A systematic review and meta-analysis of the prevalence and complications of paraphenylenediamine-containing hair dye poisoning in developing countries.

BACKGROUND: Suicide is a public health problem, and the number of paraphenylenediamine (PPD)-containing hair dye poisoning with suicidal intentions is increasing in developing countries. In order to better understand this situation, we aimed to conduct a systematic review and meta-analysis to estimate the prevalence and complications associated with hair dye poisoning in developing countries. METHODS: We conducted a systematic review of epidemiological studies using MeSh terms and text keywords to identify studies from the inception to March 2016 about hair dye poisoning with suicidal intentions in developing countries. A meta-analysis was used to calculate the pooled prevalence proportion of hair dye poisoning and its major complications. Data extraction, data analysis, and risk of bias assessment were performed. RESULTS: Thirty-two studies were included in the systematic review and 29 of these studies containing 5,559 subjects covering six countries were included in the meta-analysis. The pooled prevalence proportion of hair dye poisoning with suicidal intentions was 93.5% (95% confidence interval [CI] = 91.6-95.4) with a mortality rate of 14.5% (95% CI = 11.1-17.9). Of these, 73.8% were female, and 26.2% were male (sex ratio: 2.7:1). The occurrence of angioneurotic edema in hair poisoning patients was 67.1% (95% CI = 56.6-77.6), and tracheostomy intervention was considered in 47.9% (95% CI = 22.7-73.2) patients with respiratory distress. Acute renal failure was noticed in 54.7% (95% CI = 34.5-74.9) of the pooled samples and mortality rates were 14.5% (95% CI = 11.1-17.9). The pooled rate of the population studied from Asia and Africa showed 94.6% (95% CI = 92.5-96.7) and 82.9% (95% CI = 70.6-95.3), respectively, ingested hair dye with suicidal intentions. Further, studies carried out in Africa showed slightly higher mortality of 15.1% (95% CI = 6.56-23.7) than the Asians 14.3% (95% CI = 10.5-18.1). CONCLUSION: This meta-analysis provided clear evidence of the prevalence of hair dye poisoning among individuals with suicidal intentions and had given robust evidence for policy making to curtail emerging PPD-containing hair dye poisoning in developing countries.

Incidence Of Paraphenylene-Diamine Poisoning In Three Districts Headquarter Hospitals Of Pakistan.

BACKGROUND: Paraphenylene-diamine (PPD) poisoning is an emerging problem of developing African and South Asian countries. This study was done with the objective to determine the clinical lab diagnostic accuracy of serum creatinine phosphokinase in cases initially reporting facial oedema followed by renal failure and rhabdomyolysis due to paraphenylene-diamine (PPD) poisoning. METHODS: It was a cross-sectional study in which data was retrospectively collected at District Head Quarter (DHQ) Hospitals. Data was collected over a period of one year from Jan- Dec 2018. Data was collected from the patient file records. Data was analysed on SPSS version 20. RESULTS: In the present study, 658 cases of Kala Pathar poisoning presented and treated. M: F ratio was 5:20. There were 518 (78.8%) females. Majority of the female patients were married 488 (94%). Most common clinical manifestations included marked facial oedema; dysphagia and stridor. Post complications include rhabdomyolysis and acute renal failure which developed after two to five days. Initial lab investigations within 6-8 hours after ingestion showed marked increase in TLC count, ALT and Na+ ions. There was marked elevation of serum CPK (1400±200 U/L) levels after 24 hours. CONCLUSIONS: PPD poisoning is more common in females of younger age group belonging to rural areas. Early diagnosis and prompt supportive treatment within 2-12 hours of ingestion can save many lives. There is no specific antidote available for this poison.

[1,4-diaminobenzene and diphenylamine-induced severe methemoglobinaemia treated by hyperbaric oxygen therapy - Case report]. / Zastosowanie tlenoterapii hiperbarycznej w ciezkiej methemoglobinemii wywolanej zatruciem 1,4-diaminobenzenem i difenyloamina ­ opis przypadku.

Methemoglobin is an oxidized form of hemoglobin that is not capable of carrying oxygen. Exposure to exogenous oxidizing agents can cause severe methemoglobinemia and subsequent hypoxia. This article presents the rare case of a 23-year old patient with methemoglobinemia of 54.2% of total hemoglobin, induced by workplace exposure to 1,4-diaminobenzene and diphenylamine. Following the hyperbaric oxygen therapy the patient was discharged in good general condition and referred to a district hospital for observation. Med Pr 2018;69(3):345-350.

