Comparative case study report: Paraquat poisoning with multiorgan dysfunction

Johnson A

Group Clinical Pharmacist, Kauvery Hospital, Trichy, Tamil Nadu

Abstract

Background: Paraquat, a widely used herbicide, is notorious for its extreme toxicity and high fatality rate, even after ingestion of small quantities. Despite aggressive supportive management, outcomes are often poor.

Objective: To present and compare two fatal cases of paraquat poisoning managed at Kauvery Hospital, Trichy—highlighting clinical presentation, treatment course, and outcome variations.

Methods: Both patients were young adult males presenting after deliberate ingestion of paraquat (approximately 15–20 mL). The cases were compared based on biochemical profiles, interventions, and causes of death.

Results: Both patients developed progressive multiorgan dysfunction despite receiving hemoperfusion, corticosteroids, N-acetylcysteine, vitamin C, and supportive care. Death occurred within 5–7 days’ post-ingestion due to refractory shock and multiple organ dysfunction syndrome (MODS).

Conclusion: Paraquat poisoning continues to pose a major therapeutic challenge in India, with mortality remaining extremely high. Early recognition, prompt decontamination, and regulatory control of paraquat availability remain critical preventive measures.

Keywords: Paraquat, multiorgan failure, hemoperfusion, shock, hepatotoxicity, nephrotoxicity

Introduction

Paraquat is a fast-acting, non-selective herbicide associated with high mortality following ingestion. Its toxicity is mediated by oxidative stress leading to lipid peroxidation, pulmonary fibrosis, hepatic necrosis, and renal tubular injury. The lack of an effective antidote contributes to the poor prognosis, even with advanced supportive measures.

This paper compares two clinically similar patients who ingested of paraquat, managed at Kauvery Hospital, Trichy, to identify overlapping clinical patterns and outcomes.

Case Presentation

Case 1

History and Presentation

Date of ingestion: 06.10.2025
Amount ingested: 15–20 mL (mixed with alcohol)
Initial symptoms: Vomiting, abdominal pain. No tongue erythema or respiratory distress initially.
Referred from: Outside hospital after gastric lavage.
Vitals on admission: HR 78 bpm, BP 130/80 mmHg, RR 20/min, SpO₂ 78% RA.

Laboratory Findings

Creatinine 3.31 mg/dL, Urea 43 mg/dL
AST 470 U/L, ALT 184 U/L, ALP 103 U/L, GGT 333 U/L, Bilirubin 4.44 mg/dL
Na 131 mmol/L, K 3.55 mmol/L, HB 14.2 g/dL, Platelets 221000 /WBC 8700.

Treatment

High-dose methylprednisolone
N-acetylcysteine infusion
IV Vitamin C 1.5 g TDS
Antibiotics, PPI, antiemetics, supportive therapy
Vasopressor infusion, hemoperfusion (1 cycle), hemodialysis (1 session)

Clinical Course & Outcome

Developed shock and multiorgan dysfunction.
Cardiac arrest at 10:20 PM on 08.10.2025.
No ROSC; death declared at 10:37 PM.

Cause of Death

Immediate cause of death. Ia : Severe Hypoxia, Refractory shock, Multiple organ dysfunction syndrome (MODS)

Antecedent causes of death :

Ib : Respiratory Failure, Liver Failure, Renal Failure

I c – Underlying cause of death: Paraquat poisoning

Case 2

History and Presentation

Date of ingestion: 01.10.2025
Amount ingested: ~20 mL of 24% Paraquat
Initial symptoms: Repeated vomiting; no respiratory distress initially.
Referred from: Pudukkottai Medical College Hospital after gastric lavage and activated charcoal.
Vitals on admission: PR 80 bpm, BP 110/70 mmHg, SpO₂ 99% RA.

Laboratory Findings

Creatinine 2.46 mg/dL, Urea 49 mg/dL
Electrolytes within normal limits

Treatment

Hemoperfusion (1 session) and hemodialysis (4 cycles)
N-acetylcysteine infusion
Corticosteroids (dexamethasone), cyclophosphamide
Antioxidants (Vitamin C, K), bronchodilators, bicarbonate infusion
Multidisciplinary ICU management

Clinical Course & Outcome

Progressive Renal Failure over 6 days.
Cardiac arrest on 06.10.2025 at 12:30 PM.
No ROSC; death declared at 1:00 PM.

Cause of Death

Ia: Immediate cause of death : MODS
Ib : Respiratory, Renal and Hepatic Failure
Ia. Underlying cause of death : Paraquat poisoning.

Comparative Analysis

Parameter	Patient 1 (24 Y/M)	Patient 2 (27 Y/M)
Amount ingested	15–20 mL	20 mL (24%)
Initial presentation	Vomiting, abdominal pain, no respiratory distress	Vomiting, no respiratory distress
Time to referral	Few hours	Few hours
Renal impairment	Creatinine 3.31 mg/dL	Creatinine 2.46 mg/dL
Liver dysfunction	Markedly elevated LFT	Mild elevation initially
SpO₂ at admission	78% RA	99% RA
Interventions	NAC, steroids, Vitamin C, hemodialysis (1 session)	NAC, steroids, cyclophosphamide, HD (4 sessions), hemoperfusion
Duration of hospital stay	2 days	6 days
Final outcome	Death (shock, MODS)	Death (MODS)

Discussion

Both patients ingested a similar toxic dose of paraquat, presented early, and received aggressive supportive management. Despite the use of antioxidants, steroids, immunosuppressant’s, and extracorporeal organ support, both patients developed multiorgan failure. The first patient deteriorated rapidly, possibly due to more severe initial hypoxia and organ dysfunction at presentation. The second patient showed slower progression but eventual fatality, reflecting the inherent lethality of paraquat even with optimal ICU care.

Key therapeutic elements observed

Early decontamination with gastric lavage and charcoal
NAC and corticosteroid therapy
Hemoperfusion and hemodialysis
Multidisciplinary ICU involvement

Despite these, mortality remained 100% in this small sample.

Conclusion

Paraquat poisoning continues to carry a poor prognosis despite maximal interventions. Early recognition, prompt referral, and advanced supportive measures are crucial but not always lifesaving. Regulatory control on paraquat availability, community education, and development of novel antidotes are essential public health priorities.

References

Proudfoot AT et al. Paraquat poisoning: mechanisms, prevention, treatment. Clin Toxicol (Phila).
Vale JA, Meredith TJ. Treatment of paraquat poisoning: the role of hemoperfusion. Int J Artif Organs.
Gawarammana IB, Buckley NA. Medical management of paraquat ingestion. Br J Clin Pharmacol.

Comparative case study report: Paraquat poisoning with multiorgan dysfunction

Comparative case study report: Paraquat poisoning with multiorgan dysfunction

Johnson A

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