Hallazgos en imágenes de tórax en una intoxicación aguda con paraquat: reporte de un caso / Findings on thorax images in acute paraquat poisoning: case report

Resumen El Paraquat es un herbicida ampliamente utilizado para el control de las malezas en Chile. Su ingesta determina una alta probabilidad de mortalidad dado su inherente toxicidad mediante la producción de radicales libres, que afectan a múltiples órganos, principalmente los pulmones; a esto se suma la falta de un tratamiento efectivo. Se presenta el caso clínico de un hombre de 18 años que en un intento suicida consume 50 mL de paraquat (200 g/L), con desenlace fatal. La presentación clínica depende la cantidad de Paraquat ingerida y los hallazgos radiológicos descritos varían según la temporalidad del cuadro e, inclusive, podrían determinar el pronóstico.

Paraquat is an herbicide widely used for weed control in Chile. Its intake determines a high probability of mortality because of its inherent toxicity through the production of free radicals. Multiple organs are affected, mainly the lungs; to this is added the lack of effective treatment. We present the clinical case of an 18-year-old man who in a suicidal attempt swallows 50 mL of paraquat (200 g/L), with a fatal outcome. The clinical presentation depends on the amount of Paraquat ingested. Radiological findings described vary according to the temporality of the condition and could even determine the prognosis

Use of bone marrow for detection of toxic chemicals for the elucidation of poisoning in forensic veterinary medicine / Uso de medula óssea para detecção de produtos químicos tóxicos para a elucidação de intoxicação em patologia veterinária forense

In forensic toxicology, the detection of toxic chemicals from human bone marrow is often used in cases with an extended post mortem interval; however, in veterinary medicine, this practice is not used. Therefore, this study was performed to investigate the suitability of bone marrow for toxicological analysis in dogs and cats. Six animals with suspected poisoning were selected; the carcasses were sent for necropsy, and the organs were collected and preserved in buffered formalin and processed routinely for histological examination. In addition, bone marrow samples from the femur, humerus, and tibia were collected for toxicological analysis by liquid chromatography coupled to mass spectrometry detection (LC-MS). This analysis confirmed the presence of aldicarb, aldicarb sulfone, asulam, carbendazim, chlorpyrifos, dichlorvos, thifensulfuron methyl and trifloxysulfuron-sodium and associated with clinical symptoms and anatomo-histopathological alterations it was recognized the poisonings. It is expected that this study will promote the toxicological investigation of bone marrow and open avenues for the use of this tissue as an option for the detection of toxic chemicals in cases of forensic pathology.(AU)

Na toxicologia forense, a detecção de substâncias químicas tóxicas provenientes da medula óssea humana é frequentemente usada em casos com intervalo post mortem prolongado; no entanto, na medicina veterinária, essa prática não é utilizada. Portanto, este estudo foi realizado para investigar a utilização da medula óssea nas análises toxicológicas em cães e gatos. Seis animais com suspeita de intoxicação foram selecionados; as carcaças foram enviadas para necropsia e os órgãos foram coletados e preservados em formalina tamponada e processados rotineiramente para exame histológico. Amostras de medula óssea de fêmur, úmero e tíbia foram coletadas para análise toxicológica por cromatografia líquida acoplada à espectrometria de massa-massa (LC-MS). A análise por LC-MS confirmou a presença dos agrotóxicos aldicarbe, aldicarbe sulfona, asulam, carbendazim, clorpirifós, diclorvós, tifensulfuron metil e trifloxisulfuron-sódico, e em associação com sinais clínicos e achados anatomo-histopatológicos comprovou-se as intoxicações. Espera-se que este estudo promova a utilização da medula óssea como uma opção na investigação toxicológica para a detecção de produtos químicos tóxicos em casos de patologia forense.(AU)

Efecto de la n-acetilcisteina inhalada en el desarrollo de fibrosis pulmonar de ratas intoxicadas con paraquat / Effect of n-acetylcisteine inhaled in the development of pulmonary fibrosis of intoxicated rats with paraquat

