https://orcid.org/0009-0002-0880-3492
Abstract
Background Organophosphate poisoning causes a significant disease burden in low- and middle-income countries and places a huge demand on critical care facilities. Case report We present the case of a 5-year-old with severe organophosphate poisoning from ingestion of chlorpyrifos, further worsened by aspiration of a charcoal-palm oil mixture. The clinical illness was marked by respiratory failure, shock, coma and type I paralysis. The patient was treated in the emergency department with noninvasive ventilation, multiple episodes of exchange transfusion, intravenous atropine, inotrope infusion, antibiotics and steroids. The patient responded rapidly to treatment, did not develop intermediate syndrome and was discharged after 10 days of admission. Conclusion The dearth of paediatric intensive care facilities and complex medical equipment in many low- and middle-income countries necessitates the use of other treatment modalities for critical conditions. This case report highlights the relevance of exchange transfusion in detoxification of severe organophosphate poisoning in children.
Introduction
Unintentional pesticide poisoning is a global public health problem accounting for about a million deaths annually mainly from low- and middle-income countries (LMICs). Treatment of severe organophosphate poisoning often entails intensive care treatment and invasive monitoring, pharmacotherapy, mechanical ventilation, and sometimes blood purification. Due to the dearth of complex medical devices and intensive care facilities in many LMICs, other treatment options are required to promote the survival of children with severe poisoning. Overall, WHO reports a disproportionately fourfold higher mortality rate from poisoning in children in LMICs [1].
We report the use of fresh-whole-blood exchange-blood-transfusion (FWB-EBT) in the treatment of severe organophosphate poisoning complicated by aspiration pneumonitis in a 5-year-old child.
Materials and method
The study location was a federal teaching hospital in Nigeria. In the children’s emergency unit, FWB-EBT is a treatment modality for sepsis, specific sickle cell crises and severe poisoning. The laboratory analysis was also done in the central laboratory of the teaching hospital.
Case report
A 5-year-old presented to the paediatric emergency department (ED) having ingested chlorpyriphos 13 hours prior to presentation, followed by abnormal jerks, fast breathing and difficulty with breathing. The history was also comprised of excessive sweating and urination, mouth secretions and involuntary movement of the limbs. Vomiting followed the ingestion of crushed charcoal and palm oil. The patient had lapsed into coma prior to presentation. The temperature at presentation was 38.3°C, Glasgow coma score was 3, pupils were pinpoint pupils and there was hypotonia in all limbs. In addition, the patient was severely dyspneic, tachypneic (respiratory rate of 48/minute with intermittent sighing breaths), a saturation of 88% and widespread crackles. The pulse rate was 180/minute, blood pressure 120/80 mmHg, and random blood glucose 14 mg/dl. Serum lactate and cholinesterase tests were not done due to lack of facilities. Table 1 shows the blood parameters.
Laboratory parameters at presentation.
| Variables | Value | Range |
|---|---|---|
| Sodium (mEq/l) | 138 | 135–145 |
| Potassium (mEq/l) | 3.3a | 3.5—5.0 |
| Chloride (mEq/l) | 95 | 95–105 |
| Bicarbonate (mEq/l) | 18a | 20–30 |
| Urea (mEq/l) | 32 | <40 |
| Creatinine (mg/dl) | 1.1b | 0.3—0.7 |
| Hemoglobin (g/dl) | 12.1 | 10.5–14.5 |
| Platelet (/mm3) | 296 000 | 150 000– 400 000 |
| Total WBC count (/mm3) | 25 500b | 6000—17 000 |
| Neutrophils (%) | 78.2b | 20–42 |
| Lymphocytes (%) | 11.3a | 40–70 |
| Monocytes (%) | 9.6b | 3–6 |
| Variables | Value | Range |
|---|---|---|
| Sodium (mEq/l) | 138 | 135–145 |
| Potassium (mEq/l) | 3.3a | 3.5—5.0 |
| Chloride (mEq/l) | 95 | 95–105 |
| Bicarbonate (mEq/l) | 18a | 20–30 |
| Urea (mEq/l) | 32 | <40 |
| Creatinine (mg/dl) | 1.1b | 0.3—0.7 |
| Hemoglobin (g/dl) | 12.1 | 10.5–14.5 |
| Platelet (/mm3) | 296 000 | 150 000– 400 000 |
| Total WBC count (/mm3) | 25 500b | 6000—17 000 |
| Neutrophils (%) | 78.2b | 20–42 |
| Lymphocytes (%) | 11.3a | 40–70 |
| Monocytes (%) | 9.6b | 3–6 |
aSerum potassium, bicarbonate levels and lymphocytes were decreased at presentation.
bCreatinine, WBC, neutrophil and monocyte levels were increased at presentation.
