Surviving aluminum phosphide poisoning induced cardiotoxicity- a case report

Surviving aluminum phosphide poisoning induced cardiotoxicity- a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surviving aluminum phosphide poisoning induced cardiotoxicity- a case report Habtamu Mesele Gebray, Addisu Liknaw Chekol This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4193509/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Aluminum phosphide which is a cheap and commonly used rodenticide is also an effective solid fumigant that is frequently used for grain preservation. The pill contains around 44% inert elements to avoid disintegration of the tablet, ammonium carbonate, while the rest (about 56%) is aluminum phosphide. Because it is freely available in the market and accessibility is not controlled in developing countries, it is one of the commonly used agents for self-poisoning in different parts of the developing world Case presentation We presented a 48 years old female patient who was taken to private clinic after 6 hours of intentional ingestion of two tablets of Aluminum phosphide. She was presented with restlessness of 03 hours duration with confusion. She had 06 episodes of vomiting of ingested matter. Upon examination, the patient was drowsy, pale, cold and clammy. She had non-recordable blood pressure and radial pulsation. Glasgow Coma Scale was 14/15. Routine lab investigations and initial Electrocardiogram were normal. Six hours after Intensive Care Unit admission, the Electrocardiogram showed atrial fibrillation with fast ventricular response, ST segment elevation and inverted T-waves. Cardiac troponin level was elevated. Hospital based protocol for a hypotensive patient with aluminum phosphide poisoning was administered and medical treatment of myocardial infarction was given. These measures ultimately resulted in a complete resolution of clinical findings and laboratory derangements. Conclusion Exposure to phosphine gas released from ALP fumigants increases the risk of major morbidity and mortality. The mortality due to ALP poisoning is very high and variable. The use of Magnesium sulphate to reduce cardiac arrhythmias and mortality is well documented but there is no uniformity in dose and frequency of its administration worldwide. aluminum phosphide poisoning rat poison cardiotoxicity magnesium sulphate pesticides Figures Figure 1 Figure 2 Figure 3 Introduction The World Health Organization estimated that more than 7,000,000 people die every year because of suicide. Seventy seven percent of all suicides occur in low‑ and middle‑income countries. Pesticide ingestion is a common means of suicide. The commonly available pesticides are organophosphates, organochlorine, and Aluminum Phosphide (ALP) ( 1 , 2 ). AlP, which is a cheap and commonly used rodenticide, is also an effective solid fumigant that is frequently used for grain preservation. ALP is marketed as dark grey 3-gram tablet and the common brand names are Celphos, Alphos, Synfume, Phostek, Phostoxin, Phosfume and Quickphos. The pill contains around 44% inert elements to avoid disintegration of the tablet, ammonium carbonate ( 3 ), while the rest (about 56%) is aluminum phosphide. The lethal dose of aluminum phosphide is between 0.15 and 0.5 grams (0.0053 and 0.0176 oz). Aluminum phosphide is available in the form of 3 gm pellets (releasing 1 gm phosphine gas) or 0.6 gm pellets (releasing 0.2 gm phosphine gas). Because it is freely available in the market and accessibility is not controlled in developing countries, it is one of the commonly used agents for self-poisoning in different parts of the developing world ( 4 , 5 ). During contact with atmospheric air and hydrochloric acid in the stomach, ALP liberates lethal phosphine (PH 3 ) gas which is colorless, odourless gas. On exposure to air, it produces garlicky odour. Within minutes of ingestion, toxic features of poisoning may be seen like severe vomiting, resistant hypotension, metabolic acidosis, myocardial suppression, and acute respiratory distress syndrome (ARDS). Phosphine gas is rapidly absorbed by the lungs or gut, which causes systemic toxic effects, by free‑radical injury and inhibiting cytochrome C oxidase enzyme. Early signs of toxicity are manifested by shock and circulatory failure. No specific antidote is available until now, so aggressive supportive management is the key to survival in cases of ALP poisoning ( 1 , 6 , 7 ). A retrospective study of 125 patients in Ethiopia showed high prevalence in females (57.6%). ALP poisoning is associated with a high mortality rate, ranging from 30–80%, mostly within the first 1–2 days after admission ( 8 ). The mortality rate in hypotensive patients who were treated with Magnesium Sulphate (MgSO4), IV Calcium gluconate, IV hydrocortisone and dopamine infusion was 55.6% ( 4 ). A similar study in Iran suggested the mortality rate of ALP poisoning in Iranian population of 27% with good survival rate in younger age patients ( 9 ). Here we presented a case who survived ALP induced cardiotoxicity. Case presentation A 48 years old female patient was taken to private clinic after 6 hours of intentional ingestion of two tablets of ALP, locally known as rat poison. The reason for ingestion was marital disharmony. During her presentation, her husband stated that she had restlessness of 03 hours duration with associated confusion. She was given half a liter of milk and following that she had 06 episodes of vomiting of ingested matter. During physical examination, she had non-recordable blood pressure and radial pulsation. Apical pulse rate was 112 beats per minute. Gastric lavage was not done. She was resuscitated by 1 liter of normal saline and referred to our hospital. During her arrival at our emergency department, the family members gave additional history. She swallowed the tablets with water directly unpacking from the sealed container. She was found lied on the floor covered with her vomitus. She had fecal incontinence. She was agitated. Her family members denied any history of psychiatric illness or addiction or use of any recreational drugs. Upon physical examination, the patient was drowsy, pale, cold and clammy. Her blood pressure was 85/55mmHg, radial pulse rate was 114 beats per minute which was feeble and low in volume, respiratory rate of 38 breaths per minute, oxygen