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Aluminium Phosphide Poisoning: a Case Series at Two Hospitals in The Pyramid Journal of Medicine 2019; volume 2:21 Aluminium phosphide within the first 24 hours are cardiac dys- poisoning: A case series at two rhythmias.4 Correspondence: Friezland Oswatch, The The exact mechanism for AlP poisoning Yellow Pharmacy, Box 193, Mankayane, hospitals in the Manzini is not fully understood. It is thought that it Manzini, Eswatini Region, Eswatini inhibits Cytochrome C Oxidase, however, Tel.: +268.78313718. that has only been shown in-vitro and is E-mail: [email protected] 1 thought not to have such a significant effect Friezland Oswatch, 6 Key words: Weevil tablet, Aluminium 2 in humans. Others have suggested that for- Rodney H. Magwenya Phosphide poisoning, Eswatini, Poisoning in mation of highly reactive hydroxyl radicals 1 Africa. The Yellow Pharmacy, Mankayane, also leads to the fatal cellular respiratory Manzini, Eswatini; 2Outpatient 5 failure. Unfortunately, there is no known Acknowledgements: The authors would like Department, Mankayane Government antidote to aluminium phosphide poisoning, to thank the following who have contributed Hospital, Mankayane, Manzini, Eswatini however, several authors have suggested to the successful completion of this paper; supportive measures for treating patients Prof. Richard Heller for his expert critique, with mixed outcomes.7-11 Nompumelelo Nsibandze, Gcinekile Dlamini, Most reported cases in the literature are Khumbuzile Dlamini, Skhumbuzo Dlamini Abstract from India, Jordan, Morocco and Iran,6,9 (the data managers at both hospitals) for assisting with retrieval of the data, and others The absence of an antidote to with reported mortality rates well above 50%.4 However, not much information has who contributed to this document in one way Aluminium Phosphide (AlP) poisoning has or another but have not been mentioned here. been the subject of many studies. Very few, been published on AlP poisoning in Africa. if any, of these studies have described AlP In Eswatini AlP is commonly known as Contributions: FO, the conception of work, poisoning cases in Africa. This study report- “Weevil Tablet” and incidents of its misuse manuscript writing, acquisition, analysis of ed on AlP poisoning and its management at are so common that entering the phrase data, reference search, critically revising the Mankayane Government Hospital (MGH) “Weevil Tablet” on the online search engine paper for important intellectual content and and Raleigh Fitkin Memorial Hospital “Google”, will yield top results on news approvingonly final version to be published; (RFMH), both in the Manzini region of articles about poisonings with AlP in RHM, data collection, analysis, references Eswatini. This was a retrospective case Eswatini. Lawmakers have been aware of search, reviewing paper for important intellec- series at MGH and RFMH for AlP poisoning this public health issue, and a law on the tual content and approval of the final version for publication. victims for the period April 1st 2016 to control of AlP tablets was proposed as far 12 use March 31st 2017. Forty-two case records back as 2009. Currently, there is no known law enforcing the sale or use of AlP in Conflict of interest: The authors report no con- met the inclusion criteria comprising 26 flict of interest. (62%) females and 16 (38%) males and the Eswatini. Nevertheless, the ministry of agri- number of deaths reported was 17 (41%). culture of Eswatini, through the director’s Funding: None. The most common presentation was office, issues a permit to individuals intend- hypotension (n=10, 24%). Twenty-two ing to purchase and use AlP for grain stor- Received for publication: 20 August 2019. (52%) patients received gastric lavage. age purposes. Despite these efforts, AlP is Revision received: 26 November 2019. 13 Activated charcoal was administered the still abused and inappropriately stored. Accepted for publication: 26 November 2019. most in the emergency departments of the This paper aims to highlight the existence respective hospitals. There is a need to of AlP poisoning, describe the general pre- This work is licensed under a Creative sentations and management of the poison Commons Attribution NonCommercial 4.0 develop standard treatment protocols for the License (CC BY-NC 4.0). treatment of ALP in both hospitals. Eswatini victims at two hospitals in the Manzini region of Eswatini. issues permit for regulating the sale of AlP ©Copyright: the Author(s), 2019 and efforts should be put in place to enforce Licensee PAGEPress, Italy the use of this tool. Pyramid Journal of Medicine 2019; 2:21 Non-commercialMaterials and Methods doi:10.4081/pjm.2019.21 Study design Introduction This study was a retrospective case Aluminium Phosphide (AlP) is a fumi- series carried out at Mankayane pitals were identified as AlP poisonings gant used for protecting grain against infes- Government Hospital (MGH) and Raleigh based on a