallions in consequence of probable poisoning. The affected animals were kept in the stable only. The mares, which were grazing on pasture during the day, were not affected. All the animals were fed the same type of feed. The day before the animals became sick, between 15:00 to 19:00 h the stable was not secured against the entry of strangers. When the mares were brought back to the stable and all animals were closed and locked for the night, no signs of health issues were observed. In the following morning, the two stallions were found in lateral recumbency with seizure attacks. Despite symptomatic treatment (infusion with saline, flunixine meglumine, activated charcoal) and applications of myorelaxants, the symptoms persisted until the afternoon, and the owner agreed with euthanasia. Based on the clinical signs and pathological examination, poisoning by pesticides was suspected. The results of toxicological analyses revealed that carbofuran, metaldehyde, and strychnine were not responsible for the poisoning as they were not detected in the samples. The only positive finding was a high aluminium concentration in the stomach content, liver and kidney samples. Based on the observed symptoms and the high aluminium concentration, it was presumed that aluminium phosphide could be the source of poisoning. As there was no evidence of the possession of such product by the horse breeder and the stable stayed unsupervised for a few hours, intentional poisoning cannot be excluded.

Complicated central catheterization in atypical celphos poisoning simulating throttling homicide: Review of neck resuscitation artefacts

Therapeutic artefacts are a challenge for forensic pathologists for correct interpretation at autopsy. A 23-year-old female was found unconscious at home and immediately admitted to an emergency of a tertiary care hospital where resuscitative measures were taken. However, she died after 4 h of hospitalization. The injuries (abrasions, subcutaneous bruising and haemorrhage in the deep structures of the neck) discovered at autopsy simulated the findings of throttling and aroused the suspicion of homicide. Later, enquiry revealed that it happened due to mal-positioned central line in the carotid artery during internal jugular vein access to provide fluid as the patient was in shock due to aluminium phosphide (Celphos)poisoning. The bleeding diatheses in Celphos poisoning might have precipitated the extensive neck haemorrhage in this case.

The efficacy of Coenzyme Q10 and liquid paraffin oil in the management of acute aluminum phosphide poisoning

Aluminum phosphide (AlP) poisoning had high morbidities and mortalities with absence of a standardized approach for the treatment. The present study investigated the efficiency of GIT decontamination methods and Coenzyme Q10(Co Q10) (Ubiquinone) in improving the outcome of acute AlP poisoning. A total of 90 patients were included and all patients received immediately supportive measures, then they distributed into three equal groups: In group I, gastric lavage was done using KMNO₄ solution (1:10 000); group II received 250-500 ml liquid paraffin oil orally; group III received 300 mg of Co Q10 dissolved in liquid paraffin. Co Q10 was continued in a dose of 200 mg/day every 12 h. Follow-up blood pressure, arterial blood gases, serum troponin level and need for intubation revealed that the best improvement was in group III followed by group II. The percentage of survivors was 76.67% in group III and 70% of the patients had no residual effects. In group II, the survivors were 63.33%, and 36.67% of the cases discharged without sequelae. The survivors in group I constituted 26.67% and only 16.67% of the patients had no residual effects. GIT decontamination with aqueous solutions in acute AlP poisoning should be avoided. Rapid oral intake of any available oil as a prehospital treatment or immediately on hospital admission could critically improve the outcome of acute AlP poisoning. Besides, the addition of Co Q10 to the oil further improve patients' prognosis. HighlightsAcute aluminum phosphide (AlP) poisoning is associated with high mortalities.The appropriate method of GIT decontamination in acute AlP poisoning is controversy.Conventional gastric lavage was associated with poor prognosis in acute AlP poisoning.GIT decontamination using liquid paraffin oil improved outcome of acute AlP poisoning.Coenzyme Q10 ameliorated AlP toxicity with improvement of cardiac functions.

Forensic implications of pituitary macroadenoma: An autopsy case report

Pituitary adenomas are the most common tumours of the sellar region. Functional pituitary adenomas are related with immense assorted variety in their endocrine manifestations secondary to hypo or hyperfunction of the pituitary gland and mass impact. They can have a slow but severe impact on vision due to compression of the optic nerves, optic chiasm and cavernous sinus. Hereby, we discuss a case of a 29-year-old female patient who presented to the emergency with an alleged history of chest pain after ingestion of rat poison (zinc phosphide) in an attempt to commit suicide. Autopsy finding revealed a large mass that was present in the pituitary fossa impinging onto the optic chiasma. On further inquiry of the law enforcing agencies, it was found that the patient was undergoing treatment for psychiatric illness, and she had also complained of vision loss for the past few months. The parents of the deceased lodged a case of homicide by the husband. This case demonstrates the psycho-social and forensic implications of a pituitary tumour. The role of collaborative efforts of the autopsy team and the law enforcing agencies are emphasised.

