Clinical and Forensic Aspects of Aluminum Phosphide Poisoning: An Update and Review of Suicidal, Homicidal, and Accidental Poisoning Cases

Soltaninejad, Kambiz

doi:10.22038/apjmt.2026.97957.1567

Clinical and Forensic Aspects of Aluminum Phosphide Poisoning: An Update and Review of Suicidal, Homicidal, and Accidental Poisoning Cases

Document Type : Review Article

Author

Kambiz Soltaninejad

Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran

10.22038/apjmt.2026.97957.1567

Abstract

Background: Aluminum phosphide (AlP) is a cheap and broad-spectrum fumigant that remains one of the leading agents of fatal poisoning. It is also associated with forensically important homicidal and accidental/occupational poisoning. This narrative review synthesizes recent clinical, forensic toxicological, and medico-legal data on AlP poisoning, with specific attention to the cautious differentiation of suicidal, homicidal, and accidental circumstances when reconstructing the circumstances of death.
Methods: A literature search was conducted in PubMed/MEDLINE, Scopus, ScienceDirect, Google Scholar, and the Directory of Open Access Journals (DOAJ) for English-language publications from 1st January 2010 to 1st August 2026, using the combinations of the terms "aluminum/aluminium phosphide", "phosphine", "rice tablet", "celphos", "forensic toxicology", "autopsy", "suicide", "homicide" and "accidental poisoning". Original research, case reports, systematic reviews, and meta-analyses published in indexed journals were prioritized. Non-peer-reviewed sources and pre-2010 publications were excluded.
Results: Sixty-four sources meeting the eligibility criteria were retained. The reviewed literature confirms AlP homicidal and accidental poisoning are less common but forensically significant. These types of AlP poisoning are arising from covert administration, occupational fumigation, warehouse storage, and pediatric exposure. Autopsy findings are frequently nonspecific. Confirmatory diagnosis based on headspace gas-chromatographic with nitrogen-phosphorus or mass-spectrometric detection.
Conclusion: AlP poisoning remains a major clinical, forensic and public-health problem in developing countries. Systematic autopsy protocols, prompt toxicological confirmation, and careful reconstruction of scene evidence are essential to correctly AlP fatal poisoning cases. Cause of death and manner of death should be determined separately and through integration of the totality of available evidence.

Keywords

Aluminum phosphide

Phosphine

Suicide

Homicide

Accidental poisoning

Subjects

Forensic Medicine

1.Çakmakcı Karakaya S, Yavuz CI. Aluminum phosphide: Toxicological profiles, health risks, environmental impact, and management protocols: A review. Turk J Emerg Med. 2025; 25: 178-90.

2. Soltaninejad K. Current status of acute aluminum phosphide poisoning in Iran: A brief review. Int J Forensic Sci. 2024; 9 (4): 000415.

3. Mehrpour O, Singh S. Rice tablet poisoning: a major concern in Iranian population. Hum Exp Toxicol. 2010; 29(8):701-2.

4. Moghadamnia AA. An update on toxicology of aluminum phosphide. Daru. 2012; 20(1): 25.

5. Hosseini SF, Forouzesh M, Maleknia M, Valiyari S, Maniati M, Samimi A. The molecular mechanism of aluminum phosphide poisoning in cardiovascular disease: Pathophysiology and diagnostic approach. Cardiovasc Toxicol. 2020; 20(5):454-61.

6. Aghebat Bekhier S. Aluminum phosphide (ALP) poisoning a challenge in developing countries: Symptom, diagnosis and treatment strategies. J Forensic Toxicol Pharmacol. 2021;10:6.

7. Garg KK. Review of aluminum phosphide poisoning. Int J Med Sci Public Health. 2020;9(7):392-400.

8. Bumbrah GS, Krishan K, Kanchan T, Sharma M, Sodhi GS. Phosphide poisoning: A review of literature. Forensic Sci Int. 2012;214(1-3):1-6.

9. Etemadi-Aleagha A, Akhgari M, Iravani FS. Aluminum phosphide poisoning-related deaths in Tehran, Iran, 2006 to 2013. Medicine (Baltimore). 2015;94(38):e1637.

10. Navabi SM, Navabi J, Aghaei A, Shaahmadi Z, Heydari R. Mortality from aluminum phosphide poisoning in Kermanshah Province, Iran: Characteristics and predictive factors. Epidemiol Health. 2018;40:e2018022.

11. Tristan CD, Nugroho NA, Wijayanto MA, Kynaya EM, Ilyas MF. Autopsy findings and histopathological changes in aluminum phosphide-related death: A systematic literature review and meta-analysis. Egypt J Forensic Sci. 2025;15(1):28.

