Use of low-molecular-weight heparin in severe paraquat poisoning: a case report
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CASE REPORT
Use of low‑molecular‑weight heparin in severe paraquat poisoning: a case report Maria A. Montoya‑Giraldo1 , Luisa F. Díaz1, Ubier E. Gómez1, Juliana Quintero2 and Andres F. Zuluaga1*
Abstract Background: Acute paraquat ingestion remains a leading cause of mortality in developing countries. There is currently no evidence that treatment with high-dose immunosuppressants and antioxidants improves survival in patients with paraquat poisoning, and better options are urgently needed. Here, we describe the unexpected survival and recovery of a patient with a potentially fatal paraquat poisoning. Case presentation: After ingesting 28 mL of paraquat (20% ion w/v), confirmed by a deep blue color in the urine dithionite test (UDT), a 17-year-old Hispanic Colombian boy was treated according to the hospital protocol with cyclophosphamide, methylprednisolone, N-acetylcysteine, vitamin E and propranolol. Gastrointestinal endoscopy showed extensive ulceration and necrosis. As a novelty, enoxaparin at a single dose of 60 mg was added to his treat‑ ment. Despite the evidence of severe mucosal burns in the gastrointestinal tract and high paraquat concentrations found in the UDT, the clinical condition began to improve after 1 day of treatment, with full recovery and discharge from hospital after 21 days. Conclusions: Although the amount of paraquat ingested by the patient was large and the UDT indicated severe poisoning with a somber prognosis, unexpected survival of the patient was observed, and the addition of enoxaparin was the only change from the standard treatment. Keywords: Paraquat, Toxicity, Poisoning, Enoxaparin Introduction Paraquat (PQ) self-ingestion remains a leading cause of pesticide-induced mortality [1]. In Colombia, the burden of PQ intoxication between 2010 and 2016 was higher than that reported for all other chemicals, reaching 53.4 disability-adjusted life years (DALY) per 100,000 inhabitants [2]. Besides the accurate characterization of the patient’s exposure, quantification of the plasma PQ concentration has remarkable value for assessing the prognosis [3]. Although liquid chromatographic methods are the gold *Correspondence: [email protected] 1 CIEMTO [Drug and Poison Research and Information Center], Calle 64 # 51‑31, Laboratorio Integrado de Medicina Especializada (LIME), IPS Universitaria, Facultad de Medicina, Universidad de Antioquia, Medellín, Antioquia, Colombia Full list of author information is available at the end of the article
standard, their availability in emergency rooms is limited [4]. For this reason, a reliable and suitable rapid test such as the semiquantitative urine dithionite test (UDT) is preferred [3]. While the cutoff value for UDT is 2 mg/L, a deep blue color correlates with plasma concentrations > 10 mg/L and 100% early lethality [3–5]. Patients usually receive high-dose immunosuppressants combined with antioxidants, but there is no evidence that this treatment improves survival in severe PQ poisoning [6, 7], and better therapeutic options are
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