Exploring the Protective Role of G6PD Deficiency in Aluminum Phosphide Poisoning: A Case Report and Review of the Literature.

Aluminum phosphide (ALP) poisoning poses a significant public health concern worldwide, with a high mortality rate and no established definitive treatment. This case report highlights a 30-year-old male with G6PD deficiency who ingested ALP tablets, presenting with jaundice and anemia. Despite the severity of ALP poisoning, the concurrent G6PD deficiency appeared to confer a protective effect, potentially mitigating complications. Laboratory investigations revealed characteristic findings, including unconjugated hyperbilirubinemia and normocytic hypochromic anemia. Treatment involved supportive measures and transfusion, leading to clinical improvement and discharge. The discussion focuses on the pathophysiology of G6PD deficiency and its protective role against ALP poisoning, supported by a literature review and experimental evidence. Moreover, potential therapeutic interventions targeting oxidative stress are discussed. This case underscores the importance of considering G6PD deficiency in ALP poisoning management and highlights avenues for further research into protective mechanisms and treatment strategies.

In vivo treatment of zinc phosphide poisoning by administration of mesoporous silica nanoparticles as an effective antidote agent.

Mesoporous silica nanoparticles (MSNs) are highly advanced engineered particles with increased surface area and extreme adsorption capacity for various molecules. Herein, two types of MSNs were synthesized and applied as adsorbents for phosphine gas. One was without functional groups (MSN), and the other was post-modified with boric acid (MSN-BA). The structures of MSN and boric acid-modified MSN with high surface areas of about 1025 and 650 m2/g, respectively, were defined. MSN was found to have particles with sizes around 30 nm by transmission electron microscopy (TEM). In the present study, MSNs were used as an antidote to phosphorus poisoning, and zinc phosphide (phosphorus) powder was used as the toxic and lethal agent. In vivo analysis was carried out on rats to demonstrate the ability of MSNs to chemisorb phosphine gas. In the survival percentage assessment, Phos-poisoned animals were kept alive after treatment with MSNs, and the MSN-BA-treated group (dose of 5 mg/kg) was shown to have a 60 % survival rate. Blood serum analysis showed that MSNs have a high potential to alleviate organ blood damage, and serum biomarkers dropped sharply while phosphine-poisoned animals were treated with MSN-BA.

Evaluation of confirmatory data following the Article 12 MRL review and modification of the existing maximum residue levels for aluminium phosphide and magnesium phosphide.

The applicant Detia Freyberg GmbH submitted to the competent national authority in Germany two requests to evaluate the confirmatory data that were identified for tree nuts, oilseeds, cereals and commodities of animal origin in the framework of the maximum residue level (MRL) review under Article 12 of Regulation (EC) No 396/2005 as not available and two requests in accordance with Article 6 of Regulation (EC) No 396/2005 to increase the existing MRL for the active substance aluminium phosphide in peanuts, barley, oat, rye, rice and wheat, roots of herbal infusions, cocoa beans and seed spices and for the active substance magnesium phosphide in oilseeds (except peanuts) and pistachios. The four applications were combined by EFSA under the current assessment. To address the data gaps, validation data for the method of analysis for enforcement of phosphide in high-oil content commodities and new residue trials were submitted. The data gaps on additional residue trials supporting authorisations on oilseeds and cereal grains, on clarifications regarding the discrepancies observed in the residue trial results for pistachios, and on data confirming the negligible occurrence of phosphane and its oxidation products in livestock products were considered addressed. The data gap on independent laboratory validation (ILV) and a confirmatory method for monitoring of phosphide in high-oil content commodities was considered not fully addressed. The information provided justified a lowering of the current tentative MRLs for the whole group of cereals (except rice and 'others'), an increase of the current tentative MRLs for pistachios, the whole group of oilseeds, rice and 'other' cereals, herbal infusions from roots, cocoa beans and seed spices, and a revision of the risk assessment performed for phosphane and its phosphide salts. Based on the risk assessment results, EFSA concluded that the short-term and long-term intake of residues resulting from the use of AlP and Mg3P2 according to the reported agricultural practices is unlikely to present a risk to consumer health. Further risk management considerations are required.

