The Open Urology & Nephrology Journal




ISSN: 1874-303X ― Volume 12, 2019
CASE REPORT

Acute Kidney Injury as a Rare Complication of Prallethrin Poisoning (“All-Out”) in a Child



Anjana KS1, Raghunath CN1, *, Arvind C2
1 Department of Pediatrics, Sagar Hospitals, Bengaluru, Karnataka, India
2 Department of Nephrology, Sagar Hospitals, Bengaluru, Karnataka, India

Abstract

Pyrethroids are widely used as commercial and domestic insecticides due to their high effectiveness and low toxicity in humans and in medicine for the topical treatment of scabies and head lice. Prallethrin is a structural derivative of naturally occurring pyrethrin and active ingredient in liquid mosquito repellents. Acute human poisoning from exposure or ingestion of pyrethroids is rare because of poor dermal absorption and rapid metabolism with little tissue accumulation. Here we present a case of accidental Prallethrin poisoning(“ALL –OUT”, a liquid mosquito repellent) in a five year old child who had immediate complication as hypovolemic shock with aspiration pneumonia and delayed complications like acute kidney injury, with elevated liver enzymes, requiring renal replacement therapy and had an uneventful recovery.

Keywords: Prallethrin, Poisoning, Insecticide, Paresthesias, Acute kidney injury, Peritoneal dialysis.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 12
Issue: Suppl-1, M6
First Page: 53
Last Page: 55
Publisher Id: TOUNJ-12-53
DOI: 10.2174/1874303X01912010053

Article History:

Received Date: 11/02/2019
Revision Received Date: 24/05/2019
Acceptance Date: 30/05/2019
Electronic publication date: 31/07/2019

Article Metrics:

CrossRef Citations:
0

Total Statistics:

Full-Text HTML Views: 554
Abstract HTML Views: 325
PDF Downloads: 194
ePub Downloads: 192
Total Views/Downloads: 1265

Unique Statistics:

Full-Text HTML Views: 367
Abstract HTML Views: 199
PDF Downloads: 135
ePub Downloads: 119
Total Views/Downloads: 820
Geographical View

© 2019 KS et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Pediatrics, Sagar Hospitals, Bengaluru, Karnataka, India; E-mail: raghu.picu@gmail.com





1. INTRODUCTION

Prallethrin – is a Type 1 Pyrethroid compound, commercially available as “ALL –OUT” – a liquid mosquito repellent. Its main effect is on sodium and chloride channels. Pyrethroids modify the gating characters of voltage-sensitive sodium channels to delay their closure. When the channels are kept persistently open, the nerves cannot repolarize and the organism is paralysed. The insects are 2250 times more toxic to the insects than to the humans [1Bradberry SM, Cage SA, Proudfoot AT, Vale JA. Poisoning due to pyrethroids. Toxicol Rev 2005; 24(2): 93-106.
[http://dx.doi.org/10.2165/00139709-200524020-00003] [PMID: 16180929]
]. Reports of human pyrethroid poisoning are rare. Acute kidney injury is an uncommon presentation as most patients are present with neurologic manifestations. Here we report a case of Prallethrin poisoning due to accidental consumption in a boy, manifesting with acute kidney injury and discuss the relevant literature.

2. CASE REPORT

A five-year-old male child, a known case of Down syndrome was brought to the emergency room with a history of accidental ingestion of “All-Out” mosquito repellent liquid (Prallethrin 1.6% w/w liquid, 35 mL in each bottle, half bottle, approx. 15 ml) and one episode of vomiting. Child was initially managed in a peripheral hospital with gastric lavage and intravenous fluid administration. The child had a global developmental delay with no prior cardiac or renal diseases and was under early stimulation therapy and physiotherapy.

On admission, he was afebrile, tachycardic with heart rate of 140/min, low pulse volume, prolonged capillary refilling time(3-4 sec), blood pressure of 80/60 mmHg (<5th centile), Respiratory rate of 26/min and SpO2 of 95% with room air. On examination, the child was drowsy with Glasgow coma Scale(GCS) 12/15 (E3 V4 M5), pupils constricted and bilaterally reacting to light. Oral cavity examination was normal . Systemic examination was found to be within normal limits.

