Document Type : Case Report
Authors
1 Dept of general medicine Government medical college and hospital sector 32 chandigarh
2 Dept of general medicine, government medical college and hospital , Chandigarh, India
3 Dept of general medicine ,government medical college and hospital sector 32 Chandigarh.
4 Dept of radiodiagnosis and imaging government medical college and hospital Chandigarh
5 Dept of general medicine government medical college and hospital Chandigarh
Abstract
Objective: Dependency on agriculture and the unregulated sale of paraquat makes it an easy
alternative for homicidal and suicidal use in developing nations. It kills by multiorgan failure,
predominantly pulmonary fibrosis, and ARDS. We report a case of alleged paraquat ingestion
with spontaneous pneumothorax, spontaneous pneumomediastinum, and pneumorrhachis.
Aim is to reinforce the importance of a high index of suspicion in early diagnosis when the
above findings are present with ARDS in absence of trauma and a history of alleged substance
ingestion.
Case Presentation: A 35-year-old male presented with loose stool occasionally bloody, oral
ulcers, yellow discoloration of eyes with fever, and decreased urine output for three days after
consuming some substance with his seafood. On examination, he had yellow discoloration of
eyes and oral mucosa along with multiple ulcers on the buccal region as well as the dorsum
of the tongue and lateral margins with generalized subcutaneous emphysema. In addition,
decreased air entry in the bilateral lung field and muffled heart sounds were present. He had
an acute hepatorenal failure and severe metabolic acidosis with respiratory failure. Urine tested
positive for myoglobin and muscle enzymes (creatinine kinase and LDH) were raised. He was
intubated and shifted to the intensive care unit. Injectable N-acetyl cysteine (NAC) for acute liver
failure was started with empirical antibiotics and intravenous fluids. We supplemented thiamine
and vitamin K, and hemodialysis was done in view of progressive renal failure. Radiological
evaluation showed spontaneous pneumothorax, pneumomediastinum, and pneumorrhachis
which were managed conservatively. His respiratory parameters worsened despite maximal
ventilatory support. Renal failure and metabolic acidosis worsened in spite of hemodialysis. He
succumbed to his illness on day five of admission and seven days after toxin ingestion.
Conclusion: We recommend that the sale of paraquat be restricted and regulated to avoid its
use for suicidal and homicidal purposes. More research is required to find measures to intervene
early and prevent pulmonary fibrosis. We propose that paraquat toxicity be considered early in a
patient with the triad in an atraumatic setting with acute respiratory distress syndrome (ARDS)
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