Cervicofacial Edema Research Articles

Renal and Hemorrhagic Complications Following Bee Sting Envenomation: A Case Report from the Hospital of Zinder

Renal and hemorrhagic complications following envenomation by bee stings are rare, posing significant problems for early diagnosis and treatment in the clinical setting. Bee venom is generally well tolerated. A 44-year-old patient was admitted to the infectious and tropical diseases department of the Zinder National Hospital with cervicofacial edema following bee stings. Initially, the patient lost consciousness. Respiratory symptoms included dyspnea and 91% desaturation on room air. The patient was put on oxygen to alleviate hypoxia, doxycycline to prevent secondary bacterial infections, and prednisone to reduce inflammation. The clinical picture was complicated by a worsening of the patient's condition due to a deterioration in renal function, and the subsequent appearance of hematemesis. A renal biopsy revealed acute tubulointerstitial nephropathy, due to direct venom toxicity on the tubules. He was discharged after 35 days. We report a rare case of bee sting complicated by hemorrhagic syndrome and renal involvement.

PARAPHENYLENEDIAMINE POISONING : A CASE REPORT AND REVIEW OF LITERATURE

Paraphenylenediamine (PPD) intoxication is a medical emergency with a very poor prognosis in the absence of early and adequate treatment. Its pathophysiological mechanism is now known and results from the destruction of muscle cells by peroxidation phenomena leading to major rhabdomyolysis. The diagnosis is essentially clinical, guided by a rapid history. As there is no specific antidote, treatment is mainly symptomatic and aims at securing the VAS, reducing intestinal absorption of the toxicant, as well as managing cervico-facial oedema and complications of rhabdomyolysis. In hospital, treatment includes gastric lavage, activated charcoal, filling with alkalinisation, antioxidant treatments, corticosteroids, diuretics and even dialysis. In order to shed light on the danger of this practice, the authors have taken the liberty of reporting the clinical case of PPD intoxication in a young woman admitted to the maternity ward of the Harouchi Hospital in Casablanca.

Evaluation of Clinical Spectrum of Kala Pathar Poisoning at Jinnah Hospital Lahore

Objectives: To study the frequency of different clinical presentations of kala pathar poisoning at Jinnah Hospital Lahore. Study design: Cross sectional study Place and Duration: Department of Medicine, Jinnah Hospital, Lahore from April 2021 to October 2021. Methodology: A total of 90 patients with h/o kala pathar poisoning of both sex and of age 20-50 year were included. Case sheet of patients were prepared for age & sex and clinical presentation i.e. pain in throat, dysphagia, dysphonia, cervico-facial edema, difficulty in opening mouth, dark urine, acute renal failure, sinus tachycardia and sinus bradycardia. Results: Mean age was 33.69 ± 7.91 years. Out of 90 patients, 54 (60.0%) were males and 36 (40.0%) were females with male to female ratio of 1.5:1. Mean duration of kala pathar intake was 7.33 ± 5.86 hours. The main presentation of kala pathar poisoning was pain in throat (98.89%), dysphagia (100%), dysphonia (100%), cervico-facial edema (97.78%), difficulty in opening mouth (98.89%), dark urine (86.67%), acute renal failure (44.44%), sinus tachycardia (88.89%) and sinus bradycardia (21.11%). Conclusion: This study concluded that pain in throat, dysphagia and dysphonia are the common clinical presentations of kala pathar poisoing followed by cervico-facial edema, difficulty in opening mouth, dark urine, acute renal failure, sinus tachycardia and sinus bradychardia. Keywords: Kala pathar poisoning, dysphagia, dysphonia, angioedema, sinus tachycardia.

Retracted: Management of Patients with Cervicofacial Edema and Paresthesia during Perioperative Period of Transoral Endoscopic Thyroidectomy.

[This retracts the article DOI: 10.1155/2022/4775264.].

