Journal of The Korean Society of Clinical Toxicology

Case Report

Pulmonary thromboembolism following organophosphate intoxication: a case report: Ji Ho Lee; J Korean Soc Clin Toxicol. 2023;21(1):64-67. Published online June 30, 2023; DOI: https://doi.org/10.22537/jksct.2023.00002

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Abstract PDF: Various symptoms manifest after organophosphate intoxication due to muscarinic, nicotinic, and central nervous system effects. Complications are common, and morbidity occurs due to respiratory center depression, cardiovascular complications, aspiration pneumonia, general weakness, and neurological symptoms. Some studies have reported a statistically significant association between organophosphate intoxication and deep vein thrombosis. However, cases of pulmonary thromboembolism (PTE) resulting from organophosphate poisoning are very rare. A 45-year-old male patient was transferred to our hospital after ingesting an unknown amount of an insecticide and receiving 6 L of gastric lavage at a local hospital. Other than nausea, no symptoms (e.g., dyspnea) were present, but a hemodynamic test showed an elevated lactic acid level, and metabolic acidosis worsened over time. Accordingly, we conducted initial treatment including continuous renal replacement therapy. After 7 hours, the poisoning analysis result was confirmed, and lambda-cyhalothrin and chlorpyrifos (0.441 µg/mL and 0.401 µg/mL, respectively) were detected. We introduced pralidoxime. Although no increase in pseudocholinesterase was found during hospitalization, continuous renal replacement therapy and pralidoxime were discontinued because the patient did not show symptoms of intermediate syndrome, including dyspnea and altered consciousness. The patient complained of abdominal pain on hospital day 8. Abdominal computed tomography was performed to evaluate the possibility of a corrosive injury to the stomach or esophagus, and we confirmed PTE. The D-dimer level was 1.96 mg/L (normal range, 0–0.55 mg/dL). A radiologic examination showed a PTE in the main pulmonary artery leading to the segmental pulmonary artery. After heparinization, the patient was discharged after being prescribed a vitamin K-independent oral anticoagulant. Through this case, we would like to emphasize the need for a thorough evaluation of clinical symptoms because atypical symptoms can occur after poisoning with organophosphate pesticides.

Delayed death after chlorfenapyr poisoning: Jang Young Lee; J Korean Soc Clin Toxicol. 2021;19(1):51-54. Published online June 30, 2021; DOI: https://doi.org/10.22537/jksct.2021.19.1.51

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Chlorfenapyr is a widely used insecticide, that is very lethal if ingested. It exhibits delayed toxicity in which there are few symptoms at first which suddenly worsen after a few days. A 66-year-old female patient ingested about 90 mL of chlorfenapyr liquid hydrating agent (Chlofenapyr 10%) and showed stable vital signs with no specific symptoms and findings other than a mild fever, vomiting, and nausea. From the 3rd day of ingestion, creatine kinase was high, and rhabdomyolysis was suspected. From the 4th day of ingestion, pancreatic enzymes began to gradually increase. A diffusion-weighted image showed a multifocal high signal intensity in the white matter and corpus callosum area. On the 8th day after ingestion, she suffered a high fever and a heart attack and died. Thus, if a patient is suspected of taking chlorfenapyr, he/she needs active treatment and monitoring even if he/she does not exhibit any symptoms.

Citations

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Understanding Chlorfenapyr Toxicity: An Overview of Acute Human Exposure and Clinical Outcomes
Dalia Alsaied Moustafa Ahmed, Nermin Mahmoud Emam, Mohamed Moharram Badawy
Journal of Applied Toxicology.2026;[Epub] CrossRef
Toxicological Review of an Uncoupler, Chlorfenapyr
Sun Cheun Kim
Korean Journal of Legal Medicine.2025; 49(2): 35. CrossRef
A Fatal Case of Chlorfenapyr Poisoning and the Therapeutic Implications of Serum Chlorfenapyr and Tralopyril Levels
Ming-Jin Chung, Yan-Chiao Mao, Chia-Tien Hsu, Mu-Chi Chung, Tsai-Jung Wang, Tung-Min Yu, Po-Yu Liu, Pin-Kuei Fu, Chia-Ming Hsieh
Medicina.2022; 58(11): 1630. CrossRef