Clinical Profile and Outcome of Paraphenylene Diamine Poisoning.

OBJECTIVE: To determine the clinical presentation, complications, and outcome of paraphenylene diamine (PPD) poisoning in patients presenting to Nishtar Hospital, Multan. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Medical Unit II and III, Nishtar Hospital, Multan, from April 2015 to September 2016. METHODOLOGY: All adult patients admitted with history of paraphenylene diamine ingestion were evaluated for clinical features, complications, and outcomes on a pre-designed proforma. RESULTS: Out of 122 patients, 95 were females (77.9%) and 101/122 patients had ingested the poison with an intention of suicide or self harm (82.8%). The mean age of presentation was 23.21 ±8.2 years. Cervico-facial edema was the chief presenting complaint, seen in 116/122 (95%) of patients, with median of 2 (interquartile range=3) for time of onset after ingestion of poison. Tracheostomy was needed in 95/116 (82%) patients with cervico-facial edema. Other common complaints were dark urine in 95/122 (77.9%) and pain in limbs in 98/122 (80.3%) patients. Rhabdomyolysis was evident in 91/122 (74.5%) patients at admission. Acute kidney injury developed in 37/122 (30.3%) patients. Among these, 16 (43.2%) patients required haemodialysis. Myocarditis was diagnosed in 33/122 (27%) patients. The median for hospital stay was 9.50 days (interquartile range=6.25). The mortality was 34/122 (28%). Ventricular arrhythmias were the commonest cause of death in 25/34 (73.5%), followed by renal failure in 5/34 (14.7%), asphyxia in 2/34 (5.88%), and aspiration pneumonia in 2/34 (5.88%) patients. CONCLUSION: Paraphenylene diamine is an emerging domestic poison in Pakistan, with a high morbidity and mortality.

Epidemic of Kala Pathar(Paraphenylene Diamine) Poisoning: an Emerging Threat in Southern Punjab.

OBJECTIVE: To assess cases of the spectrum of Kala Patharpoisoning in all age groups. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Combined Military Hospital (CMH) Bahawalpur and Bahawal Victoria Hospital (BVH), Bahawalpur, from January 2016 to April 2017. METHODOLOGY: All the cases of Kala Pathar(Paraphenylene diamine (PPD)) poisoning, admitted and treated at the study places during said period were included in the study. The assessed variable included gender, age, education status, socioeconomic status, reason of poisoning and mortality. Chi-square was applied for qualitative variables with p-value less than 0.05 was considered significant. RESULTS: A total of 1,258 cases of PPD poisoning were included in the study; 814 (64.7%) females and 444 (35.3%) males. Their age ranged from 5 - 63 years, with median age 21 (IQR 4). Sixty-six (5.2%) were children and the rest 1,192 (94.8%) were adults. In adults 1,125 (94.37%) cases of PPD poisoning were suicidal and 62 (5.20%) accidental cases; only 5 (0.42%)adults were intentionally poisoned. On the other hand, only one child took it with suicidal intent, 54 (81.81%) ingested it accidentally and 11 (16.66%) children were given poison deliberately with the intent to murder. The overall mortality was 24.08% - 22.81% in adults, and 46.96% in children. CONCLUSION: Kala Pathar(PPD) is a lethal substance when ingested. PPD poisoning is not limited to adults; many cases of pediatric poisoning are also being reported in Southern Punjab. Mortality due to Kala Patharis high. Tracheostomy should be done immediately in all such cases; and high intensive multidisciplinary approach is required.

Development of Rapid and Economical Colorimetric Screening Method for p-Phenylenediamine in Variety of Biological Matrices and its Application to Eleven Fatal Cases of p-Phenylenediamine Poisoning.

A rapid colorimetric method for detection of p-phenylenediamine (PPD) in various biological samples is developed. The o-cresol test for acetaminophen detection has been modified to detect PPD in blood, urine, gastric contents, and liver. After precipitating protein with trichloroacetic acid solution (2 mL, 10% w/v), biological specimens were required to convert PPD metabolites to PPD by acid hydrolysis. Finally, o-cresol solution (1 mL, 1% w/v), hydrogen peroxide (200 µL, 3%v/v), and concentrated ammonium hydroxide (0.5 mL) were added in the biological samples. The presence of PPD was indicated by formation of violet color which was turned to bluish green color within 10-15 min. The limit of detection was found to be 2 mg/L in blood, urine, and gastric contents and 2 mg/Kg in liver. This method is also free from any potential interference by p-aminophenol, acetaminophen, and other amine drugs under test conditions. This method was successfully employed to thirteen fatal cases of PPD poisoning.