Incidence, Clinical Presentation and Outcomes of Paraphenylenediamine (Kala Pathar) Poisoning in Patients Presenting at a Tertiary Care Hospital: a Prospective Study

Objective: To assess the demographics, clinical features and outcomes of PPD poisoning in such patients. Design of the Study: It was a prospective study. Place and Duration of Study: In this cross-sectional study, the prospective study data of 47 cases were collected from Department of Forensic Medicine and Toxicology, Loralai Medical College, Loralai. Patients and Methods: From 2019 to 2022, data of 47 cases was taken worth of information were gathered from hospitals' medical records for this prospective study. Information on the subject's demographics, ingestion method, clinical features, and mode of administration was recorded using a standardized format. In addition to monitoring mortality rates, hospital stays, tracheostomies, and the efficacy of mechanical ventilation, a number of other metrics were collected. For continuous variables' means and standard deviations (SDs) were calculated. However, percentages were calculated for categorical variables. Results of the Study: Out of 47 patients, 38 (80.85%) were females and 9 (19.15%) were males. During first year of the study, only six cases were reported while in succeeding years cases increases rise rapidly and reached to fifteen in last year final year of the study. Majority of the patients 16 (34%) belong to age group 20-24 years. Nearly, 85% of the patients belong to the rural areas. Moreover, the rate of PPD poisoning in married women increases alarmingly from one case in 2019 to nine cases in 2019. Practical Implication: Currently, there is limited data available on this poisoning as it has emerged as a new tren in our local hospitals. So, the rationale of this study is to evaluate the clinical presentation and outcome of the PPD poisoning in our part so that effective preventive and treatment strategies can be implemented at the onset which would certainly decrease the morbidity and mortality associated with this deadly poisoning. This study can lay down a base for local administrative authorities to consider formulating a law for strict handling of the PPD poisoning at local level and for education of the population. Conclusion: There is a significant amount of distress and death that comes along with PPD poisoning. In order to effectively handle poisoning situations, doctors must be aware of the clinical features and therapeutic choices. In addition, PPD-containing hair colours should be banned because they are so dangerous. Keywords: Poisoning, Suicide, Hair-Dye, Cervicofacial Edema, Paraphenylenediamine, Kala Pathar

Poisoning of paraphenylene diamine hair dye: review article

Hair dye poisoning (Paraphenylenediamine-PPD) is a crucial cause of both intentional self-harm and accidental poisoning in the developing world. paraphenylene-diamine is a synthetic chemical that can cause local as well as systemic manifestation, of these are cervicofacial edema, laryngeal edema with stridor, rhabdomyolysis, severe metabolic acidosis and acute renal failure. Intervention earlier at the right time has been shown to improve the outcome. In this article reviewed the epidemiology, clinical features and treatment modalities for hair dye poisoning.

Management of Patients with Cervicofacial Edema and Paresthesia during Perioperative Period of Transoral Endoscopic Thyroidectomy.

Objective To analyze the clinical intervention effect of transoral endoscopic thyroidectomy on the neck and face during perioperative period. Method From January 2019 to January 2020, 60 patients included in this study were randomly divided into observation group and control group according to the ratio of 1 : 1, with 30 cases in each group. Both groups underwent rapid surgical intervention during the perioperative period. The patients in the observation group received neck and face management. The degree of jaw swelling, the degree of facial microexpression completion, and the changes in jaw and neck sensation were compared between the two groups. Results There was no significant difference in neck and face swelling, pain, facial microexpression, and feeling between the two groups before operation. Patients with facial I/II swelling degree in the observation group were significantly more than in the control group, and the patients with III swelling degree were less than in the control group. There was significant difference for facial swelling between the two groups in the three intervention periods after the operation, and the difference was statistically significant (P < 0.05). The scores of facial microexpression in the observation group were higher than those in the control group during the three postoperative intervention periods, with statistical significance (P < 0.05). There was no significant difference in the pain score of the first day after surgery between the two groups (P = 0.298). In the other two postoperative intervention periods, the pain score of the observation group was lower than that of the control group, with a statistically significant difference, and the difference was statistically significant (P < 0.05). The threshold of chin and neck sensory pressure in the two groups was statistically significant (P < 0.05) except that the “cheek in area 4” (P = 0.290). Conclusion The results showed that these interventions, such as the elevation of bed after operation, 24-hour intermittent cryotherapy, ice cubes in mouth, and the “meter” functional training, have good clinical effects on the symptoms of facial swelling and abnormal sensation of neck and face. It can accelerate the speed of edema dissipation, improve the patients' postoperative comfort, and improve the satisfaction and quality of life of patients with the effect of surgery and beauty.

