A CASE REPORT OF SUPERVASMOL POISONING

K Chinnu Kishore^*, M Gautham and Manoj Kumar Ravilla

^*Correspondence: K Chinnu Kishore, Department of General Medicine, Sree Balaji Medical College and Hospital, India, Email:

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Introduction

Ingesting hair dye as a deliberate self-harm technique has been well documented [1] and is becoming more common among rural Indians. Paraphenylenediamine (PPD), which is present in hair dyes in concentrations ranging from 2 to 10%, is a common component. Cervicofacial edema, mucosal damage, respiratory distress, abrupt renal failure, rhabdomyolysis, and cardiac infarction are among the major side effects of PPD when taken [2].

There are three different types of hair dyes: liquid, powder, and stone. Mortality is higher with the stone forms, whereas the liquid versions are more frequently consumed with the aim to commit suicide. We describe the case of 33 year old women who was brought after consumption of hair dye Super Vasmol.

Case Report

A 33-year-old lady was noticed by her parents lying unconscious home with blackish staining of her fingers and an empty bottle of Super Vasmol 33 (kesh kala: kesh meaning hair, kala meaning black) hair dye by her side. She was brought to a neighboring hospital where she experienced breathing problem and was eventually transported to our hospital after being intubated and given gastric lavage. She had chemosis and dramatic facial edema that extended to her neck when we first saw her. With a heart rate of 180 beats per minute, 80/40 mmHg was the blood pressure. With a gallop, a third heart sound heard. Urine that was coloured like coke was emptied from the bladder continuously. She was given 40 mL/kg of normal saline as resuscitation and was then admitted to the intensive care unit.

Her investigations showed a hematocrit of 31.7%. Total white cell count (5000 cells/cumm) with 92% neutrophils. Platelet count was 2.37 lakhs/cumm. Serum sodium was 144 mmol/L and potassium was 3.3 mmol/L. Serum creatinine was 1.7 mg/dL. Serum creatinine phosphokinase (CPK) was markedly raised (52933 U/L) with high levels of its MB fraction (CKMB- 510 ng/mL); troponin T was also very high (2389 pg/ mL). Liver function test showed elevated transaminases, (AST- 629 IU/L, ALT- 424 IU/L). Total bilirubin was 1.8 mg/dl with a direct fraction of 1.2. Total protein and albumin were 5.4 gm/dl and 3.2 gm/dl, respectively. Serum alkaline phosphatase was normal. Serum calcium was low (6.1 mg%) and phosphate was 3.5 mg%. Venous blood gas analysis showed pH 7.41, pCO2 5.7 kPa, pO2 4.8 kPa, HCO3 26 mmol/L. Serum lactate was 2.2 mmol/L and Met Hb was 1 gm%. Urinalysis revealed only RBC 2–4/HPF.

In the intensive care unit she was placed on a ventilator; dopamine was commenced. In view of rhabdomyolysis, the maintenance intravenous fluids were increased to 2 litres and bicarbonate was added. Urine output and pH and CPK levels were monitored. CPK rose to 85942 U/L at 12 hours but hemodialysis was deferred as her urine output remained good. By 36 hours CPK levels dropped to 31081 U/L and serum creatinine improved to 1.2 mg/ dL. She gradually improved with supportive care and was extubated on day 4 and later transferred to the ward. On the sixteenth day, she was walking with assistance and taking a liquid diet when she was finally allowed to leave the hospital. The left ventricle's size and functionality were normal on day 10 according to an ECHO (ejection fraction 57%). She was eating normally and had no after effects at the follow-up visit.

Discussion

Consumption of hair dye as a deliberate means of selfharm has been reported from different regions in India, Asia, and Africa. The typical subjects for whom this agent is affordable and easily accessible are rural, young, poor women [3]. A 100 mL emulsion with 4 gram of Paraphenylenediamine in the Super Vasmol 33 brand only costs Rs. 35. The weaker victims who may be using hair dyes only to frighten the family may believe that they are "not evil enough to kill." Hair colour can be purchased without generating concerns about suicidal intent, unlike the other regularly used organophosphates, especially in small towns with closed communities. In rural Africa, paraphenylenediamineis thought to have an abortive effect.

PPD is a permanent black coloring ingredient used in hair dyeing procedures along with ammonia and hydrogen peroxide [3,4]. For its darkening effect, it is also mixed to henna (Lawsonia alba) and employed in the widely practised tattooing [4]. By encouraging calcium ion leakage from the smooth endoplasmic reticulum, which leads to prolonged muscular contraction and an irreversible alteration in muscle structure, PPD has been demonstrated to cause rhabdomyolysis in rats [5].

Rhabdomyolysis can be harmful if it's severe and occurs in conjunction with high CPK levels. Despite having high initial CPK levels and serum creatinine, our patient responded to diuresis and improved without the need for dialysis. A significant side effect of PPD poisoning is acute renal failure, which is brought on by a combination of hypovolemia, toxic damage, and myoglobinuria [3,5]. Acute tubular necrosis has been identified as the most frequent finding in renal biopsy investigations [1,3,5], followed by myoglobin casts and interstitial nephritis [1,3]. In many individuals, anuria was linked to a poor prognosis and extended hemodialysis.

Less frequently observed but related with increased mortality in cases of hair dye poisoning are myocardial injury and myocarditis. The presence of myocarditis or rhabdomyolysis was suggested by extremely elevated cTnT and CKMB values. The diagnosis of cardiac involvement, which was previously only possible through autopsy, is now made through echocardiography. Angio coronarography showed myocardial infarction in 2006. Myocarditis is quite likely to be present in patients with elevated cTnT and CKMB levels.

Other constituents in Super Vasmol that are present in trace levels include resorcinol, propylene glycol, liquid paraffin, cetostearyl alcohol, sodium lauryl sulphate, sodium ethylenediaminetetraacetic acid (EDTA), herbal extracts, preservative, and perfume. On direct contact, resorcinol causes severe burns because it is caustic, acidic, and a protein denaturant. Consumption causes liver and kidney damage, convulsions, hemolysis, methemoglobinemia, pulmonary edema, mucosal injury, hypotension, and pulmonary edema [4].

Toxic effects of these ingredients could have had additive effect in our patient. Hair dye (Super Vasmol 33) poisoning is emerging as a suicidal poison that is available quite freely and extensively. There is no specific antidote for PPD and treatment is supportive [2,4,5]. Early treatment can prevent renal failure [2,4,5]. However, therapeutic dialysis and supportive therapy can result in complete recovery in those who developed renal failure [1,5]. Clinicians also have to be aware about the clinical manifestations and emergency airway management of this condition.

References

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