Changes of QT Dispersion in Patients Suffering from Aluminium Phosphide Poisoning (Rice Pill)

BACKGROUND:

Aluminium phosphide (ALP) or rice pill is a substance used in developing countries due to its low cost as pesticides. The availability of this substance has been lead to an increased rate of the use of this toxic inorganic compound for suicide. Complications are considered to be dose-related toxicity and hospitalisation time, varying from hemodynamic disorder, hypoglycemia, hyperglycemia, shock, cardiotoxicity, pulmonary and renal failures. The consumption of this substance is one of the major causes of mortality due to heart arrhythmia. QT dispersion represents a regional difference in ventricular repolarisation and electrical instability of the heart.

AIM:

The purpose of this study was to investigate the effect of ALP poisoning on QT dispersion.

METHODS:

In this study, 70 patients with ALP poisoning were enrolled, and 10 patients were excluded due to the exclusion criteria. QT dispersion rate was calculated in 60 patients using the standard electrocardiography at the time of referral. The above data were compared with the control group, which included 40 subjects with normal coronary angiography, and without cardiovascular risk factors.

RESULTS:

The findings presented herein indicated a significant correlation between QT dispersion and control group (P < 0.0.5). There was a significant relationship between the severity of acidosis and the patient’s tablets –taking a number (P < 0.05). However, there was no relationship between QT dispersion with the severity of acidosis and mortality in patients.

CONCLUSION:

Because there is no CAD risk factor in the population, it can be concluded that increase in QT dispersion in these individuals can be due to ALP poisoning; nevertheless, this is not considered to be a factor in increasing the morbidity of these patients.

Phosphine poisoning in free-range local chickens: a case report

Phosphine poisoning is rarely reported in poultry, and its diagnosis is a great challenge for veterinary toxicologists and pathologists. A case of phosphine toxicosis in local, free range chickens is reported. Fourteen dead chickens (age ≥6 months old) were presented to the veterinary clinic for necropsy. The history revealed that the chickens were normally fed with guinea corn grains, but were suspected to have been fed boiled rice laced with poison. The clinical signs observed were ruffled feathers, somnolence, anorexia and high mortality. The disease ran a 2‐day course with mortality pattern of four chickens the first day, six overnight and 14 the following day. Necropsy findings showed generalized vascular congestion and haemorrhage in the lungs and visceral organs, with the crop and gizzard filled with guinea corn and rice grains and greenish‐yellow faecal material in the intestinal lumen. The presence of widespread congestion and petechial haemorrhages on visceral organs with the microscopic pulmonary congestion, and diffuse intraparabronchial presence of air sac macrophages, strongly suggested an acute toxic cause of death. Chemical tests on the crop contents of the dead chickens were positive for phosphine gas. This report will contribute to a better understanding of the clinical signs and lesions presented in cases of acute phosphide rodenticide exposure in domestic chickens, with a brief review of the forensic literature.

Butyrylcholinesterase level in poisoned patients with phosphide compounds

BACKGROUND

Metal phosphides are widely used as a rodenticide and insecticide and poisoning with these substances has a very high mortality. The aim of this study was to evaluate the butyrylcholinesterase (BuCh) level in poisoning with metal phosphides.

METHODS

In this case series study, 60 poisoned patients with zinc phosphide (ZnP) and aluminum phosphide (ALP) who was admitted to poisoning ward in Hamadan, Iran, enrolled in the study and BuCh level was measured. The sex, age, amount of ingestion, time of consumption, signs and symptoms, ECG and arterial blood gas (ABG) changes and clinical outcomes were evaluated.

RESULTS

Most (58.3%) patients were males, the mean age was 32.76±17.65 years. The average amount of ingestion was 7.5±4.6 and 2.5±2.96 gr for ZnP and ALP, respectively. Most signs and symptoms were hypotension (97%), nausea and vomiting (82%) and abdominal pain (32%). The average amount of BuCh level in all patients was 5163.25±2158.31 U/L, that's while in ZnP and ALP poisoned patients was 5608±1577 U/L and 4721.46±2562U/L respectively. The most dysrhythmia (26.7%) was sinus tachycardia. Acidosis was seen in 33.3% of patients. 14 patients died after hospital admission, which caused a 23.3% fatality rate.

CONCLUSION

Our results showed that, there was no significant change in BuCh level in poisoned patients with phosphide compounds.