12. Bogale DE, Ejigu BD, Muche TA. Clinical profile and treatment outcome of aluminum phosphide poisoning in Felege Hiwot Referral Hospital, Northwest Ethiopia: A retrospective study. Open Access Emerg Med. 2021;13:239-48.

13. Singh RK, Tripathy S, Sinha S, Goyal K, Narain S. Mysterious death due to accidental inhalation of phosphine – a unique case study. Forensic Sci Int Rep. 2022;5:100264.

14. Hena Z, McCabe ME, Perez MM, Sharma M, Sutton NJ, Peek GJ et al. Aluminum phosphide poisoning: successful recovery of multiorgan failure in a pediatric patient. Int J Pediatr Adolesc Med. 2018;5(4):155-58.

15. Kumar S, Kumar Pannu A , Immanuel James R, Patild AN, Kwatra G, Bhalla A , et al. Meta-analysis of mortality burden due to Aluminum phosphide poisoning in India: A call for strong policy and decision making, Dialogues Health. 2025; 7: 100247.

16. Basnet A, Thapa AJ, Khadka M, Regmi B, Khadka M, Adhikari K, et al. Aluminum phosphide poisoning, an institutional experience: Case series, J Nepal Health Res Counc. 2022: 20(1): 251-56.

17. Behera C, Krishna K, Bhardwaj DN, Rautji R, Kumar A. A case of accidental fatal aluminum phosphide poisoning involving humans and dogs, J Forensic Sci. 2015;60(3): 818-21.

18. Hájek M, Chmelař D, Tlapák J, Rybárová V, Ondra P, Halouzka V. Accidental aluminum phosphide intoxication successfully treated with hyperbaric oxygen therapy: A case report, Toxics. 2024;12(4): 272.

19. Mantzke CM, Moreno NM, Shawhart JE. Accidental aluminum phosphide poisoning of a family and role of Impella® support: A case report, J Emerg Med. 2025;79: 330-35.

20. Shafahi A, Mostafazadeh B, Dadpour B, Inhalational toxicity of aluminum phosphide as an ongoing concern; A report of two cases, Arch Acad Emerg Med. 2019;7(1):e69.

21. Agarwal SS, Kumar L, Kumar S, Sheikh I. Homicidal aluminium phosphide poisoning, J Indian Soci Toxicol. 2005; 1(2): 49-50.

22. Abdelghafar S, Farrag TA, Zanaty A, Alshater H, Darwish A, Hassanien AE. Pattern and predictors of death from aluminum and zinc phosphide poisoning using multi-kernel optimized relevance vector machine. Sci Rep. 2023;13(1):8268.

23. Hadi N, Saleem A, Ullah Z, Khan MH. Electrocardiographic patterns as predictors of mortality in aluminum phosphide poisoning: A retrospective cohort single-center study. Cureus. 2025;17(4):e81713.

24. Yan H, Xiang P, Zhang S, Shen B, Shen M. Diagnosis of aluminum phosphide poisoning using a new analytical approach: Forensic application to a lethal intoxication. Int J Legal Med. 2017;131(4):1001-7.

25. Lehner A, Johnson M, Buchweitz JP. Phosphine detection in veterinary samples using headspace gas chromatography/tandem mass spectrometry with multiple reaction monitoring. Rapid Commun Mass Spectrom. 2020;34(13):e8738.

26. Imran M, Najamuddin N, Ghulam M, Mubasher M, Ashiq MI, Muhammad A, et al. Quantitative analysis of phosphine in variety of biological samples from two cases of fatal poisoning. Toxicologie Analyt Clin. 2024; 36(3): 270-77.

27. Berry A, Singh G, Kaur SJ, Bala K. Aluminium phosphide: Toxicity mechanism and credible treatments. World J Pharmacy Pharmaceutical Sci. 2015; 4(10): 2276-93.

28. Shadnia S, Soltaninejad K. Spontaneous ignition due to intentional acute aluminum phosphide poisoning. J Emerg Med. 2011;40(2):179-81.

29. Akhgari M. Aluminium phosphide poisoning and ignition in a forensic case. Toxicol Open Access. 2016;2(1):107.

30. Ahmad F, Khan MK, Mahmood A, Azmat J. Aluminum phosphide poisoning and blast in gastric tube: A case report. Asia Pac J Med Toxicol. 2019; 8:101-3.