Demographic profile and clinical picture of patients presented with Paraphenylene Diamine (PPD)/ Kala Pathar poisoning at a District Teaching Hospital.

Objectives:To document demographic profile, clinical features and management of patients presented with PPD/Kala Pathar poisoning at District Teaching Hospital Sahiwal, Pakistan.Methods:This cross-sectional study utilized data for cases of PPD poisoning presented at study place from 1st July 2019 to 30th June 2020. Relevant information was recorded on a proforma.Results:A total of 111 cases were included in study. Mean age was 23.01 ± 7.24 years. Majority of cases were observed in females (82%) and majority presented from rural areas (87.4%). Cervico-facial edema (78.4%) and respiratory distress (66.7%) were the most common findings. Evidence of some level of organ damage was recorded in following manner: kidneys (44.1%), musculoskeletal (50.5%) and cardiac (45.9%). Tracheostomy was carried out in 47.7% cases and dialysis in 11.7% cases. All cases ingested PPD in raw form. Mortality rate was 50.5%.Conclusion:PPD poisoning is associated with high rate of morbidity and mortality. Effective clinical management requires multidisciplinary approach. Measures to restrict access to this means of suicide are urgently needed. We need to set up a surveillance system for cases of attempted suicide.

Patient with uncontrolled diabetes with a nonpainful, exophytic, purulent mandibular mass

A 47-year-old man with poorly controlled diabetes presented to his local hospital with respiratory difficulty, dysphagia, and right-sided cervicofacial edema. This was found to be associated with an exophytic mass of the oral cavity overlying the mandible that was encroaching upon adjacent structures. He had first noticed this growth 6 weeks prior and reported that it was progressively enlarging. He was febrile and was found to have a leukocytosis, for which he was placed on broad-spectrum antibiotics.

Paraphenylenediamine (Kala Pathar) Poisoning at the National Poison Control Center in Karachi: A Prospective Study.

IntroductionSuicide by self-poisoning is a common cause of death, especially in the younger population. More specifically, hair-dye poisoning is being increasingly used for suicide. Paraphenylenediamine (PPD), also known as “Kala pathar”, is a highly toxic ingredient present in hair-dye that can cause death. Therefore, this study is designed to assess the demographics, clinical features, laboratory findings, and outcomes of PPD poisoning in patients admitted to the National Poison Control Center in Karachi, Pakistan.Materials and methodsWe conducted a prospective study for a period of six months at the National Poison Control Center, Karachi, Pakistan. A total of eight patients with PPD poisoning with no cardiac, liver, or renal co-morbidities were included in this study. The demographic characteristics, clinical features, laboratory findings, mode of intoxication, and route of intoxication were noted in a proforma. Furthermore, hospitalization time, tracheostomy status, mechanical ventilation status, and mortality rates were also recorded. For continuous variables, the means and SDs were calculated. Whereas for categorical data, percentages were calculated.ResultsIn our study, the mean age of the patients was estimated at 25.38 ± 3.77 years. It was deemed that the majority of poisoning cases were intentional in nature (75%). These suicide cases were more commonly observed in young females (75%) who belonged to a low socioeconomic class (87.5%). The preferred route of administration was oral (87.5%). In 87.5% of the patients, the characteristic clinical features such as cervicofacial edema, dysphagia, dysphonia, and stridor were noted. During the later clinical stages of poisoning, clinical features such as rhabdomyolysis (62.5%), chocolate-colored urine (87.5%), hepatitis (75%), and acute renal failure (12.5%) were noteworthy. The mean ± SD of total leukocyte count (TLC), creatine phosphokinase (CPK), aspartate aminotransferase (AST), alanine aminotransferase (ALT), serum creatinine and serum potassium were, respectively, noted at 10,500 ± 3,854.4 cells/mm3, 32.87 ± 11.36 IU/L, 1,239.1 ± 1,106.2 IU/L, 776.8 ± 1,149.8 IU/L, 2.125 ± 2.275 mg/dL, and 4.9 ± 1.094 mmol/L. In our patients, the mean intensive care unit stay was 8.25 ± 3.99 days. Emergency tracheostomy was performed in 25% of patients. Mechanical ventilation was required for 50% of our patients. Overall, the mortality rate observed in our study stands at 25%.ConclusionPPD poisoning is associated with a high rate of morbidity and mortality. Therefore, it is imperative for physicians to be mindful of the clinical characteristics and treatment options in order to optimally manage such cases of poisoning. In addition, the use of hair-dyes composed of highly lethal PPD should also be banned.