Study of pattern and outcome of acute poisoning cases at tertiary care hospital in North India.

Introduction: The WHO 2021 data estimate that 2 million lives and 53 million disability-adjusted life-years were lost in 2019 due to exposures to selected chemicals. It is important to know the pattern and outcome of acute poisoning cases for proper planning, prevention and management. Knowing the pattern will also help in designing training modules for primary care physicians to make them aware about newer poisons and their management. Awareness regarding newer poisons consumed is necessary for early identification, initial management and timely referral to higher centres by primary care physicians. This study was performed to see the pattern and outcome of acute poisoning cases in North Indian population and various factors related to outcome. Materials and Methods: This study was conducted in department of medicine of a teaching institute in North India after approval by the Institutional Review Board. Patients admitted in the department during the study and fulfilling the inclusion criteria were enrolled in the study after obtaining consent. Results: A total of 417 patients with poisoning were recruited in the study. Out of 417 patients, majority were males (59.5%). Maximum number of patients were in the age group of 21-30 years (33.8%), and rural population (79.9%) was found to be more affected. Most of the patients were students and private employees. Most common types of poisoning were snakebite (n = 109, 26.1%), organophosphate (n = 49, 11.8%) and aluminium phosphide (n = 39, 9.3%). Out of 417 patients, 349 (83.69%) improved, while 68 (16.3%) expired. Requirement of ventilatory support was most commonly associated with aluminium phosphide poisoning (30.12%) followed by organophosphate poisoning (24.1%). Conclusion: Poisoning was more common in young males and more prevalent in rural population. Pesticides and snakebite were major causes of poisoning. Among suicidal cases, family conflict (problem/altercation with family members/marital discord) was main reason for the consumption of poison. There is need for creation of poison information centre along with separate toxicological units in tertiary care hospitals.

Case report: Combination of veno-arterial extracorporeal membrane oxygenation and intra-aortic balloon pump in a young male patient with refractory cardiogenic shock due to aluminum phosphide poisoning.

Background: Acute toxic myocardial damage may be accompanied by the development of cardiogenic shock (CS), the mortality from which is still unacceptably high. Since there is no specific antidote for many types of toxins, treatment of such patients includes various measures of hemodynamic and respiratory support. The paper presents a case of refractory CS due to possible aluminum phosphide (AP) poisoning. Case summary: A 20-year-old man was admitted to the emergency department 4 days after home inhalation of AP due to complaints of nausea, vomiting, abdominal and chest pain. Over the next few hours, he rapidly developed CS, which was refractory to conservative treatment. Therefore, veno-arterial membrane oxygenation (VA-ECMO) was performed, during which hemodynamics stabilized, but later there were signs of left ventricular overload. To unload the left ventricle (LV), an intra-aortic balloon pump (IABP) was implanted, which significantly improved the patient's condition. After 6 days the patient was decannulated, and a few more days later IABP was discontinued. Subsequently, the patient was treated for sepsis due to bilateral pneumonia and acute respiratory distress syndrome and optimal medical therapy for heart failure was prescribed. The patient was discharged after 34th day of hospitalization.

[Clinical characteristics and follow-up analysis of 12 patients of acute phosphine poisoning].

Objective: To investigate the clinical characteristics of patients with acute phosphine poisoning, and to follow up and evaluate the prognosis of patients. Methods: In May 2022, 12 patients with phosphine poisoning by respiratory inhalation in Beijing Chao-Yang Hospital of Capital Medical University were analyzed. The patients were treated with symptomatic support therapy. Three months later, patients were re-evaluated the symptoms of poisoning, pulmonary function and magnetic resonance imaging (MRI) of the brain to understand the prognosis of the phosphine poisoning. Results: The main symptoms of 12 patients were respiratory and central nervous system symptoms with hypoxia. The symptoms of poisoning improved after treatment. Follow-up found that the patients had different degrees of residual symptoms. Pulmonary function showed increased airway resistance. Airway challenge test was positive in some patients. MRI of the head of some patients showed small ischemic focus in bilateral frontal lobes. Conclusion: Acute phosphine poisoning may cause persistent damage to the respiratory system and central system, and residual symptoms after 3 months.

