Successful treatment of paraquat poisoning: activated charcoal per os and "continuous hemoperfusion"

Effect of haemoperfusion on plasma paraquat concentration in vitro and in vivo

This study was to observe the paraquat (PQ) reduction rate after haemoperfusion (HP) on the groups of a relatively large number: 50 survivors out of 105 patients with acute PQ poisoning. We started off by measuring the clearance of haemodialysis (HD) and HP for the PQ in vitro. At the blood flow of 250 mL/min, the PQ clearance was greater in HP than in HD during the first 90 minutes: 215 versus 175 mL/min at 30 minutes, 213 versus 201 mL/min at 60 minutes, and 199 versus 179 mL/min at 90 minutes. The clearance in HP decreased rapidly after two hours. By the end of the dialysis, however, the final concentration in container decreased to 5.7 mg/mL in HD and 1.5 mg/mL in HP, which implied that although HD was cleared more effectively during the later stages, the overall elimination was greater in HP. Following this preliminary investigation, we performed HP on all the patients in order to assess the extracorporeal elimination.

One hundred and five patients who had swallowed one to three mouthfuls of PQ (24.5% w/v) solution were subjected to the in vivo study. The reduction rate of PQ was checked out by measuring the PQ concentration in plasma before and after four hours of HP. Seeing the reduction rate was significantly higher in the survivors group than in the nonsurvivors group (80.39 ± 19.9 versus 67.29 ± 19.2%, P <0.01), we concluded that adequate HP appears to be an indispensable treatment for patients with acute PQ poisoning.

Hemoperfusion for the treatment of poisoning: technology, determinants of poison clearance, and application in clinical practice

Hemoperfusion is an extracorporeal treatment based on adsorption, historically reserved for the treatment of acute poisonings. Its use was popularized in the 1970s after several in vitro and animal experiments had demonstrated its efficacy, and was even preferred over hemodialysis in the management of overdosed patients. With the advent of new and more efficient dialytic modalities, hemoperfusion is now less frequently performed in the Western world. However, hemoperfusion still remains popular in developing countries. The present article reviews the technique of hemoperfusion, the factors influencing poison clearance through adsorption and its current applications.

A bioconjugated design for amino acid-modified mesoporous silicas as effective adsorbents for toxic chemicals

A general synthetic method for functionalization of mesoporous silica with amino acid has been developed. The carboxylic acid functionalized SBA-15 was conjugated with l-phenylalanine (Phe) and l-tryptophan (Trp) to obtain nontoxic amino acid-conjugated functionalized mesoporous silica materials. The materials were used as adsorbents for the removal of the herbicide Paraquat (PQ) and its analog, ethyl viologen dibromide (EVB) from aqueous solutions. In comparison to the commercially available activated carbon adsorbents, the silica-based adsorbents prepared in this study exhibited relatively higher PQ removal efficiency in aqueous solutions at room temperature and pH 7.0. The silica-based adsorbents, pendant with amino acid moieties exhibited greater adsorption capacities toward PQ and EVB than the analogs but without the amino acid moiety, suggesting that there is a benefit for the enhanced π-π interaction between the aromatic groups of the conjugated amino acid moieties and the adsorbate. This bioconjugated method developed here provides a promising new tool to synthesize new materials for detoxification of herbicides in clinical trials.

Postmortem analyses unveil the poor efficacy of decontamination, anti-inflammatory and immunosuppressive therapies in paraquat human intoxications

Background

Fatalities resulting from paraquat (PQ) self-poisonings represent a major burden of this herbicide. Specific therapeutic approaches have been followed to interrupt its toxic pathway, namely decontamination measures to prevent PQ absorption and to increase its excretion from organism, as well as the administration of anti-inflammatory and immunosuppressive drugs. Until now, none of the postmortem studies resulting from human PQ poisonings have assessed the relationship of these therapeutic measures with PQ toxicokinetics and related histopathological lesions, these being the aims of the present study.

