Indoxacarb poisoning causing methemoglobinemia treated with parenteral vitamin C: a case report.

INTRODUCTION: This case study reports on a suicide attempt involving indoxacarb and vitamin C. Indoxacarb is a neurotoxic insecticide used in agriculture and as a flea controller in pets. Cotton, vegetables, and fruits are treated with indoxacarb, an insecticide that can be applied both indoors and outdoors. It causes skin allergies, methemoglobinemia, and hemolytic anemia. It is also attributed to allergic reactions through ingestion, inhalation, physical contact, and translaminar action. This case report highlights use of vitamin C in methemoglobinemia caused by indoxacarb poisoning. Indoxacarb poisoning has the potential to be extremely serious and even lethal. In this instance, the patient initially had no symptoms after ingesting a substance containing indoxacarb in an attempt at suicide. However, further tests revealed methemoglobinemia and low oxygen levels. CASE PRESENTATION: A 28-year-old south-east Asian female patient ingested an insecticide containing 5.25% novaluron, 4.5% indoxacarb, and 25% thiamethoxam, and reported that she noticed muddy brown urine but presented with no active signs or symptoms of poisoning. Upon examination, the patient was fully conscious, alert, and hemodynamically stable, but had an oxygen saturation of 84%. Gastric lavage was performed, and blood investigations revealed a muddy-brown-colored blood sample and methemoglobin levels of 12%. The patient was treated with high-dose vitamin C and showed significant improvement, with a drop in methemoglobin levels to 1.2% and an increase in oxygen saturation to 97%. DISCUSSION: Indoxacarb poisoning can cause severe methemoglobinemia. Vitamin C may be a useful treatment option for methemoglobinemia caused by indoxacarb, particularly in cases in which traditional treatment with methylene blue is contraindicated or not tolerated. Hence high doses of ascorbic acid, that is, vitamin C, were administered to the patient, which lowered their methemoglobin levels and improved oxygen levels without much safety concerns. CONCLUSION: This example emphasizes the significance of early indoxacarb poisoning detection and treatment as well as the possible advantages of utilizing ascorbic acid in the management of methemoglobinemia, and highlights the use of vitamin C in the treatment of methemoglobinemia caused by indoxacarb poisoning. Therefore, it is important for healthcare professionals to be aware of the potential for indoxacarb to cause methemoglobinemia and to consider vitamin C as a treatment option.

Cardiopulmonary effects of phosphine poisoning: A preliminary evaluation of milrinone.

Exposure to phosphine (PH3) presents with a host of diverse, non-specific symptoms that span multiple organ systems and is characterized by a high mortality rate. While a comprehensive mechanism for PH3 poisoning remains inconclusive, prior studies have implicated cardiac failure and circulatory compromise as potential pathways central to PH3-induced mortality. In this study, milrinone (MLR), a phosphodiesterase-3 inhibitor used to treat cardiac failure, was investigated as a potential countermeasure for PH3 poisoning. Lethality, physiological responses, and behavioral changes were evaluated in telemetrized female rats pretreated with water (sham) or one of three doses of MLR (40, 200, or 600 µg/kg) and exposed to PH3 (660 ppm for 25-40 min; 16,500-26,400 ppm × min). Animals receiving prophylactic administration of 600 µg/kg of MLR had nominally improved survivability compared to sham animals, although median lethal concentration-time and time of death did not differ substantially between treatment groups. Changes in respiration and behavior induced by PH3 appeared largely unaffected by MLR pretreatment, regardless of dose. Conversely, MLR pretreatment alleviated some aspects of PH3-induced cardiac function impairment, with slight dose-dependent effects observed for cardiac contractility, mean arterial pressure, and QRS duration. Together, these results illustrate the importance of circulatory compromise in PH3 poisoning and highlight the potential viability of MLR as a potential countermeasure option or part of a countermeasure regimen when administered prophylactically at 600 µg/kg.

[Investigation of acute poisoning event caused by carbofuran].

