Paraphenylenediamine: Blackening more than just hair
A 23-year-old female, school teacher by occupation, was brought to the emergency department, Medwin Hospital, Hyderabad, India in June 2010 with alleged history of consumption of hair dye (200 ml of 4% PPD-based emulsion-type hair dye) owing to suicidal ideation a day prior to presentation. She had been taken to a local hospital where an emergency tracheostomy was done for dyspnea and stridor. She was then referred to our hospital for further management. At presentation she had complaints of inability to open mouth, difficulty in swallowing, and cramps in hands in addition to generalized body pain. On examination she had trismus, calf tenderness, abdominal tenderness, guarding and rigidity, and both chvostek's and trousseau's signs were positive. Her urine was cola colored. Investigations obtained revealed hypocalcaemia (corrected calcium = 7.2 mg/dl) with normal sodium, potassium, creatinine, and phosphorus values. Intravenous correction with calcium gluconate (2 ampoules of 10% calcium gluconate with 100 mg elemental calcium in each ampoule slow intravenous and another 2 ampoules over 6 h) was given and cramps in hands subsided gradually. The quantity of PPD ingested was calculated to be 8 gm, which is considered toxic. As rhabdomyolysis is a well-known complication of PPD poisoning, her creatinine phosphokinase (CPK) was done which was 1 62 795 IU/L (normal 60-400 IU/L). Hydration was maintained to avoid renal failure secondary to rhabdomyolysis. Patient had intermittent apnea with hypoxia, which required mechanical ventilator support. Electrocardiogram (ECG) showed significant ST-segment depression in inferolateral leads and right bundle branch block with right axis deviation. Pre-existing underlying cardiac conditions, if any, were excluded by 2D-echocardiography. She was started on parenteral nutrition because of trismus. By day 7, her CPK was 286 IU/L; trismus improved, and endoscopic guided nasogastric tube placed which revealed severe erosive pan gastritis. By day 10, tracheostomy tube was decanulated and tracheostomy stump was closed. Later ECG was normalized except for an intraventricular conduction defect, which did not require any active medical therapy intervention. She was started on enteral feeds, which she tolerated well. She was counseled by psychiatrist prior to discharge. At follow up, she was completely asymptomatic.