Child was admitted in Pediatric ICU, kept nil per oral and managed with saline boluses, inotropic support (Dopamine), empirical antibiotics and other supportive measures. On evaluation Arterial blood gas analysis showed metabolic acidosis, (pH-7.2, PaCO2-51.2, HCO3-20.1), normal haemoglobin (11.1 mg/dl) and normal total counts (5700/cumm). CRP was not raised. Renal Function Tests, Liver Function Tests and serum electrolytes were found to be within normal limits. Pseudo-cholinesterase levels were found to be normal. As he improved clinically and became hemodynamically stable, inotropic support was weaned off.

On 6th day of admission, the child had decreased urine output (< 0.3 ml/kg/hr for 10 hours) with associated fever, periorbital oedema and respiratory distress. Further evaluation showed f an impaired renal function test (Blood urea nitrogen: 81mg/dL, Serum Creatinine: 3.92mg/dL). The Urine examination showed no proteinuria and the sediment was bland. ABG and Ultrasound abdomen were within normal limits. Urinary osmolality was 495.2 and the Fractional excretion of Sodium was elevated (19.6%). On chest x-ray, moderate pleural effusion which was probably secondary to hypersensitivity pneumonitis was detected on the right side and was drained using USG guided pig-tail catheter . The pleural fluid sent for analysis was found to be sterile.

Table 1
Blood investigations and interventions.


Fluid challenge followed by Furosemide infusion was given in view of low urine output, but there was no response and the renal function was further declined. Peritoneal dialysis was started and serum creatinine, blood urea and electrolytes were frequently monitored. Antibiotics were changed from Inj Clindamycin to Inj Cefotaxime in view of the raised CRP (126). On day 9 of hospital admission, the liver function test done was deranged (SGOT: 144U/L, SGPT: 1228U/L, Total bilirubin- 0.53mg/dL, Albumin- 2.3g/L, LDH- 554U/L) and he was started on N-Acetyl Cysteine and Albumin infusion. Liver enzymes were followed up and responded well to the treatment and reached the baseline in 3-4 days

Over a period of four days, no improvement was noted in the renal function, the serum creatinine level remained high (4.01/mg/dL) and the child was continued on peritoneal dialysis. The patient’s renal function gradually improved after 9 days of peritoneal dialysis as evidenced by increased urine output, decreased blood urea and serum creatinine levels. Peritoneal dialysis was stopped after 10 days. The patient was discharged after 17 days of hospital stay in a clinically stable condition.

3. DISCUSSION

Prallethrin – a Type 1 Pyrethroid compound, is an active compound in many insecticides. Its main effects are on sodium and chloride channels. Pyrethroids modify the gating characters of voltage-sensitive sodium channels to delay their closure. A protracted sodium influx (referred to as sodium tail current) results which, if it is sufficiently large or long, lowers the action potential threshold and causes repetitive tingling effect, which may be the mechanism of paresthesia. At relatively high concentrations, pyrethroids can also act on GABA-gated chloride channels, which may be responsible for the seizures [1Bradberry SM, Cage SA, Proudfoot AT, Vale JA. Poisoning due to pyrethroids. Toxicol Rev 2005; 24(2): 93-106.
[http://dx.doi.org/10.2165/00139709-200524020-00003] [PMID: 16180929]
]. Type 11 Pyrethroids (Deltamethrin & Fenvalerate) causes nerve membrane depolarisation and blockade leading to paralysis [2Aggarwal R, Diddee S. Organophosphate or organochlorines or something else....? Indian J Crit Care Med 2009; 13(1): 31-3.
[http://dx.doi.org/10.4103/0972-5229.53114] [PMID: 19881178]
]. Pyrethroids may have an effect on Calcium channels which are important in neuronal functioning, for neurotransmitter release, gene expression and electrical excitability in nervous system [3Chandra A, Dixit MB, Banavaliker JN. Prallethrin poisoning: A diagnostic dilemma. J Anaesthesiol Clin Pharmacol 2013; 29(1): 121-2.
[http://dx.doi.org/10.4103/0970-9185.105820] [PMID: 23494161]
]. Cardiac conduction disturbance due to prallethrin poisoning has been reported, which can probably occur due to its effect on sodium channels in the heart [4Bhaskar EM, Moorthy S, Ganeshwala G, Abraham G. Cardiac conduction disturbance due to prallethrin (pyrethroid) poisoning. J Med Toxicol 2010; 6(1): 27-30.
[http://dx.doi.org/10.1007/s13181-010-0032-7] [PMID: 20195813]
].