31. Salimi A, Jamali Z, Shabani M. Antioxidant potential and inhibition of mitochondrial permeability transition pore by myricetin reduces aluminium phosphide-induced cytotoxicity and mitochondrial impairments. Front Pharmacol. 2021;12:719081.

32. Kariman H, Heydari K, Fakhri M, Shahrami A, Dolatabadi AA, Mohammadi HA, et al. Aluminium phosphide poisoning and oxidative stress. J Med Toxicol. 2012;8(3):281-4.

33. Anand R, Binukumar B, Gill KD. Aluminum phosphide poisoning: An unsolved riddle. J Appl Toxicol. 2011;31(6):499-505.

34. Mirakbari SM. The convergence of considerations in aluminum phosphide poisoning: The occurrence of injuries beyond the metabolic manifestations. J Res Med Sci. 2017;22:94.

35. El-Sarnagawy GN, Abdelnoor AA, Ghonem MM. Performance assessment of new Poisoning Mortality Score and PGI score for predicting mortality in patients with acute aluminum phosphide poisoning. Hum Exp Toxicol. 2025;43:9603271241302208.

36. Khodavysi M, Kheiripour N, Ghasemi H, Soleimani-Asl S, Fathi Jouzdani A, Sabahi M et al. How can nanomicelle-curcumin modulate aluminum phosphide-induced neurotoxicity?: Role of SIRT1/FOXO3 signaling pathway. AIMS Neurosci. 2023;10(1):56-74.

37. Agrawal VK, Bansal A, Singh RK, Kumawat BL, Mahajan P. Aluminum phosphide poisoning: Possible role of supportive measures in the absence of specific antidote. Indian J Crit Care Med. 2015;19(2):109-12.

38.Erfantalab P, Soltaninejad K, Shadnia S, Zamani N, HassanianMoghaddam H, Mahdavinejad A, et al. Trend of blood lactate level in acute aluminum phosphide poisoning. World J Emerg Med. 2017;8(2):116-20.

39. Tehrani H, Halvaie Z, Shadnia S, Soltaninejad K, Abdollahi M. Protective effects of N-acetylcysteine on aluminum phosphide-induced oxidative stress in acute human poisoning. Clin Toxicol (Phila). 2013; 51(1):23-28.

40. Jafari A, Baghaei A, Solgi R, Baeeri M, Chamanara M, Hassani S, et al. An electrocardiographic, molecular and biochemical approach to explore the cardioprotective effect of vasopressin and milrinone against phosphide toxicity in rats. Food Chem Toxicol. 2015;80:182-92.

41. Karimani A, Mohammadpour AH, Zirak MR, Rezaee R, Megarbane B, Aristidis Tsatsakis A et al. Antidotes for aluminum phosphide poisoning - An update. Toxicol Rep. 2018:5:1053-59.

42. Sulaj Z, Drishti A, Çeko I, Gashi A, Vyshka G. Fatal aluminum phosphide poisonings in Tirana (Albania), 2009-2013. DARU J Pharm Sci. 2015; 23(1):8.

43. Dabholkar S, Pirani S, Davis M, Khan M, Eddleston M. Suicides by pesticide ingestion in Pakistan and the impact of pesticide regulation. BMC Public Health. 2023;23(1):676.

44. Pangeni R, KC RK. Successfully managed case of celphos poisoning: a case report and review. J Nepal Health Res Counc. 2014;12(28):200-2.

45. Alinejad S, Zamani N, Abdollahi M, Mehrpour O. A narrative review of acute adult poisoning in Iran. Iran J Med Sci. 2017;42(4):327-46.

46. Kordrostami R, Akhgari M, Ameri M, Ghadipasha M, Aghakhani K. Forensic toxicology analysis of self-poisoning suicidal deaths in Tehran, Iran: trends between 2011-2015. DARU J Pharm Sci. 2017;25:15.

47. Bagherian F, Kalani N, Rahmanian F, Abiri S, Hatami N, Foroughian M, Mehramiz NJ, Shahi B. Aluminum phosphide poisoning mortality rate in Iran: a systematic review and meta-analysis. Arch Acad Emerg Med. 2021;9(1):e66.

48. Alnasser S, Hussain SM, Kirdi TS, Ahmed A. Aluminum phosphide poisoning in Saudi Arabia over a nine-year period. Ann Saudi Med. 2018;38(4):277-83.

49. Qureshi MA, Nadeem S, Ahmed T, Tariq F, Rehman H, Qasim AP. Aluminium phosphide poisoning: clinical profile and outcome of patients admitted in a tertiary care hospital. Ann Punjab Med Coll. 2018;12(3):191-4.