Comparison of Mortality Rate according to Hospital Level among Patients with Poisoning Based on Korean Health Insurance and Assessment Service: Soyoung Kim, Sangchun Choi, Hyuk-Hoon Kim, Hee Won Yang, Sangkyu Yoon; J Korean Soc Clin Toxicol. 2019;17(1):21-27. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.21

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Abstract PDF: Purpose: Mortality rate in the health services research field is frequently considered as a proxy for measuring healthcare quality. We compared the mortality rate and hospitalization levels among patients with poisoning. Methods: A population-based study of hospital size and level based on the Korean health insurance and assessment service was conducted to identify the impact of hospital level on patient mortality. Results: We analyzed a total of 16,416 patients, of which 7,607 were from tertiary hospitals, 8,490 were from general hospitals, and 319 were from hospitals. The highest mortality rate of diagnosis regarding poisoning was T60.31 (other herbicides and fungicides, 16%), followed by T60.0 (organophosphate and carbamate insecticides, 12.7%). There was no statistical difference in mortality among hospital levels for gender. Among age groups, tertiary hospitals had lower mortality than general hospitals and hospitals for patients aged more than 70 years (11.9% mortality at tertiary vs 14.2% at general and 23% at hospital; p=0.003, adjusted z score=-6.9), general hospitals had lower mortality than tertiary hospitals and hospitals for patients aged 18 to 29 (0.6% at general vs 2.4% at tertiary and 3.7% at hospital; p=0.01, adjusted z score=-4.3), and hospitals had lower mortality than tertiary hospitals and general hospitals for patients between 50 and 59 years of age (0% at hospital vs 6.4% at general and 8.3% at tertiary; p=0.004). Conclusion: Overall, there was no significant difference between mortality and hospital level among poisoned patients. However, to establish an efficient treatment system for patients with poisoning, further studies will be needed to identify the role of each facility according to hospital level.

Hypoalbuminemia as a Predictor of 30-day Mortality in Patients with Acute Organophosphate Insecticide Poisoning: So Yeon Kim, Ryun Kyung Lee, Tae hu Kim, Dong Hoon Kim, Taeyun Kim, Soo Hoon Lee, Jin Hee Jeong, Sang Bong Lee, Changwoo Kang; J Korean Soc Clin Toxicol. 2017;15(1):11-16. Published online June 30, 2017; DOI: https://doi.org/10.22537/jksct.2017.15.1.11

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Abstract PDF: Purpose: The association of hypoalbuminemia with 30-day in-hospital mortality in patients with organophosphate insecticide poisoning (OPI) was studied. Methods: This retrospective cohort study was conducted between January 2006 and November 2013 in the emergency department (ED) after OPI poisoning. A Kaplan-Meier 30-day survival curve and the log-rank test were used to analyze patients stratified according to serum albumin levels on ED admission (hypoalbuminemia or normo-albuminemia). Independent risk factors including hypoalbuminemia for 30-day mortality were determined by multivariate Cox regression analysis. Results: A total of 135 patients were included. Eighty-eight (65%) patients were male and the mean age was $57.3{pm}17.0$ years. Serum albumin, mean arterial pressure, and Glasgow coma scale score were significantly higher in the survival group than the non-survival group. APACHE II score was significantly lower in the non-survival group than the survival group. The mortality of the hypoalbuminemia group (serum albumin <3.5 g/dl) was 68.8%, while that of the normo-albuminemia group (serum albumin ${geq}3.5g/dl$) was 15.1%. The area under the ROC curve of the serum albumin level was 0.786 (95% CI, 0.690-0.881) and the APACHE II score was 0.840 (95% CI, 0.770-0.910). Conclusion: Hypoalbuminemia is associated with 30-day mortality in patients with OPI poisoning.

