death, we performed continuous hemoperfusion and hemodialysis daily as previously described.3. Respiratory function progressively declined and mechanical.
Failure of radiotherapy to resolve fatal lung damage due to paraquat poisoning. D Franzen, F Baer, W Heitz, H Mecking, S Eidt, H Käferstein, C A Baldamus, J M Curtius, H W Höpp and K Wassermann Chest 1991;100;1164-1165 DOI 10.1378/chest.100.4.1164 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/100/4/1164
Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1991by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692
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Failure of Radiotherapy to Resolve Fatal Lung Damage due to Paraquat Poisoning* M.D.; Frank Barr, MD.; Winfried Heitz, M.D.; Sebastian Eidt, M.D.; Herbert Kafersteln, Ph.D.; Conrad A. Baldamu,s, M.D; Julius M. Curtius, M.D.; Hans W H&pp, M.D.; and Klaus Wassermann, M.D., FC.C.P Damlan
S
Mecking,
,
The most efibetive treatment of severe paraquat poisoning in man is uncertain. In order to prevent pulmonary fibrosis, we employed radiotherapy of both lungs in a 23-year-old patient
with
severe
to prevent
paraquat
poisoning
it failed
however,
(Chest
the fatal outcome.
S .-.‘..
they
employed
radiotherapy
to
hemorrhage nification,
CASE A 23-year-old 25th
at 7
was
transferred
PM.
A gastric
instillation forced
man
After
PM.
lavage
diuresis over
determined
recurrent
to Cologne
were
activated
by
spectrophotometr
8 g of
2); the
performed
immediately At 1:15
AM
we
Paraquat
charcoal.
declined
1-Survey
ofSelected 25.3.
PaO,, mm Hg PaCO,, mm Hg Art 02 saturation,
%
he
irrigation
started
from
by and
hemoperfu-
serum
levels,
mgfL
2.5
Findings 26.3.
as
at
1
and
cm
kinase
level
mg/L mgfL
Corticosteroids,
mg/d
on
10 to 70 UIL)
day
started on the third day pressures up to 14 mm
Hg
concentration
and
a minimal
inspiratory
oxygen
27.3.
Course
in the 23-year-old
28.3.
31.3.
aimed
Idient#{176} 8.4.90
3.4.
89
67
43
56
66
47
26
36
45
34
37
38
78
98
96
93
83
88
90
21
30
34
64 100
9
10
14
1.1
1.3
2.8
2.9
2.4
3.7
4.7
2.5 160 1000
nd 80 1000
0.8
nd
nd
nd
-
nd
nd
nd
nd
-
1000
750
750
500
250
Hemoperfusion/dialysis Mechanical
ventilation
-
I
Radiotherapy 6nd
=
1164
at
95
5
Serum paraquat, urine paraquat,
range,
no evidence
H,O
Serumcreatinine,mg/dl
(normal
of 177 U/L
(maximum
declined and mechanical ventilation was (March 28th) using positive end-expiratory
and the Clinical
FIo,,% PEEP,
creatinine for 7 days
maintaining an arterial partial pressure of oxygen (PaO,) of 50 mm Hg.4 In concordance with the radiologic findings ofbilateral, patchy opacities that started to flare up on the third day, bronchoscopy revealed severe hemorrhagic alveolitis; the examination of the bronchial lavage fluid (differential cytologic study, fibrinolytic activity) on the fourth and eighth day (Fable 2) was compatible with toxic lung injury.5’6 Because ofapparent deterioration ofthe patient’s lung function, we started radiotherapy of both lungs on the fifth day (March 30th) using parallel opposed fields with a total dose of 14.4 Gy in daily fractions of 1.8 Gy. Although the clinical condition was
at 11
6From the Departments of Medicine, Radiotherapy, Pathology, Forensic Medicine, University ofCologne, Germany.
Table
on
followed
whole-gut
serum
5); there was, ofcardiac involvement. The clinical course is depicted in Table 1. Until the patient’s death, we performed continuous hemoperfusion and hemodialysis daily as previously described.3 Respiratory function progressively however,
vomiting, Hospital
mag-
x 200).
was elevated
prevent
paraquat
spontaneous University
subsequently,
instituted.
coated
and
(Germany)
was
of absorbents;
ingested
intra-alveolar original
mg/L at 4 AM , and were not detectable at 6 AM . The serum paraquat measurements to follow (twice daily) were below the detection limit of 0.3 mg/L, except for a single peak value of 0.8 mg/L on the morning of March 27th that was most likely due to redistribution.’ On presentation, results of all routine laboratory investigations were normal. On the second day, the serum creatinine concentration (normal range, 0.7 to 1.5 mg/dl) rose from 1.1 to 2.8 mg/dl and reached a maximum of3.7 mg/dl on the eighth day; the serum cholinesterase level (normal range, 3,000 to 8,000 UIL) fell transiently from 5,100 to a minimum of 1,700 U/L (day 5) and the serum lipase level (normal range, 30 to 180 U/L fell to 15 U/L (day
REPORT
intentionally
lung specimen with severe deposits (hematoxylin-eosin,
AM to 13.
fibroblast proliferation and ultimate interstitial fibrosis. We present a case of severe paraquat poisoning and failure of radiotherapy to stop or reverse the pulmonary damage.
March
1. Postmortem and fibrin
FIGURE
a quaternary bipyridyl herbicide, is-even if ingested in small quantities-extremely toxic to man. Its toxicity is related to the generation ofoxygen-free radicals that cause lipid peroxidation of cell membranes. Although ingestion of large amounts of paraquat may be fatal within hours, death is usually delayed several weeks due to the insidious development ofsevere interstitial pulmonary fibrosis and subsequent fatal hypoxia. Conventional treatment regimens, including hemoperfusion or hemodialysis, have often failed to prevent the fatal outcome in cases of severe paraquat poisoning. In 1984, Webb and associates’ reported resolution of paraquat-induced pulmonary damage by radiotherapy in a 29-year-old man; after an unsuccessful trial with prednisolone and cyclophosphamide,
-.
1991; 100:1164-65)
P araquat,
sion
-S
M.D.;
Franzen,
Hartmut
--‘
I
I
not detectable.
Failure of Radiotherapy
to Resolve Fatal Lung Damage
Downloaded from chestjournal.chestpubs.org at COMMAX GROUP on July 10, 2011 © 1991 American College of Chest Physicians
(Franzen
eta!)
Table 2-The Lavage Fluid
Differential
a Predominance
Bronchoalveolar
Lavage
of Bronchoalveolar
Cytology
Showed
3i29,O
Fluid
verlaufende
Normal Range, %
4i2/90
(Day 4)
(Day 8)
Macrophages,
%
8
23
90-96
Lymphocytes,
%
8
9
6-8
Neutrophils,
%
65
64