Laboratory parameters at presentation.
| Variables | Value | Range |
|---|---|---|
| Sodium (mEq/l) | 138 | 135–145 |
| Potassium (mEq/l) | 3.3a | 3.5—5.0 |
| Chloride (mEq/l) | 95 | 95–105 |
| Bicarbonate (mEq/l) | 18a | 20–30 |
| Urea (mEq/l) | 32 | <40 |
| Creatinine (mg/dl) | 1.1b | 0.3—0.7 |
| Hemoglobin (g/dl) | 12.1 | 10.5–14.5 |
| Platelet (/mm3) | 296 000 | 150 000– 400 000 |
| Total WBC count (/mm3) | 25 500b | 6000—17 000 |
| Neutrophils (%) | 78.2b | 20–42 |
| Lymphocytes (%) | 11.3a | 40–70 |
| Monocytes (%) | 9.6b | 3–6 |
| Variables | Value | Range |
|---|---|---|
| Sodium (mEq/l) | 138 | 135–145 |
| Potassium (mEq/l) | 3.3a | 3.5—5.0 |
| Chloride (mEq/l) | 95 | 95–105 |
| Bicarbonate (mEq/l) | 18a | 20–30 |
| Urea (mEq/l) | 32 | <40 |
| Creatinine (mg/dl) | 1.1b | 0.3—0.7 |
| Hemoglobin (g/dl) | 12.1 | 10.5–14.5 |
| Platelet (/mm3) | 296 000 | 150 000– 400 000 |
| Total WBC count (/mm3) | 25 500b | 6000—17 000 |
| Neutrophils (%) | 78.2b | 20–42 |
| Lymphocytes (%) | 11.3a | 40–70 |
| Monocytes (%) | 9.6b | 3–6 |
aSerum potassium, bicarbonate levels and lymphocytes were decreased at presentation.
bCreatinine, WBC, neutrophil and monocyte levels were increased at presentation.
The patient was diagnosed with severe organophosphate poisoning (OPP) and aspiration pneumonitis. As ICU care was beyond the affordability of the parents, non-invasive ventilation (NIV) was administered using bubble continuous positive airway pressure (b-CPAP) causing his saturation to increase to 99%–100%. Hypoglycemia was corrected with a bolus of dextrose solution and tachycardia was treated with 20 ml/kg of normal saline. Intravenous Dexamethasone, Mannitol and IV Atropine at 0.02 mg/kg/dose were also administered. Empirical intravenous antibiotics were administered for aspiration pneumonitis. Pralidoxime was not given due to unavailability. Within 3 hours of presentation, the patient had fresh-whole-blood exchange-blood-transfusion (FWB-EBT) with 500mls of blood.
The patient’s GCS appreciated to 9/15 but IV Atropine was discontinued after the first dose due to a rapid increase in the heart rate. The blood glucose fluctuated between 41 to 259 mg/dl in the first 15 hours of admission and subsequently normalized with treatment. By the second day on admission, the patient developed thready pulses and hypotension for which another bolus of normal saline was administered. Dopamine infusion was commenced at 5mcg/kg/min using a peripheral vein and IV Mannitol discontinued. A second aliquot of FWB-EBT was administered with 500mls of blood.
Over the first 30 hours of admission, the consciousness level improved and respiratory distress slowly declined. However, the patient developed rhonchi which was treated with nebulized Salbutamol and Budesonide and was subsequently transited to Oxygen therapy with nasal prongs with clinical improvement. The saturation remained stable at 97%. On Day 2 of admission, a chest radiograph was done (Fig. 1) which showed bilateral infiltrates in keeping with pneumonia.
