Transcript Symptom of Toxicity - Pesticide Health Effects Medical

Lindane:
An Organochlorine Pesticide
Pesticide Health Effects Medical Education Database (PHEMED 2010)
About Organochlorine Pesticides
Organochlorines …
• Are chlorinated synthetic organic molecules which may contain
sulfur as well
• Tend to be fat soluble
• Are readily absorbed from the gastrointestinal tract and to a lesser
degree, through the skin
• Have a wide range of acute & chronic health effects
• Are categorized as Persistent Organic Pollutants (POPs)
meaning they persist in the environment and
accumulate in tissues of living organisms
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A little history …
• Most organochlorines have been banned in the United States because
of their long half lives.
• The most notorious organochlorine, DDT, was banned in the US 1972.
• Others that have been banned
since then include: aldrin,
dieldrin, heptachlor, toxaphene
and chlordane.
• Organochlorines still in use include
lindane, dicofol, methoxychlor,
and pentachorophenol; endosulfan
will be in use until current supplies
are exhausted.
Lindane is used to …
• Protect crop seeds from
insects
• Control pests and ticks in
forests, on pets and livestock
• Control ants and other
household pests
• Control lice and scabies in
humans
Lindane Regulations
In the US …
• The Environmental Protection Agency (EPA)
banned Lindane for agricultural uses in 2006.
• The Food and Drug Administration allowed Lindane in
pharmaceutical products (such as shampoos and lotions)
by prescription
• EPA approved the cancellation of Lindane effective Oct 1 2009
• Lindane is likely to be found in homes for a few years
Globally…
• In May 2009, the Stockholm Convention on Persistent Organic
Pollutants issued a provision that included Lindane in a list of
pollutants to be phased out.
Symptoms of
Lindane Toxicity
Pesticide Health Effects Medical Education Database (PHEMED)
Toxicology of Organochlorines
• Exposure occurs through ingestion, inhalation and
dermal absorption.
• Gastrointestinal and dermal absorption is enhanced by
the presence of fats.
• Organochlorines tend to be stored in fat tissue, Lindane
to a lesser extent than others.
• Excretion:
o The chief route of excretion is biliary
o Nearly all organochlorines yield urinary metabolites
• The primary toxic action occurs on the central nervous
system causing hyperexcitability
Array of Symptoms Associated
with Lindane Poisoning
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Convulsions
Cough
Dizziness
Headache
Nausea and vomiting
Tremors
Ataxia
Muscular weakness
Paraesthesias of
face, tongue and
extremities
May also cause eye, ear,
nose, throat or dermal
irritation and severe
respiratory problems such
as respiratory depression
Typical Order of Symptom Occurrence:
Organochlorine Poisoning
• Symptoms begin to appear
about 20 minutes to one
hour after exposure
• The progression of
symptoms depends on
dose and susceptibility of
affected person
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Nausea
Vomiting
Restlessness
Tremor
Apprehension
Convulsions
Coma
Respiratory
Failure
• Death
Source: Carl Zenz, Occupational Medicine, 3rd. Ed.., St. Louis: Mosby 1994
A Few Facts About Lindane
Poisoning with Lindane …
• Most probable route is ingestion …
though Lindane is efficiently absorbed
through the skin, especially abraded skin.
• Should not be used by …
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pregnant or nursing women
infants
persons with excoriated skin
persons with seizure disorders
Diagnosing Lindane
Poisoning
Pesticide Health Effects Medical Education Database (PHEMED)
Diagnosing Lindane Poisoning
Blood, tissue and urine determinations of
organochlorine pesticides are available from a
limited number of laboratories; however, this testing
is rarely useful for Lindane because of its rapid
Metabolism.
Diagnosing Lindane Poisoning:
Health History
• The health and exposure history is the primary means to
identify Lindane (and other pesticides) as the cause of
symptoms.
• The history should determine:
o The name of the pesticide product used
(for Lindane – lotion, cream or shampoo)
o Route of exposure (oral, skin, inhaled, eye)
o The amount of the substance ingested, inhaled or absorbed
o Circumstance of exposure – intentional or accidental
o How did it happen?
o What actions have been taken (e.g., home remedies)?
Lindane Poisoning:
A Differential Diagnosis
The common symptoms of
Lindane poisoning may be
confused with many other
conditions such as:
• Brain infections
• Meningitis
• Viral infections
• Food poisoning
• And many more….