A Case of Chlorfluazuron Insectisides Poisoning with Mental Change: Eun Suk Park, Soo Kang, Ah Jin Kim, Jin Hue Baek, Hyun Min Jung; J Korean Soc Clin Toxicol. 2015;13(1):40-42. Published online June 30, 2015

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Abstract PDF: Benzoylureas are chemical compounds best known for their use as insecticides. Diflubenzuron is one of the more commonly used benzoylurea pesticides. Others include chlorfluazuron, flufenoxuron, hexaflumuron, and triflumuron. They act as insect growth regulators by inhibiting synthesis of chitin in the body of the insect. They have low toxicity in mammals because mammals have no chitin. Chlorfluazuron insecticides, which are mixed with solvent naphatha, are commonly used. Thus we assume that in the presented case mental change outcome of poisoning was connected with toxic effects of solvent naphtha rather than with chlorfluazuron action. Components of solvent naphtha, particularly trimethylbenzenes, exert strong irritant action on the gastric mucosa and are very well absorbed from the gastrointestinal tract. We report on a 67-year-old man with stuporous mentality after intentional ingestion of approximately 200 ml of liquid chlorfluazuron in a suicide attempt. He was discharged after conservative treatments including gastric irrigation, charcoal, mechanical ventilation, hydration, and antibiotics for aspiration pneumonia without complications.

A Case Report of a First Sulfoximine Class of Insecticide, Sulfoxaflor Poisoning: Jaehoon Oh, Hyunggoo Kang, Tae Ho Lim, Sanghyun Lee, Chiwon Ahn; J Korean Soc Clin Toxicol. 2015;13(1):43-45. Published online June 30, 2015

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Abstract PDF: Sulfoxaflor is the first insecticide belonging to the sulfoximine class and is efficient against sap-feeding insects that are resistant to other insecticides. Sulfoxaflor acts as a neurotoxin to the central nervous system of insects compared with very low toxicity to mammalian. We report on a case of a 67-year-old male who ingested insecticide and received conservative treatment for mild metabolic acidosis and gastrointestinal symptoms.

Acute Pancreatitis after Carbamate Poisoning: Joseph Park, Yong Won Kim, Se Hyun Oh, Yong Sung Cha, Kyoung Chul Cha, Oh Hyun Kim, Kang Hyun Lee, Sung Oh Hwang, Hyun Kim; J Korean Soc Clin Toxicol. 2014;12(2):77-84. Published online December 31, 2014

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Abstract PDF: Purpose: Carbamate insecticides are potent cholinesterase inhibitors capable of causing severe cholinergic toxicity. Use of carbamate rather than organophosphate insecticides has been increasing. Compared with organophosphate poisoning, relatively few studies have investigated carbamate-associated acute pancreatitis. We investigated general characteristics and pancreatitis of carbamate poisoning and the predictors, among those readily assessed in the emergency department. Methods: We performed a retrospective review of consecutive patients, aged over 18 years, who were admitted between January 2008 and April 2012 to an emergency department (ED) of an academic tertiary care center for treatment of carbamate poisoning. Patients who exhibited poisoning by any other material, except alcohol, were excluded. After application of exclusion criteria, patients were divided according to carbamate-induced pancreatitis and non-pancreatitis groups. Results: A total of 41 patients were included in this study. Among these 41 patients, the prevalence of acute pancreatitis was 36.6% (15 patients). Initial blood chemistry tests showed a statistically higher glucose level in the pancreatitis group, compared with the non-pancreatitis group (222, IQR 189-284 vs. 137, IQR 122-175 mg/dL, P<0.05). Regarding clinical courses and outcomes, a significantly higher proportion of patients developed pneumonia [10 (66.7%) vs. 6 (23.1%), P<0.05] and had a longer hospital stay (7 days, IQR 6-12 vs. 5 days, IQR 2-11, P<0.05), but no difference in mortality, in the pancreatitis group vs. the non-pancreatitis group. In multivariate analysis, the initial glucose was showing significant association with the presentation of carbamate-induced acute pancreatitis (odds ratio 1.018, 95% confidence interval 1.001-1.035, P<0.05). Conclusion: Carbamate-induced acute pancreatitis is common, but not fatal. Initial serum glucose level is associated with acute pancreatitis.

Fatal Brain Injury in Pyrethroid Poisoned Patient: Case Report: Woo Jin Jung, Yong Sung Cha, Dong Keon Lee, Hyun Kim; J Korean Soc Clin Toxicol. 2014;12(2):88-91. Published online December 31, 2014

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Abstract PDF: Pyrethroids have been widely using insecticides. Although generally regarded as less toxic to mammals including humans, we report one fatal case of pyrethroid poisoning with severe brain injury.

