Case Files 4 - Emergency/ Int Med: Dying From Within
Case Submission by Dr Jeffrey Lee (July 1st, 2011)

A 17 years old teenage boy was admitted to the wards after allegedly ingested 2 cups of Paraquat. Upon admission, he was vomiting profusely and multiple oral ulcers were seen upon inspection.

On investigation, his creatinine levels were raised from 168 μmol/ L on admission to 694 μmol/ L and >1000 μmol/ L over a week. The chest radiograph shows progressive changes suggestive of massive fibrosis.

Some questions to ponder:
  1. What is your immediate management of this patient should you be the House Officer attending to this patient?
  2. Give your full medical diagnosis of this patient from the information given.
  3. What are the other signs and symptoms you should look out for?
  4. What are the other complications you should be cautious of?
  5. What are the investigations need to be done, particularly for monitoring purpose?
Upon admission, a nasogastric tube was inserted and NG Fuller's earth and Mist Alba was administered STAT with adequate hydration till diarrhea. Activated charcoal was also administered and the boy was being considered for peritoneal dialysis should his blood urea raises to a critical level.

A new protocol from the Sarawak General Hospital advocates the use of immunosuppressive agents. The agent recommended was IV Cyclophosphamide and pulse therapy of Dexamethasone. These agents presumably modulate the immunoresponse and have a reno-protective effect. These therapy was commenced on this patient. While the renal function improved with 2 or 3 cycles of immunosuppresion, the lung could not be saved as fibrosis has started to set in.

Further questions:
  1. What are the dosage of the treatment given?
  2. What are the indications for the use of immunosuppresive agents? Should we use them for all paraquat poisoning?

2 referrals:

Xu Vin said...

IV cyclophosphamide 1.7 mg/kg/8h for 14 days, IV dexamethasone 10 mg /8h for 14 days.

indicated in severe paraquat poisoning (after mild but before fulminant stage) when there is lung injury to slow down lung fibrosis.

what was the dosage for dexa pulse therapy though?

Jeffrey said...

Very sorry for the long pause. The routine thing to do in paraquat poisoning will of course be the administration of Fuller's earth and Mist Alba to induce diarrhea, activated charcoal as well as hydration. Daily urine paraquat and Renal profile is indicated. CXR should be done at presentation as a baseline.
As for the immunosuppresion therapy, the patient should be started on IV Methylprednisolone 1g per day for the first 3 days.If you are in a district without methylpred, give a stat dose of hydrocortisone 200 mg and quickly refer. If renal impairment develop later, IV cyclophosphomide 15mg/kg/day for 2 days is given. However, if renal failure or respiratory complications(as indicated by PaO2<80mmHg) after methylprednisolone therapy, IV or oral dexamethasone 16 to 24mg per day can be given.

Additional cyclophosphomide and pulse methylpred can be given if patient develop respiratory failure.

Watch urine output. Start hemodialysis if reduced with positive urine paraquat.

Please don't forget to watchout for concurrent opportunistic infections during immunosuppresive treatments.

Hope this helps. Thanx :)