combination of the following; tation from most forms of pests that attack Fitkin Memorial Hospital (RFMH), in the history, garlic odour in the breath, vomitus stored grains.1 It works by releasing phos- Manzini region, from the 1st of April 2016 or gastric washings and clinical presenta- 5 phine gas on contact with moisture.1 On to the 31st of March 2017. The sample of the tion. ingestion or absorption into the circulatory study was all ALP poison victims who pre- Patient demographics, nature of the AlP system, the phosphine gas (PH3) released sented during this period at the two hospi- taken, the time between exposure and pre- leads to multiple organ failure in humans.2,3 tals. This study received ethical approval sentation to hospital, the intention of poi- Ingestion of the poison can be con- from the Eswatini National Health Research soning, laboratory investigations, blood firmed with the silver nitrate test or a com- Review Board. pressure and first aid interventions were bination of history, garlic odour in the collected for analysis. breath, vomitus or gastric washings and Data collection clinical presentation.4,5 The most common Data were collected from the medical Statistical analysis manifestations of AlP are; cardiac dysfunc- record departments of MGH and RFMH This was an observational study, all data tion, metabolic acidosis and severe hospital. Patient files from the 1st of April collected were presented descriptively and hypotension.2 The common cause of deaths 2016 to the 31st of March 2017 at both hos- analysed using Microsoft Excel to sum- [page 56] [Pyramid Journal of Medicine 2019; 2:21] Article marise patient characteristics: mean, range, (either on ART or not), pregnant or have findings in other studies were common in mode and graphical representations. recently delivered. Considering the high these patients.2,4 prevalence of HIV in Eswatini and that this There was a wide selection of drugs is the prime childbearing age range for which was used in patients across the two women in Eswatini, these trends may be hospitals which was suggestive of a lack of Results purely coincidental.14 In addition, as these standard protocol in managing AlP poison- Between the periods of 1 April 2016 to trends were not actively sought after, these ing. In other published literature there are 31 March 2017, 42 files met the inclusion figures could be higher than what was commonly used drugs around which debate criteria with a population of 26 (62%) observed. Restlessness, lethargy, epigastric has been centred.2,8,15 This study did not females and 16 (38%) males (Table 1). The pain and vomiting which are consistent with encounter most of these drugs notably; average age of the sample was 28.3 years with a mode of 24 years, range of 17-74 years and the majority, 33 (79%), were aged below 35 years. Most cases were suicide Table 1. The relationship between patient characteristics on presentation to hospital, attempts, just as most patients ingested the nature of poison, intervention, previous medical history and patient outcome. tablet form of the poison and the total Variable Outcome deaths reported were 17 (41%). However, it Survived, Unknown, Died, seems most patients who vomited survived n (%) n (%) n (%) compared to the other patients (Table 1). Gastric lavage was done in 22 (52%) of Gender Male 10 (24) 1 (2) 5 (12) patients, and 11 (50%) died (Table 1). It is Female 14 (33) 0 (0) 12 (29) important to note that 10 out of the 11 Patient vomited patients who received gastric lavage and Yes 14 (33) 1 (2) 5 (12) died comprised 5 (50%) with a systolic No 10 (24) - 7 (17) reading of less than 90mmHg whereas, 12 Not documented only - - 5 (12) out of the 13 (92%) who survived without Nature of substance receiving lavage had systolic blood pressure Tablet 19 (45) 1(2) 16 (38) greater than 90mmHg with the exception of Powder 4 (10) - 1 (2.5) 1. Only, 37 patients had their blood pressure Unknown use 1 (2.5) - - recorded and patients with a systolic read- Intention of poisoning ing of less than 90mmHg were 10 (27%) Suicide 23 (55) 1 (2) 15 (36) and 7 (70%) of these patients died. Alleged homicide attempt 1 (2) - - Bradycardia was reported in 6 (17%) with Unknown - - 2 (5) deaths reported in 5 (83%) of the brady- Intervention cardic patients. The most common presenta- Gastric lavage 11 (50) - 11 (50) tion on arrival to the hospital was hypoten- No gastric lavage 13 (65) 1 (5) 6 (30) sion (n=10, 24%) (Figure 1). Activated Pre-hospital care charcoal was administered the most times in A/C and R/L given by EPR 1 (2.4) - - patients at the emergency departments of A/C given by EPR 1 (2.4) - - Given 8 tablets of A/C at the local clinic 1 (2.4) - - both hospitals (Figure 2). Given cooking oil at home 1 (2.4) - - The arrival time of 32 (76.2%) of the None 9 (21.4) - 3 (7.1) patients was noted, and 20 (62.5%) arrived Took milk & cooking oil at home, vomited 1 (2.4) - - within 3 hours of poison ingestion.
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