El Paraquat (PQ) es un herbicida de contacto bipiridilico ampliamente utilizado en agricultura. La intoxicación en humanos por este agente ocasiona fibrosis pulmonar. Evaluamos los cambios histológicos pulmonares de ratas intoxicadas con PQ y tratadas con N-aceticisteina (NAC) administrada vía inhalatoria. Realizamos un estudio experimental descriptivo con 25 ratas adultas, machos cepa Wistar, divididas en cinco grupos. Al grupo I no se les administro ni PQ ni NAC. Grupo II, recibió NAC inhalada a 15mg/kg diaria c/12 horas. Grupo III, PQ vía oral (VO) 15mg/kg. Grupo IV, PQ a 15mg/kg, por VO y a la hora NAC 150mg/kg. Grupo V, PQ a 15mg/kg, por VO y a las seis horas NAC dosis de 150mg/kg. Los pulmones fueron extraídos y se evaluaron mediante cortes histológicos. Resultados: Los grupos I y II (supervivencia del 100%, n=10) no desarrollaron sintomatología de intoxicación. Grupos III, IV y V predominaron síntomas respiratorios, diversos grados de edema pulmonar, enfisema, congestión vascular y hemorragia intra-alveolar focal. La eficacia de la NAC sobre la intoxicación por PQ en términos de sobrevivencia al primer día, fue del 100% y al segundo día, fue del 80% (p= 0,005; prueba Chi-cuadrado). El PQ indujo un proceso inflamatorio (agudo-crónico) por infiltrado de segmentados neutrófilos y linfocitos, lo cual fue revertido parcialmente por la administración inhalada de NAC. Conclusión: Los cambios histopatológicos observados a nivel pulmonar fueron aminorados por el tratamiento con NAC, lo que sugiere un posible efecto protector de este fármaco sobre el daño oxidativo inducido por el herbicida

Paraquat (PQ) is a bipyridyl contact herbicide widely used in agriculture. Intoxication in humans by this agent causes pulmonary fibrosis. We evaluated pulmonary histological changes of rats intoxicated with PQ and treated with N-acetycysteine (NAC) administered via inhalation. We conducted a descriptive experimental study with 25 adult rats, male Wistar strain, divided into five groups. Group I was not administered PQ or NAC. Group II, received NAC inhaled at 15mg/kg daily c/12 hours. Group III, PQ orally (VO) 15mg/ kg. Group IV, PQ at 15mg/kg, by VO and at hour NAC 150mg/ kg. Group V, PQ at 15mg/kg, by VO and at six hours NAC dose of 150mg/kg. The lungs were extracted and evaluated by histological sections. Results: Groups I and II (100% survival, n=10) did not develop intoxication symptoms. Groups III, IV and V predominantly respiratory symptoms, various degrees of pulmonary edema, emphysema, vascular congestion and focal intra-alveolar hemorrhage. The efficacy of NAC on PQ poisoning in terms of survival on the first day was 100% and on the second day it was 80% (p = 0.005, Chi-square test). The PQ induced an inflammatory process (acute-chronic) by infiltration of segmented neutrophils and lymphocytes, which was partially reversed by the inhaled administration of NAC. Conclusion: The histopathological changes observed at the pulmonary level were reduced by the treatment with NAC, which suggests a possible protective effect of this drug on the oxidative damage induced by the herbicide.

Protocolo del Sistema Nacional de Vigilancia Epidemiológica: intoxicaciones por plaguicidas, lesiones de causa externa y conducta suicida. No. 10 / Protocol of the National Epidemiological Surveillance System: pesticide poisonings, external cause injuries and suicidal behavior. No. 10

Estos protocolos están dirigido a personal médico, paramédico y otros profesionales que realizan acciones gerenciales y operativas de vigilancia epidemiológica en los servicios de salud del país, y están divididos en varios tomos para dar a conocer y actualizar la identificación y medidas de control para diversos padecimientos a fin de continuar con el mejoramiento de las capacidades técnicas de los trabajadores de salud, que permita planificar la prestación de servicios con decisiones partiendo de un enfoque epidemiológico comprobado, para responder a los cambios de tendencias epidemiológicas y con ello contribuir al fortalecimiento de prácticas asertivas de la salud pública de nuestro país.

Fibrosis pulmonar aguda asociada a intoxicación por Paraquat: caso clínico / Acute pulmonary fibrosis associated with Paraquat poisoning: report of one case

Paraquat, a non-selective bipyridyl pesticide, is one of the leading causes of death from intoxication in many parts of Asia and America. It is the second most sold herbicide worldwide, being widely used in Chile. Its ingestion generates toxicity due to the release of superoxide radicals, mainly affecting kidneys, lungs and liver. There is no antidote available. We report a 31 years old male who ingested Paraquat for suicidal purposes. He developed an acute renal and hepatic failure and a rapidly progressive severe respiratory failure with images compatible with acute pulmonary fibrosis. No response to immunosuppressive treatment was observed. He died eight days after admission. The use of cyclophosphamide associated with glucocorticoids could lower risk of death the in these patients, although the pathophysiology of respiratory failure is still under study.

