Abstract
Zinc phosphide is a gray to black powder mainly used as a rodenticide. In contact with gastric fluid, it releases phosphine which is the main toxic material of this compound. Phosphine interferes with oxidative respiratory cycle of the cells, but is generally expected to manifest its toxicity with prodromal signs and symptoms including abdominal pain, nausea and vomiting, metabolic acidosis, and increased liver function tests. A 64-year-old man was referred to our center with the history of ingestion of three full table spoons of zinc phosphide powder with only a mild GI discomfort. Abdominal X-ray revealed radiopaque material in epigastric and abdominal right upper quadrant. Despite treatment with polyethylene glycol and completely normal vital signs and lab tests, he experienced sudden cardiac arrest 19 h after admission. Autopsy showed clues of focal myopathy and fibrosis with evidences of ischemia and congestion in cardiac tissue, pulmonary edema, shrunken bilateral kidneys, and nutmeg yellow liver. Toxicology panel confirmed the presence of phosphine and zinc phosphide in the gastric fluid. The patient deteriorated suddenly despite being completely symptom-free during the hours preceding cardiovascular arrest. Since the cardiopulmonary injury is the most rampant cause of early death, checking of the cardiac enzymes and cardiac monitoring could be beneficial for early detection and efficient management of these patients.
References
Hassanian-Moghaddam, H., Zamani, N., Rahimi, M., Shadnia, S., Pajoumand, A., & Sarjami, S. (2014). Acute adult and adolescent poisoning in Tehran, Iran; the epidemiologic trend between 2006 and 2011. Arch Iran Med., 17(8), 534–538.
Hassanian-Moghaddam, H., Shahnazi, M., Zamani, N., & Bahrami-Motlagh, H. (2014). Abdominal imaging in zinc phosphide poisoning. Emergency Radiology, 21(3), 329–331.
ZINC PHOSPHIDE - National Library of Medicine HSDB Database [Internet]. 2017 [cited 24 April 2017]. Available from: https://toxnet.nlm.nih.gov/cgi-bin/sis/search/a?dbs+hsdb:@term+@DOCNO+1059.
Prabhu, M. A., Agustinus, R., & Shenthar, J. (2016). Suicidal Zinc Phosphide Poisoning Unmasking Brugada Syndrome and Triggering Near Fatal Ventricular Arrhythmia. Pacing and Clinical Electrophysiology, 39(2), 198–201.
Sogut, O., Baysal, Z., & Ozdemir, B. (2011). Acute pulmonary edema and cardiac failure due to zinc phosphide ingestion. Journal of Emergency Medicine, 40(6), e117–e118.
Wilion, R., Lovejoy, F. H., & Jaegar, R. J. (1980). Latrigen acute phosphine poisoning aboard a grain freighter Epidemiological, clinical and pathological findings. JAMA, 244, 148–150.
Frangides, C. Y., & Pneumatikos, I. A. (2002). Persistent severe hypoglycemia in acute zinc phosphide poisoning. Intensive Care Medicine, 28, 223.
Orak, M., Ustündag, M., & Sayhan, M. B. (2008). Severe metabolic acidosis secondary to zinc phosphide poisoning. The Journal of the Pakistan Medical Association, 58, 289–290.
Saraf, V., Pande, S., Gopalakrishnan, U., Balakrishnan, D., Menon, R. N., Sudheer, O. V., et al. (2015). Acute liver failure due to zinc phosphide containing rodenticide poisoning: Clinical features and prognostic indicators of need for liver transplantation. Indian Journal of Gastroenterology, 34(4), 325–329.
Trakulsrichai, S., Kosanyawat, N., Atiksawedparit, P., Sriapha, C., Tongpoo, A., Udomsubpayakul, U., et al. (2017). Clinical characteristics of zinc phosphide poisoning in Thailand. Therapeutics and Clinical Risk Management, 14(13), 335–340.
Singh, S., Bhalla, A., Verma, S., Kaur, A., & Gill, K. (2006). Cytochrome-C oxidase inhibition in 26 aluminum phosphide poisoned patients. Clinical Toxicology, 44(2), 155–158.
Dua, R., & Gill, K. (2004). Effect of aluminium phosphide exposure on kinetic properties of cytochrome oxidase and mitochondrial energy metabolism in rat brain. Biochimica et Biophysica Acta—General Subjects, 1674(1), 4–11.
Doğan, E., Güzel, A., Çiftçi, T., Aycan, İ., Çelik, F., Çetin, B., et al. (2014). Zinc phosphide poisoning. Case Rep Crit Care., 2014, 1–3.
Haridas, A., Mukker, P., Hameed, S., & Ajith, P. G. (2016). Acute on chronic liver failure presentation of zinc phosphide poisoning: a concept elucidating case report. Int J Res Med Sci., 4(6), 2494–2496.
Dua, R., & Gill, K. (2001). Aluminium phosphide exposure: implications on Rat brain lipid peroxidation and antioxidant defence system. Pharmacology and Toxicology, 89(6), 315–319.
Nakakita, H., Katsumata, Y., & Ozawa, T. (1971). The effect of phosphine on respiration of Rat liver mitochondria. Journal of Biochemistry, 69, 589–593.