saturation (SPO 2 ) was 97% at room air and a temperature of 35.2 0 C. There were clear and resonant lungs with good air entry bilaterally and had normal heart sounds with regular rhythm. On Central Nervous System examination, GCS (Glasgow Coma Scale) was 14/15 (4–4-6-best Eye response = 4/4, best verbal response = 4/5, best motor response = 6/6). She was not oriented to time, place and person. Her pupils were normal sized and reactive to light. Examinations on other systems were unremarkable. Routine investigations (complete blood count, random blood glucose, troponin, liver functions and kidney functions) were sent which were in the normal limits (Table 1 ). Chest x-ray was normal. Electrocardiogram (ECG) was done which was normal sinus rhythm (Fig. 1 ). After 03 hours, She was admitted to Intensive Care Unit (ICU) for close monitoring and for administration of local protocol for hypotensive patients with aluminum phosphide poisoning. In the ICU, her admission vital signs were as follows; non-recordable blood pressure, pulse rate was 118 beats per minute which was feeble and irregular in rythm, respiratory rate was 28 breaths per minute and oxygen saturation was 96% at room air. Six hours after ICU admission, the ECG was repeated and it showed atrial fibrillation with fast ventricular response (heart rate of 120 beats per minute), ST segment elevation on the antero-septal leads with inverted T-waves on inferior and lateral leads (Fig. 2 ) cardiac troponin level was elevated (Table 1 ). Bed side echocardiography showed septal wall hypokinesis with ejection fraction of 50%. Routine hospital based protocol for hypotensive patients with aluminum phosphide poisoning was administered which includes Dopamine 5µg/kg/minute infusion; Hydrocortisone 200mg IV QID for 48 hours; Calcium gluconate 1 vial (10mL of 10% solution) with 10mL of NS to run over 10 minutes slowly, QID for 48 hours; MgSO4 1gm (2mL of 50% solution) with 5mL of NS IV push over 2 minutes, and MgSO4 0.5 mg (1mL) with 1 mL of lidocaine IM on each buttock; Then MgSO4 1gm in 100mL of NS after 1 hour, 2 hours and 3 hours for consecutive 3 hours; Then MgSO4 1gm in 100mL of NS IV TID for 48 hours. With the diagnosis of acute Aluminum Phosphide Poisoning with Cardiotoxicity (Acute Myocardial Infarction), the following medications were added Aspirin 300mg loading then 81 mg oral daily, clopidogrel 300mg loading then 75mg oral daily, atorvastatin 80mg oral daily, unfractionated heparin 60 international unit (IU)/kg intravenous (IV) loading followed by 12 IU/kg/hr via infuser and cimetidine 200mg IV twice per day for stress ulcer prophylaxis. On the second day of admission in the ICU, her blood pressure returned to normal, 100/60 mmHg, pulse rate was 86 beats per minute and hence the dopamine was tapered off. Her CNS examination improved with GCS returning to normal 15/15, and she became oriented to time, place and person. The repeated ECG in the ICU showed complete resolution of the atrial fibrillation and significant improvement of the ST segment elevation (Fig. 3 ). She stayed another 24 hour in the ICU for close monitoring of her vital signs. After staying for 03 days in the ICU she was transferred to medical ward and discharged to home on the next day after proper psychiatric evaluation and counseling. She came to follow up clinic after 02 weeks and she had normal investigations including troponin and ECG. Discussion ALP poisoning is the second most common cause of death due to pesticide poisoning after organophosphate. ALP is a solid fumigant and ideal pesticide since 1940 as it is cheap, most efficacious and easy to use and freely available over the counter in India, Morocco ( 3 ), Nepal ( 6 ), Iran ( 10 ) and Ethiopia ( 4 ). ALP has a relatively high vapour pressure, which allows it to penetrate porous material effectively. Phosphine, like cyanide, inhibits mitochondrial cytochrome oxidase and cellular oxygen utilization. The direct toxic effects of phosphine on cardiac myocytes, fluid loss and adrenal gland can induce profound circulatory collapse ( 3 ). In most patients, like ours, vomiting, abdominal pain and restlessness are frequent presenting complaints. Cardiovascular involvement results in weak pulse, tachycardia, tachypnea, acidosis, marked hypotension, palpitation and ultimately unresponsive shock. Patients remain mentally lucid until cerebral anoxia because of shock. Several ECG changes including ST segment elevation/depression, PR and QRS interval prolongation, complete heart block to ectopic pace making and also fibrillation have been reported. Patients can present with antero-inferior wall ischemia, right bundle branch block and T-wave flattening/inversion simulating myocardial ischemia. One study showed that 10% developed cardiac arrhythmia and the most frequent arrhythmia was atrial fibrillation (31% of patients) followed by ventricular fibrillation (20%), ventricular tachycardia (17%) and AV block (12%). These changes are because of toxic injury to myocardium ( 10 , 11 ). Our patient’s ECG showed atrial fibrillation with fast ventricular response, ST elevation on the antero-septal leads, and T wave inversions on infero-lateral leads. Laboratory investigation may show Leucopenia, increased ALT (Alalnine aminotransferase) or AST (Aspartate aminotransferase) and metabolic acidosis which indicates severe toxicity. Electrolyte analysis may show decreased magnesium, whereas potassium may be increased or decreased. ( 3 , 10 ). Our patient had normal complete blood count, AST, ALT, creatinine and urea level. We didn’t do arterial blood gas analysis and serum magnesium level because they were not available in the town. Our patient presented with repeated vomiting, restlessness and hypotension which are also common presenting symptoms in patients with ALP poisoning ( 8 , 12 ). Since there are no effective antidotes till now, there has been different treatment practices worldwide associated with different ranges of mortality rate. For instance, Trimetazidine for reversal of cardiovascular manifestations of phosphine poisoning, coconut oil for prevention of absorption of ALP, Digoxin for the management of cardiogenic shock, hydroxyethyl starch, venoarterial extracorporeal membrane oxygenation, magnesium sulphate, infusion of GIK (glucose-insulin-potassium) and different inotropes have been