HAIR DYE POISONING

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Slide 1 : B. AKSHAYA SRIKANTH Pharm.D*
Slide 2 : WHAT WAS THOUGHT TO BE A PRODUCT FOR BEAUTIFICATION OF GREY HAIR TURNED OUT TO BE A DREADFUL POISON IN PEOPLE WITH DESPERATION TO SAY GOODBYE TO THIS SOCIETY
Slide 3 : INTRODUCTION Super Vasmol 33™ is an emulsion based hair dye commonly used in India. The main ingredients of the dye are, Paraphenylenediamine [PPD] (< 4%), Resorcinol, Propylene glycol, Liquid paraffin, Cetostearyl alcohol, Sodium lauryl sulfate, EDTA sodium, Herbal extracts and Preservatives and Perfumes.
Slide 4 : Some of these ingredients are known toxicants with multi-organ effects, while the toxicity profiles of others are not known.
Slide 5 : PARAPHENYLENEDIAMIDE The cosmetic trade in oxidizing hair dyes uses Paraphenylenediamine (PPD); it is also commonly used to intensify the color of henna (Lawsonia Alba). Ingestion of PPD is frequently reported from Africa and Asia. Accidental or suicidal ingestion of PPD causes systemic toxicity, manifested by severe edema of neck and face and laryngeal edema with respiratory distress frequently requiring emergency tracheotomy and mechanical ventilation. It also causes rhabdomyolysis and acute renal failure, culminating in death if not treated aggressively
Slide 6 : ANGIO EDEMA
Slide 7 : RESORCINOL Resorcinol is a phenolic chemical used in photography, tanning and cosmetics (hair dye) industry. It is also a pharmaceutical agent used topically in skin diseases. Resorcinol is a moderately toxic and corrosive chemical. It is known to cause eye, skin, oral and gastrointestinal injuries. Systemic toxicity is manifested as vomiting, dyspnea, methemoglobinemia, hypothermia, tachypnea, pallor, profuse sweating, hypotension and tachycardia.
Slide 8 : CASE STUDY Here I am presented a case of a 20-year-old female admitted to Casualty in RIMS at 4.00 pm who ingested about 100ml of a hair dye ( Super Vasmol 33™) with suicidal intent. She was conscious at the time of admission, responding to verbal commands and was admitted in casualty.
Slide 9 : CONT…. The patient was shifted to ICU at 6.00 pm, with severe face and neck swelling, respiratory distress, convulsions and loss of consciousness. She was gasping and developed bradycardia. She was intubated and 0.6 mg of atropine was given IV. The patient was put on ventilator. Her pupils were normal in size and reacting to light. She was afebrile with pulse rate 132/min, BP 118/80 mm Hg Auscultation of lungs and heart revealed no abnormality.
Slide 10 : CONT… The patient soon developed generalized tonic-clonic convulsions and her deep tendon reflexes were absent. ECG showed normal sinus rhythm with a pulse rate of 120/min.
Slide 11 : LAB DATA Serum electrolytes were, Na - 134 meq/L, K - 3.3 meq/L, Ca/iCa 1.06 ( ) [Hypocalcemia] (9-12 mgs/dl) Hemoglobin 12.4 g/dl, TLC 17700/ ml, P 71%, L 25%, E 2%, M 2% ; platelet count was 3,10,000/ml. Blood urea was 34.6 mg/dl and serum creatinine, 1.2 mg/dl Liver function tests showed serum bilirubin 1 mg/dl, SGOT 438 IU/L ( ) (80-40), SGPT 214 U/L ( ) (5-35), Alkaline phosphatase 144 U/L ( ) (12-115)
Slide 12 : LAB DATA Total serum protein was 6.6g%, serum albumin 4.4g%. Blood glucose and uric acid were normal. Routine urinalysis reported, (pH 6.6, protein 28 mg/dL, and no ketones, blood, bilirubin and nitrite) Urine was negative for myoglobin
Slide 13 : TREATMENT Mechanical ventilation was continued. For treatment of generalized clonic-tonic seizures, midazolam (General anesthetic) was given IV Due to recurrent seizures even after midazolam, a loading dose of phenytoin was followed by continuous infusion. A central line was established. Foley's catheter was inserted to monitor urine output. At the time of catheterization, urine output was 1200ml; in the next 24 hours total urine output was 700 ml
Slide 14 : TREATMENT The patient gradually developed oliguria, reflected by the decreasing urine output on second and third day( 850ml and 360 ml respectively) leading to Acute Renal Failure. Further treatment comprised intravenous fluids, Ceftriaxone (broad-spectrum antibiotic), NAHCO3 bicarbonate replacement and Rantidine (H2blockers)