Comparison of Severity in Organophosphate Insecticide Poisoning Patients Treated with Tracheostomy: Dae-Hyuk Choo, Yong-Jin Park, Sun-Pyo Kim, Seog-Jung Kim, Soo-Hyung Cho, Nam-Soo Cho; J Korean Soc Clin Toxicol. 2011;9(2):61-70. Published online December 31, 2011

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Abstract PDF: Purpose: This study investigated the effect on survival rate for organophosphate intoxication patients who received trachostomy. This research was conducted to help identify appropriate treatment of patients who received a trachostomy. Methods: This research was retrospectively conducted using the medical records of 141 patients who arrived at the Chosun University Hospital emergency medical center between Jan 2007 and Dec 2010, suffering from organophosphate intoxication. They were placed in two groups including one which received trachostomy as part of their treatment and one that did not. The effect of each variable on mortality was evaluated by regressionanalysis. Results: Of 141 patients with organophosphate intoxication, 105 of them did not tracheostomy and 16 were dead cohorts (15.2%). Their size of pupil was 1mm. Factors such as amount of organophosphate ingested, PAM time after ingestion, average body temperature, arrival time, atropinization time after ingestion, AST/ALT, Bun/Cr all appeared to be significant factors in death cohorts (P<0.05). 36 patients among the total had tracheostomy and 11 ones of them were in dead cohort (30.6%) and their average age was 58 years. The facts affect the state of patients in dead cohort include the amount of intoxication which between $327.27{pm}194.1ml$, performing intubation 686 mins after intubation, reaching to the hospital after 580mins, injecting PAM 744 mins after intoxication, injecting atropine 627 mins after intoxication. The largest cases of patient's state was found to be stupor with 14 patients (38.9%) the level of Cholinesterase in blood appeared to be significant in dead cohort as $391.00{pm}353.9IU/L$ (P<0.05). Conclusion: Further planned studies are necessary on the use of tracheostomy for treatment of poisoning victims, especially those intoxicated by organophosphorus insecticides.

Characteristics of elderly patients with acute poisoning: Bo-Kyeong Kim, Si-Young Jung, Koo-Young Jung; J Korean Soc Clin Toxicol. 2010;8(2):61-68. Published online December 31, 2010

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Abstract PDF: Purpose: Poisoning is a major health problem for the elderly, and poisoning can cause fatal side effects. However, the characteristics and clinical features of elderly patients with acute poisoning have not been well studied in the previous domestic research. So, we tried to analyze the clinical characteristics and toxic substances of the patients who were 65 years old or older and who were admitted to the regional emergency medical center due to acute poisoning. Methods: We retrospectively reviewed the medical records and poisoning protocols of the patients who were 65 years of age or older and who had with acute poisoning and who visited the ED in our emergency center from January 2005 to December 2009. We collected the demographic information, the gender, the underlying diseases, the causes and toxic substances, the initial presentation, the treatment and the outcomes. Results: A total of 2179 poisoned patients visited the hospital during 5 years, and among them 244 were 65 years of age or older (11.2%). The mean age was $75.6{pm}6.9$ years and the male:female ratio was 1:1.7. The most common cause of poisoning was suicide (73.4%) and the most common source of poisonous substances was their own drugs. Of the substances used for poisoning, benzodiazepine was the most common drug (25.8%), followed by sedatives other than benzodiazepine (25.4%), insecticide (12.7%), chemical agents (12.3%) and herbicides (8.2%). The most common initial presentation was mental change (64.8%). When comparing the factors between the three elderly groups, there was no difference in gender, the cause, the substances and the underlying disease. The outcomes of treatment included ICU admission (56.1%), a good condition at discharge (12.7%) and admission to a general ward (12.7%). The overall mortality rate was 10.2% for the elderly patients. Conclusion: In this Korean study, unlike the foreign studies, the most common cause of poisoning in elderly patients was intentional poisoning. The admission rate was 68.8% and mortality rate was 10.2%.

