Alexandria Poison Center Case Report of Acute Poisoning Following Intramuscular Injection of Cholinesterase Inhibitor Insecticide and the Possible Role of L-Carnitine in Management

Rajab, Hisham Elsayed; Elbanna, Asmaa Said; Elshaer, Noha Selim; Saad, Omnia Azzaz

doi:10.22038/apjmt.2024.77599.1442

Alexandria Poison Center Case Report of Acute Poisoning Following Intramuscular Injection of Cholinesterase Inhibitor Insecticide and the Possible Role of L-Carnitine in Management

Document Type : Case Report

Authors

Hisham Elsayed Rajab ¹

Asmaa Said Elbanna ¹

Noha Selim Elshaer ²

Omnia Azzaz Saad ¹

¹ Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Alexandria University, Egypt.

² Department of Community Medicine, Industrial Medicine and Occupational Health, Faculty of Medicine, Alexandria University, Egypt.

https://doi.org/10.22038/apjmt.2024.77599.1442

Abstract

Background: Cholinesterase inhibitor (ChEI) insecticide is a common cause of poisoning in developing countries. Toxicity occurs by ingestion, inhalation, or dermal absorption. However, only a few cases of parenteral poisoning have been reported. Inhibition of cholinesterase itself is not enough to explain the wide range of disorders associated with ChEIs insecticide exposure. Oxidative stress is supposed to be a contributing factor to the complications of ChEIs insecticide poisoning. L-carnitine (LC) is a widely accessible antioxidant therapy that is a safe drug with fewer side effects. It could be a promising adjuvant treatment in acute ChEIs insecticide poisoning.
Case presentation: The current case report describes a 60-year-old male with a homicidal intramuscular injection of ChEI insecticide, presented with chest crepitations and fasciculations. He showed an initial improvement to treatment with atropine, toxogonin, and L-carnitine (LC). However, there was a relapse of more aggressive manifestations after recovery and hospital discharge
Conclusion: Diagnosis of ChEI toxicity by the parenteral route is a challenge where the onset of symptoms may be delayed with atypical presentations. Even though the symptoms are mild initially, observation for a more extended period is mandatory. LC could be a promising adjuvant antioxidant treatment in acute ChEIs insecticide poisoning cases.