Attempted suicide by ingestion of hair dye containing p-phenylenediamine: a case report.

Para-phenylenediamine is widely used as a chemical in hair dyes and in combination with henna. This dye is used to paint the body for decorative reasons, to speed the processing time of henna and to intensify the results. Para-phenylenediamine is widely used in the Middle East, North Africa and India. Several reports have been published of the fatal ingestion of hair dye containing para-phenylenediamine. Here, we describe the case of a 14-year-old girl who ingested the compound but whose prompt treatment prevented her death. Ingestion of para-phenylenediamine produces a typical triad of angioneurotic oedema, rhabdomyolysis and acute tubular necrosis. Awareness of signs of these associated conditions in our patient, together with a comprehensive history, facilitated appropriate treatment to be instituted. We document the steps we took to enable her complete physical recovery.

Fatal paraphenylenediamine poisoning due to black henna.

Paraphenylenediamine (PPD) is an oxidative chemical allergen that can cause hypersensitivity reactions. PPD intoxication could cause severe systemic adverse effects like acute renal failure, rhabdomyolysis and multiple organ failure. In this text we present a 9 year-old female patient who developed multiple organ failure and cardiac arrhythmia as a result of extensive application of PPD added to henna to the skin. Plasma exchange (PE) and continuous venovenous hemodiafiltration (CVVHDF) were started. The patient died on day 4 after developing ventricular fibrillation that was resistant to antiarrhythmic treatment and defibrillation. In summary, the most commonly seen clinical signs in PPD intoxication are cervical, upper respiratory and muscle edema, intravascular hemolysis, rhabdomyolysis, severe cardiac arrhythmias and acute renal failure. These symptoms would be suggestive of PPD poisoning.

Acute kidney injury: A rare cause.

We present a young lady who consumed hair dye, which contained paraphenylene diamine (PPD), as a means of deliberate self-harm. This resulted in severe angio-neurotic edema for which she had to be ventilated, and thereafter developed rhabdomyolysis leading to acute kidney injury (AKI). The unusual aspect was that the patient continued to have flaccid quadriparesis and inability to regain kidney function. Renal biopsy performed 10 weeks after the dye consumption revealed severe acute tubular necrosis with myoglobin pigment casts. This suggests that PPD has a long-term effect leading to ongoing myoglobinuria, causing flaccid paralysis to persist and preventing the recovery of AKI. In such instances, timely treatment to prevent AKI in the form alkalinization of urine should be initiated promptly. Secondly, because PPD is a nondialyzable toxin, and its long-term effect necessitates its speedy removal, hemoperfusion might be helpful and is worth considering.

Paraphenylenediamine Containing Hair Dye: An Emerging Household Poisoning.

Paraphenylenediamine poisoning is among one of the emerging causes of poisoning in Asian countries, because it is a constituent of hair dye formulations and is easily available in market at low cost. Hair dyes are rampantly used in Asian households compared with the western world. Locally, hair dye constituents may have allergic adverse effects, and acute systemic poisoning presents with characteristic angioedema, upper airway obstruction, rhabdomyolysis, methemoglobinemia, myoglobinuria, and acute renal failure. This study reports about the death of a 24-year-old Indian housewife who committed suicide by taking hair dye emulsion. She had an argument with her husband, and because of fit of rage, took a bowlful (80 mL) of hair dye emulsion kept prepared for the use by husband. She developed angioedema, cervical swelling, and rhabdomyolysis and died of acute renal failure within 24 hours. Toxicological analysis of viscera and blood revealed varying levels of paraphenylenediamine. Histopathological samples of kidney showed features of acute tubular necrosis and myoglobin casts in renal tubules. The aim of the study is to create awareness about the adverse effects of the hair dye, its poisoning outcome, and possible preventive measures.

From diamonds to black stone; myth to reality: Acute kidney injury with paraphenylene diamine poisoning.

