Paraquat ingestion and COVID-19 infection: deadly double hit

ABSTRACT

Objective: To describe two cases of intentional paraquat ingestion as self-harm in patients with COVID-19 infection. Methods: We retrospectively analysed poisoning cases (accidental and suicidal), admitted to a dedicated COVID-19 care facility at our institute. As a protocol, all patients coming to our emergency department were reverse transcriptase-PCR tested for novel coronavirus disease 2019 (nCOVID-19) before being admitted to a high dependency unit (HDU) intensive care unit (ICU). If they tested positive for COVID they were transferred to a dedicated COVID care facility. These patients were treated according to the protocol developed for poisoned patients. All patients were followed until discharge or death. We describe the details of 2 patients with intentional paraquat ingestion. Results: We received nine patients at our dedicated COVID care facility created at our institute during the pandemic. Of these 9, 2 patients had ingested paraquat and presented with acute respiratory distress syndrome (ARDS). Both patients were in the third decade of life and the economic crisis due to the pandemic was the trigger for the ingestion of paraquat. Both had ingested a significant amount of commercially available paraquat. They had significant acute kidney and liver injury at presentation and required dialysis. Haemoperfusion was not performed as the charcoal filters were not available. The clinical picture and chest X-rays were similar to the findings observed in severe COVID-19 patients. Since patients were hypoxic at presentation, monoclonal antibodies were not indicated and were not administered. Both patients were given dexamethasone (6mg daily), as per the “COVID treatment protocol”. We did not administer pulse doses of methylprednisolone or cyclophosphamide due to concerns over exacerbating COVID infection. One of the patients developed significant oesophageal ulceration leading to massive haematemesis. Both developed spontaneous pneumomediastinum and succumbed to their illness after an average stay of 8 days in the HDU. Conclusion: During the pandemic, paraquat ingestion for selfharm with COVID-19 infection poses a challenge to treating physicians. Since the clinical picture of ARDS, is similar to severe COVID infection, the management with immunosuppressive agents becomes difficult.