International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - 13(20), October, 2021

Pages: 57-60

Date of Publication: 24-Oct-2021


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Massive Myocardial Infarction Due to Acute Left Main Coronary Artery Occlusion in a Young Organophosphorus Poisoning: Case Report

Author: Gautam Archana, Patil Vijaysinh, Rayannavar Nikhilesh, Goel Himalaya, Bhaleghare Sakshi, Bammidi Rohit

Category: Healthcare

Abstract:Introduction: In the farmlands what has been found to be a common chemical for suicidal attempts are Organophosphate poison. This is common in many of the countries. Organophosphate poison is quite dangerous and can have impact once someone consume. Even the smell of this liquid or touch of the chemical to the skin can have a very harmful effect. Fatal left main carotid artery occlusion is rarely reported in literature. Aim: To study the case of consumption of Chlorpyriphos- cypermethrin combination Case Report: In the present paper we have reported a specific case of a person whose age was 25 years and who consumed a Chlorpyriphos- cypermethrin combination who later developed massive myocardial infarction with an ST-elevation >12 mm in aVR followed by a cardiac arrest. Discussion: Cardiac abnormalities are rare in organophosphorus compound poisoning. The patients have include arrhythmia, heart failure, cardiogenic shock, and sudden death. In those patients, clinical manifestations of damage caused by organophosphorus pesticides to the myocardium vary. Conclusion: During the management of organophosphorus compound poisoning, intensive cardiac monitoring should be considered.

Keywords: Massive Myocardial Infarction, Acute LMCA Occlusion, Organophosphorous, Poisoning, Cardiac, Pyrethroid compound, Cypermethrin

Full Text:

Introduction

There are many types of inhibitors available, one of them are Organophosphate, it is potent cholinesterase inhibitors, which is capable of causing severe cholinergic toxicity following cutaneous exposure, inhalation or ingestion.1 Chlorpyriphos is a pesticide that contains a broad-spectrum chlorinated organophosphate.2 We use that to control many kinds of pests, termites, mosquitoes and roundworms. According to world health organization    Chlorpyrifos is considered moderately hazardous on the base of acute toxicity. Exposure surpassing recommended levels has been linked to neurological effects, persistent developmental disorders, and autoimmune disorders. The symptoms of sever poisoning is seizures, unconsciousness, paralysis and suffocation from lung failure.3 A pyrethroid compound Cypermethrin widely used as an insecticide, is moderately toxic but excessive exposure can cause nausea, headache, muscle weakness, salivation, shortness of breath and seizures. Apart from the drug toxicity, these compounds cause many cardiac complications like QT prolongation, conduction blocks, arrhythmia. But rarely do they cause myocardial infarction.

Case report

A male who is 25 years old was admitted to the intensive care unit with of alleged history of intentional consumption of HAMLA (Chlorpyriphos 50% + Cypermethrin5%) around 50 ml followed by 3 episodes of vomiting. The patient was brought to the hospital within 3-4 hours of consumption. On examination he was drowsy, sweating profusely with GCS of 6 (E1 V2 M3), pupils were constricted <2mm and neck holding was absent. Peradeniya organophosphate score was 7, suggestive of moderate poisoning. Vitals at the time of admission were was-PR-60/min; BP-110/70mmHg, RR-32/min; SPO2- 92%. Patient had no comorbid conditions. The patient was immediately taken on mechanical ventilation (ventriculocoronary arterial communication) VCAC mode and was treated with atropine, Pralidoxime and other supportive measures (IV fluids, gastric lavage, savlon body wash, and activated charcoal). Arterial blood gas analysis suggested metabolic acidosis with compensatory respiratory alkalosis and the blood analysis revealed a serum cholinesterase level of 1858 IU/L with serum CPK NAC level of 229 IU/L. ECG at the time of admission had sinus rhythm with a heart rate of ~ 68/min. For the next 3 days, the patient was kept on mechanical ventilation under mild sedation with RASS of -2 (Richmond Agitation-Sedation Scale) and heart rate was maintained at ~100/min on atropine at 0.2mg/hr. Inj. Heparin 5000 IU I.V 12 hourly was started as DVT prophylaxis on day 3. On day 4 around 10.30 P.M, the patient developed sweating and sinus tachycardia with a heart rate of 140/min lasting for 3-4 hours. Sudden ECG changes were noticed in the cardiac monitor and the ECG recorded suggested acute left main coronary artery occlusion with deep ST depression >10 mm in anterior and inferior leads and ST-elevation around 12 mm in aVR. Sooner he developed cardiac arrest and could not be revived by CPR and inotropic supports. Biochemical cardiac markers sent at that time were positive with Serum Trop I of 3.5 ng/ml.