Diagnostic and Therapeutic Approach for Acute Paraquat Intoxication

Paraquat (PQ) has known negative human health effects, but continues to be commonly used worldwide as a herbicide. Our clinical data shows that the main prognostic factor is the time required to achieve a negative urine dithionite test. Patient survival is a 100% when the area affected by ground glass opacity is <20% of the total lung volume on high-resolution computed tomography imaging 7 days post-PQ ingestion. The incidence of acute kidney injury is approximately 50%. The average serum creatinine level reaches its peak around 5 days post-ingestion, and usually normalizes within 3 weeks. We obtain two connecting lines from the highest PQ level for the survivors and the lowest PQ level among the non-survivors at a given time. Patients with a PQ level between these two lines are considered treatable. The following treatment modalities are recommended to preserve kidney function: 1) extracorporeal elimination, 2) intravenous antioxidant administration, 3) diuresis with a fluid, and 4) cytotoxic drugs. In conclusion, this review provides a general overview on the diagnostic procedure and treatment modality of acute PQ intoxication, while focusing on our clinical experience.

Cancer Incidence in Korean Vietnam Veterans During 1992-2003: The Korean Veterans Health Study / 예방의학회지

OBJECTIVES: The aim of this study was to investigate the association between Vietnam experience including exposure to military herbicides and cancer incidence in Korean Vietnam War veterans. METHODS: The cancer cases of 185 265 Vietnam veterans from January 1, 1992 to December 31, 2003 were confirmed from the Korea National Cancer Incidence Database. The age-adjusted incidence and standardized incidence ratios (SIRs) were calculated using the male population during 1992 to 2003 as a standard population. RESULTS: The age-adjusted overall cancer incidence per 100 000 person-years was 455.3 in Vietnam veterans. The overall cancer incidence was slightly yet significantly lower in veterans (SIR, 0.97; 95% confidence interval, 0.95 to 0.99) than in the general population. The overall cancer incidence in enlisted soldiers was not lower (SIR, 1.00), whereas that in officers was significantly lower (SIR, 0.87) than in the general population. The incidences of prostate cancer and T-cell lymphoma in all veterans, and lung cancer and bladder cancer in enlisted soldiers, and colon cancer and kidney cancer in non-commissioned officers, and colon cancer, kidney cancer, and prostate cancer in officers, were higher than in the general population. The SIR for overall cancer among Vietnam veterans rose from 0.92 for 1992-1997 to 0.99 for 1998-2003. CONCLUSIONS: The overall cancer incidence in Vietnam veterans was not higher than in the general male population. Vietnam veterans and military rank subcohorts experienced a higher incidence of several cancers, including prostate cancer, T-cell lymphoma, lung cancer, bladder cancer, kidney cancer, and colon cancer than the general population. The SIR for overall cancer increased over time in Vietnam veterans.

Glufosinate Herbicide Intoxication Causing Unconsciousness, Convulsion, and 6th Cranial Nerve Palsy

Although glufosinate ammonium herbicides are considered safe when used properly, ingestion of the undiluted form can cause grave outcomes. Recently, we treated a 34-yr-old man who ingested glufosinate ammonium herbicide. In the course of treatment, the patient developed apnea, mental deterioration, and sixth cranial nerve palsy; he has since been discharged with full recovery after intensive care. This case report describes the clinical features of glufosinate intoxication with a focus on sixth cranial nerve palsy. Our observation suggests that neurologic manifestations after ingestion of a "low-grade toxicity herbicide" are variable and more complex than that was previously considered.