Methodology/Principal Findings

For that purpose, during 2008, we collected human fluids and tissues from five forensic autopsies following fatal PQ poisonings. PQ levels were measured by gas chromatography-ion trap mass spectrometry. Structural inflammatory lesions were evaluated by histological and immunohistochemistry analysis. The samples of cardiac blood, urine, gastric and duodenal wall, liver, lung, kidney, heart and diaphragm, showed quantifiable levels of PQ even at 6 days post-intoxication. Structural analysis showed diffused necrotic areas, intense macrophage activation and leukocyte infiltration in all analyzed tissues. By immunohistochemistry it was possible to observe a strong nuclear factor kappa-B (NF-κB) activation and excessive collagen deposition.

Conclusions/Significance

Considering the observed PQ levels in all analyzed tissues and the expressive inflammatory reaction that ultimately leads to fibrosis, we conclude that the therapeutic protocol usually performed needs to be reviewed, in order to increase the efficacy of PQ elimination from the body as well as to diminish the inflammatory process.

Toward a comprehensive approach to the collection and analysis of pica substances, with emphasis on geophagic materials

Background

Pica, the craving and subsequent consumption of non-food substances such as earth, charcoal, and raw starch, has been an enigma for more than 2000 years. Currently, there are little available data for testing major hypotheses about pica because of methodological limitations and lack of attention to the problem.

Methodology

In this paper we critically review procedures and guidelines for interviews and sample collection that are appropriate for a wide variety of pica substances. In addition, we outline methodologies for the physical, mineralogical, and chemical characterization of these substances, with particular focus on geophagic soils and clays. Many of these methods are standard procedures in anthropological, soil, or nutritional sciences, but have rarely or never been applied to the study of pica.

Principal Findings

Physical properties of geophagic materials including color, particle size distribution, consistency and dispersion/flocculation (coagulation) should be assessed by appropriate methods. Quantitative mineralogical analyses by X-ray diffraction should be made on bulk material as well as on separated clay fractions, and the various clay minerals should be characterized by a variety of supplementary tests. Concentrations of minerals should be determined using X-ray fluorescence for non-food substances and inductively coupled plasma–atomic emission spectroscopy for food-like substances. pH, salt content, cation exchange capacity, organic carbon content and labile forms of iron oxide should also be determined. Finally, analyses relating to biological interactions are recommended, including determination of the bioavailability of nutrients and other bioactive components from pica substances, as well as their detoxification capacities and parasitological profiles.

Significance

This is the first review of appropriate methodologies for the study of human pica. The comprehensive and multi-disciplinary approach to the collection and analysis of pica substances detailed here is a necessary preliminary step to understanding the nutritional enigma of non-food consumption.

Paraquat poisonings: mechanisms of lung toxicity, clinical features, and treatment

Paraquat dichloride (methyl viologen; PQ) is an effective and widely used herbicide that has a proven safety record when appropriately applied to eliminate weeds. However, over the last decades, there have been numerous fatalities, mainly caused by accidental or voluntary ingestion. PQ poisoning is an extremely frustrating condition to manage clinically, due to the elevated morbidity and mortality observed so far and due to the lack of effective treatments to be used in humans. PQ mainly accumulates in the lung (pulmonary concentrations can be 6 to 10 times higher than those in the plasma), where it is retained even when blood levels start to decrease. The pulmonary effects can be explained by the participation of the polyamine transport system abundantly expressed in the membrane of alveolar cells type I, II, and Clara cells. Further downstream at the toxicodynamic level, the main molecular mechanism of PQ toxicity is based on redox cycling and intracellular oxidative stress generation. With this review we aimed to collect and describe the most pertinent and significant findings published in established scientific publications since the discovery of PQ, focusing on the most recent developments related to PQ lung toxicity and their relevance to the treatment of human poisonings. Considerable space is also dedicated to techniques for prognosis prediction, since these could allow development of rigorous clinical protocols that may produce comparable data for the evaluation of proposed therapies.

