Cholestatic presentation of yellow phosphorus poisoning
A forty three-year-old gentleman presented to us after eight days of suicidal ingestion of one tube (35 g) of rodenticide paste (Ratol, containing 3% YP). He had history of daily alcohol intake of about 50-60 grams for the past 5 years without any history suggestive of underlying chronic liver disease or cirrhosis. He had no past history of jaundice. He denied history of ingesting any other drugs or toxins in the recent past.\nAfter self-limiting nausea and vomiting on the day of ingestion, he remained asymptomatic for 4 days. He observed dark-coloured urine and generalized itching on day 5 after ingestion. Pruritus was severe and disturbing his sleep. After being detected to have jaundice, by his local physician, he was referred to our institute on day 8 for further investigation.\nExamination revealed clinical jaundice with excoriation marks all over the body secondary to severe pruritus. His liver was palpable 4 cm below the costal margin and was firm in consistency. Detailed examination failed to show any stigma of underlying chronic liver disease, splenomegaly, or ascites. Cardiovascular and nervous system examination was observed normal and there were no bleeding diathesis. He was not in hepatic encephalopathy as assessed by normal mini-mental state examination score (MMSE). He reported the pruritus as 8 on a visual analogue score of 0 to 10.[]\nEvaluation showed a normal hemogram, with bilirubin of 22 mg/dL (0.2-2.0 mg/dL) with a direct fraction of 18 mg/dL, serum alanine amino transferase (ALT) of 58 IU/L (0-40 IU/L), aspartate amino transferase (AST) level of 100 IU/L (0-40 IU/L), alkaline phosphatase (AP) value of 277 IU/L (50-150 IU/L), and gamma glutamyl transferase (GGT) of 140 IU/L (20-40 IU/L). Prothrombin time was prolonged by 4 seconds, which normalized after vitamin K injection. Electrocardiogram and renal functions were normal.\nOther causes of liver disease were ruled out by negative HbsAg, anti-HCV, IgM anti-HEV, and IgM anti-HAV serology. His serum ceruloplasmin and ferritin levels were normal. Ultrasound scan of the abdomen was unremarkable, except for a fatty liver. Upper Gastrointestinal (GI) endoscopy showed no varices. After normalization of prothrombin time, liver biopsy was done on day 14 of ingestion, which showed enlarged hepatocytes, giant cell transformation, intrahepatic cholestasis and spotty hepatocyte necrosis with infiltration by lymphocytes and few eosinophils []. Histopathology has not shown any evidence of architectural distortion of hepatic lobule, fibrosis, cirrhosis, or regenerating nodules.\nThe patient never developed any clinical signs of acute liver failure. Pruritus was controlled with emollients, ursodeoxycholic acid, cholestyramine and sertraline. Liver function tests normalized and pruritus also improved over the next 3 weeks. Patient is currently asymptomatic after 4-months of follow-up.