Objective: To analyze the epidemiological characteristics and response process of an acute poisoning event caused by carbofuran in buttered tea and provide scientific evidence for the investigation of similar events in the future. Methods: Field epidemiological survey, animal experiments and laboratory tests were conducted for an acute poisoning event occurred in Suopo township of Danba county of Sichuan province in 2018. Descriptive epidemiological method was used to analyze the epidemiological characteristics of the acute poisoning event. Results: A total of 26 poisoning cases occurred in 3 villages. The total attack rate was 41.27%. No death cases were reported. The 26 cases occurred in a few minutes after drinking buttered tea, the main symptoms were vomit, dizziness, miosis and nausea. A dog showed the same symptoms after drinking a sample of buttered tea. Carbofuran was detected in buttered tea, vomitus and zanba samples. Conclusions: The acute poisoning was caused by carbofuran in buttered tea, the transmission mode was point source spread. Effective epidemiological investigation and simple animal experiment can provide evidence for the rapid sample detection and clinical treatment of cases in emergency response. Timely case treatment and strict poisoning source control are the key measures to reduce casualty and prevent the spread of poisoning.

Chemical components, antioxidant potential and hepatoprotective effects of Artemisia campestris essential oil against deltamethrin-induced genotoxicity and oxidative damage in rats.

In the present study, we evaluated the antioxidant potential of Artemisia campestris essential oil (ACEO) and the possible protective effects against deltamethrin induced hepatic toxic effects. The ACEO showed radical scavenging activity with IC50 = 47.66 ± 2.51 µg/ml, ferric reducing antioxidant power (FRAP) potential (EC50 = 5.36 ± 0.77 µg/ml), superoxide scavenging activity (IC50 = 0.175 ± 0.007 µg/ml) and ˙OH scavenging activity (IC50 = 0.034 ± 0.007 µg/ml). The obtained results of phenolic profile demonstrated that phenolic compounds are the major contributor to the antioxidant activity of ACEO. GC-MS analysis revealed the presence of 61 components in which monoterpene hydrocarbons constitute the major fraction (38.85%). In in vivo study, deltamethrin exposure caused an increase of serum AST, ALT and ALP activities, hepatic malondialdehyde (MDA) (measured as TBARS) and conjugated dienes markers of lipid peroxidation (LPO), while antioxidant enzyme activities (SOD, CAT and GPx) decreased significantly. Furthermore, it induces DNA damage as indicated by DNA fragmentation accompanied with severe histological changes in the liver tissues. The treatment with vitamin E or ACEO significantly improved the hepatic toxicity induced by deltamethrin. It can be concluded that vitamin E and ACEO are able to improve the hepatic oxidative damage induced by deltamethrin. Therefore, ACEO is an important product in reducing the toxic effects of deltamethrin.

Pharmacological treatment of organophosphorus insecticide poisoning: the old and the (possible) new.

Despite being a major clinical and public health problem across the developing world, responsible for at least 5 million deaths over the last three decades, the clinical care of patients with organophosphorus (OP) insecticide poisoning has little improved over the last six decades. We are still using the same two antidotes - atropine and oximes - that first came into clinical use in the late 1950s. Clinical research in South Asia has shown how improved regimens of atropine can prevent deaths. However, we are still unsure about which patients are most likely to benefit from the use of oximes. Supplemental antidotes, such as magnesium, clonidine and sodium bicarbonate, have all been proposed and studied in small trials without production of definitive answers. Novel antidotes such as nicotinic receptor antagonists, beta-adrenergic agonists and lipid emulsions are being studied in large animal models and in pilot clinical trials. Hopefully, one or more of these affordable and already licensed antidotes will find their place in routine clinical care. However, the large number of chemically diverse OP insecticides, the varied poisoning they produce and their varied response to treatment might ultimately make it difficult to determine definitively whether these antidotes are truly effective. In addition, the toxicity of the varied solvents and surfactants formulated with the OP active ingredients complicates both treatment and studies. It is possible that the only effective way to reduce deaths from OP insecticide poisoning will be a steady reduction in their agricultural use worldwide.

Can anisodamine be a potential substitute for high-dose atropine in cases of organophosphate poisoning?

