Amitraz Poisoning - Tale of an Unusual Pesticide Poisoning: A Case Report.

Amitraz is a formamidine group of compounds used in many parts of the world as an agricultural pesticide and an ectoparasiticide. Amitraz intoxication secondary to the oral, dermal or inhalational routes, both accidental and suicidal, has been encountered in humans leading to severe life-threatening side effects. Only very few cases of amitraz toxicity have been reported to date. This emphasizes the importance to ascertain amitraz intoxication from more commonly encountered pesticides like organophosphorus poisoning to avoid erroneous management of the patient. We report a case of a twenty-seven-year-old man who presented to the emergency room following suicidal ingestion of amitraz with the clinical manifestations of vomiting, altered sensorium, bradycardia and hypotension and complete recovery following supportive management.

Clinical Profile of Amitraz Poisoning.

AIMS OF THE STUDY: To study clinical presentation, complications and response to supportive management of Amitraz poisoning. METHODS AND MATERIAL: Fifty cases of acute Amitraz poisoning were studied in detail and compared with previous data from literature. RESULTS: All the fifty cases were brought to Dr. V.M. Govt. Medical college, among them thirty one cases were males and nineteen were females, with their age ranging from 14 years to 62 years. Mode of intoxication was oral route. Twenty cases were farmers. Two cases had accidental poisoning. The ingested amount was ranging from 10ml to 80 ml. Vomiting and nausea were the prominent symptoms, next were dizziness, lethargy, respiratory distress and pain abdomen. Hyperglycemia, glycosuria, were commonest manifestations. Three cases were treated with mechanical ventilation. All the cases responded to supportive treatment and recovered completely. CONCLUSION: Vomiting and nausea were the commonest symptoms. Hyperglycemia and glycosuria was commonest sign. There was good response to supportive treatment. There was no complication and no mortality.

Amitraz: A Perpetual Silent Menace Among Children in Developing Countries-A Case Report.

Amitraz is an acaricide and insecticide used to treat ticks, which infest domestic animals in developing countries. Because of its widespread use, it is one of the common poisons unintentionally consumed by infants and children when left unsupervised. A 3-year-old boy was brought with unintentional consumption of Amitraz. On examination, he was found to be progressively drowsy, with an irregular pulse, bradycardia, and hypotension. He was treated with atropine, intravenous fluids, and dopamine infusion; hemodynamic stability was achieved within 36 hours after ingestion. Amitraz is an unusual but deadly poison unintentionally consumed by children. It can be suspected in the setting of rural households in developing countries having pets. There is no antidote available, and treatment is mainly supportive.

Amitraz poisoning: A case report of an unusual pesticide poisoning in Sri Lanka and literature review.

BACKGROUND: Amitraz is a pesticide used worldwide on animals and in agriculture. It contains triazapentadiene, which is a centrally acting alpha-2 adrenergic agonist. Amitraz poisoning is fairly uncommon in humans and occurs via oral, dermal or inhalational routes. Only a limited number of case reports of human intoxication have been published and most of them are of accidental ingestion by children. CASE PRESENTATION: A twenty-year-old Sri Lankan female presented following self-ingestion of 20 ml of amitraz resulting in 37.8 mg/ kg of amitraz poisoning. She lost consciousness after 20 min of ingestion, developed bradycardia and hypotension, which needed intravenous fluid resuscitation and dobutamine. Gastric lavage was performed. Her bradycardia persisted for 36 h and she was drowsy for 48 h. She did not develop respiratory depression, convulsions or hypothermia and the urine output was normal. Arterial blood gas revealed mild respiratory alkalosis. She recovered fully within 48 h and was discharged on day 3. CONCLUSION: The clinical manifestations of amitraz (impaired consciousness, drowsiness, vomiting, disorientation, miosis, mydriasis, hypotension, bradycardia, respiratory depression, hypothermia, generalized seizures, hyperglycemia and glycosuria) can be explained by the agonist action of amitraz on α1 and α2 receptors. Management of amitraz poisoning is still considered to be supportive and symptomatic with monitoring of nervous system, cardiovascular and respiratory systems. Activated charcoal may still be considered for treatment and the place for gastric lavage is controversial. Atropine is effective for symptomatic bradycardia and inotropic support is needed for hypotension that does not respond to fluid resuscitation. Diazepam or Lorazepam is used for convulsions and some patients may require intubation and ICU care. Several α2 adrenergic antagonists like yohimbine have been tried on animals, which have successfully reversed the effects of amitraz. Since the majority of amitraz poisoning cases are due to accidental ingestion, manufactures, regulatory authorities and national poisons control centers have a significant role to play in minimizing its occurrence.

Amitraz poisoning: an unusual cause of respiratory and peripheral circulatory failure.

