Exchange transfusion can be life-saving in severe propanil poisoning: a case report

Abstract

BackgroundPropanil is an important cause of herbicide poisoning in Sri Lanka, accounting for about 2% of all cases of self-poisoning. The outcome is extremely poor when the poisoning is severe and current medical care is of limited efficacy. Death usually occurs due to the severe and prolonged methaemoglobinaemia. We describe a case of severe Propanil poisoning, successfully treated by exchange transfusion at a tertiary care hospital in Sri Lanka.Case presentationA 17-year old Sri Lankan male (body weight – 42 kg), presented to a local hospital 1 hour after self-ingestion of nearly 500 ml (4.3 g/kg) of liquid Propanil (concentration – 360 g/l). On admission he had dizziness and peripheral cyanosis. He was given intravenous methylene blue (1 mg/kg) within one hour of admission, which was repeated subsequently due to minimal response. The next day morning, (18 hours after poisoning) the patient was transferred to the National Hospital of Sri Lanka (NHSL) for further management. On admission to NHSL, he was drowsy and confused, had a shallow respiratory effort and marked central and peripheral cyanosis. Respiratory rate was 20/min, with a pulse-oximetry of 77% on room air. The arterial blood gas analysis was as follows; pH–7.24, HCO3−–12 mmol/l, pCO2–28 mmHg, pO2–239 mmHg and O2 saturation–100%. Exchange transfusion was commenced within two hours of admission to NHSL. A dramatic improvement in oxygen saturation was observed immediately afterwards, with the saturation in pulse-oximetry rising to >95%. The level of consciousness and respiratory effort also improved. He was discharged subsequently 8 days after the initial poisoning.ConclusionPropanil has potential to produce severe life threatening clinical manifestations, despite categorization as a herbicide with low toxicity. In cases of severe poisoning, exchange transfusion may be life saving. Since methylene blue, intensive care and exchange transfusion facilities are also not readily available in local hospitals, which frequently encounter cases of severe Propanil poisoning, early transfer of patients to tertiary care hospitals should be considered. Exchange transfusion may be helpful even in late stages in patients with severe poisoning.

Therapeutic whole blood exchange in the management of methaemoglobinemia: Case series and systematic review of literature

“…Our search yielded 365 citations (Figure ), of which 25 fulfilled our inclusion criteria (27 subjects) . Studies that mentioned exchange transfusion in the management of methaemoglobinemia, but failed to provide the details, were also not included .…”

“…Naphthalene balls, rasburicase, and chloroquine, were identified as the culprit agents in two patients each. Other reported causes included ochronosis, 35 benzene, 8 propanil, 28 aniline, 14 thinner material for paints, 26 co-trimoxazole, 22 and aminophenol. 33 The intent of overdose was often suicidal (n = 13, 40.6%) or accidental ingestion (n = 7, 21.9%).…”

A New Treatment Approach for Acute Propanil Poisoning: A Case Report

“…It is the most lethal herbicide poisoning next to paraquat in Sri Lanka. The mortality varies from 6.2 to 10.7% depending on the severity of the poisoning [ 1 , 2 ]. Methemoglobinemia, hemolysis, and neurological sequel at admission predict poor prognosis [ 3 ].…”

“…Methemoglobinemia, hemolysis, and neurological sequel at admission predict poor prognosis [ 3 ]. Methylene blue is the recommended treatment modality, but there are instances where advanced management options like exchange transfusion are required in order to prevent death [ 1 ]. It can be challenging in health care with resource-poor settings.…”

Suppression of arthritis-induced bone erosion by a CRAC channel antagonist

“…Although several CRAC inhibitors are known, we pursued DCPA in part because of very low toxicity; exposure of humans to DCPA in mg/kg quantities has minimal apparent toxicity, 10 although massive doses, approximately 4–5 g/kg, can cause fatal methemoglobinaemia. 11 …”