used in different centers ( 8 , 13 , 14 ). Our patient was managed in the ICU with dopamine infusion, magnesium sulphate, hydrocortisone IV injection, and calcium gluconate infusion. This approach was practiced for more than 10 years in Felege Hiwot Referral Hospital, in Northwest Ethiopia. In retrospective study of two and half years, done in Felege Hiwot Referral Hospital, the overall mortality of ALP poisoning patients was 31.2% while mortality in hypotensive patients who were treated with the above regimen was 55.6% which was used to be nearly 100% prior to the practice of this approach ( 4 ). The use of intravenous magnesium sulfate has been shown to reduce the mortality up to 50% in many studies ( 6 ). In a study of 50 patients, individuals receiving repeated doses of intravenous magnesium showed significant improvement in indicators of oxidative stress and a lower incidence of mortality in comparison with control participants ( 3 ). Magnesium sulfate acts by stabilizing the cell membrane and hence reducing the incidence of fatal arrhythmias. Another role of magnesium sulfate is to decrease the free radical injury due to its anti-peroxidant effect. Different studies have concluded different doses of intravenous magnesium sulfate. Our patient had serious myocardial toxicity as demonstrated by ECG and raised cardiac biomarker, which are predictors of poor survival and high mortality ( 15 ). A study from Iran showed that the combination of low blood pressure (systolic blood pressure below 90 mmHg), lower blood pH, and time elapsed from consumption to treatment (greater than one hour) predicted almost 77.3% of mortality in cases of ALP poisoning. Additionally patients with low blood pressure are highly likely to die, having a mortality rate of 91.7% ( 16 ). Similarly, another study showed that the survival of patients had a significant relationship with the number of tablets consumed, the time elapsed to reach the first treatment center, hypotension, blood pH, and bicarbonate (HCO3) levels. They showed that the mortality rate of ALP poisoning was higher in patients with a systolic blood pressure below 90 mmHg, a blood pH < 7.2, or an HCO3 level < 15.0, who took over half of a rice tablet, or for whom more than half an hour elapsed from consumption to treatment ( 17 ). Our patient had most of the predictors of high mortality rate; she presented to her first treatment center after 6 hours of ingestion, she had low blood pressure and she took 2 tablets. Fortunately, with our effective management, she survived and discharged with complete improvement. Table 1 Laboratory values from admission time to discharge with reference ranges Lab results At admission After 24 hr After 2 days At discharge Reference Hgb (g/dL) 13.0 -- -- -- 12.3–15.3 WBC (10*3/ul) 7.9 -- -- -- 4.00–11.00 FBS (mg/dL) 88 -- -- -- 70–100 Sodium (mmol/L) 140 -- 134 -- 135–145 Potassium (mmol/L) 3.6 -- 4.0 -- 3.5–5.5 iCalcium (mmol/L) 1.2 -- 1.09 -- 1.05–1.35 Chloride (mmol/L) 100.4 -- 98.9 -- 96–108 ALT (mg/dL) 44.4 -- -- 38.3 0–40 AST (mg/dL) 38.5 -- -- 40.2 0–40 ALP (mg/dL) 189.6 -- -- 166 0–270 BUN (mg/ dL) 30 20 33.1 24.8 6–22 Creatinine (mg/dL) 0.9 1.35 1.2 0.8 0.3–1.3 Troponin I (ng/mL) < 0.01 1.98 1.0 < 0.01 0.0–0.3 TSH (mIU/mL) 3.2 -- -- -- 0.3–4.2 HIV test Negative -- -- -- -- Hgb = Hemoglobin, WBC = White blood cells, ALT = Alanine aminotransferase, AST = Aspartate aminotransferase, ALP = Alkaline phosphatase, TSH = thyroid stimulating hormone, HIV = Human immunodeficiency virus Conclusion Exposure to phosphine gas released from ALP fumigants increases the risk of major morbidity and mortality. The mortality due to ALP poisoning is very high and variable, and depending on a number of factors including the lack of specific antidote or standardized treatment guideline and presenting with the poor prognostic signs. The use of Magnesium sulphate to reduce cardiac arrhythmias and mortality is well documented but there is no uniformity in dose and frequency of its administration worldwide. We presented a patient who survived ALP poisoning with cardiotoxicity after aggressive management by local treatment protocol. Challenges and limitation Aluminum phosphide poisoning is a life threatening condition yet without an effective antidote. Affecting every system in the body, it is a very challenging condition to treat patients effectively without a uniform management guideline worldwide. One of the limitations of this report is the nature of the case report being retrospective design giving no chance to establish a cause-effect relationship. As it is a retrospective study, certain clinical parameters and laboratory values were not complete due to documentation problems and limitations of the setup. The recommended gastric lavage with potassium permanganate (KMnO4) solution was not used in this case, because KMnO4 is not available in Ethiopia. The other is since it is a case report from a single center; it may not be representative of the general population. These limitations might have a negative impact on the generalizability of the findings. Declarations Ethical Approval and consent to participate Ethical clearance was obtained from the ethical committee of Woldia Comprehensive Specialized Hospital and consent was obtained from our patient to prepare the case for case report. Consent to Publication Informed consent was obtained from the patient Declaration of Figures’ Authenticity The figure is created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part. Data availability statement The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Conflicts of Interest None Funding None Acknowledgment We would like to thank all the clinicians involved in the management of this patient especially the ICU team. Author contribution Habtamu Mesele: prepared the manuscript Addisu Liknaw: Conceptualization and prepared the image All authors reviewed the manuscript References Sarkar MKGN, Rakesh U, Prasad R, Raj R. Acute aluminium phosphide poisoning: A case report of rare survival with cardiac, metabolic, hepatic, and renal complications. J Family Med Prim Care 2022(11):7452–5; 10.4103/jfmpc.jfmpc_615_22 . Katwal SMK, Mandal SK, Kc S, Alam MZ, Karki P. ;. Successfully managed aluminum phosphide poisoning: A case report. Ann Med Surg (Lond). 2021;70:102868; 10.1016/j.amsu . 