Acute human poisoning from exposure to pyrethroids is rarely reported. The outbreak of acute Deltamethrin poisoning in spray men of China in 1982 was the first case report of pyrethroid poisoning. After that, few reports of pyrethroid poisoning have been reported, mostly as occupational overexposure [2Aggarwal R, Diddee S. Organophosphate or organochlorines or something else....? Indian J Crit Care Med 2009; 13(1): 31-3.
[http://dx.doi.org/10.4103/0972-5229.53114] [PMID: 19881178]
]. Occupationally, the main route of pyrethroid absorption is through the skin. Inhalation is much less important but increases when pyrethroids are used in confined spaces. The main adverse effect of dermal exposure is paraesthesias which may resolve in 12-24 hours. Within minutes, pyrethroid ingestion can cause sore throat, nausea, vomiting and abdominal pain. There may be mouth ulceration, increased secretions and/or dysphagia. Systemic effects occur 4-48 hours after exposure. The principal life threatening events are coma, convulsions and severe hypersensitivity reactions [1Bradberry SM, Cage SA, Proudfoot AT, Vale JA. Poisoning due to pyrethroids. Toxicol Rev 2005; 24(2): 93-106.
[http://dx.doi.org/10.2165/00139709-200524020-00003] [PMID: 16180929]
]. Convulsions generally occur with consumption of doses above 500mg. The frequency of convulsions can be 10-30 times a day. Severe cases may be associated with pulmonary complications including aspiration pneumonitis and pulmonary oedema, some of which may be attributable to organic solvents in the formulation. Fatal doses of these compounds are not known exactly and as there is no specific antidote known, treatment is entirely supportive and symptomatic [5Ardhanari A, Srivastava U, Kumar A, Saxena S. management of a case of prallethrin poisoning-an unusual agent for suicidal ingestion. Sri Lankan Journal of Anaesthesiology 2011; 19(1): 51-2.
[http://dx.doi.org/10.4038/slja.v19i1.1879]
-7Bashir B, Sharma SG, Stein HD, Sirota RA, D’Agati VD. Acute kidney injury secondary to exposure to insecticides used for bedbug (Cimex lectularis) control. Am J Kidney Dis 2013; 62(5): 974-7.
[http://dx.doi.org/10.1053/j.ajkd.2013.04.020] [PMID: 23800651]
].

About 40% patients are present with atypical presentations [8Cha YS, Kim H, Cho NH, et al. Pyrethroid poisoning: features and predictors of atypical presentations. Emerg Med J 2014; 31(11): 899-903.
[http://dx.doi.org/10.1136/emermed-2013-202908] [PMID: 23959805]
]. In a retrospective study conducted among 59 pyrethroid poisoning cases, atypical presentations were seen in 22 patients (39.3%). In a retrospective study of 59 patients,, atypical presentations were seen in 22 patients and included low Glasgow Coma Scale (19 patients), respiratory failure requiring ventilator care (10 patients), hypotension (6 patients), acute kidney injury (6 patients), pneumonia (4 patients), seizure (2 patients) and death (2 patients) [8Cha YS, Kim H, Cho NH, et al. Pyrethroid poisoning: features and predictors of atypical presentations. Emerg Med J 2014; 31(11): 899-903.
[http://dx.doi.org/10.1136/emermed-2013-202908] [PMID: 23959805]
]. Our case had transient elevation of liver enzymes which can be attributed to the generation of reactive oxygen species causing damage to various membranous components of the hepatocytes [9Abdel-Tawab H. Amal Ramadan, and Jalloul Bouajila, “Amelioration of Prallethrin-Induced Oxidative Stress and Hepatotoxicity in Rat by the Administration of Origanum majorana Essential Oil,” BioMed Research International, vol. 2013, Article ID 859085, 11 pages, 2013. ]. In this case, there were no features suggestive of corrosive injury or mediastinitis that may later contribute to acute renal failure.

