transfluthrin is a synthetic pyrethroid insecticide , available in the market as 0.88% w / w liquid vaporiser .
it is a repellent insecticide , generally used for the control of mosquitoes in the household .
it is also the primary insecticide in certain products for killing wasps and hornets , including their nests .
pyrethroids are 2250 times more toxic to insects than mammals because insects have increased sodium channel sensitivity , smaller body size , and lower body temperature . in humans , their ingestion give rise to burning facial sensation , itchy face sensation , tingling face sensation , paresthesia , skin irritation , mucosal irritation , respiratory tract irritation , headache , dizziness , nausea , epigastric pain , vomiting , anorexia , fatigue , muscle twitching , salivation , running nose , and convulsions .
a 25-year - old female was brought to the emergency department with a history of nausea , vomiting , dizziness , abdominal pain , and altered sensorium .
she had given history of ingestion of two bottles ( refills ) of mosquito repellent available in the house , 2 h before she was brought to the hospital .
( each refill containing 45 ml ( 396 mg ) transfluthrin ) . on examination ,
oral syrup charcoal 10 ml was given , and ryles tube was closed at proximal end for some time
tonic - clonic convulsions were observed after 1 h of admission in the emergency ward .
injection phenytoin 700 mg bolus , injection diazepam 10 mg , injection hydrocortisone 100 mg , injection frusemide 20 mg , were administered intravenously .
then patient was shifted to intensive care unit and midazolam 5 mg and propofol 100 mg ( 80 mg + 20 mg ) were administered intravenously .
endotracheal intubation was successfully performed with 7.5 mm i d endotracheal tube , and cuff was inflated and oxygen enrichment at 46 l / min via t - piece was initiated .
midazolam 4 mg / h and propofol 200 mg / h iv infusions were started .
neurophysician advised iv mannitol ( 20%)100 ml twice a day and iv phenobarbitone ( sos ) for seizures .
patient was seizure free for few hours but again seizures started , and not controlled even with repeat doses of phenytoin , midazolam , propofol , and phenobarbitone . at that time blood pressure was 80/40 mm of hg , respiratory rate was 35/min , pulse rate was 190/min , and spo2 was 95% .
serum potassium , calcium , and sodium were 2.98 mmol / l , 2.5 mmol / l and 129 mmol / l , respectively .
potassium chloride 1.5 g and hypertonic saline were administered . despite repeated doses of phenytoin , midazolam , propofol and phenobarbitone , seizures were not controlled .
patient was paralyzed by injection vecuronium 4 mg bolus and 4 mg / h iv infusion , and put on controlled mechanical ventilation ( cmv ) mode for elective ventilation .
blood pressure further decreased gradually and dopamine dose was increased and propofol infusion was stopped .
abg reports did not show any changes . computed tomography scan of brain and chest x - ray were normal .
patient was kept on a ventilator for 48 h electively and then gradually weaning started .
vecuronium and midazolam infusion were stopped , and mode of ventilation was changed to synchronized intermittent mandatory ventilation ( simv ) .
airway pressure support was set to 15 cm h2o with positive end expiratory pressure of 4 cm h2o .
patient 's pulse rate was 102 beats / min , blood pressure 132/82 mmhg and spo2 remained above 96% .
patient had total leucocyte count on day 1 of 7200/mm and it increased to 22,000/mm on the day 2 , 32,000/mm on the day 3 and 13,000/mm on the day 4 , all with neutrophilia without other signs of septicaemia , although antibiotics were continued .
after 48 h on ventilator , dopamine infusion was tapered down in next 6 h and then stopped .
about 6 h on simv mode , spontaneous respiration was noticed at 16 breaths / min .
patient started breathing spontaneously with adequate tidal excursion and followed verbal commands and then extubated .
respiratory rate was 25 breaths / min , blood pressure was 108/72 mmhg and pulse rate , 119/min .
patient was nebulised with mistabron 3 mg , repeated 8 hourly . patient was referred to psychiatrist for counselling .
on the day 4 , patient was shifted to ward and discharged uneventful from hospital on 7 day .
the pyrethrins are a pair of natural organic compounds normally derived from chrysanthemum cinerariifolium that have potent insecticidal activity .
pyrethrins are neurotoxins that attack the nervous systems of all insects . in the 1800s , it was known as 
zacherlin. they affect the flow of sodium out of the nerve cells in insects , resulting in repeated and extended firings of the nerves , causing the insects to die .
transfluthrin is a pyrethroid available at home as liquid mosquito repellent . in humans after oral ingestion highest levels of the transfluthrin in tissues are found in liver and kidney , lowest levels are found in the brain .
excretion is rapid , 74 - 90% in urine within 48 h. there are no indications of its accumulation in the body .
increased neutrophilic counts were a matter of worry because it was thought to be due to some fulminating infections , but there were no other signs of sepsis .
literature search revealed that the poison causes severe neutrophilocytosis , and this decreases over 34 days .
seizure in pyrethroid neurotoxicity is believed to be due to its ability to modify sodium , chloride and calcium channels of the neurons .
pyrethroids modify the gating characters of voltage - sensitive sodium channels to delay their closure .
if the delay is sufficiently long it lowers the action potential threshold and causes repetitive firing , which may be the mechanism of paraesthesia .
relatively high concentration of pyrethroids can also act on gaba - gated chloride channels , which may be responsible for the seizures .
convulsions generally occur after consumption of doses above 500 mg and their frequency can be 1030 times a day .
tachycardia in this case raises the possibility that the cardiac arrhythmia due to pyrethroid poisoning can occur due to its effect on sodium channels in the heart .
this patient had seizures not controlled by conventional drugs like phenytoin , midazolam , propofol and phenobarbitone .
the patient had to be paralysed and ventilated with management of haemodynamics , leading to successful recovery .
the seizures can however be resistant to standard anti convulsants and may need neuromuscular paralysis and controlled mechanical ventilation .
 transfluthrin is being used as fast acting insecticide and liquid mosquito repellent . 
 this is a case report of poisoning with transfluthrin ( 90 ml liquid containing 792 mg of transfluthrin ) by a 25-year - old female . 
 tonic - clonic convulsions were not controlled with conventional drugs . in intensive care unit , 
 patient was managed with muscle paralysis by neuromuscular blocking drug vecuronium and elective mechanical ventilation for more than 48 h under care of the anaesthesiologist with uneventful recovery . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION