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Mohanka R, Rao P, Shah M, Gupte A, Nikam V, Vohra M, Kohli R, Shrimal A, Golhar A, Panchwagh A, Kamath S, Shukla A, Patel P, Chattopadhyay S, Chaubal G, Shaikh Y, Dedhia V, Sarmalkar SS, Maghade R, Shinde K, Bhilare P, Nalawade R, As J, Shah S. Acute liver failure secondary to yellow phosphorus rodenticide poisoning: Outcomes at a center with dedicated liver intensive care and transplant unit. J Clin Exp Hepatol 2020; 11:S0973-6883(20)30149-3. [PMID: 33052182 PMCID: PMC7543916 DOI: 10.1016/j.jceh.2020.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/17/2020] [Accepted: 09/28/2020] [Indexed: 12/12/2022] Open
Abstract
Accidental or suicidal poisoning with yellow phosphorus or metal phosphides (YPMP) such as aluminum (AlP) zinc phosphide (Zn3P2) commonly cause acute liver failure (ALF) and cardiotoxicity. These are used as household, agricultural and industrial rodenticides and in production of ammunitions, firecrackers and fertilizers. In absence of a clinically available laboratory test for diagnosis or toxin measurement or an antidote, managing their poisoning is challenging even at a tertiary care center with a dedicated liver intensive care unit (LICU) and liver transplant facility. PATIENTS AND METHODS Patients with YPMP related ALF were monitored using standardized clinical, hemodynamic, biochemical, metabolic, neurological, electrocardiography (ECG) and SOFA score and managed using uniform intensive care, treatment and transplant protocols in LICU. Socio-demographic characteristics, clinical and biochemical parameters and scores were summarized and compared between 3 groups i.e. spontaneous survivors, transplanted patients and non-survivors. Predictors of spontaneous survival and the need for liver transplant are also evaluated. RESULTS Nineteen patients with YPMP related ALF were about 32 years old (63.2% females) and presented to us at a median of 3 (0 - 10) days after poisoning. YPMP related cardiotoxicity was rapidly progressive and fatal whereas liver transplant was therapeutic for ALF. Spontaneous survivors had lower dose ingestion (<17.5 grams), absence of cardiotoxicity, < grade 3 HE, lactate < 5.8, SOFA score < 14.5, and increase in SOFA score by < 5.5. Patients with renal failure need for CVVHDF and KCC positivity on account of PT-INR > 6.5 had higher mortality risk. Patients undergoing liver transplant and with spontaneous recovery required longer ICU and hospital stay. At median follow-up of 3.4 (2.6 - 5.5) years, all spontaneous survivors and transplanted patients are well with normal liver function. CONCLUSIONS Early transfer to a specialized center, pre-emptive close monitoring, and intensive care and organ support with ventilation, CVVHDF, plasmapheresis and others may maximize their chances of spontaneous recovery, allow accurate prognostication and a timely liver transplant.
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Key Words
- AKI, Acute kidney injury
- ALF, acute liver failure
- Acute Liver Failure
- CVVHDF, Continuous Veno-Venous Hemodiafiltration
- Continuous Veno-Venous Hemodiafiltration
- DDLT, Deceased donor liver transplant
- IEH, Ingestion to encephalopathy interval
- KCC, King College criteria
- LDLT, living donor liver transplant
- Liver Transplant
- MELD, Model for end-stage liver disease
- MOF, Multi-Organ Failure
- Multi-Organ Failure
- Plasmapheresis
- Rodenticide
- SIRS, systemic inflammatory response syndrome
- SOFA, sequential organ failure assessment
- YPMP, yellow phosphorus or metal phosphides
- Yellow Phosphorus
- Zinc Phosphide
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Affiliation(s)
- Ravi Mohanka
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Prashantha Rao
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Mitul Shah
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Amit Gupte
- Department of Hepatology, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, 400012, Maharashtra, India
| | - Vinayak Nikam
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Mihir Vohra
- Department of Hepatology, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, 400012, Maharashtra, India
| | - Ruhi Kohli
- Department of Liver Intensive Care, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, 400012, Maharashtra, India
| | - Anurag Shrimal
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Ankush Golhar
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Ameya Panchwagh
- Department of Liver Transplant Anesthesia, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, 400012, Maharashtra, India
| | - Saurabh Kamath
- Department of Liver Transplant Anesthesia, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, 400012, Maharashtra, India
| | - Akash Shukla
- Department of Hepatology, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, 400012, Maharashtra, India
| | - Priyesh Patel
- Department of Hepatology, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, 400012, Maharashtra, India
| | - Somnath Chattopadhyay
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Gaurav Chaubal
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Yasmin Shaikh
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Vidhi Dedhia
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Shivali S. Sarmalkar
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Ravikiran Maghade
- Department of Hepatology, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, 400012, Maharashtra, India
| | - Kavita Shinde
- Department of Liver Intensive Care, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, 400012, Maharashtra, India
| | - Priyanka Bhilare
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Rohini Nalawade
- Department of Liver Transplantation and HPB Surgery, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, Maharashtra, 400012, India
| | - Jacob As
- Department of Liver Intensive Care, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, 400012, Maharashtra, India
| | - Samir Shah
- Department of Hepatology, Global Hospital, 35, Dr. E Borges Road Opp. Shirodkar High School, Parel, Mumbai, 400012, Maharashtra, India
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Dharanipradab M, Viswanathan S, Kumar GR, Krishnamurthy V, Stanley DD. Yellow phosphorus-induced Brugada phenocopy. J Electrocardiol 2017; 51:129-131. [PMID: 28987296 DOI: 10.1016/j.jelectrocard.2017.08.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Metallic phosphides (of aluminum and phosphide) and yellow phosphorus are commonly used rodenticide compounds in developing countries. Toxicity of yellow phosphorus mostly pertains to the liver, kidney, heart, pancreas and the brain. Cardiotoxicity with associated Brugada ECG pattern has been reported only in poisoning with metallic phosphides. METHODS AND RESULTS Brugada phenocopy and hepatic dysfunction were observed in a 29-year-old male following yellow phosphorus consumption. He had both type 1 (day1) and type 2 (day2) Brugada patterns in the electrocardiogram, which resolved spontaneously by the third day without hemodynamic compromise. CONCLUSION Toxins such as aluminum and zinc phosphide have been reported to induce Brugada ECG patterns due to the generation of phosphine. We report the first case of yellow phosphorus-related Brugada phenocopy, without hemodynamic compromise or malignant arrhythmia.
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Affiliation(s)
- Mayakrishnan Dharanipradab
- Department of General Medicine, Indira Gandhi Medical College & Research Institute, Kathirkamam, Pondicherry 605009, India
| | - Stalin Viswanathan
- Department of General Medicine, Indira Gandhi Medical College & Research Institute, Kathirkamam, Pondicherry 605009, India.
| | - Gokula Raman Kumar
- Department of General Medicine, Indira Gandhi Medical College & Research Institute, Kathirkamam, Pondicherry 605009, India
| | - Vijayalatchumy Krishnamurthy
- Department of General Medicine, Indira Gandhi Medical College & Research Institute, Kathirkamam, Pondicherry 605009, India
| | - Daphene Divya Stanley
- Department of General Medicine, Indira Gandhi Medical College & Research Institute, Kathirkamam, Pondicherry 605009, India
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