1768 Esophagitis Dissecans Superficialis Secondary to Ingestion of Hair Dye

INTRODUCTION: Esophagitis dissecans superficialis (EDS) is a rare and underdiagnosed esophageal lesion characterized by sloughing of the esophageal mucosa that has been associated with various autoimmune disorders and exposure to some chemical irritants. Our case highlights a 65-year-old woman diagnosed with EDS after incidental ingestion of hair dye containing resorcinol and paraphenylenediamine (PPD). CASE DESCRIPTION/METHODS: The patient is a 65 year-old female with a medical history of diabetes, hypertension, major depressive disorder, asthma, alcohol use disorder who presented to our emergency department complaining of nausea and vomiting after ingesting a colored hair dye. The patient stated she accidentally ingested 2 oz of hair dye believing it was cough syrup. Notable laboratory findings on admission included a complete blood count within normal limits; a venous blood gas showing a pH of 7.274; pCO2 of 39.2 mm Hg; HCO3 of 17.2 mEq/L and a lactic acid of 5.1. Notable imaging included a chest x-ray showing focal patchy opacities at both lung bases; and an X-ray of the neck showed no retropharyngeal soft tissue swelling. Physical exam was unremarkable. After initial evaluation esophagogastroduodenoscopy (EGD) was done and showed mild superficial mucosal desquamation in entire esophagus suggestive of esophagitis dissecans superficialis (Figure 1). After the procedure the patient was started on pantoprazole and admitted to the general medical floor for further monitoring. The following night the patients symptoms resolved and she was discharge with follow up appointments. DISCUSSION: PPD is an aromatic amine that is widely used in hair dye due to its favorable cosmetic outcomes. Adverse effects of PPD include cervicofacial edema, upper airway tract edema, oliguria, and shock. Resorcinol is a phenolic chemical that is also used in hair dye. Readily absorbed by the gastrointestinal tract, resorcinol is a corrosive acid that causes severe burns on direct contact. Its consumption may also result in pulmonary edema, hemolysis, and metabolic acidosis. Clinical manifestations of EDS are non-specific and include vomiting and dysphagia. Endoscopically it is characterized by sheets of sloughed squamous tissue which typically appear as multiple columns of strips, often described as "gift wrap paper" like distribution as was present in our case. Its prognosis is very favorable and long term complications are rare. To our knowledge this makes the first reported case of EDS occurring secondary to ingestion of hair dye.

Clinical Profile and Outcome of Paraphenylene Diamine Poisoning.