Zuryn, S., Kuang, J., & Ebert, P. (2007). Mitochondrial modulation of phosphine toxicity and resistance in Caenorhabditis elegans. Toxicological Sciences, 102(1), 179–186.
Anand, R., Binukumar, B. K., & Gill, K. D. (2011). Aluminum phosphide poisoning: an unsolved riddle. Journal of Applied Toxicology, 31, 499–505.
Sagah, G. A., Oreby, M. M., El-Gharbawy, R. M., & Ahmed Fathy, A. S. (2015). Evaluation of Potential Oxidative Stress in Egyptian Patients with Acute Zinc Phosphide Poisoning and the Role of Vitamin C. Int J Health Sci (Qassim)., 9(4), 375–385.
Oghabian, Z., & Mehrpour, O. (2016). Treatment of Aluminium Phosphide Poisoning with a Combination of Intravenous Glucagon, Digoxin and Antioxidant Agents. Sultan Qaboos Univ Med J., 16(3), e352–e355.
Nasa, P., Gupta, A., Mangal, K., Nagrani, S. K., Raina, S., & Yadav, R. (2013). Use of continuous renal replacement therapy in acute aluminum phosphide poisoning: a novel therapy. Renal Failure, 35(8), 1170–1172.
Hsu, C. H., Chi, B. C., Liu, M. Y., Li, J. H., Chen, C. J., & Chen, R. Y. (2002). Phosphine-induced oxidative damage in rats: role of glutathione. Toxicology, 179(1–2), 1–8.
Marashi, M., et al. (2015). Protective role of coenzyme Q10 as a means of alleviating the toxicity of aluminum phosphide: an evidence-based review. Tzu Chi Med J., 27, 7–9.
Asghari, M. H., Abdollahi, M., de Oliveira, M. R., & Nabavi, S. M. (2017). A review of the protective role of melatonin during phosphine-induced cardiotoxicity: focus on mitochondrial dysfunction, oxidative stress and apoptosis. Journal of Pharmacy and Pharmacology, 69(3), 236–243.
Baghaei, A., Solgi, R., Jafari, A., Abdolghaffari, A. H., Golaghaei, A., Asghari, M. H., et al. (2016). Molecular and biochemical evidence on the protection of cardiomyocytes from phosphine-induced oxidative stress, mitochondrial dysfunction and apoptosis by acetyl-L-carnitine. Environmental Toxicology and Pharmacology, 42, 30–37.
Zamani, N., Hassanian-Moghaddam, H., & RE Comment on Asghari et al,2017. (2018). On the mechanisms of melatonin in protection of aluminum phosphide cardiotoxicity. Archives of Toxicology, 92(5), 1905–1906.
Marashi, S. M. (2015). What really happens after zinc phosphide ingestion? A debate against the current proposed mechanism of phosphine liberation in zinc phosphide poisoning. Eur Rev Med Pharmacol Sci., 19(22), 4210–4211.
Hassanian-Moghaddam, H., Shahnazi, M., Zamani, N., Rahimi, M., Bahrami-Motlagh, H., & Amiri, H. (2014). Plain abdominal radiography: a powerful tool to prognosticate outcome in patients with zinc phosphide poisoning. Clinical Radiology, 69(10), 1062–1065.
Lall, S. B., Sinha, K., Mittra, S., & Seth, S. D. (1997). An experimental study on cardiotoxicity of aluminium phosphide. Indian Journal of Experimental Biology, 35, 1060–1064.
Siwach, S. B., Singh, H., Jagdish, K. V. K., & Bhardwaj, G. (1998). Cardiac arrhythmias in aluminium phosphide poisoning studied by on continuous holter and cardioscopic monitoring. Journal of the Association of Physicians of India, 46(7), 598–601.
Yogendranathan, N., Herath, H. M. M. T. B., Sivasundaram, T., Constantine, R., & Kulatunga, A. (2017). A case report of zinc phosphide poisoning: complicated by acute renal failure and tubulo interstitial nephritis. BMC Pharmacol Toxicol., 18(1), 37.
El Okle, O. S., Derbalah, A., & El Euony, O. (2016). Hepatic damage associated with fatal zinc phosphide poisoning in broiler chicks. Int J Vet Sci Med., 4(1), 11–16.
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We particularly thank the relatives of the patient for consenting to share the details of this case.
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HHM designed the study. PP, SKH and RF contributed in drafting the manuscript. NZ and HHM contributed to analysis and interpretation of data and assisted in the preparation of the manuscript. RF and NZ have contributed to data collection and interpretation, and critically reviewed the manuscript. All authors approved the final version of the manuscript.
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This study is part of a larger study with local ethics approval (IR.SBMU.RETECH.REC.1397.428).
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Parhizgar, P., Forouzanfar, R., Hadeiy, S.K. et al. Sudden Cardiac Arrest in an Asymptomatic Zinc Phosphide-Poisoned Patient: A Case Report. Cardiovasc Toxicol 20, 525–530 (2020). https://doi.org/10.1007/s12012-020-09578-2
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DOI: https://doi.org/10.1007/s12012-020-09578-2