Failure of continuous venovenous hemofiltration to prevent death in paraquat poisoning

Paraquat poisoning is characterized by multiorgan failure and pulmonary fibrosis with respiratory failure. Multiorgan failure with circulatory collapse is a major cause of early death within 3 days of paraquat ingestion. Recent studies suggested that continuous venovenous hemofiltration (CVVH) had a role in the treatment of multiorgan failure by promoting hemodynamic stability. We therefore evaluated the effect of prophylactic CVVH in 80 patients with paraquat poisoning (August 1996 to February 1999). The amount ingested was 2.1 +/- 1.0 mouthfuls (as 20% concentrate). All patients were treated with hemoperfusion (HP; duration, 6.4 +/- 3.0 hours) within 24 hours of ingestion and then randomly assigned to the HP-alone or HP-CVVH group. Forty-four patients underwent HP only, and 36 patients underwent CVVH (duration, 57.4 +/- 31.3 hours; ultrafiltration volume, 40.2 +/- 4.8 L/d) after HP. Although time to death after ingestion was significantly longer in the HP-CVVH than HP group (5.0 +/- 5.0 versus 2.5 +/- 2.1 days; P < 0.05), there was no difference in mortality rates between the two groups (66.7% versus 63.6%; P = 0.82). In the HP group, early circulatory collapse was a major cause of death compared with the HP-CVVH group, in which late respiratory failure was a major cause of death. In conclusion, prophylactic CVVH after HP prevented early death caused by circulatory collapse and prolonged survival time. However, it could not prevent late death caused by respiratory failure and did not provide a survival benefit in acute paraquat poisoning.

Evaluation of severity indexes of patients with paraquat poisoning

1. Three indexes for evaluating the severity of paraquat poisoning based on plasma-paraquat concentration are presently in use; the curves of Proudfood et al. and Scherrmann et al. and the SIPP. Their effectiveness in determining the prognosis of patients with paraquat poisoning was evaluated. 2. To determine which index was more accurate, contigency tables of the three indexes were obtained and compared; Proudfoot's curve vs the SIPP Scherrmann's curve vs the SIPP. Proudfoot's curve and the SIPP were applied to patients admitted within 24 h after intoxication. Scherrmann's curve and the SIPP were applied to patients admitted more than 24 h after intoxication. The proportions of patients with true positive and true negative results to total patients were compared by a ratio test. 3. Proudfoot's curve was found to be more accurate than the SIPP for predicting the prognosis of patients admitted within 24 h (P less than 0.05). No significant difference, however, was noted between Scherrmann's curve and the SIPP in determining the prognosis of patients admitted after more than 24 h. 4. In conclusion, Proudfoot's curve proved a better index for predicting the outcome of patients who were admitted within 24 h. However, for the prognosis of patients admitted more than 24 h after the ingestion of paraquat, further study is required.

An enzyme-linked immunosorbent assay for plasma-paraquat levels of poisoned patients

To investigate the efficacy of medical treatments, plasma-paraquat levels were measured in patients who had ingested the liquid weedkiller, Gramoxon, containing paraquat. We determined the levels by an enzyme-linked immunosorbent assay (ELISA) using a murine paraquat-specific monoclonal antibody developed by Niewola et al. (Clin. Chim. Acta, 148 (1985) 149-156). Using this ELISA, concentrations of paraquat in the range 1.56-100 ng/ml could be measured. This assay method had good precision and was suitable for measurement of low levels of paraquat. The therapeutic treatments were most effective on the day of admission. The plasma-paraquat levels of poisoned patients decreased significantly. However, the levels tended to increase again during the pause period of the haemoperfusion and this increase was serious for fatal cases. It is clear that elimination of poison not only from blood but also from tissues is necessary to lower the mortality rate.

Failure of haemoperfusion and haemodialysis to prevent death in paraquat poisoning. A retrospective review of 42 patients

In this review the efficacy of haemoperfusion in the treatment of paraquat poisoning is addressed. 42 reports containing sufficient information of paraquat-poisoned patients were evaluated. These reports, from 35 patients reported in the literature and 7 new cases, were chosen for the following reasons: the timed plasma paraquat concentrations were known, patient outcome was known, and details of haemoperfusion were available. In some cases, haemodialysis was also performed. The plasma paraquat concentrations and the specific times post-ingestion were plotted on a contour graph that predicts the probability of survival. Comparison of the predicted probability of survival versus the actual outcome showed that haemoperfusion, single or repeated, did not affect patient survival. None of the patients whose initial plasma concentrations were greater than 3 mg/L paraquat survived, regardless of the time after ingestion that the concentrations were measured, and despite haemoperfusion. Therefore, such patients might not be considered for haemoperfusion because of their uniformly bad prognosis, despite the procedure being used, and because of the morbidity, discomfort and cost associated with it. Clearly, the need for better techniques to remove paraquat and to prevent the consequences of the metabolic effects of the compound are required urgently before the treatment of the paraquat-poisoned patient will be successful.