To determine the clinical presentation, complications, and outcome of paraphenylene diamine (PPD) poisoning in patients presenting to Nishtar Hospital, Multan. Descriptive study. Medical Unit II and III, Nishtar Hospital, Multan, from April 2015 to September 2016. All adult patients admitted with history of paraphenylene diamine ingestion were evaluated for clinical features, complications, and outcomes on a pre-designed proforma. 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. Paraphenylene diamine is an emerging domestic poison in Pakistan, with a high morbidity and mortality.

Pathar dye (paraphenyldiamine) poisoning: our experience of this lethal emerging health problem in a tertiary care centre

&lt;div class="page" title="Page 1"&gt;&lt;div class="section"&gt;&lt;div class="layoutArea"&gt;&lt;div class="column"&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The aim of this case series study is to share our experiences regarding paraphenylenediamine (PPD) poisoning, its otolaryngological clinical presentation ,outcomes and need of tracheostomy in patients of hair dye poisoning at GSVM Medical College, Kanpur, U.P.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This prospective study was carried out on 165 patients who presented in GSVM medical college Kanpur in period of December 2012 till December 2014. Data including demographic features (age, sex, marital status, socio-economic status), clinical features, laboratory findings, mode of intoxication (accidental or suicide) were collected and recorded. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; A majority of the patients were young females (21-30 years) and belonged to a low socioeconomic class. The main cause was intentional suicidal ingestion. Cervicofacial edema, stridor, hoarseness of voice and pain in throat were initial symptoms. Tracheostomy was needed in 115 (69.69%) patients. Mortality of 21 (12.72%) patients was observeds.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; It is a major emerging health problem with high mortality. It is a medical emergency and early intervention is needed to save patient's life. It is imperative to raise public awareness of the potential toxicity of the dye as well as to educate physicians about the need for aggressive and early treatment. &lt;/p&gt;&lt;/div&gt;&lt;/div&gt;&lt;/div&gt;&lt;/div&gt;

Frequency of Acute Hepatitis Following Acute Paraphenylene Diamine Intoxication.

IntroductionParaphenylene diamine (PPD) ingestion is manifesting as one of the more common ways of committing suicide in Southern Punjab, Pakistan, especially Bahawalpur. PPD is an ingredient of a compound commonly known “Kala Pathar” which means “Black Stone” in Urdu. It is readily available in the market at low cost and is used to dye hair and fur. Its intoxication inhibits cellular oxidation and affects the muscles causing rhabdomyolysis. This leads to myoglobinuria followed by renal failure and edema of face and throat resulting in respiratory difficulty. Very little is known about the impact of PPD intoxication on liver tissue.ObjectiveThe purpose of the study was to find out the frequency of acute hepatitis following PPD intoxication.MethodsWe reviewed the medical records of 109 patients with PPD intoxication admitted to Medical Unit-2, Bahawalpur Victoria Hospital from January 1, 2015, to June 30, 2015, in a descriptive, cross-sectional study. We noted the frequency of acute hepatitis and other complications, and we recorded the demographic features, clinical features, and outcomes of these patients.ResultsOur study included 32 men (29%) and 77 women (71%). The mean age was 22 ± 3.4 years, and most patients were young women aged 15 to 24 years. Suicidal ingestion was the leading cause of admission for 101 patients (93%). The most common clinical presentation was cervicofacial edema (95%), throat pain (88%), dysphonia (95%), cola-colored urine (100%), and oliguria (95%). Rhabdomyolysis (86%), acute hepatitis (51%), and acute renal failure (63%) were the most common clinical conditions following poisoning. Overall mortality was noted in 39 patients (36%) while all other patients achieved complete clinical recovery (64%). In patients with mortality, 20 of 39 (51%) developed acute hepatitis. Most patients (95%) in our study underwent tracheostomy.ConclusionThe frequency of acute hepatitis in PPD intoxication is high in this population, especially in young women. Measures need to be instituted regarding the management of acute hepatitis in PPD intoxication to improve patient outcomes. Workups in patients with PPD poisoning should include regular monitoring of aspartate aminotransferase and alanine aminotransferase to observe any damages to the liver so that acute hepatitis can be managed in a timely fashion.