• Laboratory studies to rule out other
causes of symptoms may include:
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Electrolytes,
Renal panel
Liver function tests
Arterial blood gas
Urinalysis
• Imaging studies may include:
o Chest or abdominal radiography
o CT scan
o Lumbar puncture
• Other tests
o Electroencephalogram
Chronic Problems Associated with
Lindane and other Organochlorines
Studies that have explored possible correlations include:
– Various types of cancer (Xu X et al., 2010; Chiu BC et al., 2009;
Purdue M, 2007)
– Neurological damage (several organochlorines are known
neurotoxins) (Kamel F et al., 2005; Mladenovic D et al., 2010)
– Parkinson's disease (Corrigan, FM, 2000; Hammond DB et al.
2008)
– Respiratory illness (Valcin M. et al., 2007)
– Birth defects (Fernandez, MF et al., 2007; Matsuura, I, 2005;
Pierik, FH et al., 2007)
– Abnormal immune system function (Farr SL et al., 2004)
Other Facts about Lindane*
• Lindane has been a second line treatment for scabies
and lice. Alternatives include pyrethrins & permethrins.
• Available products should be limited and will become
more scarce as time goes on.
• Most serious adverse events are related to misuse of
prescription Lindane.
*http://www.fda.gov/Drugs/DrugSafety/PublicHealthAdvisories/UCM052201
Treatment of
Organocholorine Poisoning
Pesticide Health Effects Medical Education Database (PHEMED)
First Aid Measures
• Ingestion:
o Rinse Mouth
o Do not induce vomiting (patient may aspirate)
o Give plenty of water to drink
• Dermal exposure:
o Remove any contaminated clothing;
o Wash skin
• Refer for medical attention
Treatment for Lindane (and other organochlorine)
Poisoning
• If the pesticide has been ingested …
– Gastric lavage with 2 to 4 liters of tap water
– follow with saline purgative (30 gram sodium sulfate in
250 mL water)
• To control restlessness and/or convulsions …
– Barbiturate or diazepam IM or IV in appropriate dosage
– Make sure patient is physically safe
• Mechanical respiratory assistance with oxygen if
needed
Treatment (continued)
• If severely poisoned, monitor cardiac status and
pulmonary ventilation
• DO NOT GIVE epinephrine or other adrenergic
amines. The heart is also hyperexcitable.
• DO NOT GIVE vegetable oils or fats by mouth
(enhanced GI absorption)
Follow-up Considerations
• After 6 hours of observation, determine if patient
needs to be admitted or sent home.
• Survey for on-going home, school or work
exposure
• Instruct patient and/or family regarding safe
storage of pesticides
• Provide verbal and written information about
pesticide poisoning
References
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Chiu, BC & Blair, A (2009). Pesticides, chromosomal aberrations, and nonHodgkins lymphoma. Journal of Agromedicine, 14(2)250-255.
Corrigan, FM et al. (2000). Organochlorine pesticides in substantia nigra in
Parkinson’s disease. Journal of Toxicology and Environmental Health,
59(4):229-234
Farr SL et al. (2004). Pesticide use and menstrual cycle characteristics among
premenopausal women in the Agricultural Health Study. American Journal of
Epidemiology, 160(12):1194-204.)
Fernandez, MF et al. (2004). Human exposure to endocrine-disrupting chemicals
and prenatal risk factors for cryptorchidism and hypospadias: a nested casecontrol study. Environmental Health Perspectives, 15 Suppl 1:8-14.
Hammond DB et al. (2008). Pesticide exposure and risk of Parkinson's disease:
a family-based case-control study. BMC Neurology 8:6 .
Kamel F, et al. (2005). Neurologic Symptoms in Licensed Private Pesticide
Applicators in the Agricultural Health Study. Environmental Health Perspectives
113:877–882.
Matsuura, I et al., (2005). Evaluation of a two-generation reproduction toxicity
study adding endpoints to detect endocrine-disrupting activity using lindane.
Journal of Toxicology Science, 30 Spec No.:135-161.
References (continued)…
• Mladenovic, D et al., (2010) The correlation between lipid
peroxidationin different brain regions and the severity of lindaneinduced seizures in rats. Molecular Cellular Biochemistry,
333(1-2):243-50.
• Pierik FH et al Maternal pregnancy serum level of heptachlor epoxide,
hexachlorobenzene, and beta-hexachlorocyclohexane and risk of
cryptorchidism in offspring. (2007). Environmental Research,
105(3):364-9.
• Purdue M. (2007). Occupational exposure to organochlorine
insecticides and cancer incidence in the Agricultural Health Study.
International Journal of Cancer. 1;120(3):642-9.
• Valcin M, et al. (2007). Chronic bronchitis among nonsmoking farm
women in the agricultural health study. Journal of Occupational
Environmental Medicine, 49(5):574-83.]
• Xu, X,et al. (2010). Association of serum concentrations of
organochlorine pesticides with breast cancer and prostate cancer in
U.S. adults. Environmental Health Perspectives, 118(1):60-66