“SUPER VASMOL 33 WITH AYUR PRASH” POISONING – A CASE REPORT

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Dr. B.K. Barik, Dr. Dinabandhu Sahu, Dr. Abhiram Behera, Dr. Pusparani Das

ABSTRACT

"Super Vasmol" a commonly used hair dye containing various chemical and herbal ingradients may produce severe local and systemic manifestation when ingested. The fatality is low, the incidence is rare. Here we are reporting a case of vasmol poisoning who was thoroughly investigated and followed up till complete recovery.

KEYWORDS:

Super Vasmol, PPD, Resorcinol, Gastritis, Angioneurotic oedema.

NTRODUCTION:

`"SUPER VASMOL 33 WITH AYURPRASH" is an emulsion hair dye containing Paraphenyl Diamine (PPD), Liquid Paraffin, Cetostearyl Alcohol, Sodium Lauryl Sulphate, EDTA Disodium, Resorcinol, Propylene glycol, Herbal extracts, preservatives and perfume. 

Severe angioneurotic oedema, acute renal failure (PPD); oedema, haemolysis, methemoglobinemia in infants, blue black pigmentation (Resorcinol); Acute haemolysis (Propylene glycol); headache, vomiting, gastritis (EDTA) are the serious systemic manifestations when the dye is ingested besides the local allergic reactions observed when in contact with skin in few cases.

CASE REPORT: 

A 20 year female alleged to consume 'Super Vasmol 33' on previous night at 10 PM presented with vomiting , dyspnoea, dysphagia, difficulty of speech and gross swelling of neck and face below the chin and mandible (both sides) and dark urination. 

The Patient was admitted to the local hospital (after 8 hours of ingestion) with worsening of above mentioned symptoms and treated with injection hydrocortisone (200 mg), injection Chlorpheniramine maleate (1 Amp) injection Cefotaxim (1gm-2 vials), injection Deriphylline (1 Amp) , injection Ranitidine (1 Amp) and oxygen inhalation. As the patient did not improve he was referred to this hospital.

At the time of admission (12 hours after ingestion) the patient was severely dyspnoeic with semi opened mouth having gross swelling of tongue and oral mucosa with salivation. The lip and gums were swollen with black pigmentation, ulceration and bleeding. There was difficulty in speech and swallowing. The urine colour was greenish black and volume was 400 ml since 12 hours. There was swelling efface (submandibular, submental and parotid region) extending to neck. 

On examination the temperature was 98.8°F, Pulse 88/minute, regular , BP 126/80 mm Hg, without any localized or generalized lymphadenopathy. There was no pallor, cyanosis or icterus except black pigmentation of lip and gum. Respiration rate was 24/min, regular with vesicular breath sound without any added sound. Heart sounds, were normal without any murmur. There was no neurological deficit. The pharynx could not be examined due to oedema and ulceration of tongue & oral cavity. P/A examination revealed soft abdomen without any organomegaly. The urine was greenish black in color with suppressed volume (400 ml -12 hours). Other systemic examination were normal. 

Patient was treated with gastric lavage by normal saline, O₂ inhalation, injection Adrenaline - 0.6 mg (starting dose), Injection Avil, Injection Hydrocortisone (100mg) 8 hourly, injection Pantoprazole OD, injection Frusemide, injection Deriphylline 8 hourly and Cefriaxone 1 gm I/V twice daily and Tiniba infusion 500 mg daily and intravenous fluid. Patient gradually improved 3^rd day onwards with decrease in mucosal swelling and face & neck swelling. There was slow improvement of the voice, dysphagia, dyspnoea and throat pain. Pharyngeal examination revealed oral mucositis with inflamed postcricoid area and presence of slough in the pyriform fossa. Gradually the colour of urine changed from greenish black to normal with increased volume. The patient was able to take orally (from liquid to solid) with supportive treatment of Xylocaine viscus, antacids.

Early investigation report shows Hb- 10.2gm%, ESR - 28mm/1^st hr, TLC-13,000, DC - N 92, EO, BO, L8, MO, RBS - 148mg%, B. Urea 58mg%, S. Creatinine - 2.3mg%, S. Sodium -138 mmol/L, S.Potassium - 3.8 mmol/L, S. Bilirubin - 2.8 mg/dl (Total) 1.6 mg/dl (Direct), SCOT - 852 IU/L, SGPT - 1100 ILJ/L, Alkaline Phosphatase 290IU/L. Urine examination shows proteinurea (+), Puscells 0-3 /HPF with granular and hyaline cast. Upper Gl endoscopy (on 4^th day of admission) shows erosive gastritis.

On 10^th day, the patient recovered fully. The investigation parameters were normal.

DISCUSSION:

The commonly used hair dye having multiple chemical ingredients cause various complications. The fatality is low and incidence of poisoning is rare.

PPD, one of the intermediate dye used in hair colour is associated with systemic toxicities like severe angioneurotic oedema, acute renal failure and rhabdomyolysis. Liquid paraffin, a saturated hydrocarbon can produce extremely rare hypersensitivity reaction and dermatitis. Cetostearyl alcohol, the combination of aliphatic alcohol and esters act as non-ionic surfactant can produce allergic and urticaria! reaction. Sodium lauryl sulphate, an anionic surfactant used as detergent and foaming agent act as direct irritant at high concentration to the skin. 1% may cause contact dermatitis with burning, redness, tightening of skin with painful fissure and lamellar exfoliation. 2% may produce painful oral desquamation. Resorcinol can produce oedema, haemolysis and methemoglobinaemia in infants with blue-black pigmentary chages.

EDTA (0.3gm%) in excess produce headache, vomiting and gastritis. Propylene glycol is relatively nontoxic, may cause acute hemolysis. In animal when injected causes haemoglobinuric acute renal failure. It has low oral toxicity. Absorption through intact skin is minimal but the application of Propylene glycol containing compounds to infants with large areas of desquamation (e.g. Silver Sulphadizine Therapy in Toxic Epidermal necrolysis) has resulted in cardio-respiratory arrest. The kidney excretes 45% of absorbed dose unchanged and the remainder is metabolized by hepatic alcohol dehydrogenase to lactate, acetate and pyruvate. Liver metabolism produces lactic acids, which enters the glycolytic pathway and after large exposure causes an anion gap and metabolic acidosis. Used as a vehicle in oral, injectable and topical preparations, signs of alcohol intoxication seen after intake of vitamins suspended in Propylene glycol. The compound may be absorbed and produce a rise in serum osmolarity. Contact dermatitis, erythematous oedematous plaque and hypersensitivity occurs. Primarily Propylene glycol is a CMS depressant in large doses and such doses may cause hypoglycaemia, lactic acidosis and seizure in susceptible patients. 

Our patient who was attended within hours of ingestion presented with some degree of renal, hepatic and haemolytic features. Local reaction, orophayngeal involvement were profound along with erosive gastritis.

REFERENCES:

1.        Goldfrank's Toxicologic Emergencies - 6^th Edition, Year 1998, Page Nos. 476-r, 477_T, 913-915, 1057-1058.

2.        Medical Toxicology Diagnosis and Treatment of Human Poisoning - Mathew J. Ellenhorn, Donald G, Barceloux, Year 1998, Page Nos. 31,32, 36, 442, 528-530,809-810,906,964.