Discussion

Cardiac abnormalities are rare in organophosphorus compound poisoning. The patients have to include arrhythmia, heart failure, cardiogenic shock, and sudden death. In those patients, clinical manifestations of damage caused by organophosphorus pesticides to the myocardium vary. Myocardial injuries and myocardial infection are rarely reported, which cause by organophosphorus poisoning.

According to a study conducted by Aktar S et al. in 2019 on the complications of Organophosphorus poisoning, out of 100 cases, 29 had cardiac complications like premature ventricular contractions, prolonged QT, conduction block, polymorphic VT, Torsade de Pointes, sinus bradycardia which occurred during early hours of acute poisoning.1 But none of them had myocardial infarction as a complication in their study. For the development of these complications Hypoxia, electrolyte imbalance and acidosis is very important. Our case did not have any predisposing factors and never developed these complications. (Though metabolic acidosis was present when the admission is going on, it was corrected immediately).

According to a report of a case by P Joshi et al. on a 40-year- old patient with parathion consumption, it was found that patient had sinus bradycardia on admission. On the second day, the patient developed ST-segment elevation with T inversion in V3-V6 with Trop I of 3ng/ml. The patient was treated with antiplatelet, nitrates, LMWH and was discharged with the resolution of ST and T changes.2 In contrast to this, our case was a young male with no previous comorbidities who developed Massive myocardial infarction on day 4 with ECG showing ST elevation > 12 mm in aVR and ST depression in other leads >10mm, with serum Trop I of 3.5 ng/ml indicating blockade in LMCA territory.3 Later he had a cardiac arrest and could not be revived.

The mechanism of cardiotoxicity by these compounds is not completely understood.

There are few postulations by which OP compounds can cause cardiac toxicity.4, 5

1. Brief period of increased sympathetic tone. 2. Prolonged period of parasympathetic activity

3. QT prolongation followed by torsades de pointes. And also, other mechanism includes sympathetic/parasympathetic overactivity, hypoxia, dyselectrolemia and direct toxicity. Coronary vasospasm can also lead to myocardial infarction. Coronary vasospasm was caused by intracoronary injection of acetylcholine in individuals as demonstrated in a study conducted by Hario et al. and Yasue et al.. 6,7

In a person with previous coronary artery plaque, the release of vasoactive amines like histamines and catecholamines leads to penetration of collagen matrix of plaque-causing erosion and rupture causing myocardial infarction.8 Release of inflammatory cytokines like histamines, neutral proteases, platelet-activating factors, arachidonic acid products, chemokines causes vasospastic angina, nonvasospastic angina, myocardial infarction known as Kounis phenomenon.9

Serious cardiac complications cause by Patchy myocardial involvement as a result of direct cardiac toxicity.10,11 Myocardial may not be manifest clinically or on echocardiography because it is involved in patchy. Continuous cardiac monitoring should be undertaken to detect dynamic cardiac changes Continuous cardiac monitoring should be undertaken to detect dynamic cardiac changes.4

Conclusion

Organophosphorus poisoning can cause severe cardiac complications within few hours of exposure. Myocardial infarction occurs as a complication during the early phases of poisoning, but it also has chances of occurring during the recovery phases. Thus, during the management of organophosphorus compound poisoning, intensive cardiac monitoring should be considered.

 Acknowledgement: We acknowledge the contribution of our university and department for the unending support.

Conflict of Interest: There is no conflict of  Interest 

Source of Funding: No Source of Funding

Authors Contribution: This is a collaborative work among both authors. Gautam Archana, Patil Vijaysinh, Rayannavar Nikhilesh and Goel Himalaya performed the statistical analysis, wrote the protocol, and wrote the first draft of the manuscript.  Bhaleghare Sakshi, Bammidi Rohit managed the literature searches. All the authors read and approved the final manuscript.

References:

1. Akhtar MS, Rehman AU, Akbar K, Hussain M, Atif MA, Hussain MS. Complications of organophosphorus poisoning. Prof. Med. J. 2020 Oct 10;27(10):2149-53.

2. Joshi P, Manoria P, Joseph D, Gandhi Z. Acute myocardial infarction: Can it be a complication of acute organophosphorus compound poisoning?. J Postg Med. 2013 Apr 1;59(2):142.

3. Knotts RJ, Wilson JM, Kim E, Huang HD, Birnbaum Y. Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease? J Electroc. 2013 May 1;46(3):240-8.

4. Anand S, Singh S, Nahar Saikia U, Bhalla A, Paul Sharma Y, Singh D. Cardiac abnormalities in acute organophosphate poisoning. Clin Toxic. 2009 Mar 1;47(3):230-5.