Para Phenylene Diamine Poisoning: Hepatic and Renal Damage

Suicide is the second leading cause of death and it kills one person in every 40 seconds mostly between age limits 15-29 years. The global official surveys conducted reported higher death rates in low and middle income countries; however, women were affected more than men. Poisoning with chemicals is known to be a preferred method of suicide. The morbidity and mortality data following hair dye poisoning peaked in last few years. Interestingly, poisoning with Para Phenylene Diamine (PPD) is an emerging way of intentional self-harm in developing countries of Asia and Africa. We report here a case of 15 years old patient brought to our hospital emergency unit. The patient developed sudden onset of acute cervico-facial edema, lacrimation and abdominal pain, later followed by deranged liver and renal functions progressing towards liver and renal failure. The history selectively indicated the ingestion of a hair dye locally called “Kala Pathar” which predominantly contains PPD. The lack of specific diagnostic tests, a specific antidote for PPD poison and the importance of early supportive treatment are discussed.

Black Stone Poisoning: A Case Report

Introduction: Paraphenylenediamine (PPD) is the constituent of hair dyes that is responsible for toxicity. Hair dye (PPD) poisoning is associated with high morbidity and mortality and dramatic increase in its incidence has been seen in recent years. We share our experience of a case of complicated PPD poisoning and its management. Case Description: A 3 year old boy presented to A&E with extensive cervicofacial edema and difficulty breathing for past 6 h. Patient underwent emergency tracheostomy and was kept under mechanical ventilation. Patient responded well to corticosteroids and anti-allergic medications. There was a history of ingestion of hair dye mixed water prior to the onset of symptoms. Conclusion: Paraphenylene diamine (PPD) (Kala Pathar) poisoning is associated with high morbidity & mortality. It is emerging as a common form of poisoning both accidental and intentional among Asian and African countries due its easy availability and low cost. PPD intoxication can have serious and lethal manifestation that require prompt diagnosis and management. Therefore, we recommend public awareness and education regarding this toxin and early recognition and aggressive airway management.

Hair Dye Poisoning in a Paediatric Patient

Hair dye ingestion with suicidal intention has increased among rural Indian population and is associated with significant mortality. We report a teenager who presented with cervicofacial edema, respiratory distress, rhabdomyolysis, and myocarditis after ingesting the hair dye Super Vasmol 33. Early and supportive treatment can prevent morbidity and mortality.

