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.
The patient was a 16-month-old boy who was admitted to our hospital’s emergency department with a 15-min history of nausea, shortness of breath, and dyspnea. He subsequently developed cyanosis and impairment of consciousness. Foreign body inhalation had initially been diagnosed and the Heimlich maneuver served as the urgent treatment, but no foreign body was coughed up. On physical examination, he was unconscious, bilateral pupil diameter was 3 mm and sluggishly reactive to light. He exhibited rapid and shallow breathing with nasal flaring. The three concave signs were positive. Lung auscultation revealed clear breath sounds present bilaterally. His pulse rate was 161 per minute, and the blood pressure was 75/35 mmHg. Generalized tonic-clonic convulsions were observed after 5 min of admission in the emergency ward. 10% chloral hydrate 5 ml (5 mg/kg) was firstly administered via enema. After intravenous access was available, 2 mg midazolam was administered intravenously twice with intervals of 5 min, as well as intramuscular injection of phenobarbital 0.1 g. Despite of these interventions, the patient kept having uncontrolled convulsions for about 35 min, then 20 mg propofol by intravenous infusion was given to finally control his seizures. The patient’s trachea was intubated during the treatment, and then he was transferred to the intensive care unit for mechanical ventilation. During the hospitalization, meperfluthrin poisoning was considered when his parents provided a critical information that they found an empty liquid mosquito repellent bottle (Jiaojie®) in the location where the patient’s symptoms onset. According to the instruction, nearly 30 ml of meperfluthrin containing 8 mg / ml, total dose of 240 mg, was ingested.\nAfter hospitalization, he presented with fever and had a total leucocyte count of 23,600/mm3 and C-reactive protein (CRP) of 116.4 mg/L on day 1. The chest radiograph (as arrowed in Fig. a) only revealed a little bilateral pulmonary exudate. Serum electrolytes, lactate dehydrogenase (LDH), creatine phosphokinase (CRK), alanine aminotransferase, aspartate aminotransferase and creatinine level were normal. Cholinesterase was 6188 U/L. Initial arterial blood gas (ABG) analysis showed pH 7.218, pO2 76 mmHg, pCO2 48.1 mmHg, HCO3 19.6 mmol/L, base excess − 8 mmol/L, plasma lactate 4.28 mmol/L. Cerebrospinal fluid (CSF) analysis and cranial computed tomography (CT) showed no abnormalities. On the second day of hospitalization, X-ray chest radiograph (as arrowed in Fig. b) showed multiple patchy and cord-like high-density shadows in the lungs bilaterally. Meanwhile, auscultation of the lungs revealed coarse crackles and wheezes. On day 3, Chest CT (Fig. ) revealed consolidation and atelectasis in the lower lobe of right lung and upper lobe of left lung, and multiple striated exudation could be seen in both lungs. On day 5, his X-ray chest radiograph (as arrowed in Fig. c) displayed consolidation and atelectasis in the right lower lobe and left upper lobe. His brain magnetic resonance imaging (MRI) (as arrowed in Fig. ) showed abnormal signal beside the anterior horn of the right lateral ventricle, and electroencephalogram (EEG) showed the diffused 2.0–4.0 Hz slow wave activity. Fiberoptic bronchoscopy revealed edema and congestion of mucous membrane without erosion or ulcers. The sputum culture gave a positive result for Hemophilus influenzae.\nAccording to the clinical symptoms, laboratory results and imaging findings, the patient was diagnosed with meperfluthrin poisoning, status epilepticus and severe pneumonia. Methylprednisolone (1 mg/kg every 12 h) by intravenous drip infusion and aerosolized beclomethasone dipropionate were prescribed to reduce pulmonary inflammation. Cefoperazone-sulbactam (60 mg/kg every 8 h) was administrated to control lung infection. Mannitol and monosialoteterahexosyl ganglioside were used to reduce intracranial pressure and protect injured nerve cells. He was successfully weaned off from the ventilator on day 15. Routine blood tests and CRP revealed no abnormalities after retesting. After a recheck on day 20, the chest X-ray radiograph (Fig. d) showed a significant improvement of the bilateral pulmonary exudate. After obvious symptoms relief, he was transferred to the rehabilitation department and the hyperbaric oxygen therapy was utilized for further neural repair. After a psychiatric consultation, he was discharged from the hospital on day 30. No symptoms had occurred after 12 months of follow up. The chronology of events was showed in Table .