2021. Singh Yatendra JSC, Satyawali Vivekanand GA. Acute aluminium phosphide poisoning, what is new? Egypt Soc Intern Med. 2014;26:99–103. 10.4103/1110-7782.145298 . Muche DEBBDETA. Clinical Profile and Treatment Outcome of Aluminum Phosphide Poisoning in Felege Hiwot Referral Hospital, Northwest Ethiopia: A Retrospective Study Dove press. Open Access Emerg Med. 2021;13. https://doi.org/10.2147/OAEM.S313181) . Wahab AZM, Wahab S, Khan RA. Acute aluminium phosphide poisoning: an update. Hong Kong J Emerg Med. 2008;15(3):152–5. https://doi.org/10.1177/102490790801500306 . Jha SKBA, Chaulagain S, Ojha SK. A case of Aluminum Phosphide poisoning managed successfully in Nepal: A Case Report. Iberoam J Med. 2022;4(2):123–7. 10.53986/ibjm.2022.0018 . Jan SSH, Naveed H, Ullah A, Bilal M, Asad M. Demographic and clinical profiles and mortality of aluminium phosphide poisoning cases in Khyber Pakhtunkhwa Province, Pakistan. Gomal J Med Sci. 2021; Jan-Mar; ;19(1):11 – 8; https://doi.org/0.46903/gjms/19.01.931. Sedaghattalab M. Treatment of critical aluminum phosphide (rice tablet) poisoning with high-dose insulin: a case report. J Med Case Rep. 2022;16:192. https://doi.org/10.1186/s13256-022-03425-4 . Bagherian FKN, Rahmanian F, Abiri S, Hatami N, Foroughian M. Aluminum Phosphide Poisoning Mortality Rate in Iran; a Systematic Review and Meta-Analysis. Arch Acad Emerg Med. 2021;9(1):66. 10.22037/aaem.v9i1.1396 . Behrooz Hashemi-Domeneh NZ, Hossein Hassanian-Moghaddam M, Rahimi S, Shadnia P, Erfantalab, Ostadi A. A review of aluminium phosphide poisoning and a flowchart to treat it. Arh Hig Rada Toksikol. 2016;67:183–93. 10.1515/aiht-2016-67-784 . Forens HMTMJ. Study of the Causes of Mortality in Acute Aluminium Phosphide Poisoning. Med Clin Toxicol July. 2018;26(2). MA. G. Wheat pill (aluminum phosphide) poisoning; Commonly ignored dilemma. A comprehensive clinical review. Prof Med J. 2013;20(6):855–63. Shahin Shadnia MR, Abdolkarim Pajoumand M-H, Rasouli, Mohammad Abdollahi. Successful treatment of acute aluminium phosphide poisoning: possible benefit of coconut oil. Hum Exp Toxicol. 2005;24:215–8. 10.1191/0960327105ht513oa . Priya Bansal SG, Rohit Bansal. Laxmikant Ramkumarsingh Tomar. Survival in a case of aluminum phosphide poisoning with severe myocardial toxicity. Indian J Health Sci Biomedical Res September-December. 2017;10(3):343–6. 10.4103/kleuhsj.ijhs_2_17 . Oghabian ZMOSQ. Treatment of Aluminium Phosphide Poisoning with a Combination of Intravenous Glucagon, Digoxin and Antioxidant Agents. Univ Med J. 2016;16(3):e352–5. 10.18295/squmj.2016.16.03.015 . Seyed Mohammad Navabi JN, Abbas Aghaei Z, Shaahmadi R, Heydari. Mortality from aluminum phosphide poisoning in Kermanshah Province, Iran: characteristics and predictive factors. Korean Soc Epidemiol. 2018;40:6. https://doi.org/10.4178/epih.e2018022 . Rahbar Taramsary MOR, Zarkami T, Palizkar M, Mousavian SA. Survey patients poisoned with aluminum phosphide (rice tablet). J Guilan Univ Med Sci. 2006;14:4247. (Persian). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4193509","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":286362826,"identity":"9789c76c-bf3c-4030-80da-44ce857bc6b7","order_by":0,"name":"Habtamu Mesele Gebray","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYBACAwYeCIOfvQHEtSBKCyNILYNkzwEQV4IELQY3EkAUEVrM2c8ef/Az53C05MznVzf8KJBg4G/vTsCrxbInL7Gxd9vh3H7pnLKbPUCHSZw5uwG/ww7kGDbwArXMnJ2TdoMHqMVAIpeAlvNvDBv/ArVsuHkm7eYforTcyDFsBtmy4Qb7sdvE2XLjXeJs2W3puTN7cthuyxhI8BD2y/ncAx/fbrPO7Wc//uzmmz82cvztvfi1IAEeAzBJrHIQYH9AiupRMApGwSgYQQAAUcVQVF0KYGsAAAAASUVORK5CYII=","orcid":"","institution":"Woldia Comprehensive Specialized Hospital","correspondingAuthor":true,"prefix":"","firstName":"Habtamu","middleName":"Mesele","lastName":"Gebray","suffix":""},{"id":286362827,"identity":"74709863-67f8-4e78-933d-0a3949b7d86d","order_by":1,"name":"Addisu Liknaw Chekol","email":"","orcid":"","institution":"Woldia Comprehensive Specialized Hospital","correspondingAuthor":false,"prefix":"","firstName":"Addisu","middleName":"Liknaw","lastName":"Chekol","suffix":""}],"badges":[],"createdAt":"2024-03-30 20:44:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4193509/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4193509/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54163284,"identity":"fec4156a-e170-4da6-a60f-03ec329f3bb0","added_by":"auto","created_at":"2024-04-05 13:14:13","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":276541,"visible":true,"origin":"","legend":"\u003cp\u003eECG of the patient at the emergency department showing sinus rhythm with heart rate of 94 beats per minute and left ventricular hypertrophy\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4193509/v1/15dd448ad0df7af93f887105.jpeg"},{"id":54163287,"identity":"700c7eee-c2e8-4f47-9810-e7b135f70127","added_by":"auto","created_at":"2024-04-05 13:14:13","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":312962,"visible":true,"origin":"","legend":"\u003cp\u003eECG of the patient in the ICU showing atrial fibrillation with fast ventricular response (heart rate of 120 beats per minute) and ST segment elevation on the antero-septal leads with inverted T-waves on inferior and lateral leads.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4193509/v1/0bf160aad0b9350eda0f5b1b.jpeg"},{"id":54163286,"identity":"490da82f-6187-4ef9-9f26-c17eb08023d3","added_by":"auto","created_at":"2024-04-05 13:14:13","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":241544,"visible":true,"origin":"","legend":"\u003cp\u003eECG of the patient on the second day in the ICU showing sinus rhythm with heart rate of 100 beats per minute and significant improvement of the ST segment elevation and T-wave inversions\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4193509/v1/6c7e65db345c390678421ef6.jpeg"},{"id":55265036,"identity":"5d493406-2f10-43a1-8699-083f9b2199b3","added_by":"auto","created_at":"2024-04-25 01:54:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":612334,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4193509/v1/c1b7729b-4bd7-4220-bc02-9bd8f5a8b64a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surviving aluminum phosphide poisoning induced cardiotoxicity- a case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe World Health Organization estimated that more than 7,000,000 people die every year because of suicide. Seventy