We report a case of respiratory failure with unconsciousness in an adult occurring within 1 h of ingestion of a pesticide, amitraz, along with alcohol with a suicidal intent. Although commonly available and potentially fatal, this compound is not usually used as a suicidal agent.

Amitraz Poisoning Treated Successfully with Atropine.

Very few cases have been reported with Amitraz as a suicidal agent from India. Here we present such a case treated successfully with atropine sulphate.

Amitraz: a mimicker of organophosphate poisoning.

Amitraz is used as an ectoparasiticide for dogs and cattle. Human poisoning due to amitraz may be misdiagnosed as organophosphate/carbamate (OPC) toxicity, since amitraz poisoning shares several clinical features (miosis, bradycardia and hypotension) encountered with OPC poisoning. A 19-year-old man with an alleged history of suicidal ingestion of a pesticide presented with drowsiness and was found to have constricted pupils, hypotension and bradycardia. He was diagnosed as a case of OPC poisoning and was treated with atropine and pralidoxime prior to presentation to our centre. Absence of a hypersecretory state, and the presence of hyperglycaemia and hypothermia along with a normal serum cholinesterase level suggested an alternate possibility. Retrieval of the poison container confirmed the diagnosis of amitraz poisoning. The patient made a rapid recovery with supportive management. Clinician awareness is key to successful management of this poisoning, which carries a good prognosis.

Determination of amitraz and its metabolites in whole blood using solid-phase extraction and liquid chromatography-tandem mass spectrometry.

A method was developed for determination of amitraz and its metabolites, N-[2,4-(dimethylphenyl)-N'-methylformamidine (DMPF), 2,4-dimethylformamidine (DMF), 2,4-dimethylaniline (DMA) in whole blood. The analytes were extracted by solid-phase extraction (SPE) using dichloromethane, acetonitrile and methanol (2:1:1) mixture as elute solution. Analysis was performed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) in the positive ion mode using multiple reaction monitoring (MRM) technique. Collision-induced dissociation (CID) of amitraz at the electrospray source in MS/MS was observed in the analytic conditions. The method was validated in human whole blood spiked at three concentration levels. The low limit of detection (LOD) and the low limit of quantification (LOQ) for all the analytes were below 0.5µg/L and 2µg/L, respectively. Recoveries were between 90.2% and 104.5%, Bias and relative standard deviation (RSD) were below 15% (n=6). The good linear relationships were obtained in certain concentration ranges of amitraz and its metabolites. The results demonstrated the method is exclusive, sensitive and accurate, and can be applied in forensic toxicology.

Amitraz poisoning.

Amitraz is a formamidine insecticide and acaricide which acts on alpha 2-adrenergic receptors. There is little information available in the literature about the toxicity and treatment of poisoning by this compound. The authors report amitraz poisoning in a 13-y-old boy which was managed with supportive care with a good outcome.

Does the nose know? Amitraz poisoning and olfaction.

The initial clinical presentation of amitraz and organophosphate poisoning may be similar. Reduced serum pseudocholinesterase supports a diagnosis of organophosphate toxicity, but there is no similar laboratory test for amitraz poisoning. A 'mothball-like' odour associated with poisoned patients may have diagnostic potential. In a blinded controlled trial, 83% (95% confidence interval, 63% to 93%) of 23 healthcare workers were able to distinguish between the odours of amitraz and organophosphate. Awareness of this simple component of bedside examination may allow earlier recognition of this potentially fatal poisoning.

N-nitrosamines are associated with shorter telomere length.

OBJECTIVES: Telomeres are critical to maintain the integrity of the chromosomes, and telomere abnormalities are important features of carcinogenesis. Telomere length differs among individuals due to genetic and environmental factors. Aiming to examine the relationship between DNA-damaging agents and average telomere length in peripheral blood, we conducted a cross-sectional study among 157 workers working in the rubber industry in Sweden. METHODS: N-nitrosamines were measured in air by personal sampling on Thermosorb/N tubes and analyzed by liquid chromatography tandem mass spectrometry (LC/MS/MS) for 60 individuals. Based on a similar working situation, the exposure was estimated for all workers. Polycyclic aromatic hydrocarbons (PAH) were measured as the metabolite 1-hydroxypyrene (1-HP) in urine by LC. Carbon disulphide (CS2) was measured as the metabolite 2-thiothiazolidine-4-carboxylic acid (TTCA) in urine by LC/MS/MS. Toluidines (orto-, meta-, and para-) were measured in urine by gas chromatography (GC)/MS. The average telomere length in peripheral blood was determined by quantitative polymerase chain reaction (PCR). RESULTS: There was a reduction in telomere length with increasing exposure to N-nitrosamines in air [measured (N=60) N-nitrosamines ß-coefficient= -10, (95% confidence interval [95% CI] -17- -1.9) P=0.016; estimated (N=157) N-nitrosamines ß-coefficient = -5.3, (95% CI -9.5- -0.97) P=0.016]. Also, there were negative associations between para-toluidine [ß-coefficient= -0.031 (95% CI -0.055- -0.0063) P=0.014], as well as age ß-coefficient= -0.005 (95% CI -0.007- -0.002) P=0.001] and telomere length. There were no strong associations between other exposures and telomere length nor did smoking modify the effect. CONCLUSION: N-nitrosamines exposure may lead to telomere shortening.