Pneumothorax in hair dye poisoning: An unrecognized danger

Sir, Hair dye (Super-Vasmol) poisoning causes cervicofacial edema, laryngeal edema, rhabdomyolysis, acute renal failure, severe acidosis, and rarely bronchospasm and pulmonary edema,[12] but pneumothorax was not documented earlier. We report two cases of right sided pneumothorax in hair dye poisoning on admission along with probable mechanisms, in order to create awareness and recognition of this entity among practitioners for better patient care. Young, tall, unmarried females aged 20 and 18 years were brought with alleged history of consuming 200 and 150 ml of hair dye on different days, respectively. Both had cervicofacial edema, difficulty in breathing, hoarseness of voice, and inspiratory stridor. They were not in menstrual periods and were without positive clinical history. Physical examination revealed alert and acyanotic status with tachypnoea, tachycardia, and hypotension. There was an audible inspiratory stridor with drooling of saliva. Both had hyper-resonant right hemithorax with decreased air entry. Rest of the physical examination was unremarkable. Dyspnoea increased over the next few minutes. Direct laryngoscopy showed bizarre anatomy with almost totally occluded laryngeal inlet due to supraglottic edema with viscous crusts. They were mechanically ventilated. Bedside lung sonography with 10-5 MHz linear transducer was suggestive of pneumothorax [Figure 1] on right side, which was confirmed by chest X-ray.Figure 1: Alternating pattern of absent lung sliding with normal lung slidingTube thoracostomy was done for both, as they were on positive-pressure ventilation. The tube was removed on the third day, as the air leak stopped. Post procedure radiography demonstrated complete re-expansion of the right lung. Contrast swallow ruled out esophageal rupture, and thoracic CT scan did not reveal emphysematous change or bullous disease in the expanded nonatelectatic lung parenchyma in these cases. They were dis-charged on day seven and were asymp-tomatic during follow-up. Oral ingestion of hair dye produces severe airway compromise as a result of direct trauma to the tissues by chemicals and causes dyspnoea and asphyxia[3] which frequently warrants an emergency airway intervention as noticed in our cases. In the absence of significant lung disease and/or bullae on the CT scan of these patients, it is likely that alveolar rupture may be secondary to trapping of large volume of air possibly due to intense inspiratory effort secondary to laryngeal edema which might have contributed to over-distension of the alveoli, and interstitial pulmonary air leak in these two cases, rather than rupture of bullae. The development of pneumothorax following laryngeal edema due to insect sting anaphylaxis was reported[4] earlier. In an autopsy series of eight cases of hair dye poisoning, we noticed pneumothorax in two without any other demonstrable pathology. In view of clinical observations and autopsy evidences of pneumothorax in hair dye poisoning, physicians treating such cases may consider the possibility of pneumothorax if patient has respiratory distress, as timely intervention saves lives. The diagnosis of spontaneous pneumo-thorax may also be made at the bedside with lung sonography by identifying “lung point” which has greater sensitivity and specificity than supine chest radiography.[5] The strength of this report is that pneumothrax was considered clinically identified by sonography at bedside and confirmed by radiography, and other causes for pneumothorax were ruled out by thoracic CT. ACKNOWLEDGEMENTS We thank Dr. K. Arthanari, M.S, for his logistic support.

Hair dye poisoning – an emerging problem in the tropics: an experience from a tertiary care hospital in South India

Super-Vasmol, a cheap, freely-available hair dye is emerging as a major cause of suicidal poisoning in India. It contains potential toxins including paraphenylene diamine, resorcinol, sodium ethylenediaminetetraacetic acid and propylene glycol which can result in multiorgan dysfunction. A retrospective study was conducted over 3.5 years (January 2006-July 2009) of 13 consecutive patients with Super-Vasmol poisoning admitted to a tertiary care, referral hospital in South India. A chart review including records of clinical presentations, laboratory findings and treatment details was carried out. Eleven of the patients were women and the mean age was 27.2 years. The predominant clinical features were cervico-facial oedema and pain, cola-coloured urine and oliguria. Laboratory investigations revealed elevated hepatic transaminases (100%), leucocytosis (92.3%), elevated creatinine phosphokinase (92.3%), metabolic acidosis (84.6%), hypocalcaemia (61.5%), hyperphosphataemia (46.2%) and renal failure (38.5%). Eight of the patients were discharged with complete recovery. Trends towards a poor outcome were evident among the following patients: late presentation at our centre; when no gastric lavage was done at the primary-care centre; those requiring tracheostomy/intubation at the primary centre; presentation with a low Glasgow Coma Score or seizures; established renal failure; and those who subsequently require dialysis, mechanical ventilation or intensive care. Hair dye poisoning classically presents with cervico-facial oedema, severe rhabdomyolysis and renal failure. Early therapy with tracheostomy and aggressive forced diuresis are essential in order to prevent the high mortality associated with this toxin. It is imperative to raise public awareness of the potential toxicity of the dye as well as to educate physicians about the need for aggressive and early treatment.

Upper airway cmompression after arthroscopy of the tempormomandibular joint

An unusual cmomplication is presented following a tempormomandibular arthroscopy carried out under general anaesthesia. Severe cervicofacial oedema occurred immediately after surgery which required prolonged endotracheal intubation. Retrospective analysis revealed a massive fluid escape in the surrounding tissues leading to laryngeal oedema.