A Study on Organophosphate Poisoning Patients: Comparison of the Survivor Group and Dead Group: Youn-Gyu Choi, Dong-Hyeon Lee, Woo-Hyung Kim, Gang-Wook Lee, Sun-Pyo Kim, Seong-Jung Kim, Soo-Hyung Cho, Nam-Soo Cho; J Korean Soc Clin Toxicol. 2010;8(1):16-23. Published online June 30, 2010

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Abstract PDF: Purpose: Organophosphate insecticide poisoning is common in Korea, but there is no definitive guideline for determining the severity of the poisoning and the predictive factors. Therefore, we evaluated the organophosphate poisoned patients and we divided them into two groups, the survivors and the dead, and the results might be useful for treating organophosphate poisoning patients. Methods: We performed a retrospective analysis of 68 organophosphate poisoned patients who visited the Chosun University Hospital Emergency Medical Center during a 24-month period from January, 2007 to December, 2008. We made a work sheet of the patients' characteristics and the collected data was analyzed and we compared this data between the survivor group and the dead patient group. Results: There were significant differences between the survivor group and the dead patient group for the mean age, the alcohol intake state and the typically expressed signs. The dead patients had lower blood pressure, tachycardia and a lower Glasgo Coma Score (GCS) score than the survivor group. On the arterial blood gas analysis, the dead patients had more severe acidemia and they had lower saturations. Increased serum amylase levels were found in the dead patients. The survivors'initial and follow up serum pseudocholinesterase activity (after 6~8 days) was significantly higher than that of the dead group. The total amount of atropine injected to patient was less in the survivors than that in the dead patients. Conclusion: Old age and expressing the typical intoxication signs, a lower GCS score and blood pressure, showing acidosis on the gas analysis and low serum cholinesterase activity may be useful as poor prognostic indicators for patients with organophosphate poisoning. We suggest that physicians must pay careful attention to the signs and prognostic factors of organophosphate insecticide poisoned patients.

Clinical Characteristics of Patients with Neonicotinoid Insecticide Poisoning: Jin-Chul Kim, Byung-Hak So, Han-Joon Kim, Hyung-Min Kim, Jung-Ho Park, Se-Min Choi, Kyu-Nam Park, Kyoung-Ho Choi; J Korean Soc Clin Toxicol. 2010;8(1):24-29. Published online June 30, 2010

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Abstract PDF: Purpose: Neonicotinoid insecticides are widely used as they have been proven by experimental studies to have low toxicity to mammals, including humans. As the use of neonicotioids increases, the number of patients with neonicotinoid poisoning has also increased. We conducted a study to investigate the clinical manifestations of neonicotinid poisoning. Methods: We retrospectively analyzed the patients who ingested neonicotinids and who visited the emergency department located in Korea from March 2002 to February 2010. We reviewed the patients' age, gender, the amount of exposure, the elapsed time to presentation, the treatment and the outcome. According to the poisoning severity score, we divided the patients with a Poisoning severity score (PSS) of 0 or 1 into the mild/moderate toxicity group and the patients with a PSS of 2 or 3 into the severe/fatal toxicity group. Results: A total of 24 patients were analyzed. The most common clinical manifestations of neonicotinoid insecticide toxicity were gastrointestinal symptoms (66.7%) such as nausea, vomiting and abdominal pain and the others are respiratory symptoms (16.7%), cardiovascular symptoms (12.5%), metabolic imbalance (12.5%), renal dysfunction (8.3%), CNS symptoms (8.3%), and asymptomatic (29.2%). Twenty patients (83.3%) showed mild/moderate toxicity and 4 patients (16.7%) showed fatal conditions such as shock and mutiorgan failure. The mortality rate was 4.2%. In these fatal cases, the patients developed respiratory failure, hypotension, altered mentality and renal failure at the acute stage and they deteriorated to a more serious condition. This severe toxicity was caused by decreased renal excretion of neonicotinid metabolite, and this was improved after hemodialysis. Conclusion: Most patients with neonicotinoid poisoning and who showed mild toxicity usually improved after symptomatic treatment. However, some patients showed significant toxicity with respiratory failure and renal function deterioration, and intensive care needed, including mechanical ventilation and hemodialysis.

