A retrospective study of clinical profile of para-phenylenediamene poisoning (hair dye poisoning) in cases admitted in medical college

Introduction

Agreeing to world health organization (WHO) more than 8 lakh people decease worldwide from suicide every year. This designates an annual global standardized suicide rate 11.4 per 100,000 population. 1 In Asia their figure has doubled in past partial of century.2

Hair dye is accessible in numerous forms and the shared cheap form is stone hair dye which is obtainable in 20 gm pack. Additional branded hair dyes like godrej, kesh kala, supervasmol 33 etc., are available in powder or liquid formulae. The attentiveness of active substance i.e paraphenyl diamine differs from 70-90 % in stone hair dye and 2-10 % in branded dyes which are used for giving black color to hair. The stone hair dye is tremendously inexpensive and freely available, making it an good-looking option for suicidal intent.2, 3

The chemical used in hair dye poisoning is an imitative of paranitro-anailine and is termed paraphenyl diamine (PPD) it is effortlessly solvable in hydrogen peroxide (H₂O₂). PPD is good hydrogen donor & is absorbed by electron oxidation to a lively radical by cytochrome P450 peroxidase to form a sensitive benzoquinone diamine. This is added oxidized to a trimmer known as Brandowaski’s base, a compound testified to cause anaphylaxis as well as being powerfully mutagenic. 4, 5 It is conventionally used for dying palm and soles along with hinna.

Interaction with PPD causes dermatitis, skin irritation, conjunctivitis, arthritis, asthma, chemosis, lacrimation, exophthalmos and even permanent blindness. Systemic toxicity happens moreover by percutaneous absorption or oral ingestion.

Ingestion of PPD yields rapid development of edema of face, neck, pharynx, tongue and larynx with respiratory distress which one-time requires tracheostomy. In the later stages, rhabdomylosis and acute tubular necrosis with acute renal failure and hepatic failure progresses, bleeding tendencies (bleeding from gums), sub- conjunctival hemorrhage and bleeding from mucus membrane also occur. 6, 7 It can also originate renal tubular necrosis which happens due to credits of the toxic metabolites of paraphenyl diamine foremost to high mortality rates which has been stated by some authors as 68.8% 8 and 60%. 9

The quantity of PPD that can cause systemic toxicity is only three grams, though the lethal dose is 7 to 10 grams. 10 The sorts of poisoning were experiential with ingesting of even lower volumes such as 25 ml. There is threefold increase in the cases of rhabdomylosis & hepatitis upon consumption of larger volumes suggesting its dose dependent toxicity. The classical features of acute poisoning were seen in 3-6 hours. 11

There is no specific antidote to PPD poisoning. It has fairly tall mortality and hostile management in association with various subjects especially ENT for the need of timely tracheostomy is important.12, 13, 14

Materials and Methods

This study was conducted at Emergency department, I.C.U & Forensic Medicine Department of Rama Medical College, Mandhana, Kanpur. The Study was conducted on patients of period of 3 years from 2018 to 2021. Prospectively collected data of 80 cases of paraphenylendiamine poisoning was studied. Inclusion and exclusion criteria consist of:

Results

There were entire 80 patients out of which 25 remained males and 55 were females. Out of which 42 (52.5%) patients existed in age group of 15 to 25 years and 24 (30%) were between age of 26 to 35 years which constitute major group of patients. Out of 80 patients 47 (58.75%) were Illiterate and 19 (23.75%) has just got primary education. Majority of the cases who consumed PPD were of middle class 40 (50%) or low social economic status 36 (45%). Among cases that consumed PPD 52 (65%) were married and 28 (35%) were unmarried.

Out of 80 patients who consumed PPD 75 cases with intension of suicide and 3 cases were accidental poisoning.

Angioedema was existent in 91.25% cases, pain in Muscles 81.25% cases, vomiting in 86.25% cases, dyspnnea in 83.75% cases, facial edema in 90% cases, dark colored urine in 92.5% cases, oligouria in 15% cases and anuria in 10 % cases.

Out of 80 patients 63 were having raised TLC count, elevated blood urea in 38 patients, raised serum creatinine in 38 patients, elevated bilirubin in 55 patients, raised liver enzymes in 50 patients, ABG derangement in 37 patients, albuminuria in 40 patients.

Out of 80 patients tracheostomy was performed in 66 patients. 20 patients existed having pathological results in chest x-ray and 55 patients remained having variations in ECG. Out of 80 patients taken for study 78.75% patients survived and mortality rate is 21.25.

Discussion

Poisoning with paraphenylene diamine is developing as an significant means of self-harm with tall mortality rate in emerging countries. 15, 16 In our study witnessed that females were 68.85% and males were 31.15% with a male to female ratio of 1:2.1, which is very alike to many additional studies i.e by Akbar et al 17 and anagram chrismal et al. 18 This may be due to informal obtainability, its use as hair dye and females are more uncovered to gender disparities and social burdens in the developing countries. It was observed that in our hospital most of patients belong to low (45%) and middle (50%) class families. We observed that about 65% cases were married and 35% were unmarried which shows comparable results to a study by Churro et al 1 43.8% were single and 56.3% were married.

In rural area there is tendency of doing marriage in premature age, which is the main cause that in our study most of the cases were married. 19 About 70% of patients in this study were between 15-30 years of age and these outcomes also parallel with other studies like, Akbar et al 17 reported the mean age as 26.5±4.56 years, Chrismal et al, 18 as 27.75 years, Normal and Ganesh,20 24.7±6.51 years, and Suleiman et al 21 as 40 years. This outcome is also in agreement with the WHO report that young age group is more susceptible to have self-harm in the low and middle income countries. The general frequency of poisoning is complex in rural areas as associated to the urban areas this may be due to nonexistence of mindfulness and knowledge, poverty, and social problems. In our study 81% cases were from rural upbringing which are similar with many other studies e.g. in a study by Churro ET al, 22 all their patients were from rural background. The most shared clinical feature perceived in this study was angioedema and facial swelling tailed by vomiting, dyspnea, and muscle pain. Suleiman ET al, 21 who stated cervicofacial edema in all their patients with 15.8% necessitating tracheostomy.

Most of the patient who presented with decrease urine output and raised urea, creatinine developed acute kidney injury and some of them needed hemodialysis to survive. In ECG we observed change like ventricular arrhythmias, AV block, atrial fibrillation, hyperkalemia, negative T-waves and supra-ventricular tachycardia. Tracheostomy was performed in 82.5% patients in this. Mortality rate was 21.25%. Churro et al, 22 documented the mortality of 37.5% among the patients in their study, whereas 22.48% mortality has been reported by Jain PK et al. 19

Conclusion

Paraphenylene diamine (kala pathar) poisoning is developing now days due to easy accessibility and low-priced. It is more communal in poor, illiterate, married females of younger age group living in rural areas. Belligerent treatment and tracheostomy can save life of patients.

Source of Funding

None.

Conflict of Interest

None.

Acknowledgement

The authors thanks Rama medical college Hospital & Research Centre management for support of study and medical record department of Rama Hospital for providing all the records.