Protective Effect of Curcumin and Nanocurcumin on Sperm Parameters and Oxidant-antioxidants System of Rat Testis in Aluminium Phosphide Subacute Poisoning.

OBJECTIVE: Aluminum phosphide (AlP) as an effective pesticide may contribute to oxidative stress and adversely influence sperm parameters. This study aimed to investigate the protective role of curcumin and nanocurcumin on oxidative damage in the testis of rats with AlP toxicity. METHODS: A total of 42 adult male Wistar rats were equally randomized into the following study groups (n = 7): Control, Control+Curcumin, Control+Nanocurcumin, AlP, AlP+Curcumin, and AlP+Nanocurcumin. The testis tissue was used to investigate the levels of testicular malondialdehyde (MDA), total oxidant status (TOS), total antioxidant capacity (TAC), and reduced glutathione (GSH) as well as the Catalase (CAT) and superoxide dismutase (SOD) enzyme activity. Epididymal sperm was used to perform sperm analysis. RESULTS: AlP administration led to a significant increase in MDA, and TOS levels and also markedly decreased the SOD activity and the levels of TAC and GSH in testis tissue (p <0.001). Moreover, the motility and viability of sperms were significantly reduced (p <0.001). Curcumin and Nanocurcumin co-administration with AlP remarkably decreased the MDA and TOS level (p <0.001) and significantly increased the GSH and TAC levels as well as the activity of SOD in AlP intoxicated groups (p<0.001). Our findings demonstrated that Nanocurcumin administration has significantly enhanced the sperm quality in AlP intoxicated rats as compared to the control group (p <0.001). CONCLUSION: According to the results of this study, Curcumin as a potential antioxidant could be an effective attenuative agent against AlP-induced oxidative damage in testis, especially when it is used in encapsulated form, nanocurcumin.

Blocking vicious cycle of cardiac dysfunction by external cardiopulmonary resuscitation is the key to rescue acute aluminium phosphide poisoning.

Aluminium phosphide (ALP) and aluminium zinc phosphide (ZnP), the two main ingredients of fumigation drugs, are commonly used to kill insects or rodents in grain. When exposed to water, highly toxic phosphine gas is released and absorbed through the respiratory or digestive tract. Phosphine gas could non-selectively block cytochrome oxidase, inhibit electron transfer and suppress oxidative phosphorylation, leading to cellular hypoxia and organ dysfunction. The characteristic clinical manifestations are refractory shock and metabolic acidosis with high mortality. However, patients with ALP poisoning have a chance to be cured. Here, we report a case of oral ALP poisoning that was successfully treated by extracorporeal membrane oxygenation (ECMO) combined with continuous renal replacement therapy (CRRT) during frequent ventricular fibrillation and cardiac dysfunction.

Aluminum Phosphide Poisoning in the North of Iran: A Register-based Research.

BACKGROUND: Aluminum phosphide (ALP) poisoning is considered one of the health care issues in Iran, which is associated with the mortality outcome of patients. INTRODUCTION: According to the ALP poisoning that commonly results in death, we aimed to evaluate the prevalence of ALP pill poisoning by employing register-based research. METHODS: In this descriptive cross-sectional study, all selected patients diagnosed and confirmed with ALP poisoning by a specialist and referred to the poisoning ward from the beginning of April 2016 to the end of October 2017 were enrolled, and data were registered in the Disease Registration System by a technical expert for daily follow-up during hospitalization. RESULTS: Approximately 12.4% of patients had neurological problems, with the majority having paresis (68.3%). Self-poisoning with the purpose of suicide was documented for 96.2% of cases, with the most common cause being family problems (54.1%). In 97.3% of cases, the method of contact with the toxic substance was oral. Hypotension, cardiac, and respiratory complications were observed in 25.2%, 30.8%, and 25% of the patients, respectively. The most gastrointestinal symptoms were nausea and vomiting (86.7%). CONCLUSION: The results indicate that the rate of ALP pill poisoning is relatively high. Suicide is the most important cause of ALP poisoning, which is more common in men under 40 years of age.

