Revisiting Endosulfan
A 17-year-old female presented with history of ingestion of about 35 ml of an insecticide (containing endosulfan 35% EC) 4 hours ago following which she developed continuous involuntary jerky movements and associated up-rolling of eyes and frothing from the mouth. She was taken to the local hospital where she was given benzodiazepines and phenytoin, intubated and mechanically ventilated and rushed to our center for further care. Glasgow coma scale was 3 on arrival. Activated charcoal was given and the prior gastric lavage sample was sent for analysis. The patient continued to seize and midazolam and lorazepam infusions were given with no benefit followed by phenobarbital and propofol. Seizures persisted and Levetiracetam was tried but in vain. Hypotension was noted and inotropic support added. Blood gas analysis showed high anion gap metabolic acidosis. ECG showed sinus tachycardia with ST depressions in II, III, AVF, and V4-V6. 2D Echo showed paradoxical motion of intraventricular septum with dilated right atrium and ventricle without PAH. Labs showed TWBC-44,800 which subsided over the next few days. S creatinine increased from 1.75 to 6.06 mg/dL and SGPT from 19 to 473 IU/L. S-Ca- 7.3 mg/dl; S Mg- 3.1 mg/dL; LLDH- 3347 U/L. The peak serum concentration of endosulfan was 1.82 mg/L about 23 hours after ingestion. Supportive treatment with antibiotics, hemodialysis and hydration continued. CT brain showed evidence of cerebral edema []. Electroencephalogram (EEG) was suggestive of severe anoxic/ischemic encephalopathy. Chest X-ray (CXR) showed mild ground glassing on the right. Multi-organ failure was noted with acute kidney injury, hepatitis, acute lung injury, myocardial depression, and encephalopathy. Her seizures were unrelenting and she developed multiple episodes of bradycardia and cardiac arrest before finally succumbing to death.