A case of organophosphate (OP) poisoning was admitted to the emergency room. The patient accepted treatment with pralidoxime (PAM), atropine, and supporting therapy. It was observed that even after 22 h after treatment, 960 mg of atropine was not enough for the patient to be atropinized. However, a 160-mg follow-up treatment of anisodamine was quite enough for atropinization after 4 h. As a case report, more studies are required before any definite conclusion can be reached regarding the use of anisodamine as a potential substitute for high-dose atropine in cases of OP poisoning.

Efficiency of anisodamine for organophosphorus-poisoned patients when atropinization cannot be achieved with high doses of atropine.

Poisoning by organophosphorus insecticides is a major global public health problem. Although atropine has been widely used to treat organophosphate (OP) poisoning, sometimes atropinization cannot be achieved, even with high doses of atropine. Hence, we aimed to assess the effect of anisodamine for organophosphorus poisoned patients for whom atropinization could not be achieved through high doses of atropine. In this study, sixty-four OP-poisoning patients, all of whom accepted routine treatments but who did not attain atropinization after high doses of atropine for 12 h, were enrolled. The result showed that the time to atropinization was 24.3±4.3 h in the anisodamine group, significantly shorter than in the atropine group (29.2±7.0 h, p<0.05); the hospital stay in the anisodamine group was 5.3±2.5 days, significantly shorter than the 6.9±2.3 days needed by the atropine group (p<0.05). We draw a conclusion that anisodamine can shorten the process of atropinization and hospital stay in organophosphorus poisoned patients for whom atropinization cannot be achieved with high doses of atropine.

Fresh frozen plasma as a successful antidotal supplement in acute organophosphate poisoning.

Despite improvements to intensive care management and specific pharmacological treatments (atropine, oxime, diazepam), the mortality associated with organophosphate (OP) poisoning has not substantially decreased. The objective of this examination was to describe the role of fresh frozen plasma (FFP) in acute OP poisoning. After a deliberate ingestion of malathion, a 55-year-old male suffering from miosis, somnolence, bradycardia, muscular fasciculations, rales on auscultation, respiratory insufficiency, as well as from an inhibition of red blood cell acetylcholinesterase (AChE) and plasma butyrylcholinesterase (BuChE), was admitted to hospital. Malathion was confirmed in a concentration of 18.01 mg L(-1). Apart from supportive measures (including mechanical ventilation for four days), antidotal treatment with atropine, oxime-pralidoxime methylsulphate (Contrathion(R)), and diazepam was administered, along with FFP. The potentially beneficial effects of FFP therapy included a prompt increase of BuChE activity (from 926 IU L(-1) to 3277 IU L(-1); reference range from 7000 IU L(-1) to 19000 IU L(-1)) and a reduction in the malathion concentration, followed by clinical recovery. Due to BuChE replacement, albumin content, and volume restitution, FFP treatment may be used as an alternative approach in patients with acute OP poisoning, especially when oximes are not available.

[The observations of curative efficacy of rhubarb combined with blood purification on treatment patients with severe acute organophosphorus pesticide poisoning].

OBJECTIVE: To observe the curative efficacy of rhubarb, montmorillonite powder combined with blood purification on treatment for patients with severe acute organophosphorus pesticide poisoning (AOPP). METHODS: 39 patients with AOPP were divided into treatment group (received the combined treatment of rhubarb, montmorillonite powder and blood purification on the basis of routine therapy, n = 21) and control group (only received the routine treatment because of financial difficulties or the will of family members, n = 18). The differences of clinical manifestations, curative effects and prognosis between two groups were compared. RESULTS: The time of consciousness recovery, the duration of mechanical ventilation and the length of stay in hospital in treatment group were (6.5 ± 1.3), (7.9 ± 2.0) and (13.1 ± 3.2) days, which were significantly shorter than those [(8.4 ± 2.4), (10.7 ± 2.9) and (16.5 ± 3.7) days] of control group (P < 0.05). In 5, 6 and 7 day after treatment,the cholinesterase (ChE) activities of treatment group were significantly higher than those of control group (P < 0.05). The total amount and using time of atropine and pyraloxime methylchloride in treatment group were significantly smaller and shorter than those in control group (P < 0.05). The death rate of treatment group was [19.0% (4/21)], which were significantly lower than that of control group [19.0% (4/21)] (P < 0.05). CONCLUSION: The combined treatment of rhubarb, montmorillonite powder and blood purification of the AOPP patients has a better curative effect.

