Emergency. 2018; 6 (1): e45 CA S E RE P O RT Intravascular Hemolysis following Acute Zinc Phosphide Poisoning; a Case Report Zana Ramezani1, Asrin Babahajian2, Vahid Yousefinejad2∗ 1. Student Research Committee, Kurdistan University of Medical Sciences, Sanandaj, Iran. 2. Liver & Digestive Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran. Received: June 2018; Accepted: July 2018; Published online: 21 July 2018 Abstract: Zinc phosphide (ZnP) is low-cost, accessible, and very effective as a rodenticide. It has been used for many human suicide poisonings around the world, including Iran. Nonspecific gastrointestinal symptoms and car- diotoxicity are the most serious complications of ZnP poisoning, which are associated with a high mortality rate. The aim of this paper was to report a poisoned patient that ingested ZnP with suicidal attempt and faced complications due to hemolysis. Keywords: Zinc phosphide; poisoning; jaundice; hemolysis © Copyright (2018) Shahid Beheshti University of Medical Sciences Cite this article as: Ramezani1 Z, Babahajian A, Yousefinejad V. Intravascular Hemolysis following Acute Zinc Phosphide Poisoning; a Case Report. Emergency. 2018; 6 (1): e45. 1. Introduction Zinc phosphide (ZnP) is a metallophosphide, dark grey and crystalline compound that is commonly used as a rodenti- cide due to its low cost and ease of availability (1, 2). ZnP poi- soning could happen accidentally or intentionally as means of suicidal or homicidal attempts (3). Routes of entry into the body could be via ingestion, inhalation or through the skin. The most common clinical symptoms in poisoned cases include nausea, vomiting, abdominal pain, hypoten- sion, metabolic acidosis, respiratory alkalosis and acute re- nal failure (4). Moreover, in some cases, rare complications such as acute pancreatitis, pulmonary edema, transient hy- perglycemia, transient leucopenia and intravascular hemol- ysis may be seen (5-9). In this case report, we report a 37- year-old male patient who ingested ZnP in order to commit a suicide and faces complications due to hemolysis. 2. Case report A 37-year-old man with no significant past medical history was admitted to emergency ward with a history of acute in- gestion of 8 packs (about 40 grams) of a dark grey, crystalline ∗Corresponding Author: Vahid Yousefinejad; Liver and Digestive Research Center, Tohid Hospital, Geriashan Ave, Sanandaj, Iran. Postal code: 6616812131 Tel:+98-87-33249435 Email: hooman56y@yahoo.com compound rodenticide in order to commit suicide. On ad- mission, the patient was lethargic and had nausea, vomit- ing, abdominal pain and lacrimation with the following vi- tal signs: blood pressure: 130/80 mmHg, pulse rate: 110 beat/minute, respiratory rate: 22 per minute, temperature: 37◦C and saturation of O2: 92% in room air. The general physical and neurological examination was not significant. Supportive therapy was initiated and he underwent gastric lavage with %0.9 NaCl solution and activated charcoal treat- ment. Primary results of laboratory tests in emergency de- partment are shown in Table 1. Full blood count, coagulation parameters, biochemistry, and urine analysis were in normal range and mild metabolic acidosis was reported in arterial blood gas (ABG) analysis. His electrocardiogram (ECG) only revealed sinus tachycardia. With the impression of organophosphorus poisoning, treat- ment with 0.5 mg intravenous Atropine every 5 minutes and 2 grams intravenous pralydoxim every 6 hours was started. After receiving care for three days, the sclera and skin of the patient became icteric and nausea and epigastria pain increased. In Laboratory tests, hemoglobin and platelet had decreased with normal coagulation parameters (Table 2). Liver enzymes, serum bilirubin, creatine phosphokinase (CPK) and lactate dehydrogenase (LDH) had increased. We started infusion of fresh frozen plasma (FFP) with diag- nosis of hemolysis and diffuse intravascular coagulation (DIC). The patient underwent antioxidant therapy with N This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com Z. Ramezani et al. 2 Table 1: Laboratory data of the patient in emergency department Laboratory parameters Normal range Results Laboratory parameters Normal range Results BUN (mg/dl) 5-20 17 Platelet count (*103 /m3 ) 150-400 298 Creatinine (mg/dl) 0.5-1.5 0.7 PTT (s) 25–36 s 29 Serum Na (mEq/l) 135-145 143 PT (s) 11–13 s 14.7 Serum K (mEq/l) 3.5-4.5 3.5 INR 1-1.5 1.3 LDH (U/L) 225-500 273 Bilirubin (mg/dl) CPK (U/L) 20-200 107 Total 0.2–1.3 0.9 Amylase (U/L) 30-100 66 Direct < 0.2 0.2 Blood glucose (mg/dl) 70-110 116 AST (IU/L) 11–47 38 WBC (*103 /m3 ) 4-11 9.6 ALT (IU/L) 7–53 22 RBC (*103 /m3 ) 3.5-5.5 5.4 ALP (IU/L) 38–126 50 Hemoglobin (g/dL) 12.5-17.5 16.8 pH 7.35-7.45 7.33 BUN: Blood Urea Nitrogen; LDH: Lactate dehydrogenase; CPK: Creatinine phosphokinase; WBC: White blood cells; RBC: Red blood cells; PTT: Partial thromboplastin time; PT: Prothrombin time; INR: International normalized ratio; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase Table 2: Serial laboratory results of the patient during hospitalization Laboratory parameters Normal range 12 hours Day 1 Day 2 Day 3 Day 4 Serum Na 135-145 mEq/l 136 140 138 135 138 Serum K 3.5-4.5 mEq/l 2.9 3.3 3 3.7 4 Lactate dehydrogenase (LDH) 225-500 U/L 370 1325 2471 1840 768 Creatinine phosphokinase (CPK) 20-200 U/L 450 625 706 400 68 White blood cells (WBC) 4-11 *103 /m3 6.4 10.1 18.4 10.2 6.6 Red blood cells (RBC) 3.5-5.5 *106 /m3 3.8 2.44 3 3.5 4 Hemoglobin 12.5-17.5 g/dL 12.3 7.6 9 10.5 11.8 Platelet count 150-400 *103 /m3 209 129 151 168 252 Partial thromboplastin time (PTT) 25–36 s 29 31 29 28 22 Prothrombin time (PT) 11–13 s 14.7 20 16.1 12.7 12.4 International normalized ratio (INR) 1-1.5 1.3 3.9 1.3 1.5 1 Total bilirubin 0.2–1.3 mg/dL 20 31.7 15.5 4.2 3.3 Direct bilirubin