Amitraz poisoning in South Africa: a two year survey (2008-2009).

INTRODUCTION: Analysis of the annual pesticide poisoning statistics of the Tygerberg Poison Information Centre (TPIC) for the period 2005-2007 showed an increase in the number of amitraz poisonings. This prompted a 2-year survey (2008-2009) to establish the extent of amitraz poisoning in South Africa. Amitraz is a pesticide used as a tick dip. It acts as an α(2)-adrenoceptor agonist and the principal clinical effects of amitraz poisoning are related to its stimulation of these receptors; METHODS: Data from amitraz poisoning cases in humans were evaluated for 2 years and analyzed for: demographic data, type of exposure, type of formulation, and clinical details. Serious cases were followed up; RESULTS: 4.6% of the pesticide poisoning cases were amitraz-related which comprised 0.8% of all TPIC poisoning consultations. Ingestion of amitraz formulations accounted for the majority of the cases (94%). Forty-one percent of cases were children (n = 28) and all were accidental exposures. Of the adult cases (59%), 88% were intentional ingestions. The majority of the cases were from the predominantly rural province of KwaZulu Natal (44.9%). CNS depression was the most common clinical sign (76.8%) followed by bradycardia 34.8%, respiratory depression 27.5%, miosis 27.5%, and hypotension 23.1%. Mechanical ventilation was required in 15.9% of cases. Other commonly reported clinical signs were hypothermia 15.9%, mydriasis 10.1%, and hyperglycaemia 7.2%. Supportive and symptomatic care was shown to be adequate treatment. Amitraz poisoning was misdiagnosed as cholinesterase inhibitor poisoning in 17.4% of cases; CONCLUSION: This is the first report of amitraz poisoning in humans in Africa. The data suggest a different demographic pattern in South Africa to that currently reported in the literature. The study identified a very high incidence of intentional poisoning in adults. The misuse of amitraz for deliberate self-harm emphasizes the necessity for continued toxicovigilance.

Amitraz poisoning--an unusual pesticide poisoning.

AIMS OF THE STUDY: To report the clinical features, laboratory findings and the management instituted for the patients with acute Amitraz Poisoning. METHODS AND MATERIAL: Three cases of acute Amitraz Intoxication were studied and compared with previous reports from the literature. RESULTS: All the three female cases were brought to our hospital with age ranging from 2 years to 40 years, consumed poison by oral route. The ingested amount was ranging from 15 ml to 30 ml. Giddiness and vomiting were the prominent symptoms, next were drowsiness, irritability and respiratory distress. Two cases revealed gastric dilatation. Except hyperglycaemia and glucosuria other laboratory parameters were normal. Unconscious patient's CT brain revealed brain edema. One patient with hypotension improvement with i.v. fluids administration. All the patients recovered completely. DISCUSSION: Formamidines show toxic effects on both humans and animals. Amitraz is slightly toxic. Amitraz shows hepatotoxic, CNS stimulative or depressive effects. It can cause gastric stasis. Amitraz leads to rise in plasma glucose level and suppress insulin release. Decreased body temperature is due to inhibitory effect of Amitraz on Prostaglandin E2 synthesis. Even after poisoning by potentially lethal dose of Amitraz, studies have reported complete recovery. As there is no specific antidote for Amitraz Poisoning the medical management with O2 supplementation, airway maintenance, proper hydration and supportive management are the key factors for complete recovery of the patient. Public Health Education and instructions to drug producing companies will be necessary to decrease the incidence of Amitraz Poisoning.

[Amitraz poisoning]. / Intoxicación por amitraz.

Poisoning due to amitraz together with its solvent xilene, is an unusual condition although may be increasing in rural areas where it is used as insecticide-ectoparasiticide.1-3 At present, there is scare references to orient physicians concerning its handling in childhood. We present the case of a 2-year-old boy who suffered an accidental intake of amitraz and was admitted into our Pediatric Intensive Care Unit requiring mechanical ventilation. We consider the usefulness of informing the medical community about this case so as to be aware of this rare kind of poisoning in our community.

