Pneumomediastinum: An Early Predictor of Mortality in Paraquat Poisoning: A Rare Case Presentation

Abstract

Paraquat is a broad spectrum liquid herbicide (1,1'- dimethyl-4,4'- dipyridylium) associated with both accidental and intentional ingestion. It has a very high case fatality rate assuming to be due to inherent toxicity and lack of effective treatments. Poisoning by Paraquat herbicide has been a major medical problem in parts of Asia. Despite widespread availability, reports of Paraquat poisoning is not common due to very high case fatality rate might be due to not reaching to tertiary care centres and non specific clinical features with absence of proper history. Case Presentation: We report a case of previously healthy 19 years old male who was brought to the emergency department 3 days after intentional ingestion of approximately 100ml of 24% Paraquat herbicide with complaints of retrosternal chest pain while breathing & dysphagia followed by several episodes of vomiting followed by the development of pneumomediastinum and death from respiratory failure. Paraquat poisoning should always be considered in the differential diagnosis in patients presenting with spontaneous pneumothorax or pneumomediastinum in places with high paraquat poisoning prevalence. Conclusion: Though Pneumomediastinum being an early predictor of 100% mortality in Paraquat poisoning but an emergency physician should establish the diagnosis early and to pursue aggressive decontamination and prevention of further absorption. Increased awareness of the clinician and availability of the laboratory diagnostic methods will definitely help in successful management of paraquat poisoning and to decrease the case fatality rate. What we already know? There are quite a few case reports that already mentioned about possibilities of occurrence of spontaneous pneumomediastinum, pneumothorax or lung fibrosis along with acute renal failure, liver toxicity and mucosal injury. What this paper adds? This is rare case report of spontaneous pneumomediastinum in Paraquat poisoning presenting to our tertiary care centre. A chest radiograph or a CT chest should be performed which may be useful in early detection of pneumomediastinum, pneumothorax or lung fibrosis for assessing long term damage in survivors. We specifically point towards the fact that no obvious clinical guideline can decrease the case fatality rates in these kind of cases.