Extracorporeal life support in cardiotoxicant poisoning-A narrative review.

Extracorporeal life support (ECLS) improves circulation in life-threatening cardiac dysfunction or arrest patients. Its benefits in drug-induced cardiovascular complications are debated. Indications and outcomes are poorly established. We performed a narrative review discussing ECLS indications, timing and results in cardiotoxicant-poisoned patients. The review was focused on antiarrhythmic drugs and aluminium phosphide. Literature analysis was limited to the past 30 years in adults. Most reports were single cases and retrospective except one prospective case series of limited size, two of them controlled. ECLS indications and timing were at the discretion of physicians in charge but mostly included persistent cardiovascular failure despite elevated doses of inotropic/vasopressor support associated with elevated blood lactate concentrations (usually, >5 mmol/L) and collapsed left ventricular ejection fraction (LVEF; usually, ≤40%). Survival improved using ECLS versus standard care in one study. Survival was ~80% if ECLS was implemented in refractory cardiovascular failure and 25%-66% if implemented in cardiac arrest. In two controlled studies, survival of ECLS-treated aluminium phosphide-poisoned patients was improved versus standard care, if implemented in the presence of systolic blood pressure ≤80 mmHg despite inotropic/vasopressor treatment, arterial pH ≤ 7.0 and LVEF ≤ 40%. Despite low-to-moderate level of evidence, ECLS seems effective to improve survival in selected cardiotoxicant-poisoned patients. Selection criteria need clarification.

Clinical characteristics and follow-up analysis of 12 patients of acute phosphine poisoning / 中华劳动卫生职业病杂志

Objective: To investigate the clinical characteristics of patients with acute phosphine poisoning, and to follow up and evaluate the prognosis of patients. Methods: In May 2022, 12 patients with phosphine poisoning by respiratory inhalation in Beijing Chao-Yang Hospital of Capital Medical University were analyzed. The patients were treated with symptomatic support therapy. Three months later, patients were re-evaluated the symptoms of poisoning, pulmonary function and magnetic resonance imaging (MRI) of the brain to understand the prognosis of the phosphine poisoning. Results: The main symptoms of 12 patients were respiratory and central nervous system symptoms with hypoxia. The symptoms of poisoning improved after treatment. Follow-up found that the patients had different degrees of residual symptoms. Pulmonary function showed increased airway resistance. Airway challenge test was positive in some patients. MRI of the head of some patients showed small ischemic focus in bilateral frontal lobes. Conclusion: Acute phosphine poisoning may cause persistent damage to the respiratory system and central system, and residual symptoms after 3 months.

Analysis of the Distribution of Total Phosphine and the Characteristics of Phosphine Poisoning in 29 Victims.

OBJECTIVES: To study the distribution of total phosphine in phosphine poisoning victims and summarize the characteristics of phosphine poisoning cases. METHODS: The phosphine and its metabolites in the biological samples of 29 victims in 16 phosphine poisoning cases were qualified and quantified by headspace gas chromatography-mass spectrometry. RESULTS: Five victims among 29 were poisoned by ingestion of aluminium phosphide and 24 by inhalation of phosphine gas. Phosphine metabolites were detected in the biological samples of 23 victims, and the concentrations of total phosphine in blood ranged 0.5-34.0 µg/mL. The total concentration of phosphine in liver tissue was up to 71.0 µg/g. Phosphine was not detected in the blood of the other six survived victims, which may be related to the small amount of phosphine exposure and the delay in blood sampling. CONCLUSIONS: The total concentration of phosphine in blood and tissues caused by aluminum phosphine ingestion is higher than that caused by phosphine gas inhalation. The death cases of phosphine inhalation are characterized by long exposure time, repeated exposures and age susceptibility.