Intralipid fat emulsion decreases respiratory failure in a rat model of parathion exposure.

BACKGROUND: Therapies exist for acute organophosphate (OP) exposure but mortality rates remain high (10% to 20%). Currently, treatment focuses on reversing the resultant cholinergic excess effects through the use of atropine. Intralipid fat emulsion (IFE) has been used to treat lipophilic drug ingestions and theoretically would be beneficial for some OP agents. OBJECTIVES: The hypothesis was that IFE would decrease the acute respiratory depressant effects following lethal OP exposure using a lipophilic OP agent (parathion). METHODS: The authors used a previously validated animal model of OP poisoning with detailed physiologic respiratory recordings. The model consisted of Wistar rats anesthetized but spontaneously breathing 100% oxygen. Airflow, respiratory rate, tidal volume, mean arterial pressure, and pulse rate were digitally recorded for 120 minutes following OP exposure or until respiratory failure. Three study groups included parathion alone (n = 6), parathion and IFE 5 minutes after poisoning (n = 6), and parathion and IFE 20 minutes after poisoning (n = 6). In all groups, parathion was given as a single oral dose of 54 mg/kg (four times the rat oral 50% population lethal dose [LD(50) ]). Three boluses of IFE (15 mg/kg/min) were given over 3 minutes, 20 minutes apart, starting either 5 or 20 minutes after poisoning. Timing of IFE was based on parathion kinetics. In one study group IFE was initiated 5 minutes after poisoning to coincide with initial absorption of parathion. In another study group IFE was given at 20 minutes to coincide with peak intravenous (IV) parathion concentration. Primary outcome was percentage of animals with apnea. Secondary outcome was time to apnea. RESULTS: Animals exposed to parathion alone demonstrated a steady decline in respiratory rate and tidal volume postexposure, with apnea occurring a mean of 51.6 minutes after poisoning (95% confidence interval [CI] = 35.8 to 53.2 minutes). Animals treated with IFE 5 minutes postexposure demonstrated no difference in mean time to apnea (44.5 minutes vs. 51.6 minutes, p = 0.29) or number of animals with respiratory arrest (100% vs. 100%, p = 1.00). Animals treated with IFE 20 minutes postexposure demonstrated a significantly prolonged mean time to apnea (95.3 minutes vs. 51.6 minutes, p = 0.002), but there was no difference in number of animals with respiratory arrest (100% vs. 66.7%, p = 0.45). CONCLUSIONS: All animals exposed to 4 × LD(50) of oral parathion demonstrate apnea and respiratory arrest. IFE given immediately after oral parathion does not prolong time to apnea. IFE given 20 minutes after oral exposure to parathion decreases the acute effects of the OP and prolongs the time to apnea.

[Detection of chloropyridinyl neonicotinoid insecticide metabolite 6-chloronicotinic acid in the urine: six cases with subacute nicotinic symptoms].

