title: Acute human self-poisoning with bispyribac-containing herbicide Nominee: a prospective observational study.
abstract: BACKGROUND
  Self-poisoning with herbicides is an important reason for hospital admission and death in Asia. Although some herbicides have a well-described toxicity profile in humans, many of the newer compounds rely on extrapolation from animal results as no published literature on clinical outcomes of human self-poisoning has been described. One example of these compounds is bispyribac, a selective herbicide used in rice and wheat cultivation that is marketed in two containers, one containing bispyribac 400 g/L with a solvent and the other the surfactant, polyethylene glycol. We present the first case series of acute human self-poisoning with an herbicide product containing bispyribac.
  
  
  METHODS
  Clinical data for all patients who presented with acute poisoning from a bispyribac-containing herbicide (Nominee) to two general hospitals in Sri Lanka from June 2002 to January 2009 were collected prospectively. Admission and serial blood samples were collected from consenting patients to confirm exposure and to study the toxicokinetics of bispyribac, respectively.
  
  
  RESULTS
  One hundred ten patients with a history of bispyribac ingestion presented after a median time of 4 h post-ingestion. There were three deaths at 15, 6, and 5 h post-ingestion because of asystolic cardiac arrest. All three patients had reduced Glasgow Coma Score (GCS) (3, 12, and 13, respectively) of whom the former two had co-ingested ethanol and developed tonic-clonic seizures. Admission blood sample was obtained from the former two of these patients but bispyribac was detected in only one of these patients. The other patient presented 2.5 h post-ingestion with a GCS of 12 but bispyribac was not detected. Excluding the patient with undetectable bispyribac, a conservative estimate of the case fatality ratio at 1.81% (95% confidence interval 0.32-5.8) can be made. The majority of the remaining patients had self-limiting upper gastrointestinal symptoms and eight patients had an abnormal GCS on presentation to hospital. The overall median hospital stay was 3 days. Bispyribac was not detectable on admission in 21 patients; in the remaining patients, the median plasma concentration was 50.55 microg/mL (interquartile range 1.28-116.5; n=32). The peak concentration was noted around 3 h post-ingestion and plasma bispyribac concentration did not predict the severity of poisoning.
  
  
  CONCLUSIONS
  The majority of patients developed self-resolving symptoms and were successfully managed in rural general hospitals without transfer to larger tertiary hospitals. Patients who died developed significant poisoning within 6 h and plasma bispyribac concentrations did not appear to predict mortality. The lack of correlation between bispyribac outcomes and the available plasma concentrations may be because of exposure to nonbispyribac components or other undefined factors. Clinical outcomes from acute self-poisoning with bispyribac-containing herbicides appear to be relatively more favorable than other commonly used herbicides.
authors.affiliation: Faculty of Medicine, Department of Medicine and South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka. indika@sactrc.org
authors.forename: Indika
authors.initials: I
authors.lastname: Bandara Gawarammana
authors.forename: Darren M
authors.initials: DM
authors.lastname: Roberts
authors.forename: Fahim
authors.initials: F
authors.lastname: Mohamed
authors.forename: Michael S
authors.initials: MS
authors.lastname: Roberts
authors.forename: Gregory
authors.initials: G
authors.lastname: Medley
authors.forename: Shaluka
authors.initials: S
authors.lastname: Jayamanne
authors.forename: Andrew
authors.initials: A
authors.lastname: Dawson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001565:Benzoates / Q000493:pharmacokinetics / Q000506:poisoning*; D000431:Ethanol / Q000506:poisoning; D005260:Female; D006323:Heart Arrest / Q000139:chemically induced*; D006540:Herbicides / Q000493:pharmacokinetics / Q000506:poisoning*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011092:Polyethylene Glycols / Q000737:chemistry; D011446:Prospective Studies; D011743:Pyrimidines / Q000493:pharmacokinetics / Q000506:poisoning*; D012720:Severity of Illness Index; D012997:Solvents / Q000737:chemistry; D013188:Sri Lanka / Q000453:epidemiology; D013406:Suicide, Attempted / Q000706:statistics & numerical data*; D013997:Time Factors; D055815:Young Adult
chemical_list: D001565:Benzoates; D006540:Herbicides; D011743:Pyrimidines; D012997:Solvents; D000431:Ethanol; D011092:Polyethylene Glycols; C549011:bispyribac
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