The first reported case of pyrethroid-induced toxic Acute Tubular Necrosis (ATN) was in a 66-year-old healthy woman receiving no prior nephrotoxic medications presented with extreme weakness, decreased urine output, and acute kidney injury following prolonged exposure to Permethrin spray in 2013 [7Bashir B, Sharma SG, Stein HD, Sirota RA, D’Agati VD. Acute kidney injury secondary to exposure to insecticides used for bedbug (Cimex lectularis) control. Am J Kidney Dis 2013; 62(5): 974-7.
[http://dx.doi.org/10.1053/j.ajkd.2013.04.020] [PMID: 23800651]
]. In our case, the AKI may not be just due to prallethrin and may well be due to hypotension/sepsis and this has to be kept in mind.

The signs and symptoms of Pyrethroid poisoning can be easily misdiagnosed as organophosphate or organochlorine poisoning. Atropine may be given to decrease secretions in cases with salivation and pulmonary edema. Low doses of atropine (0.5-10/mg) are generally sufficient as there is no inhibition of plasma cholinesterase [2Aggarwal R, Diddee S. Organophosphate or organochlorines or something else....? Indian J Crit Care Med 2009; 13(1): 31-3.
[http://dx.doi.org/10.4103/0972-5229.53114] [PMID: 19881178]
]. As there is no specific antidote, early diagnosis and aggressive supportive therapies are the only remedies to prevent mortality.

CONCLUSION

There is limited data on features of severe prallethrin poisoning and its manifestations, although the mechanisms of toxicity have been well described. Most cases of prallethrin poisoning present with neurological and gastrointestinal manifestations, while acute kidney injury is rarely reported. We report a rare case of severe prallethrin poisoning with acute kidney injury, that reversed completely following peritoneal dialysis.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

Not applicable.

CONSENT FOR PUBLICATION

Informed consent was obtained from the patient.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared None.

REFERENCES

[1] Bradberry SM, Cage SA, Proudfoot AT, Vale JA. Poisoning due to pyrethroids. Toxicol Rev 2005; 24(2): 93-106.
[http://dx.doi.org/10.2165/00139709-200524020-00003] [PMID: 16180929]
[2] Aggarwal R, Diddee S. Organophosphate or organochlorines or something else....? Indian J Crit Care Med 2009; 13(1): 31-3.
[http://dx.doi.org/10.4103/0972-5229.53114] [PMID: 19881178]
[3] Chandra A, Dixit MB, Banavaliker JN. Prallethrin poisoning: A diagnostic dilemma. J Anaesthesiol Clin Pharmacol 2013; 29(1): 121-2.
[http://dx.doi.org/10.4103/0970-9185.105820] [PMID: 23494161]
[4] Bhaskar EM, Moorthy S, Ganeshwala G, Abraham G. Cardiac conduction disturbance due to prallethrin (pyrethroid) poisoning. J Med Toxicol 2010; 6(1): 27-30.
[http://dx.doi.org/10.1007/s13181-010-0032-7] [PMID: 20195813]
[5] Ardhanari A, Srivastava U, Kumar A, Saxena S. management of a case of prallethrin poisoning-an unusual agent for suicidal ingestion. Sri Lankan Journal of Anaesthesiology 2011; 19(1): 51-2.
[http://dx.doi.org/10.4038/slja.v19i1.1879]
[6] Panda B. Niranjan Sahoo and Sumit Mandal. A Case Report on Pyrethroid Poisoning. Int J Recent Sci Res 2016; 7(6): 1193-4.
[7] Bashir B, Sharma SG, Stein HD, Sirota RA, D’Agati VD. Acute kidney injury secondary to exposure to insecticides used for bedbug (Cimex lectularis) control. Am J Kidney Dis 2013; 62(5): 974-7.
[http://dx.doi.org/10.1053/j.ajkd.2013.04.020] [PMID: 23800651]
[8] Cha YS, Kim H, Cho NH, et al. Pyrethroid poisoning: features and predictors of atypical presentations. Emerg Med J 2014; 31(11): 899-903.
[http://dx.doi.org/10.1136/emermed-2013-202908] [PMID: 23959805]
[9] Abdel-Tawab H. Amal Ramadan, and Jalloul Bouajila, “Amelioration of Prallethrin-Induced Oxidative Stress and Hepatotoxicity in Rat by the Administration of Origanum majorana Essential Oil,” BioMed Research International, vol. 2013, Article ID 859085, 11 pages, 2013.
Society Affiliation


Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents




Webmaster Contact: info@benthamopen.net
Copyright © 2019 Bentham Open