seven percent of all suicides occur in low‑ and middle‑income countries. Pesticide ingestion is a common means of suicide. The commonly available pesticides are organophosphates, organochlorine, and Aluminum Phosphide (ALP) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). AlP, which is a cheap and commonly used rodenticide, is also an effective solid fumigant that is frequently used for grain preservation. ALP is marketed as dark grey 3-gram tablet and the common brand names are Celphos, Alphos, Synfume, Phostek, Phostoxin, Phosfume and Quickphos. The pill contains around 44% inert elements to avoid disintegration of the tablet, ammonium carbonate (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), while the rest (about 56%) is aluminum phosphide. The lethal dose of aluminum phosphide is between 0.15 and 0.5 grams (0.0053 and 0.0176 oz). Aluminum phosphide is available in the form of 3 gm pellets (releasing 1 gm phosphine gas) or 0.6 gm pellets (releasing 0.2 gm phosphine gas). Because it is freely available in the market and accessibility is not controlled in developing countries, it is one of the commonly used agents for self-poisoning in different parts of the developing world (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). During contact with atmospheric air and hydrochloric acid in the stomach, ALP liberates lethal phosphine (PH\u003csub\u003e3\u003c/sub\u003e) gas which is colorless, odourless gas. On exposure to air, it produces garlicky odour. Within minutes of ingestion, toxic features of poisoning may be seen like severe vomiting, resistant hypotension, metabolic acidosis, myocardial suppression, and acute respiratory distress syndrome (ARDS). Phosphine gas is rapidly absorbed by the lungs or gut, which causes systemic toxic effects, by free‑radical injury and inhibiting cytochrome C oxidase enzyme. Early signs of toxicity are manifested by shock and circulatory failure. No specific antidote is available until now, so aggressive supportive management is the key to survival in cases of ALP poisoning (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). A retrospective study of 125 patients in Ethiopia showed high prevalence in females (57.6%). ALP poisoning is associated with a high mortality rate, ranging from 30\u0026ndash;80%, mostly within the first 1\u0026ndash;2 days after admission (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The mortality rate in hypotensive patients who were treated with Magnesium Sulphate (MgSO4), IV Calcium gluconate, IV hydrocortisone and dopamine infusion was 55.6% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). A similar study in Iran suggested the mortality rate of ALP poisoning in Iranian population of 27% with good survival rate in younger age patients (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Here we presented a case who survived ALP induced cardiotoxicity.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 48 years old female patient was taken to private clinic after 6 hours of intentional ingestion of two tablets of ALP, locally known as rat poison. The reason for ingestion was marital disharmony. During her presentation, her husband stated that she had restlessness of 03 hours duration with associated confusion. She was given half a liter of milk and following that she had 06 episodes of vomiting of ingested matter. During physical examination, she had non-recordable blood pressure and radial pulsation. Apical pulse rate was 112 beats per minute. Gastric lavage was not done. She was resuscitated by 1 liter of normal saline and referred to our hospital.\u003c/p\u003e \u003cp\u003eDuring her arrival at our emergency department, the family members gave additional history. She swallowed the tablets with water directly unpacking from the sealed container. She was found lied on the floor covered with her vomitus. She had fecal incontinence. She was agitated. Her family members denied any history of psychiatric illness or addiction or use of any recreational drugs. Upon physical examination, the patient was drowsy, pale, cold and clammy. Her blood pressure was 85/55mmHg, radial pulse rate was 114 beats per minute which was feeble and low in volume, respiratory rate of 38 breaths per minute, oxygen saturation (SPO\u003csub\u003e2\u003c/sub\u003e) was 97% at room air and a temperature of 35.2\u003csup\u003e0\u003c/sup\u003eC. There were clear and resonant lungs with good air entry bilaterally and had normal heart sounds with regular rhythm. On Central Nervous System examination, GCS (Glasgow Coma Scale) was 14/15 (4\u0026ndash;4-6-best Eye response\u0026thinsp;=\u0026thinsp;4/4, best verbal response\u0026thinsp;=\u0026thinsp;4/5, best motor response\u0026thinsp;=\u0026thinsp;6/6). She was not oriented to time, place and person. Her pupils were normal sized and reactive to light. Examinations on other systems were unremarkable.\u003c/p\u003e \u003cp\u003eRoutine investigations (complete blood count, random blood glucose, troponin, liver functions and kidney functions) were sent which were in the normal limits (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Chest x-ray was normal. Electrocardiogram (ECG) was done which was normal sinus rhythm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). After 03 hours, She was admitted to Intensive Care Unit (ICU) for close monitoring and for administration of local protocol for hypotensive patients with aluminum phosphide poisoning.\u003c/p\u003e \u003cp\u003eIn the ICU, her admission vital signs were as follows; non-recordable blood pressure, pulse rate was 118 beats per minute which was feeble and irregular in rythm, respiratory rate was 28 breaths per minute and oxygen saturation was 96% at room air.\u003c/p\u003e \u003cp\u003eSix hours after ICU admission, the ECG was repeated and it showed atrial fibrillation with fast ventricular response (heart rate of 120 beats per minute), ST segment elevation on the antero-septal leads with inverted T-waves on inferior and lateral leads (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) cardiac troponin level was elevated (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Bed side echocardiography showed septal wall hypokinesis with ejection fraction of 50%.