Acute aluminium phosphide poisoning: A case report of rare survival with cardiac, metabolic, hepatic, and renal complications.

Poisoning is a very common way to commit suicide. It is more common in low- and middle-income countries. Aluminium phosphide is a very commonly available pesticide in such countries including India. Aluminium phosphide is a very toxic compound. Ingestion of aluminium phosphide can cause severe toxicity to various cells, and mortality is very high. We are presenting a case of rare survival of acute aluminium phosphide poisoning, who presented with signs and symptoms of severe toxicity including metabolic acidosis and shock. During hospitalisation, he developed ventricular tachycardia, acute kidney, and liver failure.

Unexpected survival after deliberate phosphine gas poisoning: An Australian experience of extracorporeal membrane oxygenation rescue in this setting.

Phosphine poisoning is responsible for hundreds of thousands of deaths per year in countries where access to this pesticide is unrestricted. Metal phosphides release phosphine gas on contact with moisture, and ingestion of these tablets most often results in death despite intensive support. A 36-year-old woman presented to a regional hospital after ingesting multiple aluminium phosphide pesticide tablets and rapidly developed severe cardiogenic shock. In this case, serendipitous access to an untested Extracorporeal Membrane Oxygenation (ECMO) service of a regional hospital effected a successful rescue and prevented the predicted death. We discuss the toxicology, management and the evidence for and against using ECMO in this acute poisoning.

Analysis of the Distribution of Total Phosphine and the Characteristics of Phosphine Poisoning in 29 Victims / 法医学杂志

OBJECTIVES@#To study the distribution of total phosphine in phosphine poisoning victims and summarize the characteristics of phosphine poisoning cases.@*METHODS@#The phosphine and its metabolites in the biological samples of 29 victims in 16 phosphine poisoning cases were qualified and quantified by headspace gas chromatography-mass spectrometry.@*RESULTS@#Five victims among 29 were poisoned by ingestion of aluminium phosphide and 24 by inhalation of phosphine gas. Phosphine metabolites were detected in the biological samples of 23 victims, and the concentrations of total phosphine in blood ranged 0.5-34.0 μg/mL. The total concentration of phosphine in liver tissue was up to 71.0 μg/g. Phosphine was not detected in the blood of the other six survived victims, which may be related to the small amount of phosphine exposure and the delay in blood sampling.@*CONCLUSIONS@#The total concentration of phosphine in blood and tissues caused by aluminum phosphine ingestion is higher than that caused by phosphine gas inhalation. The death cases of phosphine inhalation are characterized by long exposure time, repeated exposures and age susceptibility.

Chest Pain and Hemodynamic Instability in a Young Woman.

We report the case of an 18-year-old female admitted to the hospital for severe hemodynamic instability and fatal outcome within 6 hours following admission. Significant electrocardiographic modifications were noted and are presented with diagnostic options. (Level of Difficulty: Intermediate.).

Importance of pesticides for lethal poisoning in India during 1999 to 2018: a systematic review.