Chest radiograph on day 2 of admission indicating bilateral opacities.
The patient regained full consciousness by the 39th hour of admission. Intravenous Vitamin C and B, as well as oral Vitamin E and Zinc were commenced for their antioxidant effects, and regular diet was recommenced in a graded manner over the subsequent 48 hours. The patient’s clinical condition progressively improved and was discharged home after 10 days but was subsequently lost to follow-up.
Discussion
The diagnosis of severe OPP was made clinically based on the unambiguous history of organophosphate ingestion and supporting clinical signs [2, 3]. The patient’s clinical syndrome was characterized by a combination of the effects of OPP and aspiration pneumonitis. In addition, the patient had very low blood glucose levels. Although less frequent than hyperglycemia, hypoglycemia also occurs in severe OPP and may result from biologic toxicity which induces neuroglycopenia and systemic inflammation, while inhibiting corticosteroid stress response [4]. The rapidity of symptoms and deterioration conforms with the pattern of chlorpyrifos poisoning which reaches peak plasma concentrations within 6 hours of poisoning [3]. The contents of the aspirated mixture likely comprised of chlorpyrifos, palm oil and crushed charcoal. Palm oil and charcoal are commonly used as cultural antidotes for poisons in general and may cause life-threatening complications including aspiration [5, 6].
Pralidoxime, indicated for treating nicotinic symptoms, was unavailable in the hospital while intravenous atropine, recommended for muscarinic symptoms of OPP, was discontinued after a single dose. Thus, the severe OPP could not be treated pharmacologically. Therefore, FWB-EBT was administered promptly as a blood purification procedure. It was done in two sessions 24 hours apart. While the first session was done on arrival for immediate detoxification, the second was done 24 hours later to allow for optimal passage of compounds and inflammatory mediators from the tissues into the blood stream [7], and thus to optimize the efficacy of their removal from the blood stream by the subsequent session. However, FWB-EBT could be done at shorter intervals e.g. 6 hours apart depending on the availability of fresh whole blood.
Researchers report that OPP causes the release of TNFα, IL-1ß, platelet derived growth factor and intracellular calcium which latter releases reactive oxygen species [8]. This exposes the potentially therapeutic benefit of antioxidants and anti-inflammatory agents. For this purpose, the patient received vitamins/antioxidants as part of the treatment for both OPP and pneumonitis/pneumonia, which latter is also an inflammatory process [9]. As intensive care facilities were beyond reach, b-CPAP was used for respiratory support in the patient. While on CPAP, glucose infusions were the only form of nutrition administered due to the lack of facilities for total parenteral nutrition. The patient’s rapid recovery and early discharge were facilitated by not being exposed to mechanical ventilation and its attendant complications.
Conclusion
The outcome of OPP is compromised in LMICs by dearth of requisite medical facilities, late presentation and inappropriate home interventions. In this context, best practice [10] requires the use of appropriate technology to increase the chances of survival and limit disability. FWB-EBT made it possible to resuscitate and detoxify this patient, manage organ failure and promote a favourable outcome up to discharge. Due to the prompt acute recovery, delayed polyneuropathy may not occur in this patient.
Consent
Written informed consent was obtained from the parents of this patient using the WHO informed consent form for participation in research, and duly signed/attested by the parents.
Guarantor
Adaugo Chizoma Owobu is the guarantor of this paper.
Acknowledgements
The authors acknowledge all the clinical staff who were involved in the care of the patient from admission until discharge.
Author contributions
Adaugo Owobu participated in conceptualization, obtaining consent, treatment and documentation, retrieval of records/data, writing of the original draft, reviewing and editing aspects, Chiemeka Ogbonnaya participated in obtaining consent, treatment and documentation, retrieval of records/data, writing of the original draft, reviewing and editing aspects, Jeremiah Alli participated in treatment and documentation, retrieval of records/data, reviewing and editing aspects, Abimbola Ekusunmi participated in treatment and documentation aspects.
Conflict of interest
No conflicts of interest.
Funding
There were no sources of funding.
Ethical approval
No approval is required for this work.