\u003c/p\u003e \u003cp\u003eRoutine hospital based protocol for hypotensive patients with aluminum phosphide poisoning was administered which includes Dopamine 5\u0026micro;g/kg/minute infusion; Hydrocortisone 200mg IV QID for 48 hours; Calcium gluconate 1 vial (10mL of 10% solution) with 10mL of NS to run over 10 minutes slowly, QID for 48 hours; MgSO4 1gm (2mL of 50% solution) with 5mL of NS IV push over 2 minutes, and MgSO4 0.5 mg (1mL) with 1 mL of lidocaine IM on each buttock; Then MgSO4 1gm in 100mL of NS after 1 hour, 2 hours and 3 hours for consecutive 3 hours; Then MgSO4 1gm in 100mL of NS IV TID for 48 hours.\u003c/p\u003e \u003cp\u003eWith the diagnosis of acute Aluminum Phosphide Poisoning with Cardiotoxicity (Acute Myocardial Infarction), the following medications were added Aspirin 300mg loading then 81 mg oral daily, clopidogrel 300mg loading then 75mg oral daily, atorvastatin 80mg oral daily, unfractionated heparin 60 international unit (IU)/kg intravenous (IV) loading followed by 12 IU/kg/hr via infuser and cimetidine 200mg IV twice per day for stress ulcer prophylaxis.\u003c/p\u003e \u003cp\u003eOn the second day of admission in the ICU, her blood pressure returned to normal, 100/60 mmHg, pulse rate was 86 beats per minute and hence the dopamine was tapered off. Her CNS examination improved with GCS returning to normal 15/15, and she became oriented to time, place and person. The repeated ECG in the ICU showed complete resolution of the atrial fibrillation and significant improvement of the ST segment elevation (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). She stayed another 24 hour in the ICU for close monitoring of her vital signs. After staying for 03 days in the ICU she was transferred to medical ward and discharged to home on the next day after proper psychiatric evaluation and counseling. She came to follow up clinic after 02 weeks and she had normal investigations including troponin and ECG.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eALP poisoning is the second most common cause of death due to pesticide poisoning after organophosphate. ALP is a solid fumigant and ideal pesticide since 1940 as it is cheap, most efficacious and easy to use and freely available over the counter in India, Morocco (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), Nepal (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), Iran (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and Ethiopia (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). ALP has a relatively high vapour pressure, which allows it to penetrate porous material effectively. Phosphine, like cyanide, inhibits mitochondrial cytochrome oxidase and cellular oxygen utilization. The direct toxic effects of phosphine on cardiac myocytes, fluid loss and adrenal gland can induce profound circulatory collapse (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn most patients, like ours, vomiting, abdominal pain and restlessness are frequent presenting complaints. Cardiovascular involvement results in weak pulse, tachycardia, tachypnea, acidosis, marked hypotension, palpitation and ultimately unresponsive shock. Patients remain mentally lucid until cerebral anoxia because of shock. Several ECG changes including ST segment elevation/depression, PR and QRS interval prolongation, complete heart block to ectopic pace making and also fibrillation have been reported. Patients can present with antero-inferior wall ischemia, right bundle branch block and T-wave flattening/inversion simulating myocardial ischemia. One study showed that 10% developed cardiac arrhythmia and the most frequent arrhythmia was atrial fibrillation (31% of patients) followed by ventricular fibrillation (20%), ventricular tachycardia (17%) and AV block (12%). These changes are because of toxic injury to myocardium (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Our patient\u0026rsquo;s ECG showed atrial fibrillation with fast ventricular response, ST elevation on the antero-septal leads, and T wave inversions on infero-lateral leads.\u003c/p\u003e \u003cp\u003eLaboratory investigation may show Leucopenia, increased ALT (Alalnine aminotransferase) or AST (Aspartate aminotransferase) and metabolic acidosis which indicates severe toxicity. Electrolyte analysis may show decreased magnesium, whereas potassium may be increased or decreased. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Our patient had normal complete blood count, AST, ALT, creatinine and urea level. We didn\u0026rsquo;t do arterial blood gas analysis and serum magnesium level because they were not available in the town.\u003c/p\u003e \u003cp\u003eOur patient presented with repeated vomiting, restlessness and hypotension which are also common presenting symptoms in patients with ALP poisoning (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Since there are no effective antidotes till now, there has been different treatment practices worldwide associated with different ranges of mortality rate. For instance, Trimetazidine for reversal of cardiovascular manifestations of phosphine poisoning, coconut oil for prevention of absorption of ALP, Digoxin for the management of cardiogenic shock, hydroxyethyl starch, venoarterial extracorporeal membrane oxygenation, magnesium sulphate, infusion of GIK (glucose-insulin-potassium) and different inotropes have been used in different centers (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Our patient was managed in the ICU with dopamine infusion, magnesium sulphate, hydrocortisone IV injection, and calcium gluconate infusion. This approach was practiced for more than 10 years in Felege Hiwot Referral Hospital, in Northwest Ethiopia. In retrospective study of two and half years, done in Felege Hiwot Referral Hospital, the overall mortality of ALP poisoning patients was 31.2% while mortality in hypotensive patients who were treated with the above regimen was 55.6% which was used to be nearly 100% prior to the practice of this approach (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The use of intravenous magnesium sulfate has been shown to reduce the mortality up to 50% in many studies (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In a study of 50 patients, individuals receiving repeated doses of intravenous magnesium showed significant improvement in indicators of oxidative stress and a lower incidence of mortality in comparison with control participants (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Magnesium sulfate acts by stabilizing the cell membrane and hence reducing the incidence of fatal arrhythmias. Another role of magnesium sulfate is to decrease the free radical injury due to its anti-peroxidant effect. Different studies have concluded different doses of intravenous magnesium sulfate.