Paraphenylenediamine: Blackening more than just hair

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. 2012 Jun;17(6):584–586.

Abstract

Paraphenylenediamine is an important constituent of hair dye toxicity of which one could herald fatal complications such as rhabdomyolysis, renal failure, angioneurotic edema, and respiratory failure. We present a case of hair dye poisoning that presented with respiratory distress due vĩ đại laryngeal edema and later developed trismus, subclinical tetany, apnea, and conduction abnormality on electrocardiogram. This case report highlights the need for a thorough toxicological review of the components of any ingested substance.

Keywords: Hair dye poisoning, Paraphenylenediamine, renal failure

INTRODUCTION

Paraphenylenediamine (PPD—a common ingredient in hair dyes) poisoning, although a rare khuông of intoxication in the West, is fairly common in some parts of the world such as East Africa, Indian subcontinent, and Middle East countries.[1] Literature tìm kiếm via Google scholar revealed that a study in northern India reported 323 cases over a span of about 5 years (July 2004-March 2009) and another study in Morocco reported 374 cases over a 11 yr study period (1992-2002).[2,3] PPD poisoning poses considerable risk with mortality rates ranging from 12% vĩ đại 42%.[1] We bring forth a case of PPD poisoning which developed severe edema of the face and neck requiring emergency tracheostomy, followed by rhabdomyolysis, and respiratory failure requiring mechanical ventilator tư vấn but recovered after prompt management.

CASE REPORT

A 23-year-old female, school teacher by occupation, was brought vĩ đại the emergency department, Medwin Hospital, Hyderabad, India in June 2010 with alleged history of consumption of hair dye (200 ml of 4% PPD-based emulsion-type hair dye) owing vĩ đại suicidal ideation a day prior vĩ đại presentation. She had been taken vĩ đại a local hospital where an emergency tracheostomy was done for dyspnea and stridor. She was then referred vĩ đại our hospital for further management. At presentation she had complaints of inability vĩ đại open mouth, difficulty in swallowing, and cramps in hands in addition vĩ đại generalized toàn thân pain. On examination she had trismus, calf tenderness, abdominal tenderness, guarding and rigidity, and both chvostek's and trousseau's signs were positive. Her urine was cola colored. Investigations obtained revealed hypocalcaemia (corrected calcium = 7.2 mg/dl) with normal sodium, potassium, creatinine, and phosphorus values. Intravenous correction with calcium gluconate (2 ampoules of 10% calcium gluconate with 100 mg elemental calcium in each ampoule slow intravenous and another 2 ampoules over 6 h) was given and cramps in hands subsided gradually. The quantity of PPD ingested was calculated vĩ đại be 8 gm, which is considered toxic. As rhabdomyolysis is a well-known complication of PPD poisoning, her creatinine phosphokinase (CPK) was done which was 1 62 795 IU/L (normal 60-400 IU/L). Hydration was maintained vĩ đại avoid renal failure secondary vĩ đại rhabdomyolysis. Patient had intermittent apnea with hypoxia, which required mechanical ventilator tư vấn. Electrocardiogram (ECG) showed significant ST-segment depression in inferolateral leads and right bundle branch block with right axis deviation. Pre-existing underlying cardiac conditions, if any, were excluded by 2D-echocardiography. She was started on parenteral nutrition because of trismus. By day 7, her CPK was 286 IU/L; trismus improved, and endoscopic guided nasogastric tube placed which revealed severe erosive pan gastritis. By day 10, tracheostomy tube was decanulated and tracheostomy stump was closed. Later ECG was normalized except for an intraventricular conduction defect, which did not require any active medical therapy intervention. She was started on enteral feeds, which she tolerated well. She was counseled by psychiatrist prior vĩ đại discharge. At follow up, she was completely asymptomatic.

DISCUSSION

The first documentation of systemic PPD poisoning in 1924 described the case of a hairdresser who developed toxicity from handling the dye.[4] PPD, a derivative of paranitro-aniline, on oxidation produces several intermediates, of which Bondrowski's base is most allergenic, mutagenic, and highly toxic.[5] PPD is readily absorbed even with dermal liên hệ. The symptoms have an onset of 4-6 h and are dose related (8 gm being the toxic dose in our case). A three-phase evolution can be seen in PPD intoxication with inflammatory stress characterized by a relative immunodepression in the first three days, proinflammatory state (due vĩ đại rhabdomyolysis) from third vĩ đại sixth day and immunomodulative action (due vĩ đại oxidative metabolism) from the sixth day. It is a systemic inflammatory reaction specific vĩ đại a cytotoxic cell tư vấn. The pathophysiologic mechanisms could be the increased không tính phí radical formation,[6] skeletal and cardiac muscle necrosis (scattered coagulation necrosis),[5] formation of highly nephrotoxic quinonediamine (an oxidation product of PPD metabolites), renal tubular occlusion due vĩ đại myoglobin casts, and acute tubular necrosis.[7] Methemoglobinemia, hoarseness of voice, cardiac toxicity, hepatitis, hypotension, convulsions, coma, and sudden cardiac death are on the toxic over of the spectrum.[5]