Slide 15 : TREATMENT Since the patient did not respond to Phenytoin infusion, Sodium valproate was administered, which was also was ineffective. Ultimately, the seizures were controlled by Thiopentone infusion In view of the gradually developing oliguria and increasing serum urea and creatinine levels, the patient was put on peritoneal dialysis on the third day
Slide 16 : The patient also developed pulmonary edema and hypotension Despite vigorous treatments, metabolic acidosis persisted The patient could not maintain normal breath even after ventilation with 100% oxygen
Slide 17 : Cardiac arrest occurred and despite cardiopulmonary resuscitation, the patient died on the morning of 4th day Autopsy revealed diffuse pulmonary edema, renal congestion, an eosinophilic substance in renal cortical tubular lumen and hyperemia in all abdominal organs Renal collecting tubule and distal tubule epithelium was seen to be necrotic. The blood showed methemoglobinemia (10%)
Slide 18 : DISCUSSION Here I am have presenting the key clinical manifestations of systemic hair dye poisoning. Common hair dye ingredients used are, hydrogen peroxide, PPD, resorcinol or aminophenols But the manufacturer of Vasmol claims that no hydrogen peroxide or ammonia were added. Although there are a few studies that indicate systemic toxic effects of PPD on humans, information on the effects of resorcinol in acute poisoning after oral ingestion is limited
Slide 19 : In this case, the patient developed symptoms common to both resorcinol and PPD poisoning Resorcinol is of moderate acute toxicity. Studies have reported rapid absorption of resorcinol from GI tract following its oral ingestion. It is rapidly metabolized and excreted Resorcinol ingestion is associated with, convulsions, salivation, dyspnea, emaciation and hyperemia of the GI tract The lowest lethal dose (LDL) of resorcinol in humans has been reported as 29 mg/kg body wt RESORCINOL
Slide 20 : Studies report that systemic manifestations of resorcinol poisoning may include nausea, dyspnea, methemoglobinemia, tachypnea, pallor and profuse sweating, with hypotension and tachycardia Since respiratory arrest occurred in this patient 1hr 30 min after ingestion, she had to be intubated and pulmonary edema developed later Resorcinol is also Neurotoxic and its acute exposure effects range from seizures, followed by CNS depression to lethargy, coma and death
Slide 21 : PARAPHENYLENEDIAMINE (PPD) PPD is a key ingredient of hair dyes, used for color enhancement. Only few studies have been done on systemic PPD poisoning. Common clinical manifestations of systemic toxicity are, cervicofacial edema, chocolate brown colored urine, upper airway tract edema, oliguria, muscular edema and shock The biological results were dominated by rhabdomyolysis, metabolic acidosis, acute renal failure and hyperkalemia.
Slide 22 : On arrival, patient showed characteristic face and neck swelling, dyspnea, following which she was intubated She presented diagnostic chocolate brown colored urine and gradually developed oliguria due to impaired renal function. Treatment with hydrocortisone, antihistaminic drugs, broad spectrum antibiotic and metabolic acidosis correction did not prove effective. The patient Died after 72 hours
Slide 23 : CONCLUSION In this case the patient presented with the mixed symptoms of Resorcinol and PPD poisoning Clinical manifestations of hair dye poisoning were associated with Respiratory, Neurological, renal and Hematologic symptoms
Slide 24 : THANK YOU
Slide 25 : GLOSSARY Rhabdomyolysis : Necrosis or disintegration of skeletal muscles often followed by myoglobinuria Dyspnea : Difficulty in breathing Tachypnea : Unusual elevated breath than normal breath Methemoglobinemia : The presence of methemoglobin in the blood, results in cynosis, occurs due to toxicity Oliguria: Production of a smaller than normal quantity of urine Metabolic acidosis : Acidosis refers to excess of acid or base deficit Emaciation : There is a wasting of body’s muscles after using up all the store of energy in form of fat

 


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