Neonicotinoid is a recently developed insecticide with worldwide use that has been increasing. It acts as a nicotinic acetylcholine receptor agonist. Chloropyridinyl neonicotinoid is a subgroup of neonicotinoid, and are commercially available as imidacloprid, nitenpyram, acetamiprid, and thiacloprid. The maximum residue limits of acetamiprid for fruits and tea leaves are high in Japan, e.g. 5 ppm for grapes and 30 ppm for tea leaves. 6-chloronicotinic acid (6 CNA) is a common metabolite in animals after exposure to chloropyridinyl neonicotinoids, but has not yet been detected in human urine. 'Spot' urine samples on the first visit and after were collected from eleven patients 6-52 years-old, who visited X-clinic from August to December in 2008, within 24 hours after symptom onset with unknown origin. Urinary 6 CNA was detected in six out of the eleven patients (IC positive group), by ion chromatography and identified in twenty specimens of these six patients by liquid chromatography-mass spectrometry (LC/MS), maximum 84.8 microg/L from the first visit to the 20th visit. The sensitivity of ion chromatography for LC/MS was 45%, and the specificity was 100%. The IC positive group showed headache, general fatigue, finger tremor, and short time memory disturbance in 100%, fever (> 37.0 degrees C), cough, palpitation, chest pain, stomachache, myalgia/muscle spasm/muscle weakness in 83%, heart rate abnormality (sinus tachycardia, sinus bradycardia, or intermittent WPW syndrome) in 83%, high domestic fruits intake (> 500 g/day) in 83%, high tea beverage intake (> 500 mL/day) in 66%. Five patients who were not among the IC positive group showed < 80%, < 40%, 60%, 60%, 20%, respectively. The patients gradually recovered through supportive therapy and the restriction of fruits and tea intake within several days to two months. In conclusion, urinary 6-chloronicotinic acid, a common metabolite of chloropyridinyl neonicotinoid insecticide, was detected for the first time, from six patients with subacute nicotinic symptoms.

Botanical insecticides: for richer, for poorer.

Botanical insecticides presently play only a minor role in insect pest management and crop protection; increasingly stringent regulatory requirements in many jurisdictions have prevented all but a handful of botanical products from reaching the marketplace in North America and Europe in the past 20 years. Nonetheless, the regulatory environment and public health needs are creating opportunities for the use of botanicals in industrialized countries in situations where human and animal health are foremost--for pest control in and around homes and gardens, in commercial kitchens and food storage facilities and on companion animals. Botanicals may also find favour in organic food production, both in the field and in controlled environments. In this review it is argued that the greatest benefits from botanicals might be achieved in developing countries, where human pesticide poisonings are most prevalent. Recent studies in Africa suggest that extracts of locally available plants can be effective as crop protectants, either used alone or in mixtures with conventional insecticides at reduced rates. These studies suggest that indigenous knowledge and traditional practice can make valuable contributions to domestic food production in countries where strict enforcement of pesticide regulations is impractical.

Pralidoxime in carbaryl poisoning: an animal model.

INTRODUCTION: Poisoning from organophosphates and carbamates is a significant cause of morbidity and mortality worldwide. Concerns have been expressed over the safety and efficacy of the use of oximes such as pralidoxime (2-PAM) in patients with carbamate poisoning in general, and more so with carbaryl poisoning specifically. The goal of the present study was to evaluate the role of 2-PAM in a mouse model of lethal carbaryl poisoning. METHODS: Female ICR Swiss Albino mice weighing 25-30 g were acclimated to the laboratory and housed in standard conditions. One hundred and ten mice received an LD50 dose of carbaryl subcutaneously. Ten minutes later, they were randomized by block randomization to one of eight treatment groups: normal saline control, atropine alone, 100 mg/kg 2-PAM with and without atropine, 50 mg/kg 2-PAM with and without atropine, and 25 mg/kg 2-PAM with and without atropine. All medications were given intraperitoneally and the atropine dose was constant at 4 mg/kg. The single objective endpoint was defined as survival to 24 hours. Fatalities were compared using a Chi squared or Fisher's exact test. RESULTS: Following an LD50 of carbaryl, 60% of the animals died. Atropine alone statistically improved survival (15% lethality). High dose 2-PAM with and without atropine was numerically worse, but not statistically different from control. While the middle dose of 2-PAM was no different than control, the addition of atropine improved survival (10% fatality). Low-dose 2-PAM statistically improved survival (25% lethality). Atropine further reduced lethality to 10%. CONCLUSION: When appropriately dosed, 2-PAM alone protects against carbaryl poisoning in mice. Failure to demonstrate this benefit in other models may be the result of oxime overdose.

Validation of an automated spectrophotometric assay for the determination of cholinesterase activity in canine serum.