The angioedema of face and neck on initial presentation (probably from allergic or hypersensitive reaction associated with the increased permeability of mast cells) with chocolate colored urine is characteristic in most cases[8] and might point vĩ đại PPD poisoning especially when the labs and history are inconsistent. Stigmata of rhabdomyolysis (rigidity and tenderness of limbs) and acute renal failure (from hemolysis, rhabdomyolysis, hemoglobinuria methemoglobinemia, and direct tubular toxicity), leukocytosis, anemia secondary vĩ đại hemolysis, are the usual accompaniments and rarely exophthalmos and blindness may also be seen. In a study of PPD poisoning spanning 7 years, cervicofacial and laryngeal edema was the dominating presenting manifestation in 72% of the cases, rhabdomyolysis in 100%, impaired renal functions in 80%, hyperkalemia in 75%, elevated liver transaminases in 76%, and fatal ventricular arrhythmias in16%.[9] A case of myocardial lysis in a fetus expelled (nonviable) by a 22-year-old mother after apparent PPD ingestion of an unknown amount of PPD was reported which on histopathology showed heart and lung congestion (interstitial edema and inflammation at the base of the lingua), in addition vĩ đại a chorionic villus thrombosis and abruptio placentas.[10] Another report of two cases of PPD poisoning showed diffuse myocarditis in one and septo-apical myocardial infarction in the other.[11] Rarer complications of PPD, such as chronic kidney disease, severe myocardial rhabdomyolysis leading vĩ đại cardiogenic shock and death, severe aplastic anemia, severe liên hệ dermatitis, and optic atrophy have also been reported. As there is no specific antidote available, the treatment is mainly symptomatic and supportive and asphyxia (early on) and renal failure (later) are the most life threatening factors that need emergent addressing with tracheostomy and/or hemodialysis, respectively, when required. Our patient also had apnea with hypoxemia and fascicular conduction defect, probably because of direct toxic effect of PPD.

Early diagnosis, medical treatment with steroids and antihistaminics, and if airway compromise is not improving, endotracheal intubation or tracheostomy and in cases of refractory oliguria and rhabdomyolysis, dialytic tư vấn are the key strategies in the management of PPD poisoning.[12]

ACKNOWLEDGMENT

We thank our colleagues and staff of Internal Medicine and Critical Care

Footnotes

Source of Support: Nil

Conflict of Interest: None declared.

REFERENCES

  • 1.Abdelraheem M, Hamdouk M, Zijlstra EE. Paraphenylene Diamine (Hair Dye) Poisoning in Children. Arab J Nephrol Transplant. 2010;3:39–43. [Google Scholar]
  • 2.Filali A, Semlali I, Ottaviano V, Furnari C, Corradini D, Soulayman R. A restrospective study of acute systemic poisoning of Paraphenylenediamine (occidental takawt) in Morocco. Afr J Trad CAM. 2006;3:142–9. [Google Scholar]
  • 3.Jain PK, Agarwal N, Sharma AK, Akhtar A. Prospective study of ingestional hair dye poisoning in Northern India (Prohina) J Clin Med Res. 2011;3:9–19. [Google Scholar]
  • 4.Praveen Kumar AS, Talari K, Dutta TK. Super vasomol hair dye poisoning. Toxicol Int. 2012;19:77–8. doi: 10.4103/0971-6580.94503. [DOI] [PMC không tính phí article] [PubMed] [Google Scholar]
  • 5.Jain PK, Agarwal N, Kumar Phường, Sengar NS, Agarwal N, Akhtar A. Hair dye poisoning in Bundelkhand region (prospective analysis of hair dye poisoning cases presented in Department of Medicine, MLB Medical College, Jhansi) J Assoc Physicians India. 2011;59:415–9. [PubMed] [Google Scholar]
  • 6.Chen SC, Chen CH, Tioh YL, Zhong PY, Lin YS, Chye SM. Para-phenylenediamine induced DNA damage and apoptosis through oxidative stress and enhanced caspase-8 and -9 activities in Mardin-Darby canine kidney cells. Toxicol In Vitro. 2010;24:1197–202. doi: 10.1016/j.tiv.2010.02.011. [DOI] [PubMed] [Google Scholar]
  • 7.Hummdi LA. Histopathological Alterations in Renal Tubules of Female Rats Topically Treated with Paraphenylen Diamine. World Appl Sci J. 2012;16:376–88. [Google Scholar]
  • 8.Prabhakar Y, Kamalakar K. Hair dye poisoning: A report of three cases. J Dr NTR Univ Health Sci. 2012;1:46–8. [Google Scholar]
  • 9.Shalaby SA, Elmasry MK, Abd-Elrahman AE, Abd-Elkarim MA, Abd-Elhaleem ZA. Clinical profile of acute paraphenylenediamine intoxication in Egypt. Toxicol Ind Health. 2010;26:81–7. doi: 10.1177/0748233709360200. [DOI] [PubMed] [Google Scholar]
  • 10.Abidi K, Himdi B, Cherradi N, Lamalmi N, Alhamany Z, Zeggwagh A, et al. Myocardial lysis in a fetus induced by maternal paraphenylenediamine poisoning following an intentional ingestion vĩ đại induce abortion. Hum Exp Toxicol. 2008;27:435–8. doi: 10.1177/0960327108092288. [DOI] [PubMed] [Google Scholar]
  • 11.Brahmi N, Kouraichi N, Blel Y, Mourali S, Thabet H, Mechmeche R, et al. Acute myocarditis and myocardial infarction induced by Paraphenylenediamine poisoning.Interest of angiocoronarography. Int J Cardiol. 2006;113:E93–5. doi: 10.1016/j.ijcard.2006.05.034. [DOI] [PubMed] [Google Scholar]
  • 12.Chrispal A, Begum A, Ramya I, Zachariah A. Hair dye poisoning--an emerging problem in the tropics: an experience from a tertiary care hospital in South India. Trop Doct. 2010;40:100–3. doi: 10.1258/td.2010.090367. [DOI] [PubMed] [Google Scholar]