Intoxicação aguda por metano arsonato ácido monossódico em bovinos / Acute poisoning by monosodium methanearsonic acid in cattle

O presente trabalho estudou a intoxicação acidental por arsênico em um lote de 24 vacas Girolando, as quais tiveram acesso a pasto pulverizado com herbicida à base de metano arsonato ácido monossódico (MSMA). Os bovinos apresentaram apatia, anorexia e diarreia profusa. Foram necropsiados na fazenda dois animais de 14 que morreram. Os principais achados macroscópicos foram úlceras abomasais e congestão renal. No exame microscópico, as principais lesões observadas foram abomasite e omasite necro-hemorrágica multifocal acentuada e, nos rins, necrose tubular difusa. As concentrações médias de arsênico em vacas com sinais clínicos foram 1,19±0,40, 10,52±2,16 e 76,06±48,37ppm no sangue, leite e fezes, respectivamente. Os níveis de arsênico encontrados em dois animais necropsiados foram 25,58 e 23,85ppm em fígado, e 28,71 e 35,94ppm em rins, respectivamente. No feto de uma vaca necropsiada, os níveis de arsênico mensurados no fígado e rim foram 9,0 e 8,92ppm, respectivamente. A concentração de arsênico no capim do piquete pulverizado foi 111,58ppm. No Brasil, o uso MSMA na composição de pesticidas e herbicidas é permitido somente para uso agrícola, mas não pecuário. A utilização desse ou de outros produtos à base de arsênico na pecuária pode causar altos índices de mortalidade no rebanho, além de diminuição da produção e contaminação de produtos de origem animal.

Poisoning by monosodium methanearsonic acid (MSMA) is reported in a herd of 24 Girolando cows that were introduced into a pasture sprayed with the herbicide. Clinical signs were apathy, anorexia, and profuse diarrhea. Fourteen cows died and two were necropsied. Abomasal ulcers and renal congestion was observed. Main histologic lesions were multifocal, accentuated, necrotizing and hemorrhagic abomasitis and omasitis, and tubular necrosis in the kidneys. Mean arsenic concentrations in cows with clinical signs were 1.19±0.40, 10.52±2.16, and 76.06±48.37ppm in blood, milk, and feces, respectively. In the two necropsied cows arsenic concentrations were 25.58 and 23.85ppm in liver, and 28.71 and 35.94ppm in kidney, respectively. In a fetus of a cow that was necropsied, arsenic concentrations were 9.0 and 8.92ppm in liver and kidney, respectively. Arsenic concentration in the grass collected from the paddock sprayed with MSMA was 111.58ppm. In Brazil, the use of MSMA in the composition of herbicides is allowed only for agricultural use, not for livestock. The use of arsenic based products for livestock can lead to high mortality rates in the herd, as well as reduced production and contamination of animal products.

Acute Oral Poisoning Due to Chloracetanilide Herbicides

Chloracetanilide herbicides (alachlor, butachlor, metachlor) are used widely. Although there are much data about chronic low dose exposure to chloracetanilide in humans and animals, there are few data about acute chloracetanilide poisoning in humans. This study investigated the clinical feature of patients following acute oral exposure to chloracetanilide. We retrospectively reviewed the data on the patients who were admitted to two university hospitals from January 2006 to December 2010. Thirty-five patients were enrolled. Among them, 28, 5, and 2 cases of acute alachlor, metachlor, butachlor poisoning were included. The mean age was 49.8 +/- 15.4 yr. The poison severity score (PSS) was 17 (48.6%), 10 (28.6%), 5 (14.3%), 2 (5.7%), and 1 (2.9%) patients with a PSS of 0, 1, 2, 3, and 4, respectively. The age was higher for the symptomatic patients (1-4 PSS) than that for the asymptomatic patients (0 PSS) (43.6 +/- 15.2 vs 55.7 +/- 13.5). The arterial blood HCO3 was lower in the symptomatic patients (1-4 PSS) than that in the asymptomatic patients (0 PSS). Three patients were a comatous. One patient died 24 hr after the exposure. In conclusion, although chloracetanilide poisoning is usually of low toxicity, elder patients with central nervous system symptoms should be closely monitored and cared after oral exposure.

Intoxicación pediátrica por paraquat (gramoxone) supervivencia en dos casos / Pediatric intoxication with paraquat (gramoxone) survival of two children

El paraquat es un plaguicida agricola bipiridilo, cuyos efectos tóxicos más severos son año hepato-renal y fibrosis pulmonar irreversible. Se reportan dos casos de intoxicación en niños, por ingestión accidental de paraquat; ellos desarrollaron sialorrea, vómitos azul verdoso, lesión digestiva cáustica. dificultad respiratoria, daño hepato-renal, alteraciones radiológicas y presencia de paraquat en orina y sangre. Ambos pacientes recibieron el tratamiento disponible entre 24-48 horas despues de la ingestion y tuvieron una evolución satisfactoria. El tratamiento consistió basicamente en diálisis gastrointestinal, diuresis forzada ácida, N-acetilcisteína y dexametasona.