AIM: We report here, a case series of patients with acute kidney injury (AKI) after ingestion of paraphenylene diamine (PPD) a derivative of analine. It is used as a colouring agent to dye hair, fur and plastic and in photographic films. METHODS: Subjects for the study reported here comprised a cohort of 100 patients coming to this institution with AKI following PPD poisoning. AKI was defined according to RIFLE criteria and PPD poisoning on the basis of history and presenting features. All patients had normal sized kidneys on ultrasonography and no previous co- morbidity. RESULTS: One hundred patients with AKI after PPD exposure were brought to this institute between May 2010 and February 2015. Among these, 56 were females, with mean age of 23.11 ± 7.94 years. Cause of AKI was toxic rhabdomyolysis as indicated by marked rise in muscle enzymes with mean lactate dehydrogenase and creatinine phosphokinase levels of 6665.22 ± 6272.04 and 194 486.66 ± 301 905.80, respectively. Hepatotoxicity with raised aspartate aminotransferase and alanine aminotransferase was a main feature of the studied population. Renal replacement was required in 97% of patients. Complete renal recovery was observed in 77 patients, while 16 died during the acute phase of illness. Respiratory failure and recurrent hyperkalaemia were the main causes of mortality. CONCLUSION: Easy availability and low cost of PPD has lead to a remarkable increase in the use of this substance, especially for suicidal purposes. Awareness of its effects among health professionals, as well as at a societal and government level, is needed at this time.

Paraphenylene diamine hair dye poisoning: an uncommon cause of rhabdomyolysis.

Paraphenylene daimine (PPD) is a kind of aromatic amine that is widely used in several industrial products. Women also use PPD added to henna (Lawasonia alba) as a hair dye. Though rare in Western countries, PPD poisoning is quite common in East Africa, India and Middle Eastern countries because it is a traditional product at these countries. Different pathologies were described as caused by PPD ingestion including angioedema of head and neck, rhabdomyolysis, and acute renal failure. The authors report a case of systemic poisoning with PPD that lead to angioedema resulting in tracheostomy and rhabdomyolysis.

Filicide and suicide in a family by paraphenylene diamine poisoning: a mother who committed suicide and poisoned her four children of which one died.

Paraphenylene diamine (PPD) hair dye poisoning is a common health problem in the Middle East and Indian subcontinent. It is the most common cause of suicide intent especially among females. We hereby present a 27-year-old female who presented with a clinical feature of PPD poisoning due to a suicidal attempt, and she died soon after arrival. She had survived a previous suicide attempt with PPD 4 years before. This time she also intentionally tried to kill her four children using PPD. One child died, one recovered after dialysis for acute kidney injury and the other two survived without any further intervention. This case illustrates that PPD poisoning may be used in filicide and suicide intent and that all patients who committed suicide should be reviewed and assessed by clinical psychiatrist.

Clinical presentation, treatment and outcome of paraphenylene-diamine induced acute kidney injury following hair dye poisoning: a cohort study.

INTRODUCTION: In Africa and Asia hair dye is applied together with henna to decorate the hands and feet. Paraphenylene-diamine (PPD), a highly toxic constituent of hair dye can lead to acute kidney injury (AKI). METHODS: A cohort study was conducted during the period from April 2012 to March 2013 in Khartoum Teaching Hospital, Sudan. It targeted adults presenting acutely with an evident history and clinical features of hair dye poisoning, together with AKI as per the RIFLE criteria. Analysis of data was done using SPSS. RESULTS: 30 adults were included, their mean age was 25.6 ± 4.2 years, 93.3% were females. Exposure to PPD was suicidal in 86.7%. The mean duration to onset of renal symptoms was 34.8 ± 7.6 hours, maximum median serum creatinine was 8.6 ± 2.3 mg/dl, 86.7% had loss of kidney function as per the RIFLE classification and required dialysis. Initial renal recovery was seen after a mean duration of 9.8 ± 2.2 days. One patient died, 3.3%; all others, 96.7%, recovered normal kidney function. The amount of ingested PPD correlated significantly to the severity of symptoms, number of dialysis sessions required and time for renal recovery with P values < 0.05. CONCLUSION: Hair dye poisoning was associated with prolonged hospital stay, requirement of dialysis and increased morbidity. The severity of symptoms directly correlates to the dose of PPD ingested, with the kidney damage being reversible in almost all survivors.

Paraphenylenediamine poisoning.

Hair dye containing paraphenylenediamine (PPD) is widely used in India because of its free availability and low cost. PPD produces local as well as systemic toxic effects when applied topically and/or ingested. It is highly toxic when taken by mouth and the outcome depends mainly on the dose taken. Important clinical manifestations are angioedema leading to dysphasia and respiratory distress, rhabdomyolysis, intravascular hemolysis, acute renal failure and hepatic necrosis. Myocarditis or fatal arrhythmia may also occur in PPD poisoning. Mainstay of management is early recognition and supportive measures as there is no specific antidote. We hereby report a young female who presented to us with features of angioedema, cardiac manifestation and hepatic dysfunction after ingesting PPD, which was treated successfully. In the absence of laboratory facilities, clinical features like angioedema and chocolate brown-colored urine could be suggestive of PPD poisoning.