A 48-year-old male, pharmacist by occupation was found lying unconscious on the floor of his chemist shop with a 50 cc syringe partially filled with carbolic acid (household phenol) by his side. He was immediately rushed to the emergency department of our hospital. On inquiry, his wife said that he was staying aloof for past 1 week. He was otherwise healthy and was not on any regular medication. There was no history of smoking or alcohol intake.\nOn examination, he was irritable, but still following simple command like showing tongue when asked for. His extremities were cold. He was pale but not icteric. He had tachycardia (heart rate 116/min, regular) with blood pressure of 86/56 mmHg. He was tachypnic with a respiratory rate of 40/min. No abnormality was detected in respiratory system and abdominal examination. He was moving all four limbs spontaneously and there was no apparent cranial nerve deficit. His left forearm was swollen with evidence of thrombophlebitis extending up to the arm []. Random Blood Glucose was 95 mg/dl. Initial blood gas revealed hypoxia, lactic acidosis and respiratory alkalosis with a compensated pH (pH 7.35, PO2 75.9 mmHg, on 12 L O2 by mask, PCO2 33.1 mmHg, HCO3 17.8 mmol/L, lactate 5.2 mmol/L). Electrocardiogram was unremarkable except sinus tachycardia. Echocardiogram showed prominent Right Atrium with mild Tricuspid Regurgitation (estimated Pulminary Artery Systolic Pressure 37 mmHg); Inferior Vena Caval diameter of 12 mm with large respiratory variation; no wall motion abnormality and global ejection fraction EF 55%.\nAfter an initial fluid bolus of 1000 ml Normal Saline (NS) over half an hour and 500 ml × 2 of NS over next one and a half hour, he was continued on NS 100 ml/h with intermittent boluses of Furosemide. Oxygen supplementation with 40% Venturi Mask was started to maintain Oxygen saturation SpO2 above 92%. He was also given other supportive therapy in the form of intravenous Pantoprazole as stress ulcer prophylaxis and Ondansetron. After 2 h in the ICU, he had improvement in blood pressure, normalization of serum lactate level (2.3 mmol/L) and sensorium. He confessed to the self-injection of intravenous phenol. He also revealed that he tried to consume “All Out” liquid (Mosquito repellent containing 1.6% Pyrethrin) but immediately vomited out. At this time, he was oliguric and progressively more tachypneic with worsening oxygenation status. Chest X-ray showed bilateral patchy infiltrate []. Initial laboratory investigations revealed normal complete blood count; high blood urea nitrogen (21.1 mg/dl) and S Creatinine 2 mg/dl with normal electrolytes; deranged liver function test (S Bilirubin 3.02 mg/dl, direct Bilirubin 0.14 mg/dl, aspartate aminotransferase AST 211 U/L. alanine aminotransferase ALT 95 U/L, alkaline phosphate ALP 95 U/L. lactate dehydrogenase LDH 2574 U/L); normal serum Amylase; deranged coagulation parameters partial thromboplastin time 63.7 min, control 26 min and prothrombin time 27.8 min, control 12.4 min); high creatine phosphokinase (447 U/L). Urine analysis showed hemoglobinuria and proteinuria 3+. After an initial trial of noninvasive ventilation for half an hour, he was intubated and started on mechanical ventilation support with low tidal volume strategy.\nAfter 6 h, he was still oliguric with 45 ml of dark urine [] (Total intake 3500 ml). There was evidence of intravascular hemolysis with low serum Haptoglobin. His G-6PD level was normal. Abdominal ultrasonography examination was unremarkable. Hemodialysis was initiated in view of oliguria persistent metabolic acidosis and probable fluid overload. On day 2 he developed thrombocytopenia (platelet count 100,000/dl). In the subsequent days in the ICU his hypoxia improved but he continued to remain anuric. He was successfully weaned off the ventilator on day 4. On day 5 he was shifted to the ward on oxygen supplementation with 4 L O2 by nasal prong (maintaining SpO2 of 95%), still anuric on daily hemodialysis. On day 14, he was discharged from the hospital with normalization of all parameters except kidney function. He was advised 3 times a week maintenance hemodialysis, at discharge. His kidney function tests normalized over the subsequent 8 weeks of follow-up.
A 20-year-old girl was brought to the emergency department with a history of sudden onset convulsions. There was no history of fever, drug usage, trauma, or any past history of convulsions before the onset of convulsions. The patient was given a single dose of intravenous (IV) diazepam 10 mg for control of generalized tonic-clonic convulsion but since control over the convulsions was achieved, a loading dose of phenytoin 1 g was given. As the convulsions persisted, propofol 50 mg IV was given, which controlled the convulsions. Computed tomography (CT) scan head revealed no abnormality. Electroencephalograpy could not be done due to lack of facilities. Blood sugar, electrolytes, and arterial blood gas analysis showed no deviation from normal values. Noninvasive blood pressure, electrocardiography, and oxygen saturation monitoring was done. The patient was then shifted to the intensive care unit (ICU) and IV infusion of midazolam 0.1 mg/kg/h was initiated and phenytoin 100 mg given 8 hourly. There was no episode of convulsions thereafter. The patient developed hypotension for which inotropic support was started. A central venous cannulation was done to guide the fluid therapy and titrate the dose of inotrope. Breathing was normal and there was no need to mechanically ventilate the patient.\nOn arrival in the ICU, the relatives accompanying gave some history of domestic dispute and doubt of ingestion of some substance. A Ryle's tube was inserted and gastric lavage given. The patient had complaint of nausea, vomiting, and abdominal discomfort for which symptomatic treatment was given. The patient's sensorium improved the next day and she gave the history of ingestion of contents of two bottles of mosquito repellent available in the house commercially marketed as All-Out (prallethrin 1.6% w/w liquid, 35 mL in each bottle, that is, total dose of 1120 mg). The patient had excessive secretions so atropine 0.6 mg IV was started at 4 hourly intervals, in addition to antiemetics and proton-pump inhibitors. The condition of the patient improved gradually and by 5th day the patient was shifted to the ward from where she was discharged on the 7th day.