Case reports

Carmelo Denaro, Carla Giansiracusa, Anna Maria Falciglia, Mauro Gennaro, Nicoletta Comitini, Melpomeni DogramatziIl

Anesthesia and Resuscitation Unit, "Cannizzaro" Hospital, Catania

INTRODUCTION

The use of poractant alpha, already widespread in neonatal diseases and subsequently extended to adult pathologies (ARDS, acute lung damage, inhalation pneumonia) is producing extremely positive results. Having used Curosurf for roughly a year now with excellent results for the treatment of mono- and bilateral chest injuries, administering it via endotracheal route by bronchoscopy, through BAL with subsequent local instillation, we decided to extend its use to a case of accidental weed-killer poisoning, the clinical and bronchoscopic picture of which was similar to that of Acute Lung Injury (ALI) secondary to inhalation of gastric contents.

MEDICAL HISTORY NOTES

A 48-year-old man was transferred to our unit from a smaller hospital with the indication to admit him to the intensive care unit for dehydration shock secondary to fever and profuse diarrhea which had already lasted for a number of days. The patient was groggy but could easily be awoken, had no neurological deficits and presented with bilateral conjunctivitis and photophobia, hypotension, moderate dyspnea and hemogasanalytic data within normal limits. He was also suffering from profuse non-mucous diarrhea. Laboratory tests revealed leukocytosis, increased creatinine (2 mg/100ml) and azotemia (latent renal insufficiency?), but diuresis had been maintained. The chest X-ray appeared normal.

CLINICAL PICTURE

After consulting the infectologist, a diagnosis of suspected typhoid enteritis was made and chloramphenicol was administered by intravenous route, leading to a rapid improvement in the alvus in the course of the 24 hours that followed.

We had decided to transfer the patient to another department, given the stability of his vital parameters and hence the needlessness for him to remain in the Resuscitation Unit, when he unexpectedly presented with severe pulmonary edema (but with osmolarity 323!) requiring immediate intubation and controlled ventilation with FiO2 0.7 and Peep 10 in order to correct the significant levels of desaturation and hypoxia. Bilateral subconjunctival hemorrhages also become manifest combined with skin rash localized to the trunk area. The renal picture deteriorated, with oliguria and an increase in retention indices, to such an extent that we had to resort to the use of CVVHD (Continuous Veno-Venous Hemodialysis ) using the Prisma system. A significant increase in transaminases was also observed. None of the culture tests, including the repeated stool culture tests, nor the serodiagnosis test identified an infectious disease.

The chest X-ray now showed opacification of the upper left quadrant, and the hemogasanalytic parameters had become particularly worrying, revealing hypoxia with PaO2 78 with FiO2 0.7, low compliance and high resistance.

The bronchoscopic picture manifested an extremely inflamed mucosa in both bronchial hemisystems showing diffuse, slightly bleeding, erosions Suspecting an etiopathgenesis of poisoning, and insisting on the gathering of medical notes with the aid of family members we finally discovered that, 10 days earlier, the patient had used a weed-killer named Roundup 400 to eradicate weeds from the vegetable garden surrounding his house, without being sufficiently informed as to the hazardous nature of the substance and how to use it safely. He used the product without using a mask, on a particularly windy day, wearing normal clothing. Roundup is a weed-killer containing glyphosate (41%) and surfactants (59%), POEAs (polyoxyethylene-alkylamine and isopropylamine) which are added to it in order to facilitate the absorption and penetration of the foliage through a mechanism that is still not entirely understood, and which actually varies from one plant species to another. The surfactants are the ingredients of the weed-killer that are the most dangerous for humans. Acute intoxication manifests itself through symptoms such as irritation of the eyes, gastrointestinal and respiratory tracts.

In particular, a severe alteration in the function of the P450 cytochromes and their glutathione S-transferase activity takes place; this alteration is, moreover, thought to be the cause of the carcinogenic effects that may manifest themselves at a later date. In particular, it is thought to be the isopropylamine that brings about the alteration in the mucous membrane of the respiratory tract, leading to the emergence of erosions. the POEAs are also thought to alter the physiological surfactant at an alveolar level.

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TREATMENT

We decided to administer a 250 mg dose of Curosurf^® diluted in 100 ml of physiological solution, per lobe, carrying out bilateral BAL, followed by a 250 mg bolus in 7.5 ml of physiological solution per side.

In the hours immediately following the procedure, we observed a rapid improvement in the hemogasanalytic picture, which enabled us to reduce the O2 percentage and the PEEP. As from the next day, the patient was subjected to progressive weaning and, in the course of 48 hours, was breathing spontaneously with a T tube. A tracheotomy did, however, have to be carried out due to a decubitus ulcer caused by the TET cap leading to the onset of respiratory insufficiency due to obstruction of the upper airways.

After a few days, the patient was transferred to the nephrology department due to the persistence of the renal insufficiency, despite the fact that the CVVHD had been suspended 10 days earlier. The cannula was finally removed and the patient discharged from the hospital in good conditions

DISCUSSION

It is clearly evident that the use of porcine surfactant resolved the respiratory insufficiency and significantly modified the chest X-ray in addition to the clinical conditions of the patient with surprising rapidity. This enabled us to reduce the time spent by the patient under mechanical ventilation and that required for weaning him from the ventilator. The treatment of acute lung damage (ALI) from toxic substances using surfactant has not yet been reported in literature. The anti-poison centres in Milan and Pavia, which we consulted on several occasions, have never experienced a case of this type. In actual fact, there are no other existing cases involving such a prolonged latency of intoxication from glyphosate and its components, and such a serious clinical picture. After extensive research we discovered an American report regarding a patient who, 15 days after exposure, had suffered a respiratory and skin reaction of such gravity that admission to hospital and non invasive ventilation was required, but the said patient recovered within a period of 48 hours. Given the rapidity recovery that we observed, we would, without hesitation, recommend the use of the drug in the treatment of similar cases.

REFERENCES

1. Il Surfattante nella Patologia Respiratoria Acuta" Editor Nicola Dirozzi, Daniela Perrotta. Edizione fuori commercio Riservata ai Sigg.Medici SEEd srl in collaborazione con Chiesi Farmaceutici.

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