A Case of Amitraz Insecticide Intoxication after Ingestion of Large Amount: Joo-Hyun Suh, Hyung-Keun Roh; J Korean Soc Clin Toxicol. 2008;6(1):52-56. Published online June 30, 2008

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Abstract PDF: Amitraz is used as farm-animal insecticide. Its side effects in humans are related to its pharmacological activity on alpha 2-adrenergic receptors. The case describes a previously healthy 46-year-old woman who intentionally ingested approximately 250mL of liquid amitraz. She presented with vomiting, altered mental status, miosis, dry mouth, hypopnea, metabolic and respiratory acidosis, hypotension, hypothermia, polyuria, metabolic acidosis, elevated serum aminotransferase and abdominal distension. Supportive treatments including mechanical ventilation, hydration, dopamine infusion, bicarbonate infusion and gastric decompression resulted in improvement. By hospital day 3, she recovered with resolution of abdominal distension. It is paramount to recognize amitraz poisoning when a pesticide-intoxicated patient presets with signs and symptoms consistent with organophosphate intoxicated patients but with greater alpha 2-adrenergic related symptoms such as decreased bowel motility and xerostomia.

Clinical Characteristics of Acute Dichlorvos Poisoning in Korea: Mi-Jin Lee, Joon-Seok Park, Woon-Yong Kwon, Eun-Kyung Eo, Bum-Jin Oh, Sung-Woo Lee, Joo-Hyun Suh, Hyung-Keun Roh; J Korean Soc Clin Toxicol. 2008;6(1):9-15. Published online June 30, 2008

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Abstract PDF: Purpose: Dichlorvos has been in widespread use as an organophosphate (OP) insecticide compound. The purpose of this study was to access the epidemiology and clinical features of dichlorvos in Korea. Methods: This was a 38 multi-center prospective study of dichlorvos poisoning using surveys, a structural reporting system and review of hospital records from August 2005 to July 2006. A total of 54 patients with acute dichlorvos poisoning on a national basis were enrolled. We analyzed the epidemiologic characteristics and clinical manifestations of dichlorvos poisoning. In addition, the clinical features of dichlorvos poisoning were compared with others OP compounds. Results: During the study period, compounds involving pure OP poisoning were dichlorvos (22.7%), methidathion (8.4%), and phosphamidon (6.7%). In acute dichlorvos poisoning, all ingestion routes were oral. Intentional poisoning involved 74.1% of cases. The common initial complaints involved gastrointestinal (64.8%), systemic (61.1%), central or peripheral nervous system (53.7%), and respiratory symptoms (50.0%). The median arrival time to hospital after dichlorvos poisoning was 2.6 hours and mean hospitalization duration was 7.1 days. 2-PAM was administered in 35 patients in mean doses of 6.3 g/day intravenously. Atropine was administered in 30 patients with a mean dose of 62.8 mg/day (maximal 240 mg/day). Overall mortality rate for dichlorvos poisonings were 14.8% (8/54). Immediate causes for death included sudden cardiac arrest or ventricular dysrhythmias (50%), multi-organ failure (25%), acute renal failure (12.5%), and unknown causes (12.5%). Conclusion: When compared to previous reports, dichlorvos poisoning displayed relatively moderate severity. The presence of a lower GCS score, altered mental status, serious dysrhythmias, systemic shock, acute renal failure, and respiratory complications upon presentation were associated with a more serious and fatal poisoning.

A Case of a Patient with Stuporous Mentality and Hypotension after Amitraz Ingestion: Si-Young Jung, Jin-Hee Jung, Eun-Kyung Eo; J Korean Soc Clin Toxicol. 2007;5(2):123-125. Published online December 31, 2007

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Abstract PDF: Amitraz is a formamidine-derived insecticide and acaricide which is commonly used throughout the world. Amitraz intoxication is mediated through ${alpha}_2$ adrenergic receptor agonist effects, similar to those of the ${alpha}_2$ agonist clonidine. We report a case of a patient who experienced coma and hypotension after amitraz ingestion. A 37-year-old woman visited the ER with symptoms of vomiting and altered mental state. She had ingested a mouthful of liquid amitraz concentrate (12.5%), which rapidly led to vomiting, hypotension, bradycardia, hyperglycemia, and mental stupor. Supportive treatment, including mechanical ventilation and administration of inotropics, resulted in full recovery within four days.

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