5. Ludomirsky A, Klein HO, Sarelli P, Becker B, Hoffman S, Taitelman U, Barzilai J, Lang R, David D, DiSegni E, Kaplinsky E. QT prolongation and polymorphous (“torsade de pointes”) ventricular arrhythmias associated with organophosphorus insecticide poisoning. Am J Cardiol. 1982 May 1; 49(7):1654-8.

6. Horio Y, Yasue H, Okumura K, Takaoka K, Matsuyama K, Goto K, Minoda K. Effects of intracoronary injection of acetylcholine on coronary arterial hemodynamics and diameter. Am J Cardiol. 1988 Nov 1;62(13):887-91.

7. Yasue H, Touyama M, Shimamoto M, Kato H, Tanaka S, Akiyama F. Role of the autonomic nervous system in the pathogenesis of Prinzmetal's variant form of angina. Circulation. 1974 Sep;50(3):534-9.

8. Karasu-Minareci E, Gunay N, Minareci K, Sadan G, Ozbey G. What may happen after an organophosphate exposure: acute myocardial infarction. J Forensic Leg Med. 012 Feb 1;19(2):94-6.

9. Gázquez V, Dalmau G, Gaig P, Gómez C, Navarro S, Mercé J. Kounis syndrome: report of 5 cases. J Investig Allergol Clin Immunol. 2010 Jan 1;20(2):162-5.

10. Anand S, Singh S, Nahar Saikia U, Bhalla A, Paul Sharma Y, Singh D. Cardiac abnormalities in acute organophosphate poisoning. Clin. Toxicol.. 2009 Mar 1;47(3):230-5.

11. Eddleston M, Chowdhury FR. Pharmacological treatment of organophosphorus insecticide poisoning: the old and the (possible) new. Br J Clin. Pharmacol. 2016 Mar; 81(3):462-70.

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Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

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Best Article Award

A study by Dorothy Ebere Adimora et al. entitled \"Remediation for Effects of Domestic Violence on Psychological well-being, Depression and Suicide among Women During COVID-19 Pandemic: A Cross-cultural Study of Nigeria and Spain\" is awarded Best Article of Vol 14 issue 23
A study by Muhas C. et al. entitled \"Study on Knowledge & Awareness About Pharmacovigilance Among Pharmacists in South India\" is awarded Best article for Vol 14 issue 22
A study by Saurabh Suvidha entitled \"A Case of Mucoid Degeneration of Uterine Fibroid with Hydrosalphinx and Ovarian Cyst\" is awarded Best article of Vol 14 issue 21
A study by Alice Alice entitled \"Strengthening of Human Milk Banking across South Asian Countries: A Next Step Forward\" is awarded Best article of Vol 14 issue 20
A study by Sathyanarayanan AR et al. entitled \"The on-task Attention of Individuals with Autism Spectrum Disorder-An Eye Tracker Study Using Auticare\" is awarded Best article of Vol 14 issue 19
A study by Gupta P. et al. entitled \"A Short Review on \"A Novel Approach in Fast Dissolving Film & their Evaluation Studies\" is awarded Best Article of Vol 14 issue 18.
A study by Shafaque M. et al. entitled \"A Case-Control Study Performed in Karachi on Inflammatory Markers by Ciprofloxacin and CoAmoxicillin in Patients with Chronic Suppurative Otitis Media\" is awarded Best Article of Vol 14 issue 17
A study by Ali Nawaz et al. entitled \"A Comparative Study of Tubeless versus Standard Percutaneous Nephrolithotomy (PCNL) \? A Randomized Controlled Study\" is awarded Best Article for Vol 14 issue 16.
A study by Singh R. et al. entitled \"A Prospective Study to Find the Association of Astigmatism in Patients of Vernal Keratoconjunctivitis (VKC) in a Tertiary Health Care Centre in India (Vindhya Region MP)\" is awarded Best Article for Vol 14 issue 15
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A Study by Manoj KP et al. entitled "A Randomized Comparative Clinical Trial to Know the Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block Against Multimodal Analgesia for Postoperative Analgesia Following Caesarean Section" is awarded Best Article Award of Vol 13 issue 23
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A Study by Bhat Asifa et al. entitled "Efficacy of Modified Carbapenem Inactivation Method for Carbapenemase Detection and Comparative Evaluation with Polymerase Chain Reaction for the Identification of Carbapenemase Producing Klebsiella pneumonia Isolates" is awarded Best Article for Vol 13 issue 17
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A Study by Sarmila G. B. et al. entitled "Study to Compare the Efficacy of Orally Administered Melatonin and Clonidine for Attenuation of Hemodynamic Response During Laryngoscopy and Endotracheal Intubation in Gastrointestinal Surgeries" is awarded Best Article for Vol 13 issue 07
A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
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A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
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A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
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A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
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A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
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A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
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A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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