Selective inhibition of bipyridyl-stimulated NADPH oxidation by ascorbic acid

The effect of the bipyridyl herbicides, paraquat and diquat (0.01-1.0 mM), on NADPH oxidation was determined in vitro using rat lung microsomal preparations. Experiments were performed in the absence of mixed function oxidation (MFO) substrates, in the presence of substrates (ethylmorphine or benzphetamine), and also in the presence of ascorbic acid (0.1-10.0 mM). NADPH oxidation was stimulated by both herbicides in the absence or presence of either substrate in a concentration-dependent manner. When ascorbic acid was included in incubations along with either bipyridyl, the stimulated rate of NADPH oxidation decreased in the presence of benzphetamine but the stimulation was unaltered in the presence of ethylmorphine or in the absence of substrate. These studies indicate that ascorbic acid may offer some protection from bipyridyl-mediated NADPH oxidation in rat lung microsomal fractions, but that protection appears to be dependent upon the simultaneous presence of specific MFO substrates.

Evaluation of paraquat concentrations in paraquat poisoning

The toxicological significance of paraquat concentrations in paraquat poisonings was evaluated by means of multivariate analysis methods. Paraquat could be determined by a newly developed procedure, which involved thin-layer chromatography with flame ionization detector (TLC-FID) and solid-phase extraction with a disposable octadecylsilane cartridge. This new method proved to be simple, rapid and reliable for the analysis of paraquat in our seven cases of suicidal poisoning. The relationship between plasma paraquat concentration (C) and time from ingestion (T) could be best described by the following functions. The regression equation of fatal cases was ln[ln(C X 1000)] = 2.5453 - 0.2114 lnT. The regression equation of survivors was ln[ln(C X 1000)] = 2.1041 - 0.2826 lnT. The discriminant function (D) to separate the fatal and survival cases was D = 1.3114 - 0.1617 lnT - 0.5408 [ln(C X 1000)] (fatal cases: D less than 0, survivors: D greater than 0). The discriminant function was demonstrated to have a high reliability for the toxicological significance in our seven poisoned patients. The significant correlation between plasma paraquat concentration and urine paraquat concentration (C') in our cases was obtained. The regression equation was lnC' = 0.953 lnC + 1.409. This also indicated that urinary concentrations are 3.3 - 4.5 times greater than plasma concentrations. The multiple regression equation among plasma paraquat concentration, time from ingestion, and the ingested volume (V) of Gramoxone (trade name of paraquat), was lnC = 0.009V - 0.232T + 3.612. It is suggested that the determination of paraquat is of great value, and that these data are useful in assessing the severity and predicting the outcome of poisoning for forensic and clinical purposes.

The new black magic: activated charcoal and new therapeutic uses

Activated charcoal has been used for centuries as antidotal therapy for poisonings. New variations of charcoal therapy have developed over the last two decades. These modifications include multiple-dose activated charcoal (MDAC) therapy, charcoal hemoperfusion, and a new "superactive" charcoal (SAC). Recent literature suggests using initial charcoal therapy instead of ipecac as a first-line antidotal agent for many acute poisonings. The palatability of charcoal slurries has been enhanced by the addition of carboxymethylcellulose, sucrose, saccharin, chocolate syrup, or sorbitol. The new SAC has shown to adsorb 1.7 to 4 times the amount of substance tested compared with other activated charcoal preparations. Multiple-dose activated charcoal therapy has been shown effective in treating phenobarbital, digoxin, digitoxin, theophylline, and dapsone intoxications, among others. The problems associated with charcoal hemoperfusion therapy have been partially alleviated, and it is now alternative therapy for the seriously intoxicated patient.