\u003c/p\u003e \u003cp\u003eOur patient had serious myocardial toxicity as demonstrated by ECG and raised cardiac biomarker, which are predictors of poor survival and high mortality (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A study from Iran showed that the combination of low blood pressure (systolic blood pressure below 90 mmHg), lower blood pH, and time elapsed from consumption to treatment (greater than one hour) predicted almost 77.3% of mortality in cases of ALP poisoning. Additionally patients with low blood pressure are highly likely to die, having a mortality rate of 91.7% (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Similarly, another study showed that the survival of patients had a significant relationship with the number of tablets consumed, the time elapsed to reach the first treatment center, hypotension, blood pH, and bicarbonate (HCO3) levels. They showed that the mortality rate of ALP poisoning was higher in patients with a systolic blood pressure below 90 mmHg, a blood pH\u0026thinsp;\u0026lt;\u0026thinsp;7.2, or an HCO3 level\u0026thinsp;\u0026lt;\u0026thinsp;15.0, who took over half of a rice tablet, or for whom more than half an hour elapsed from consumption to treatment (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Our patient had most of the predictors of high mortality rate; she presented to her first treatment center after 6 hours of ingestion, she had low blood pressure and she took 2 tablets. Fortunately, with our effective management, she survived and discharged with complete improvement.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory values from admission time to discharge with reference ranges\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLab results\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAt admission\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter 24 hr\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAfter 2 days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAt discharge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHgb (g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.3\u0026ndash;15.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC (10*3/ul)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.00\u0026ndash;11.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFBS (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70\u0026ndash;100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSodium (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e134\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e135\u0026ndash;145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePotassium (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.5\u0026ndash;5.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eiCalcium (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.05\u0026ndash;1.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChloride (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e96\u0026ndash;108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALP (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e189.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u0026ndash;270\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBUN (mg/\u003c/p\u003e \u003cp\u003edL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u0026ndash;22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (mg/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.3\u0026ndash;1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTroponin I (ng/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0\u0026ndash;0.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTSH (mIU/mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.3\u0026ndash;4.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIV test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eHgb\u0026thinsp;=\u0026thinsp;Hemoglobin, WBC\u0026thinsp;=\u0026thinsp;White blood cells, ALT\u0026thinsp;=\u0026thinsp;Alanine aminotransferase, AST\u0026thinsp;=\u0026thinsp;Aspartate aminotransferase, ALP\u0026thinsp;=\u0026thinsp;Alkaline phosphatase, TSH\u0026thinsp;=\u0026thinsp;thyroid stimulating hormone, HIV\u0026thinsp;=\u0026thinsp;Human immunodeficiency virus\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eExposure to phosphine gas released from ALP fumigants increases the risk of major morbidity and mortality. The mortality due to ALP poisoning is very high and variable, and depending on a number of factors including the lack of specific antidote or standardized treatment guideline and presenting with the poor prognostic signs. The use of Magnesium sulphate to reduce cardiac arrhythmias and mortality is well documented but there is no uniformity in dose and frequency of its administration worldwide. We presented a patient who survived ALP poisoning with cardiotoxicity after aggressive management by local treatment protocol.\u003c/p\u003e\n\u003ch3\u003eChallenges and limitation\u003c/h3\u003e\n\u003cp\u003eAluminum phosphide poisoning is a life threatening condition yet without an effective antidote. Affecting every system in the body, it is a very challenging condition to treat patients effectively without a uniform management guideline worldwide.\u003c/p\u003e \u003cp\u003eOne of the limitations of this report is the nature of the case report being retrospective design giving no chance to establish a cause-effect relationship. As it is a retrospective study, certain clinical parameters and laboratory values were not complete due to documentation problems and limitations of the setup. The recommended gastric lavage with potassium permanganate (KMnO4) solution was not used in this case, because KMnO4 is not available in Ethiopia. The other is since it is a case report from a single center; it may not be representative of the general population. These limitations might have a negative impact on the generalizability of the findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical Approval and consent to participate\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the ethical committee of Woldia Comprehensive Specialized Hospital and consent was obtained from our patient to prepare the case for case report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent to Publication\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the patient\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDeclaration of Figures\u0026rsquo; Authenticity\u003c/p\u003e\n\u003cp\u003eThe figure is created by the authors who confirm that the images are original with no duplication and have not been previously published in whole or in part.