Multi-organ Dysfunction Syndrome with Dual Organophosphate Pesticides Poisoning
A 27-year-old male was brought to the emergency department in an unconscious state. History from family members revealed that patient had ingested about 100 ml of preformed mixture (50:50) of dichlorvos and profenofos used as pesticide for agriculture purpose. He developed nausea, vomiting, abdominal cramps, difficulty in breathing and altered level of consciousness within 1 h of ingestion of poison. He had no significant past medical history or addiction. On arrival, approximately 6 h after ingestion, he was comatose with Glasgow coma scale of 3/15, pulse 94/min, respiratory rate 7/min, SpO2 85% on room air and systolic blood pressure 80 mm of Hg. His pupils were small in size with sluggish reaction to light and there were no focal neurological signs. There were coarse crepitations on chest auscultation. Examination of the abdomen and cardiovascular system was unremarkable. Clinical severity assessment showed severe poisoning: Acute physiology and chronic health evaluation (APACHE II) score 26, Glasgow coma scale of three and poison severity scale of three. He was immediately intubated, gastric lavage was performed and atropine, pralidoxime, bicarbonate infusion was started. Patient was shifted to intensive care unit on inotropic support. His initial investigations showed white blood cells 31400/mm3, hemoglobin 13.5 mg/dL, platelets 328000/mm3, random blood sugar 120 mg/dL, serum creatinine 1.73 mg/dL, serum lipase 425 U/L, serum glutamic-pyruvic transaminase (SGPT) 350 IU/L, serum glutamic oxaloacetic transaminase (SGOT) 310 IU/L, serum cholinesterase level 329/L and deranged coagulation profile (international normalized ratio 2.2 and activated partial thromboplastin time 97). Urine analysis revealed pH 5.5, specific gravity 1.030 and proteinuria. Arterial blood gas analysis on FiO2 28% was pH 7.03, PCO2 55 mm Hg, PO2 77 mm Hg and HCO3 of 7 mEq/L. Chest X-ray showed bilateral infiltrates. Other investigations, including creatinine phosphokinase, serum electrolytes were within normal limits. Electrocardiogram and computed tomography scan head were unremarkable. Hepatitis B surface antigen, hepatitis C virus and human immunodeficiency virus serology was negative.\nDuring 48 h after admission, his condition remained critical requiring inotropes, hemodialysis and ventilatory support. Arterial blood gas analysis showed persistent metabolic acidosis and hypoxia pH 7.14, PCO2 44, PO2 79, HCO3 13, PO2/FIO2 0.80. Creatinine phosphokinase increased to 10504 U/L. SGPT and SGOT peaked at 11320 IU/L and 15800 IU/L.\nDespite intensive resuscitation, the patient expired due to cardiac arrest 48 h after hospitalization.