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Suicide With Endosulfan
A Case Report
A. Raaiskarimi, M.D.
Department of internal Medicine, SUMS
Abstract:
The case is a 17 year old girl, case of suicidal attempt by endosulfan, which had
interactable convulsions and finally developed cardiac arrest. Endosulfan is a
chlorinated insecticide that causes CNS hyperstimulation state. They are absorbed
from GI, skin or respiratory tract and lead to nausea, vomiting, paresthesia, giddiness,
convulsion, coma and respiratory failure. Hepatic, renal and myocardial toxicity,
agranulocytosis, aplastic anemia and skin reaction have also been reported. Mortality
and morbidity rates are high and there is no special treatment for this toxin.
Supportive cares for these patients include decontamination of skin, gastric lavage,
active charcoal, lidocaine for arrhythmia and treatment of status epilepticus.
Case Report :
A 17 years old teenage girl was brought to emergency room with cardiopulmonary
arrest. She was cyanotic, pulseless with 5mm fixed pupils. She ingested a glass of
endosulfan in a suicidal attempt one hour prior to arrest . Basic CPR was done for her
and after 15 min she had BP:110/70 and PR: 140/min regular rapid and deep
respiration. Due to intractable tonic-clonic convulsion, Diazepam , Phenytion and
Phenobarbital were given. She was transferred to ICU for mechanical ventilation and
supportive care. After 6 hours she developed cardiac arrest and didn't respond to CPR
and the expired in less than 12 hours after ingestion of endosulfan.
Discussion :
Endosulfan is a chlorinated insecticide or organochlorines like linden and DDT. It's
complete name is 1,4,5,6,7 Hexachloro8,9,10. Trinorborn - 5en -2,3 ylenebis
methylene sulphite and is used in agriculture . Most organochlorines are stored
indefinitely in human fat tissues and have estrogenic effect and enhance the risk of
breast cancer.
DDT & many of organochlorines have been banned or restricted by environmental
protection agencies world wide .These insecticides produce symptoms consistent with
CNS stimulation. They are absorbed from gastrointestinal and respiratory tracts and
skin. Acute poisoning is usually accompanied with nausea , vomiting , paresthesia ,
giddines , convulsion , coma and respiratory failure. Hepatic , renal and myocardial
toxicity , agranulocytosis , aplastic anemia and skin reaction have been reported. The
first known survivor after endosulfan ingestion has been reported in 19888. Form
1969 till 2000 eleven cases with endosulfan poisoning were reported that survived
after suicide. 3 cases had complete recovery and 8 cases survived with residual
morbidity including neurologic and psychiatric complications and renal failure 3-10.
All of the above cases and those who expired after poisoning had generalized tonicclonic convulsion . Management of endosulfan poisoning is supportive and there is no
antidote for it 1.
Supportive care include:
1- Decontamination of skin with soap and water .
2- Gastric lavage and activated charcoal.
3- Symptomatic treatment for CNS stimulation and classic therapy for status
epilepticus.
4- Lidocaine for cardiac arrhythmia. Atropine and epinephrine should be avoided in
organochlorine sensitized myocardium.
Summary :
Endosulfan is a very fatal poison that produces CNS stimulation and status
epilepticus. There is no specific therapy for this poison and management of
endosulfan poisoning is only supportive .
References :
1. Clinical Management of poisoning and drug over dosage. Haddad , shannon ,
Winchester 3rd edition 1998; p: 841-842.
2. The complete drug reference. Martin dale , 32nd edition 1999; p:1403-1406.
3. Boeroboom-FT, Van-DIJK-A, Van-Zoonen-P, Menlenbelt-J: Non accidental
endosulfan intoxication, a case report with toxicokinetic calculation and tissue
concentration. J-Toxicol-Clin-Toxicol -1998 36: 345-52 .
4. Pradhan-S, Pandey - N, Phadke-RV , Kaur-A, Sharma-K , Gupta-RK: Selective
involvement of basal ganglia and occipital cortex in a patient with acute endosulfan
poisening.J-Neurol-Sci-1997, 15:147:209-13.
5. Lo-RS, Chan-JC , Lockram - CS, Lai - FM : Acute tubular necrosis following
endosulfan insecticide poisoning. J-Toxicol -clin-toxicol-1995:33:67-9.
6. Sood-AK, Yadav-SP, Sood-S: Endosulfan poisoning presenting as status
epilepticus. Indian-J-Med-Sci 1994;48:68-9.
7. Blanco - Coronado-JL , Repetto-M, Ginestal -RJ, Vicente-JR:acute intoxication by
endosulfan. J-Toxicol-clin-toxicol-1992;30:575-83.
8.Shemesh-Y, Bourvine - A, Gold -D, Brancha-P: Survival after actue endosulfan
poisoning . J-Toxicol-Clin-toxicol 1988;26:265-8.
9. Aleksandrowicz-DR: Endosulfan poisoning and chronic brain syndrome : Archtoxicol-1979;43:65-8.
10. Demeter-J, Heyndrickx-A, Timperman-J, letevere-M, De-Beer-J: Toxicological
analysis in a case of endosulfan suicide . Bull-Environ-Contam-Toxicol-1997;18.1104.
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Copyright © 2000 by Shiraz University of Medical Sciences, Department of Internal
Medicine. All rights reserved.
Mahmood Beheshti, M.D.