Paraquat is a bipyridyl agricultural pesticide, whose more severe effects are hepatic-renal damage and irreversible pulmonary fibrosis. Two children with paraquat accidental poisoning are reported; they developed syalorrhea, blue greenish vomiting, caustic digestive injury, breathing difficulty, liver and kidney damage, radiographic changes and presence of paraquat in blood and urine. Both patients received the available treatment 24-48 hours after ingetion and had a satisfactory autcome. The consisted basically of gatrointestinal dialysis, acidic forced diuresis, N-acetylcysteine and dexamethasone.

Paraquat Intoxication in Subjects Who Attempt Suicide: Why They Chose Paraquat

BACKGROUND/AIMS: Paraquat (PQ) has been used in suicide attempts; an estimated 2,000 toxic ingestions occur annually, with 60-70% mortality. We sought to determine why PQ is such a common agent for suicide attempts in Korea. METHODS: We analyzed 250 cases (143 males, 107 females) of attempted suicide by PQ ingestion from January to December 2007. The procurement of the PQ was divided into two categories: purchased and preexisting. RESULTS: Men were more likely to have purchased PQ than women (66% vs. 22%, p=0.042). Additionally, men were more likely to be unmarried (n=34, 23.9% vs. n=10, 9.3%) or divorced or separated (n=16, 11.3% vs. n=5, 4.6%) than the women (p<0.001). The group who intentionally selected PQ (38.4%) consisted of 96 cases (54 males, 42 females) and the group who did not intentionally select PQ (61.6%) included 154 cases (89 males, 65 females). The incidence of PQ purchase was higher in the intentional selection PQ group (46.9% vs. 18.2%, p<0.01). CONCLUSIONS: Only 38% of patients who attempted suicide with PQ intentionally selected PQ. Thus, greater control of PQ availability is needed, especially in patients at risk.

Comparison between Kidney and Hemoperfusion for Paraquat Elimination

The mortality rate of acute paraquat (PQ) poisoning depends on the PQ concentration in the blood. It has been shown that the kidneys eliminate PQ effectively. However, early renal function deterioration is frequently observed in acute PQ intoxication. This study is designed to compare the efficacy of PQ elimination with hemoperfusion (HP) and kidneys, taking into account the functional deterioration of the kidneys. The amount of renal and HP excretion of PQ were measured during the procedure of HP in patients with acute PQ intoxication. The PQ clearance and the actual amount of PQ elimination by the HP cartridge during the HP procedure were 111+/-11 mL/min (range; 13.2-162.2 mL/min) and 251.4+/-506.3 mg (range; 4.6- 1,655.7) each. While, the renal clearance and actual amount of renal elimination of PQ was 79.8+/-56.0 mL/min (range; 9.7-177.0) and 75.4+/-73.6 mg (range; 4.9- 245.8). As the creatinine clearance decreased, the PQ elimination by HP was as effective as or more effective than the renal elimination. In conclusion, early HP must be provided for life saving treatment in patients with acute PQ intoxication.

Accidental scrotal burns from paraquat while handling a patient.

The main risk of paraquat poisoning is from deliberate ingestion. Serious accidental or occupational poisoning is comparatively rare. We report two patients who had accidental exposure to paraquat, resulting in scrotal burns in both and systemic poisoning in one, while attending to a patient who had ingested paraquat for deliberate self harm.

Intoxicación por Paraquat: descripción de un caso clínico / Paraquat poisoning: a case report

El paraquat es el herbicida más vendido en todo el mundo. Se absorbe por las vías digestiva e inhalatoria. Si llega a los pulmones, produce congestión, edema alveolar con aumento de macrófagos que progresa a fibrosis y edema pulmonar, los cuales se presentan hasta 14 días después de la exposición si el afectado no recibió tratamiento oportuno y correcto. El paraquat se dirige fundamentalmente a los pulmones y genera allí radicales libres oxidantes; por eso, en los casos de intoxicación aguda está totalmente contraindicado usar oxígeno excepto cuando la presión parcial de oxigeno en sangre arterial sea inferior a 50 mmHg. Se presenta un caso clínico de un paciente quien desarrolló un síndrome de distress respiratorio del adulto (SDRA) secundario a ingesta intencional de paraquat. El manejo inicial se realizó con lavado gástrico y tierra de Fuller en solución acuosa al 30%. Posteriormente, el paciente desarrolló compromiso pulmonar y renal, los cuales fueron manejados con pulso de ciclofosfamida a 15 mg/kg/día por 2 días, metilprednisolona 1g/día por 3 días y posteriormente dexametasona 5 mg IV cada 6 horas por 5 días con una evolución clínica satisfactoria.