The determination of enzymatic activity of cholinesterase is a useful diagnostic method to detect exposure to anticholinesterase compounds in human and in veterinary medicine. We validated a modification of the Ellman method in canine serum and applied it to the diagnosis of dogs poisoned with anticholinesterase substances. The method used butyrylthiocholine as substrate and potassium hexacyanoferrate as chromophore. The reference range calculated on 60 clinically healthy dogs was set between 3405 and 6561 U/L (chi-square test for normal distribution, p > 0.05). The overall mean intra-assay and inter-assay coefficients of variation were 0.53% and 3.83%, respectively. The assay was linear when using two sera with 12,538 U/L and 6604 U/L serum cholinesterase activity (r(2) = 0.997) and 0.999, respectively). The mean recovery values of pooled sera with a mean pseudocholinesterase (PChE) activity of 12,081 U/L and pooled sera with a mean PChE activity of 3415 U/L were 103.5% and 102.8%, respectively. Six dogs with a diagnosis of anticholinesterase compound intoxication showed a decrease in cholinesterase activity of at least 50% of normal activity with a mean +/- SD of 487 +/- 291 U/L ranging from 169 to 847 U/L. This technique conforms to the current standard for precision, linearity and accuracy and is a useful method for the complementary diagnosis of organophosphate or carbamate insecticide intoxication in dogs.

[Experimental study on protective effects of HupA in the treatment of isocarbophos poisoning].

OBJECTIVE: To investigate the therapeutic and prophylactic efficiency of HupA in mice with acute isocarbophos poisoning, and the protective effects of the HupA on AChE inhibited by isocarbophos. METHODS: Mice were randomizedly divided into the non-treatment group, the atropine control group, the HupA treatment group and the atropine and HupA combined treatment group. Toxic signs and survival rates were observed and compared among these groups. The AChE activity was monitored in the whole blood, the red cells and brain tissue exposed to isocarbophos in the either treated with HupA or non-treated groups. RESULTS: In HupA treatment group compared with the non-treatment group, toxic signs were significantly decreased and the survival rate was increased. The therapeutic efficiency in the atropine and HupA combined treatment group was better than other groups. After isocarbophos was administered, the AChE activity in the HupA treatment group and the non-treatment group was decreased. However, the AChE activity in the whole blood (1.096 +/- 0.111), (1.262 +/- 0.146), (1.181 +/- 0.353) U/ml, the red cells (0.798 +/- 0.063), (1.000 +/- 0.176), (0.837 +/- 0.331) and the brain tissue (13.739 +/- 2.970), (18.507 +/- 3.466), (10.764 +/- 2.212) U/g in HupA treatment group 0.5, 1 and 2 hours after isocarbophos was administered was significantly higher than those in the non-treatment group (P < 0.05 or P < 0.01). CONCLUSION: HupA has therapeutic effect on mice with acute isocarbophos poisoning. The protective effect of HupA on blood and brain AChE inhibited by isocarbophos may be one of the mechanisms of the therapeutic effect of HupA in acute Isocarbophos poisoning.

A case of poisoning in a man who drank a nutrition supplement containing methomyl, a carbamate pesticide.

A 50-year-old man was admitted to the emergency room complaining oppression on his chest, sweating and vomiting. He had drunk a 30 ml volume nutrition supplement 60 minutes before. As myosis and decrease of serum choline esterase activity were observed on admission examination, poisoning was suspected and toxicological analyses were carried out on the heeltap of the drink. Drug screening by gas chromatography-mass spectrometry (GC/MS) revealed the presence of methomyl and the concentration of methomyl in the heeltap determined by liquid chromatography was 2.1 mg/ml. Methomyl concentrations in the serum and urine were determined after converting methomyl to its oxime form followed by derivatization and GC/MS. Methomyl concentration in the serum collected 6 hours after ingestion was 0.63 microg/ml, and that in the urine collected 7-20 hours after ingestion was 0.10 microg/ml. Based on these values and reported data, the amount of methomyl contaminated to the drink was considered to be a toxic dose.