50. Wahab A, Zaheer MS, Wahab S. Aluminium phosphide poisoning: clinical characteristics and outcome. Pak Armed Forces Med J. 2011;61(3):486-7.

51. Rahim A, Ullah N, Alam I. Etiological and clinical profile of patients presenting with acute poisoning to a teaching hospital. J Postgrad Med Inst. 2018;32(1):54-59.

52. Kanchan T, Menezes RG, Kumar TS, Bakkannavar SM, Bukelo MJ, Sharma PS, et al. Toxicoepidemiology of fatal poisonings in Southern India. J Forensic Leg Med. 2010;17(6):344-7.

53. Karunarathne A, Bhalla A, Sethi A, Perera U, Eddleston M. Importance of pesticides for lethal poisoning in India during 1999 to 2018: a systematic review. BMC Public Health. 2021;21(1):1441.

54. Morovatdar N, Moradi-Lakeh M, Malakouti SK, Nojomi M. Most common methods of suicide in Eastern Mediterranean Region of WHO: a systematic review and meta-analysis. Arch Suicide Res. 2013;17(4):335-44.

55. O'Malley M, Fong H, Sánchez ME, Roisman R, Nonato Y, Mehler L. Inhalation of phosphine gas following a fire associated with fumigation of processed pistachio nuts. J Agromedicine. 2013;18(2):151-73.

56. Lemoine TJ, Schoolman K, Jackman G, Vernon DD. Unintentional fatal phosphine gas poisoning of a family. Pediatr Emerg Care. 2011 Sep;27(9):869-71.

57. Soltaninejad K, Nelson LS, Bahreini SA, Shadnia S. Fatal aluminum phosphide poisoning in Tehran-Iran from 2007 to 2010. Indian J Med Sci. 2012;66(3-4):66-70.

58. Khalifa HK, Masoud WM, Elmansy AM. Arterial blood gases and serum cortisol level as predictors for mortality in acute aluminum phosphide poisoned patients: a prospective cohort study. Toxicol Rep. 2024;14:101865.

59. Ghonem MM, Abdelnoor AA, Hodeib AA. Shock and modified shock indices in predicting poisoning severity and outcomes in acute aluminum phosphide poisoned patients. Toxicol Res (Camb). 2024. 13(1):tfad124.

60. Meena MC, Mittal S, Rani Y. Fatal aluminium phosphide poisoning. Interdiscip Toxicol. 2015;8(2):65-67.

61. El-Sarnagawy G, Hafez A, Amer R. Characteristics of suicidal poisoned patients admitted to tertiary care center during COVID-19 pandemic. Egypt J Neurol Psychiatry Neurosurg. 2022;58:138.

62. El-Farouny R, Helmy M. Suicidal self-poisoning and its relation with personality traits among admitted cases to Menoufia poisoning control center. Egypt J Forensic Sci Appl Toxicol. 2021;21:13-30.

63. Valipour R, Shekari A, Setareh M, Soltaninejad K. Pattern of suicide methods and postmortem toxicological findings in suicide-related deaths: A retrospective 7-year forensic-based study in Iran. Am J Forensic Med Pathol. 2021;42(1):23-29.

64. Wang B, Han L, Wen J, Zhang J, Zhu B. Self-poisoning with pesticides in Jiangsu Province, China: A cross-sectional study on 24,602 subjects. BMC Psychiatry. 2020;20 (1):545.

65. Doğan E, Güzel A, Çiftçi T, Aycan I, Çelik F, Çetin B et al. Zinc phosphide poisoning. Case Rep Crit Care. 2014;2014:589712.

66. Shi L, Jian T, Tao Y, Li Y, Yu G, Zhao L. et al. Case report: acute intoxication from phosphine inhalation. Int J Environ Res Public Health. 2023;20(6):5021.

67. Moirangthem S, Vidua R, Jahan A, Patnaik M, Chaurasia J. Phosphine gas poisoning: A case report. Am J Forensic Med Pathol. 2023;44(4):350-353.

68. Yan H, Chen H, Li Z, Shen M, Zhuo X, Wu H, et al. Phosphine analysis in postmortem specimens following inhalation of phosphine: Fatal aluminum phosphide poisoning in children. J Anal Toxicol. 2018;42(5):330-6.

69. Hashemi-Domeneh B, Zamani N, Hassanian-Moghaddam H, Rahimi M, Shadnia S, Erfantalab P, et al. A review of aluminium phosphide poisoning and a flowchart to treat it. Arh Hig Rada Toksikol. 2016;67(3):183-93.