Antidotes for aluminum phosphide poisoning - An update

Aluminum phosphide (AlP), an inexpensive solid fumigant, is frequently used for grain conservation despite its alleged high toxicity. Increased utilization of AlP for agricultural and non-agricultural purposes during the last four decades has resulted in increment of AlP-attributed poisoning numbers. Moreover, due to its limitless accessibility in developing countries, AlP has been increasingly used for suicide. Moisture-exposed AlP undergoes a chemical reaction producing phosphine gas, which in turn inhibits cytochrome oxidase and impedes cellular oxygen consumption. Lethality remains elevated reaching rates of >50% and no effective antidote is available. Nevertheless, experimental and clinical studies suggested that magnesium sulfate, melatonin, N-acetylcysteine, glutathione, sodium selenite, vitamin C and E, triiodothyronine, liothyronine, vasopressin, milrinone, Laurus nobilis L., 6-aminonicotinamide, boric acid, acetyl-L-carnitine and coconut oil, may serve as antidotes by reducing the deleterious oxidative properties of AlP. This article reviews the afore-mentioned chemicals suggested to specifically treat AlP poisoning and discusses their protective mechanisms and main outcomes.

G6PD deficiency and aluminum phosphide poisoning

Aluminum phosphide (ALP) poisoning is one of the fatal poisonings in the world. Hemolysis is a rare presentation of this poisoning. Here, we report an episode of hemolysis due to G6PD deficiency after ingestion of ALP and also the patient survived.

Fresh red blood cells transfusion protects against aluminum phosphide-induced metabolic acidosis and mortality in rats

BACKGROUND

Aluminum phosphide (AlP) is used as pesticide in some countries for protection of stored grains. Human poisoning with AlP due to suicide attempt or accidental environmental exposure is associated with very high mortality partially due to development of severe metabolic acidosis. Previous studies have shown that hemoglobin has high buffering capacity and erythrocytes can potentially be used for management of metabolic acidosis. The aim of this study was to evaluate the effect of fresh packed red blood cells (RBC) transfusion on survival and cardiovascular function in AlP-poisoned rats.

METHODOLOGY/PRINCIPAL FINDINGS

Rats were poisoned with AlP by gavage. Fresh packed RBC was transfused via tail vein after AlP administration. Acid-base balance, vital signs and mortality was assessed and compared in experimental groups. Infusion of fresh packed RBC (1.5 ml) one hour after AlP (4-15 mg/kg) intoxication was associated with a significant decrease in mortality rate. Packed RBC infusion improved blood pH, HCO3-, Na+ and Ca2+ levels. Plasma troponin level was also reduced and ECG changes were reversed following packed RBC infusion in AlP intoxicated rats.

CONCLUSIONS

Our results showed that fresh RBC transfusion could ameliorate metabolic acidosis and enhance survival in AlP-poisoned rat. We assume that an increase in pool of RBCs may modulate acid-base balance or potentially chelate AlP-related toxic intermediates via phosphine-hemoglobin interaction.

Using Intra-Aortic Balloon Pump for Management of Cardiogenic Shock Following Aluminum Phosphide Poisoning; Report of 3 Cases

INTRODUCTION

Aluminium phosphide (Alp) poisoning mortality rate has been reported as high as 70-100%, and refractory hypotension and cardiogenic shock are the two most common presentations leading to death. Due to lack of specific antidote, all treatments are focused on supportive care and recently, intra-aortic balloon pump (IABP) has been suggested to treat cardiogenic shock resulting from toxic myocarditis. In the current paper, we introduce three Alp poisoned patients for whom IABP was applied to manage their refractory shock.

CASE PRESENTATION

Two men and one woman who were admitted to emergency department (ED) of Imam Reza academic Hospital, Mashhad, Iran due to intentional Alp poisoning are reported. The cases visited the ED shortly after ingestion and nearly all of them showed hypotension, tachycardia and metabolic acidosis during early hospitalization. Due to persistent shock state, despite receiving intravenous fluid therapy and vasopressor agents, IABP insertion was performed in these cases. Finally, one of them survived and the other two died.

CONCLUSION

It still cannot be decided whether IABP insertion is effective in cases of Alp poisoning or not. It might be reasonable to try this intervention along with other conservative treatments in patients who survive more than 12 hours and consistently suffer from refractory hypotension.

Successful management of aluminium phosphide poisoning using intravenous lipid emulsion: Report of two cases

Aluminum phosphide (ALP) is a cheap, easily available agricultural pesticide which causes lethal poisoning by liberation of phosphine and inhibition of cytochrome c oxidase thereby leading to cellular hypoxia. Although there is no known specific antidote, clinical trials are still going on. We present here two cases of ALP poisoning who were successfully managed by treatment with lipid emulsion and intravenous magnesium sulfate.