\u003c/p\u003e\n\u003cp\u003eData availability statement\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eConflicts of Interest\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgment\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the clinicians involved in the management of this patient especially the ICU team.\u003c/p\u003e\n\u003cp\u003eAuthor contribution\u003c/p\u003e\n\u003cp\u003eHabtamu Mesele: prepared the manuscript\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAddisu Liknaw: Conceptualization and prepared the image\u003c/p\u003e\n\u003cp\u003eAll authors reviewed the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSarkar MKGN, Rakesh U, Prasad R, Raj R. 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Arch Acad Emerg Med. 2021;9(1):66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.22037/aaem.v9i1.1396\u003c/span\u003e\u003cspan address=\"10.22037/aaem.v9i1.1396\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBehrooz Hashemi-Domeneh NZ, Hossein Hassanian-Moghaddam M, Rahimi S, Shadnia P, Erfantalab, Ostadi A. A review of aluminium phosphide poisoning and a flowchart to treat it. Arh Hig Rada Toksikol. 2016;67:183\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1515/aiht-2016-67-784\u003c/span\u003e\u003cspan address=\"10.1515/aiht-2016-67-784\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForens HMTMJ. Study of the Causes of Mortality in Acute Aluminium Phosphide Poisoning. Med Clin Toxicol July. 2018;26(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMA. G. Wheat pill (aluminum phosphide) poisoning; Commonly ignored dilemma. A comprehensive clinical review. Prof Med J. 2013;20(6):855\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShahin Shadnia MR, Abdolkarim Pajoumand M-H, Rasouli, Mohammad Abdollahi. Successful treatment of acute aluminium phosphide poisoning: possible benefit of coconut oil. Hum Exp Toxicol. 2005;24:215\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1191/0960327105ht513oa\u003c/span\u003e\u003cspan address=\"10.1191/0960327105ht513oa\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePriya Bansal SG, Rohit Bansal. Laxmikant Ramkumarsingh Tomar. Survival in a case of aluminum phosphide poisoning with severe myocardial toxicity. 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Mortality from aluminum phosphide poisoning in Kermanshah Province, Iran: characteristics and predictive factors. Korean Soc Epidemiol. 2018;40:6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4178/epih.e2018022\u003c/span\u003e\u003cspan address=\"10.4178/epih.e2018022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahbar Taramsary MOR, Zarkami T, Palizkar M, Mousavian SA. Survey patients poisoned with aluminum phosphide (rice tablet). J Guilan Univ Med Sci. 2006;14:4247. (Persian).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"aluminum phosphide, poisoning, rat poison, cardiotoxicity, magnesium sulphate, pesticides","lastPublishedDoi":"10.21203/rs.3.rs-4193509/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4193509/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction\u003c/p\u003e\n\u003cp\u003eAluminum phosphide which is a cheap and commonly used rodenticide is also an effective solid fumigant that is frequently used for grain preservation. The pill contains around 44% inert elements to avoid disintegration of the tablet, ammonium carbonate, while the rest (about 56%) is aluminum phosphide. Because it is freely available in the market and accessibility is not controlled in developing countries, it is one of the commonly used agents for self-poisoning in different parts of the developing world\u003c/p\u003e\n\u003cp\u003eCase presentation\u003c/p\u003e\n\u003cp\u003eWe presented a 48 years old female patient who was taken to private clinic after 6 hours of intentional ingestion of two tablets of Aluminum phosphide. She was presented with restlessness of 03 hours duration with confusion. She had 06 episodes of vomiting of ingested matter. Upon examination, the patient was drowsy, pale, cold and clammy. She had non-recordable blood pressure and radial pulsation. Glasgow Coma Scale was 14/15. Routine lab investigations and initial Electrocardiogram were normal. Six hours after Intensive Care Unit admission, the Electrocardiogram showed atrial fibrillation with fast ventricular response, ST segment elevation and inverted T-waves. Cardiac troponin level was elevated. Hospital based protocol for a hypotensive patient with aluminum phosphide poisoning was administered and medical treatment of myocardial infarction was given. These measures ultimately resulted in a complete resolution of clinical findings and laboratory derangements.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eExposure to phosphine gas released from ALP fumigants increases the risk of major morbidity and mortality. The mortality due to ALP poisoning is very high and variable. The use of Magnesium sulphate to reduce cardiac arrhythmias and mortality is well documented but there is no uniformity in dose and frequency of its administration worldwide.\u003c/p\u003e","manuscriptTitle":"Surviving aluminum phosphide poisoning induced cardiotoxicity- a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-05 13:14:08","doi":"10.21203/rs.3.rs-4193509/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e330e1b0-6607-4762-a827-36a6d8f472eb","owner":[],"postedDate":"April 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-22T22:39:55+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-05 13:14:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4193509","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4193509","identity":"rs-4193509","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}