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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 42-43

Zinc phosphide poisoning precipitating undiagnosed coronary artery disease: successfully managed


Specialist in Pulmonary Medicine, Former Doctor of Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India

Date of Submission10-Dec-2019
Date of Acceptance17-Jan-2020
Date of Web Publication17-Mar-2020

Correspondence Address:
Krittibus Samui
Jilipibagan Near Ata Chaki, Sripally, Burdwan - 713 103, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_77_19

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  Abstract 


Zinc phosphide is a rodenticide which reacts with gastric acid and produces phosphine gas which produces systemic effects. We present the case of a 32-year-old patient with alleged history of zinc phosphide ingestion. After 15 h of ingestion, he was brought to us following initial supportive care outside. All routine investigations were done. Electrocardiogram showed antero–inferior wall acute myocardial infarction with right bundle branch block. The patient developed chest pain on the next day of admission. Coronary angiography revealed stenosis of the left anterior descending artery with clot. Percutaneous coronary angioplasty with stenting was done. He was discharged in a stable condition. Zinc phosphide poisoning precipitating acute coronary syndrome is a rare entity. Although patients may not present with initial chest pain, still they need intensive monitoring.

Keywords: Coronary syndrome, phosphine, zinc phosphide


How to cite this article:
Samui K, Thakur DK. Zinc phosphide poisoning precipitating undiagnosed coronary artery disease: successfully managed. Apollo Med 2020;17:42-3

How to cite this URL:
Samui K, Thakur DK. Zinc phosphide poisoning precipitating undiagnosed coronary artery disease: successfully managed. Apollo Med [serial online] 2020 [cited 2020 Jul 4];17:42-3. Available from: http://www.apollomedicine.org/text.asp?2020/17/1/42/280919




  Introduction Top


Zinc phosphide is a dark gray-colored crystalline rodenticide.[1] The clinical features of its poisoning are circulatory collapse, hypotension, shock, myocarditis, pericarditis, acute pulmonary edema, and congestive heart failure. Acute coronary syndrome refers to a spectrum of clinical presentations ranging from those for ST or non-ST segment elevated myocardial infarction or unstable angina.[2] We present the case of a 32-year-old patient with ingestion of zinc phosphide for suicidal attempt.


  Case Report Top


A 32-year-old male from North India, a nonsmoker, a nonalcoholic, a farmer by occupation, and with no known comorbidities, came to us with an alleged history of ingestion of zinc phosphide. He had severe burning pain abdomen and was admitted to a local hospital initially. He was managed there with gastric lavage, intravenous fluid, proton pump inhibitor, and other supportive measures. The patient was brought to Indraprastha Apollo Hospital, New Delhi, after 15 h of poison ingestion for further management. Examination revealed general consciousness with Glasgow Coma Scale score of 15/15, heart rate of 90/min, blood pressure of 118/78 mmHg, and SpO2 of 98% on room air. Respiratory and cardiovascular examination systems were within normal limits. Routine blood and kidney function tests were within normal limits. Liver enzymes were mildly deranged (aspartate transaminase/alanine transaminase – 100/59). Arterial blood gas pH was 7.4; electrocardiogram showed antero–inferior wall acute myocardial infarction with right bundle branch block. Blood creatine phosphokinase MB was 243. Troponin-T level was 6.42. Symptom of chest pain developed on the next day of admission. Coronary angiography done revealed stenosis of the left anterior descending artery with clot (80% in proximal and 100% in distal parts). Percutaneous coronary angioplasty with stenting was done. The patient's general condition improved. He was discharged in stable condition with antiplatelet therapy.


  Discussion Top


Zinc phosphide is similar to aluminum phosphide and forms phosphine gas when it reacts with water. This gas is absorbed from the gastrointestinal tract, which downgrades the mitochondrial function by blocking cytochrome C oxidase enzyme. Phosphine may result various metabolic and nonmetabolic complications. It may result in retrosternal chest pain, circulatory collapse, hypotension and shock, myocarditis, pericarditis, and pulmonary edema following congestive cardiac failure. It may also affect the gastrointestinal system, resulting in nausea, vomiting, loose motion, hepatomegaly, and respiratory complications such as cyanosis and breathlessness. This gas has toxic potential for metabolic acidosis and acute kidney injury. It also causes severe hypoglycemia, delirium, and generalized tonic-clonic seizures. Features such as coma, hypocalcemia, hepatotoxicity, and thrombocytopenia were also reported in Chugh et al.'s study.[3] Free radical generation also results in lipid peroxidation.

A case study by Sanaei-Zadeh showed that zinc phosphide poisoning can cause hypotension and premature atrial and ventricular contractions.[4] However, our patient had antero–inferior wall acute myocardial infarction with right bundle branch block, which got diagnosed on angiography. Thota et al.'s study showed the development of hypotension, seizure, and pulmonary edema after its poisoning.[5] In a case report by Yogendranathan et al., a patient with zinc phosphide poisoning had severe acute kidney injury with acute tubular necrosis and tubular interstitial nephritis that needed hemodialysis.[6] However, renal function in our case was within normal limits.


  Conclusion Top


Acute coronary syndrome is a potentially lethal condition. Precipitation of undiagnosed coronary artery disease by zinc phosphide poisoning is a rare entity. As there is no antidote or any specific treatment available for zinc phosphide poisoning, careful monitoring in intensive care unit setting can reduce the high mortality, although mortality still remains high despite all the measures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shakoori V, Agahi M, Vasheghani-Farahani M, Marashi SM. Successful management of zinc phosphide poisoning. Indian J Crit Care Med 2016;20:368-70.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Kumar A, Cannon CP. Acute coronary syndromes: Diagnosis and management, part I. Mayo Clin Proc 2009;84:917-38.  Back to cited text no. 2
    
3.
Chugh SN, Aggarwal HK, Mahajan SK. Zinc phosphide intoxication symptoms: Analysis of 20 cases. Int J Clin Pharmacol Ther 1998;36:406-7.  Back to cited text no. 3
    
4.
Hossein Sanaei-Zadeh. The Case Files: Ingestion of Zinc Phosphide. Exclusively for EM-News.com: November 1, 2012. Available from: https://journals.lww.com/em-news/fulltext/2012/11011/The_Case_Files__Ingestion_of_Zinc_Phosphide.3.aspx. [Last accessed on 2020 Jan 23].  Back to cited text no. 4
    
5.
Naga T, Nagaraja VT, Sachin B, Muralidhar H. A case report on zinc phosphide poisoning and its rare effects. J Evid Based Med Healthc 2017;4:694-6.  Back to cited text no. 5
    
6.
Yogendranathan N, Herath HM, Sivasundaram T, Constantine R, Kulatunga A. A case report of zinc phosphide poisoning: Complicated by acute renal failure and tubulointerstitial nephritis. BMC Pharmacol Toxicol 2017;18:37.  Back to cited text no. 6
    




 

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