Keywords

Homicidal

Cholinesterase Inhibitor Insecticide

L-carnitine

Case Report

Subjects

Medical Toxicology

1. Rani L, Thapa K, Kanojia N, Sharma N, Singh S, Grewal AS, et al. An extensive review on the consequences of chemical pesticides on human health and environment. J Clean Product. 2021;283:124657.
2. Elshamy RA, Hassan AAH, El-Naggar SAE-M, Nomier MAE, El-Shafei DA. Oxidative stress indices of organophosphates pesticides among agricultural workers at mit-ghamr district, Egypt. Zagazig Univ Med J. 2019;25(2):187-97.
3. Ssemugabo C, Halage AA, Neebye RM, Nabankema V, Kasule MM, Ssekimpi D, et al. Prevalence, Circumstances, and Management of Acute Pesticide Poisoning in Hospitals in Kampala City, Uganda. Environ Health Insights. 2017;11:1178630217728924.
4. Madea B. Handbook of Forensic Medicine. Germany: John Wiley & Sons; 2014.
5. Alahakoon C, Dassanayake TL, Gawarammana IB, Weerasinghe VS. Can we predict intermediate syndrome? A review. Neurotoxicology. 2018;69:209-16.
6. Tehrani M-SM-A, Soltaninejad K, Yazdani S, Nelson LS, Shadnia S. Bilateral loculated pleural effusion as a manifestation of acute parenteral organophosphate intoxication: a case report. J Emerg Med. 2011;41(6):630-4.
7. Mohamed RA, Ong KK, M. Kasim NA, A. Halim N, M. Noor SA, Knight VF, et al. Transitioning from Oxime to the Next Potential Organophosphorus Poisoning Therapy Using Enzymes. J Chem. 2021;2021:1-16.
8. Rambabu L, Megson IL, Eddleston M. Does oxidative stress contribute to toxicity in acute organophosphorus poisoning? - a systematic review of the evidence. Clin Toxicol. 2020;58(6):437-52.
9. Alhasaniah AH. l-carnitine: Nutrition, pathology, and health benefits. Saudi J Biol Sci. 2023;30(2):103555.
10. Maldonado C, Vázquez M, Fagiolino P. Potential Therapeutic Role of Carnitine and Acetylcarnitine in Neurological Disorders. Curr Pharm Des. 2020;26(12):1277-85.
11. Liu H, Kan B, Jian X, Zhang W, Zhou Q, Wang J. Parasuicidal poisoning by intramuscular injection of insecticide: A case report. Exp Ther Med. 2013;6(3):696-8.
12. Badrane N, Askour M, Berechid K, Abidi K, Dendane T, Zeggwagh AA. Severe oral and intravenous insecticide mixture poisoning with diabetic ketoacidosis: a case report. BMC Res Notes. 2014;7:1-4.
13. Hai N, Levi Y, Golan J. Subcutaneous injection of household spray insecticide: A rare cause of soft tissue damage. Eur J Plastic Surg. 2003;25:421-3.
14. Premaratna R, Tilakarathna Y, Fonseka MM, Gunatilake SB, de Silva HJ. Parasuicide by self-injection of an organophosphate insecticide. Hum Exp Toxicol. 2001;20(7):377-8.
15. Kumar A, Kumar A, Murty OP, Gupta VP, Das S. A rare case of homicidal insecticide (organochloro compound) poisoning by intraperitoneal injection. Med Sci Law. 2012;52(4):231-3.
16. Jindal TR. Toxicology of Organophosphate Poisoning: New Insights. Cham: Springer Nature; 2021.
17. Blumer J. Principles of Drug Disposition in the Critically Ill Child. In: Zimmerman JJ, Fuhrman BP, (eds). Pediatric Critical Care E-Book. 4^th ed. Philadelphia: Elsevier Health Sciences; 2011. 1538-52.
18. Mahmood T, Arulkumaran S, Chervenak f. Obesity and Gynecology. 2^nd ed. New York: Elsevier; 2020.
19. Peter JV, Sudarsan TI, Moran JL. Clinical features of organophosphate poisoning: A review of different classification systems and approaches. Indian J Crit Care Med. 2014;18(11):735-45.
20. Malla G, Basnet B, Vohra R, Lohani SP, Yadav A, Dhungana V. Parenteral organophosphorus poisoning in a rural emergency department: a case report. BMC Res Notes. 2013;6:524.
21. Erenler AK, Başara G, Kayabaş A. Parenteral Insecticide Injection for Suicidal Attempt: A Case Report. Health. 2014;6(15):1929-32.
22. Agrawal R, Bhargava V, Sharma A, Jain R, Agarwal N. Organophosphate insecticide poisoning by intramuscular injection. Flora Fauna. 2015;21(1):123-5.
23. Liu S-H, Lin J-L, Weng C-H, Yang H-Y, Hsu C-W, Chen K-H, et al. Heart Rate-Corrected QT Interval Helps Predict Mortality after Intentional Organophosphate Poisoning. PLOS ONE. 2012;7(5):e36576.
24. Khan J, Parihar AS, Umalkar G, Gadkari C. An unusual case of organophosphate poisoning presenting Wellens or Pseudo-Wellens pattern: A diagnostic dilemma. Med Sci. 2023;27:e96ms2726.
25. Khan S, Kumar S, Agrawal S, Bawankule S. Correlation of serum cholinesterase and serum creatine phosphokinase enzymes with the severity and outcome of acute organophosphorus poisoning: study in rural central India. World J Pharm Pharma Sci. 2016;5(4):1365-73.
26. Kalil AA, Pandian TK, Priya V, Sathiya P. A study on the prognostic significance of serum creatine phosphokinase levels in organophosphorus poisoning. Int J Acad Med Pharm. 2024;6(1):1522-6.
27. Islam A, Chowdhury D, Palit PK, Sohel M, Mozibullah M, Islam MJ, et al. Serum creatinine phosphokinase: A potential prognostic marker in assessing clinical severity with organophosphorus poisoning. J Clin Lab Anal. 2023;37(21-22):e24980.
28. Bharathisezhian A, Kalaisezhian N, Kumarraja M, Yoganandh T. A study of the prognostic significance of serum creatine phosphokinase level in organophosphorus compound poisoning patients. Int J Acad Med Pharm. 2023;5(2):453-7.
29. Nizami MF, Sharma CB, Singh B, Guria RT. Intramuscular pyrethroid with organophosphorus (cypermethrine 3% + quinolphos 20%) mixed poisoning, its clinical presentation and management. J Family Med Prim Care. 2020;9(5):2521-3.
30. Juluganti B, Reddy KP, Balasubramaniyan S. Parenteral Organophosphate Poisoning Presenting With Seizure. J Med Sci Clin Res. 2014;2(10):2664-8.
31. Singh RS, Vengadakrishnan K, Damodaran J. Parenteral Administration of Organophosphorus Compound-An Unusual Route of Poisoning Presenting With Severe Toxicity. J Med Sci Clin Res. 2015;3(1):3642-5.
32. Sule RO, Condon L, Gomes AV. A common feature of pesticides: oxidative stress—the role of oxidative stress in pesticide-induced toxicity. Oxid Med Cell Longev. 2022;2022:5563759.
33. Chakravarthula S, Venkatesh PS, Ramishetty S, Namoshi AG. Treatment of Organophosphorus Poisoning–Atropine Causing Atrial Fibrillation. Telang J IMA. 2023;3(1):27-9.
34. Neykova L, Traykova V, Stoykova S, Atanasov V, Stankova E. Red blood cell acetylcholinesterase (RBC-AChE) assay as a first indicative marker in organophosphate poisoning. Clin Toxicol. 2017;55(5):390.
35. Pearson JN, Patel M. The role of oxidative stress in organophosphate and nerve agent toxicity. Ann N Y Acad Sci. 2016;1378(1):17-24.
36. Vanova N, Pejchal J, Herman D, Dlabkova A, Jun D. Oxidative stress in organophosphate poisoning: role of standard antidotal therapy. J Appl Toxicol. 2018;38(8):1058-70.
37. Khatua BC, Rao BRP, Nayak S, Mohanty AP. Intramuscular pyrethroid with organophosphate mixed poisoning – A rare case report. J Integr Med Res. 2023;1(3):116-8.
38. Nishioka Sde A. Parenteral injection of organophosphate insecticide. Apropos of two cases. Sao Paulo Med J. 1994;112(2):561-3.
39. Zoppellari R, Borron SW, Chieregato A, Targa L, Scirci I, Zatelli R. Isofenphos Poisoning: Prolonged Intoxication After Intramuscular Injection. J Toxicol Clin Toxicol. 1997;35(4):401-4.