An unusual case of acute poisoning with paraformaldehyde, benzoic acid, and kaolin.

Abstract

Sir, We present a rare case of acute poisoning with paraformaldehyde, benzoic acid, and kaolin in a 26-year-old married female who presented to the emergency department with alleged history of consuming some insecticide substance. On examination, her Glasgow Coma Scale (GCS) was E3 V4 M6, pulse rate of 78/min, and blood pressure of 110/70 with urinary and fecal incontinence. Systemic examination revealed basal crepitus in the chest. Gastric lavage was given and the patient was decontaminated. However, after 1 h of admission, patient's condition worsened and her GCS deteriorated to E1 V1 M4 and arterial blood gas (ABG) revealed metabolic acidosis. Patient was intubated and shifted to the Intensive Care Unit. Chest X-ray revealed bilateral hazy infiltrates. Serial ABG of the patient showed metabolic acidosis. Serum lactate levels were within normal range. Serum electrolytes revealed hypernatremia (170 meq/l) which was gradually corrected to 147 over next 72 h and hypokalemia (2.9 meq/l) for which replacement was given to the patient. During initial 12 h, the patient developed oliguria which responded well to fluid challenge. Liver function test revealed elevation of aspartate transaminase and alanine transaminase levels twice the normal values. Prothrombin time was 20 s with an international normalized ratio of 1.8. Patient had one episode of upper gastrointestinal bleeding which was managed successfully with pantoprazole infusion. Patient was given weaning trial after 72 h of ventilation and was successfully extubated. This patient represented a rare case of acute poisoning and was initially suspected to be a case of organophosphorus poisoning which is the most common poisoning in India.[1] However, the atypical presentation and further enquiry found the agent to be an insecticide “Vetcare Vijetha” used in sericulture and composed of paraformaldehyde 2%, benzoic acid 2%, and kaolin (china clay) 96% (per kilogram of the pink powder). No identifiable specific antidote could be found in literature, and the patient was given symptomatic and supportive treatment.[2] Acute ingestion of kaolin as such has essentially no adverse effects, and mild and transient constipation may occur.[3] Kaolin is a potent adsorbent and has been implicated to result in hypokalemia due to potassium binding.[4] Acute overdose of paraformaldehyde causes vomiting, mucous necrosis, vertigo, intense pain, anuria, convulsions, and death.[5] Acute exposure to benzoic acid or its sodium salt is associated with nonspecific signs and symptoms although metabolic acidosis has been implicated and daily intake of 4–6 g does not cause toxic symptoms aside from slight gastric irritation.[6] The presence of kaolin in the consumed substance might explain in part the survival benefit as it is a potent adsorbent. These compounds have very limited human exposure, and human toxicity is often extrapolated from toxicological studies or case reports of this nature. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.