Acute amitraz intoxication: retrospective analysis of 45 cases.

OBJECTIVE: To present special clinical and laboratory features of 45 cases (44 adult cases) who were intoxicated through oral route. DESIGN: Retrospective study. SETTING: Intensive care unit (ICU) of a university hospital. PATIENTS: Forty-five patients admitted to the ICU of Cumhuriyet University Hospital. RESULTS: Forty-five patients between 4 and 97 years of age were evaluated. Intoxication was the result of a suicide attempt in 67% of cases and accidental in 33% of cases. Unconsciousness, nausea and vomiting were the common initial symptoms. The major clinical findings in the ICU were bradycardia, myosis, hypothermia, hyperglycemia, hypotension, coma and respiratory depression. Blood glucose level was increased in 64% of cases. No problem was noted in the patient or the fetus in a pregnant, 27-year-old patient, who was intoxicated with 10 mL of 12.5% amitraz. The length of stay in the ICU was between 2 and 15 days. None of the patients died. All patients were discharged without neurological sequela. CONCLUSION: The prognosis of amitraz intoxications through oral route is benign and results in complete healing; however, we suggest that these cases should be well monitored and followed-up in ICUs.

Acute amitraz poisoning in adults: clinical features, laboratory findings, and management.

BACKGROUND: Amitraz is a formamidine pesticide widely used in agriculture and veterinary medicine as an insecticide and acaricide. Reports on amitraz poisoning in humans are not as prevalent as those in animals. Of human intoxications in the medical literature, the majority of intoxications are in children. The number of adult intoxications with amitraz is limited. METHODS: In this study, we discuss the clinical features, laboratory findings, and management of 23 adults with amitraz poisoning cared for in our center. Data were extracted from the charts retrospectively, and included age, gender, mode of poisoning, initial symptoms, time to appearance of initial symptoms, clinical and laboratory findings, management, and prognosis. RESULTS: Fourteen of 23 patients were female (61%). Ages ranged from 16 and 78 years (mean 38.6 +/- 19.8 years). Twenty-one patients ingested amitraz orally while one was exposed through skin contact and one probably through skin contact and/or inhalation. Seven patients ingested amitraz with intent to commit suicide and 11 patients accidentally. Vomiting, altered consciousness, and drowsiness were the predominant initial symptoms. Initially, hypotension was present in seven patients (30%), bradycardia in two (8.7%), myosis in six (26%), and mydriasis (without atropine administration) in three (13%). Time to appearance of the initial symptoms ranged from 5 to 120 minutes. Laboratory findings included an initial blood glucose level higher than 120 mg/dL in 62% of patients (mean 191 +/- 70 mg/dL) and elevations in AST levels in four patients (81 +/- 28 U/L) and ALT levels in three (60 +/- 14 U/L). Ten patients had central nervous system depression, which resolved spontaneously. Five patients required mechanical ventilation for respiratory depression (mean duration of mechanical ventilatory support: 50 +/- 16 hours). Six patients were thought to have been poisoned with an organophosphate and three with a carbamate pesticide due to confusing clinical picture; four of these nine patients received pralidoxim. CONCLUSIONS: In spite of a rapidly progressing and life-threatening clinical picture, amitraz intoxication in humans carries a low morbidity and mortality when appropriate supportive treatment is given. No antidote has been developed for use in more serious cases. To prevent accidental ingestions, prominent and clear warning labels should be placed on its containers.

Amitraz: an unusual aetiology of Ogilvie's syndrome.

UNLABELLED: Amitraz is an insecticide/acaricide of formamidine pesticides used worldwide for ectoparasites in animals. Because of its widespread use, amitraz poisoning is frequently encountered in Turkey. CASE REPORT: A 36-year-old, comatose female was admitted to the hospital. Although it was stated that she had taken a glass of water containing amitraz, the exact volume of the substance was unknown. On admission, her Glasgow Coma Scale score was 10/15. Clinical findings were vomiting, miosis, bradycardia and hypotension. The patient's vital signs were body temperature 37.2 degrees C, pulse 54 bpm, blood pressure 80/50 mmHg and pulseoximetry 84%. Supportive treatment consisting of oxygen, fluid replacement and gastric lavage, activated charcoal and atropine was administered. On the second day, signs of Ogilvie's syndrome characterized by severe tenderness, distension and pain in the abdomen were seen. On the third day, the patient's condition improved except for abdominal distension and pain, inability to pass faeces or flatus through the anus. Although continuous nasogastric tube decompression was performed, her complaints were not resolved completely. Neostigmine was administered on the fourth day. On the fifth day, abdominal pain and distension were decreased, and stool passage began. She had a complete clinical and laboratory improvement, which warranted her discharge on the seventh day of admission.