BACKGROUND: Poisoning is a major problem in India. However, there is little systematic information on the key poisons responsible for most deaths by geographical area and over time. We aimed to review the literature to identify the poison classes causing the greatest number of deaths in India over the last 20 years. METHODS: We performed a systematic literature review in Medline, Embase and Google Scholar (1999-2018), and Indian online medical journals, to find papers that reported deaths from all forms of poisoning in India, with last search 20 April 2020. We included epidemiological studies, observational studies, randomised trials, interventional studies, and case series published from 1999 to 2018 that showed the number of deaths and autopsy studies indicating the specific poisons or poison classes. Studies providing the case fatality for specific poisons or classes, which enabled calculation of the number of deaths, were also included. We excluded deaths due to animal bites and stings, ethanol or methanol poisoning, and gas inhalation as well as papers reporting a single death (case study of single patient). We grouped the papers into 5-year intervals and identified the two most common poison classes in each paper. We used descriptive statistics to summarise the findings over time based on the causative poison and the location of the study. RESULTS: We identified 186 papers reporting 16,659 poisoning deaths between 1999 and 2018. The number of publications per 5-year interval showed no clear trend over the period (48, 38, 67, and 36 for consecutive periods). Half of the deaths (n = 8338, 50.0%) were reported during the first 5 years of the study (1999-2003), the number of deaths declining thereafter (to n = 1714 in 2014-2018). Deaths due to pesticide poisoning (94.5%) were dominant across the study period compared to other classes of poison [hair dye paraphenylenediamine poisoning (2.6%), medicine overdose (1.4%) or plant poisoning (1.0%)]. Among the pesticides, aluminium phosphide was the most important lethal poison during the first 10 years before declining markedly; organophosphorus insecticides were important throughout the period, becoming dominant in the last decade as aluminium phosphide cases declined. Unfortunately, few papers identified the specific organophosphorus insecticide responsible for deaths. CONCLUSION: Use of the published literature to better understand the epidemiology of lethal poisoning in India has clear limitations, including secular variation in publishing practices and interest in poisoning. Unfortunately, there are no long-term detailed, combination hospital and community studies from India to provide this information. In their absence, our review indicates that pesticides are the most important poison in India, with organophosphorus insecticides replacing aluminium phosphide as the key lethal poison after government regulatory changes in 2001 reduced the latter's lethality. Plant and hair dye poisoning and medicines overdose caused few deaths. Aluminium phosphide deaths mostly occurred in northern Indian states, whereas deaths from organophosphorus insecticide poisoning occurred throughout India. Paraquat poisoning has become a clinical problem in the last 10 years. Lethal pesticide poisoning remains alarmingly common, emphasising the need for additional regulatory interventions to curtail the burden of pesticide poisoning deaths in India. More detailed reporting about the specific pesticide involved in lethal poisoning will be helpful to guide regulatory decisions.

COVID-19: Asymptomatic Carrier: An Autopsy Case Report.

The severe acute respiratory syndrome (SARS)-coronavirus- 2 (CoV-2) outbreak in Wuhan, China has now spread to many countries across the world including the India with an increasing death toll. On March 11, 2020, the new clinical condition COVID-19 (Corona-Virus-Disease-19) was declared a pandemic by the World Health Organization (WHO). Owing to its infectivity, high risk of transmission, and limited handling of dead bodies, published data on the course of diseases has been limited. Most patients with COVID-19 have a mild disease course and remain as asymptomatic carrier; however, few patients of older age and with co-morbidites develop severe disease leading on to fatality. If due to COVID-19 infection death occurs, an autopsy is unlikely. However in unnatural deaths the legal duty impels the proper performance of a full autopsy, to find out the cause and manner of death. The detailed autopsy examination along with histo-pathological findings in the organs of asymptomatic patient of COVID-19 and its comparison with microscopic findings in Aluminium Phosphide poisoning are discussed below. This will summarizes the research status for COVID-19 deaths, which will be important for evaluation of cause of death, prevention, control and clinical strategies of COVID-19.

Aluminium Phosphide Poisoning: Early Suspicion of Cardiotoxicity Is Necessary for Improved Outcomes.

Poisoning is one of the more conventional modes of suicide in some parts of India. Aluminium phosphide (ALP) is a chemical used for this purpose and manifests severe cardiovascular complications, such as hypotension, shock, various arrhythmias, congestive heart failure with toxic myocarditis, and in rare cases, ST-segment elevation myocardial infarction or other electrocardiogram changes. Upon contact with moisture, ALP yields phosphine gas, a toxic systemic poison found in pesticides that can lead to cardiovascular-related mortality. We present a case of ALP poisoning in a 60-year-old woman who was asymptomatic for the first 48 hours. She gradually developed cardiac complications in the form of anteroseptal acute myocardial infarction (AMI). As AMI is very rare among the various cardiac complications, an early vigilance is necessary to prevent further complications in ALP poisoning.