Repeated hemoperfusion and continuous arteriovenous hemofiltration in a paraquat poisoned patient

Prompt hemodialysis or hemoperfusion can be of value during the first 24 hours after paraquat ingestion particularly when the patient has developed acute renal failure. However, many cases of paraquat poisoning occur in areas where hemoperfusion facilities are unavailable. In contrast, continuous arteriovenous hemofiltration (CAVH) could be instituted easily. We have measured the removal of paraquat from the body by CAVH in a 46 year old male cane farmer who ingested 70 ml, 20% paraquat and died twelve days later from pulmonary fibrosis. Renal failure developed rapidly. Concentrations of paraquat were measured by an indirect competitive ELISA using a murine paraquat monoclonal IgG antibody. Hemoperfusion was performed daily for five days, beginning 78 hours post-ingestion. By 180 hours, when the patient was in respiratory failure, hemoperfusion was replaced with CAVH which was continued for 46 hours. During this time interval, 1.1 mg paraquat was recovered in the hemofiltrate and 1.56 mg paraquat in the urine. The extraction of paraquat by the hemofilter was close to 100%. The plasma clearance of paraquat across the hemofilter was 6.1 ml/min and the renal clearance was 8.2 ml/min. The mean hemoperfusion clearance of paraquat was 50 ml/min and the total amount of paraquat removed by the 34 hours of hemoperfusion was 9 mg. Because of the relative ease with which CAVH can be performed, its low cost, compared to that of hemoperfusion or hemodialysis, and the continuous nature of the procedure, CAVH may be worth considering in paraquat poisoning. It could be used particularly in those patients who have developed renal failure or while patients are being prepared for hemoperfusion.

Elimination of paraquat

There is a striking discrepancy between the efficacy of the kidneys, haemodialysis and haemoperfusion in removing paraquat from the body and the poor prognosis of paraquat poisoning even when the blood and urine concentrations (which are good indices of concentrations in lung and other tissues) are very low. Extracorporeal elimination techniques have been used world-wide in paraquat poisoning. Do they remove paraquat effectively? Certainly. Do they increase the survival rate? Probably not. The reason being that when these techniques of elimination are initiated, potentially lethal concentrations of paraquat have already been attained in the highly vascular tissues of vital organs and in pneumocytes. The data presented here suggest that the successful treatment of paraquat poisoning will not be achieved by modification of toxicokinetics.

Haemodialysis for paraquat poisoning

Paraquat can be removed by haemodialysis and haemoperfusion but, although clearance values are high, the quantities recovered are insignificant. Prevention of death is most unlikely except perhaps in patients with plasma paraquat concentrations very close to the previously proposed line separating concentrations in fatal cases and survivors at different time intervals. Even if delays incurred in measuring plasma paraquat concentrations and in setting up haemodialysis or haemoperfusion could be reduced to a minimum, elimination by these procedures would achieve little because paraquat disappears rapidly from the plasma in the first few hours after ingestion as it is taken up by the tissues and excreted into the urine. Further studies on patients at borderline risk are required and the value of 'continuous' haemoperfusion requires further assessment.

Hemoperfusion of Phencyclidine in the Dog

Experiments were conducted to determine whether charcoal hemoperfusion (HP) would be useful in severe phencyclidine (PCP) overdose. Dogs were given a single 5 mg/kg injection of PCP. In 6 experiments HP for 2.5 hours was done; and in 6 control experiments, the extracorporeal circuit contained no HP cartridge. The number of seizures, symptoms, duration of coma, and PCP concentrations in the tissues of HP dogs were not different from control. PCP clearance by HP was 67 ± 16.5 ml/min. PCP recovery by HP was 2.25 ± 0.25 mg (2.0% of the administered dose). Urinary excretion of PCP was 1.33 ± 0.46 mg (1.2% of the dose). Volume of distribution of PCP was 21.8 ± 1.7 L/kg. Due to the high volume of distribution, high lipid solubility and low plasma levels of PCP, HP was not effective in managing PCP overdose in the dog.