Paraquat is the best-selling herbicide throughout the world. It is absorbed by the digestive and inhalatory routes. If it reaches the lungs, congestion with swelling is developed, increased alveolar macrophages that progresses to fibrosis and pulmonary edema, which occur until 14 days after exposure if not treated timely and correct. Paraquat is directed primarily to the lungs and therefore generates free radicals oxidants, which is why, in cases of acute poisoning is absolutely forbidden to use oxygen except where arterial blood partial pressure of oxygen in is less than 50 mm Hg. A patient who developed an adult respiratory distress syndrome (ARDS) secondary to deliberate ingestion of paraquat is presented. Initial patient management was performed with gastric lavage and land Fuller in aqueous solution at 30%. Subsequently developing pulmonary and renal failure were handled with cyclophosphamide pulse of 15 mg/kg/day for 2 days, methylprednisolone 1g/día for 3 days, then dexamethasone 5 mg IV every 6 hours for 5 days, with favourable outcome.

A Case of Green Urine after Ingestion of Herbicides

The development of discolored urine may have many possible causes. Here we present the case of a 76-year-old woman who was admitted after ingesting the inorganic herbicides, mefenacet and imazosulfuron. Her urine color changed to green almost immediately. Since the patient had no specific medication or medical history we considered that the most likely cause of the change in urine color was the ingestion of the herbicides. Spectrophotometric analysis of the urine was conducted and a peak was observed in the green area of the wavelength spectrum. These findings show that mefenacet and imazosulfuron should be considered in the differential diagnosis of green discolored urine.

Pesticide poisoning.

Acute poisoning with pesticides is a global public health problem and accounts for as many as 300,000 deaths worldwide every year. The majority of deaths occur due to exposure to organophosphates, organochlorines and aluminium phosphide. Organophosphate compounds inhibit acetylcholinesterase resulting in acute toxicity. Intermediate syndrome can develop in a number of patients and may lead to respiratory paralysis and death. Management consists of proper oxygenation, atropine in escalating doses and pralidoxime in high doses. It is Important to decontaminate the skin while taking precautions to avoid secondary contamination of health personnel. Organochlorine pesticides are toxic to the central nervous system and sensitize the myocardium to catecholamines. Treatment involves supportive care and avoiding exogenous sympathomimetic agents. Ingestion of paraquat causes severe inflammation of the throat, corrosive injury to the gastrointestinal tract, renal tubular necrosis, hepatic necrosis and pulmonary fibrosis. Administration of oxygen should be avoided as it produces more fibrosis. Use of immunosuppressive agents have improved outcome in patients with paraquat poisoning. Rodenticides include thallium, superwarfarins, barium carbonate and phosphides (aluminium and zinc phosphide). Alopecia is an atypical feature of thallium toxicity. Most exposures to superwarfarins are harmless but prolonged bleeding may occur. Barium carbonate Ingestion can cause severe hypokalaemia and respiratory muscle paralysis. Aluminium phosphide is a highly toxic agent with mortality ranging from 37% to 100%. It inhibits mitochondrial cytochrome c oxidase and leads to pulmonary and cardiac toxicity. Treatment is supportive with some studies suggesting a beneficial effect of magnesium sulphate. Pyrethroids and insect repellants (e.g. diethyltoluamide) are relatively harmless but can cause toxic effects to pulmonary and central nervous systems. Ethylene dibromide-a highly toxic, fumigant pesticide-produces oral ulcerations, followed by liver and renal toxicity, and is almost uniformly fatal. Physicians working in remote and rural areas need to be educated about early diagnosis and proper management using supportive care and antidotes, wherever available.

Butachlor-induced acute toxic hepatitis.

Butachlor is a highly effective herbicidal substance widely used by farmers. We report a 60-year-old man with exfoliative dermatitis, jaundice, increase in liver enzymes and eosinophilia one day after accidental dermal exposure to butachlor toxin. The diagnostic workup showed no other cause and liver histology was consistent with substance-induced toxic hepatitis. Within two weeks of conservative therapy, his liver function tests returned to normal.