Letter to the Editor: “Management of acute endosulfan poisoning in an organophosphate poisoning clinic”

Management of acute endosulfan poisoning in an organophosphate poisoning clinic

To the Editor:

Endosulfan has a high toxicity consistent with other members of the family of chlorinated hydrocarbon insecticides (1), and may be absorbed via skin, inhalation, and the gastrointestinal system for the purpose of suicide or by accident (2–4). Characteristic clinical signs are seizures, nausea, vomiting, abdominal discomfort, headache, agitation, hyperactivity, in-coordination, confusion, dizziness, and myoclonus (3–6).

Cases

Six cases were admitted into our hospital due to nausea, vomiting, and dizziness after eating a dessert containing flour, sugar, and oil. According to information acquired from patients' relatives, 27 of 50 affected patients were sent to a tertiary centre. Six of 27 were brought to our service, but 21 were sent to another service. It was learned that four patients had grand mal type convulsions and that three of them died.

Upon physical examination, five patients were observed to be confused with miotic pupils and hyperactive bowel sounds. Severe bradycardia was observed in one patient. One patient had a seizure that was unresponsive to diazepam and phenytoin treatment. Respiratory arrest occurred and the patient responded to cardiopulmonary resuscitation and was placed on mechanical ventilation. Approximately six hours later the patient was extubated. Cranial tomography was normal and no further convulsions were noted. Demographic features of the patients and findings of physical examinations are summarized in Table 1.

Table 1. Demographic features of the patients and findings upon physical examination

	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6
Age	58	13	10	15	32	68
Sex	Female	Female	Male	Female	Male	Female
Vomiting	+	+	+	+	+	+
Nausea	+	+	+	+	+	+
Dizziness	+	+	+	+	+	+
Conscious	Unconscious	Confusion	Confusion	Confusion	Confusion	Normal
Heart beat (min)	78	55	82	76	78	72
Miosis	+	+	+	+	+	−
Convulsion	+	−	−	−	−	−
Atropine dose (mg)	3	3	3	3	3	−
Pralidoxime dose (mg)	2000	1000	1500	1000	1000	−

Upon laboratory examination, white blood cell count, glucose, aminotransferases, and LDH levels were high. Abnormal electrocardiographic findings consisting of sinus bradycardia and ST-T changes were observed in two patients. The laboratory results are summarized in Table 2.

Table 2. The laboratory results of the patients

	Case 1	Case 2	Case 3	Case 4	Case 5	Case 6
WBC (cell/mm^3)	23.000	21.000	18.000	20.000	18.000	7.500
Glucose(mg/dl)	238	156	185	142	136	110
AST (IU/L )	150	58	85	60	55	25
CKMB(IU/L	255	78	100	67	76	20
Pseudocholinesterase ( 5400–13200) (U/L)	9800	9350	7600	9760	6700	8540
Electrocardiography	STD	B	N	N	N	N

STD: ST-T changes, B: bradycardia, N: normal.

Atropine and pralidoxime had been administered to five patients. After eight hours of observation, consciousness of all of the cases had become clear. Food analysis for toxic substances, reported two days later, revealed endosulfan. All patients were followed for five days prior to discharge.

Discussion

Toxic quantities of endosulfan have been taken in via the gastrointestinal system route predominantly following the consumption of contaminated food (2–4,7). The reason for poisoning in this outbreak was consumption of sweets which were made from flour contaminated with liquid endosulfan. Symptoms began nearly one-half to one hour following consumption.

Venkateswarlu et al. reported 44 individuals who consumed food accidentally contaminated by endosulfan in a rural area. Nausea and vomiting had been seen in 43 patients, emotional changes in 72%, seizure in 50%, stupefaction in 18%, peevishness in 9%, and diarrhea in 6.8% (4).

Endosulfan-induced seizures should be controlled with a benzodiazepine, followed by phenobarbital if needed (3,6,8). Our patients' seizures failed to respond to diazepam and diphenylhydantoin treatment, resulting in respiratory arrest and intubation. Atropine and pralidoxime treatment was administered to five cases due to suspected muscarinic symptoms such as nausea, vomiting, miosis, leading to suspicion of organophosphate or carbamate insecticide poisoning. Following atropine and pralidoxime, their state of conscious appeared to improve, confusion resolved, and miosis was decreased.

Acute endosulfan poisoning due to gastrointestinal exposure is rarely seen. In these patients, clinical effects span a wide range from uncomplicated gastrointestinal symptoms such as nausea and vomiting to convulsions or death, presumably related to dose. In the acute endosulfan poisoning patients who have predominant muscarinic symptoms such as miosis, the use of atropine and pralidoxime might be beneficial.