Curtesy from Hamdouk & Benghanem

Transcription

1 Paraphenylene Diamine (PPD) Hair dye poisoning in Sudanese Children Mohamed B. Abdelraheem Soba University Hospital University of Khartoum Sudan

2 Curtesy from Hamdouk & Benghanem

3 Introduction Paraphenylene diamine (PPD) has been used internationally as a key ingredient in different hair dye formulations to produce a variety of shades depending on its concentration In Sudan PPD is used by women to color their hair and as a dye when added to henna (Lawasonia alba) to color the palms and soles University of Khartoum - Soba University Hospital Thirtle GR et al, 1968

4

5 The concentration of PPD in hair dye formulation range from 0.20% in golden blond dyes to 3.75% in black hair dyes. For safety reasons, different occupational health authorities, developed standards regarding the degree of air contamination The European union restricted the concentration of PPD in hair dye formulations to a maximum of 6% In Sudan it is available in its pure form (97%) University of Khartoum - Soba University Hospital Grasseli JG (editor) 1973

6 Uses in Sudan and Arab countries

7

8

9

10 The toxicity of PPD occurs through skin absorption It is well known that PPD is an allergen Saito K et al 1990 University of Khartoum - Soba University Hospital

11

12 Its major systemic problem occurs when ingested accidentally, or during self harm or homicidal acts Grasseli JG (editor) 1973 University of Khartoum - Soba University Hospital

13 Systemic poisoning Acute poisoning with PPD causes a characteristic: Severe oedema of the face and neck often requiring tracheostomy, Swollen dry hard tongue Chocolate brown color of the urine PPD intoxication is a multisystem poison and can cause rhabdomyolysis and acute renal failure (ARF) University of Khartoum - Soba University Hospital

14 Bahri Renal Centre

15

16

17

18 Flaccid paralysis, severe gastrointestinal manifestations, cardiotoxicity and arrhythmias were also reported This form of severe intoxication is fatal if not treated aggressively There is no specific antidote available University of Khartoum - Soba University Hospital

19 Clinical Presentation Clinical symptoms Percentage Oedema 94% Acute respiratory insufficiency - Trachial intubations (72%) - Tracheostomy (21%) 56% Signs of rhabdomyolysis 88% Gastrointestinal symptoms (Abdominal pain) 53% Oliguric acute renal failure 32% University of Khartoum - Soba University Hospital Charra B, Menebhil L 2000

20 PPD intoxication is a major health problem in Sudan, Morocco and Indian subcontinent Acute PPD poisoning is the most frequent cause of suicidal attempts requiring hospitalization in Morocco In adult practice 70 90% of PPD poisoning is due to suicidal attempts The mortality rate range between 10.6% and 38.7% University of Khartoum - Soba University Hospital Ayoub Filali et al, 2006

21 Statistics from the ENT teaching hospital in Khartoum from 1995 to 2005 showed PPD intoxication in 3159 patient with an average of per year The common age group affected was years (52%) There was a predominance of females 80.7%, and the majority of cases 87% were due to suicidal attempts The average mortality rate over 10 years was 10.6% peaking up to 27% in 1995 and declining to 5.5% in 2005 which reflects better care. University of Khartoum - Soba University Hospital M.HAMDOUK, 2008

22 Recent report from the Poison control centre of Morocco ( ) reported 374 cases. There were female predominance 77% The majority of poisoning was intentional 78.1% and the younger population years accounted for 54.3%. The mortality rate remained high 21.1% Ayoub Filali Afr. J.Trad. CAM (2006) 3 (1): University of Khartoum - Soba University Hospital

23 A report from Tunisia showed 19 patients over 6 years in the ICU H. Kallel JN (2005) 3 (1): There were also few case reports from Saudi Arabia and Egypt (Upper Egypt) A. Asher, JPMA (2006) 3 (1): University of Khartoum - Soba University Hospital

24 PPD in Children The experience of PPD intoxication in children is even worse 31 Sudanese children (1984 and 1989) All children presented with acute and severe angioneurotic oedema, 15 required tracheotomy. ARF was reported in 5 children The mortality rate was 41%, most children died within the first 24 hours M. Sir Hashim, Annals of Tropical Paediatrics 1992 University of Khartoum - Soba University Hospital

25

26

27

28 A Report of Wad Medani teaching hospital 2.6% from their series were children and the common cause of poisoning was accidental ENT teaching hospital in Khartoum (18%) were children below the age of 14 years Morocco, PPD intoxication was reported in 43 (11.5%) children below the age of 15 years University of Khartoum - Soba University Hospital O.Mustafa, Journal of the Arab Board of Specialization 2001: 3 (2) Ayoub Filali Afr. J. Trad. CAM (2006) 3 (1):

29 Most reports of PPD intoxication are in adult patients We report the 1st three years experience with PPD intoxication in Sudanese children University of Khartoum - Soba University Hospital

30 Patients and Methods Data for this study The unit is a tertiary care PPD poisoning was confirmed by its unique clinical presentation and by detecting PPD in the urine using thin layer chromatography Definition of Acute renal failure Treatment University of Khartoum - Soba University Hospital

31 Peritoneal dialysis was performed in two small children and haemodialysis was done in 7 patients children were seen and assessed by psychologist University of Khartoum - Soba University Hospital

32 Results PPD intoxication represent 17/234 (7.2%) from the total number of ARF admissions The mean age at presentation was 13.8 years and (94.1%) were females 13 (76.5%) had taken PPD as part of deliberate self harm Eight (47%) required tracheostomy for the severe angioneurotic oedema University of Khartoum - Soba University Hospital

33 Results One child accidentally ingested PPD The 3 homicidal acts (2sisters and one girl) were due to conflicts between families and were taken to court 4 had severe depression disorder 3 attempted suicides after failure of school examinations In two patients major family problems was the leading cause In 4 patients no cause could be identified University of Khartoum - Soba University Hospital

34 Clinical features Clinical feature Angioneurotic Oedema Abdominal Pain Flaccid Paraplegia Oliguric ARF Dark discoloration of urine Frequency Percentage 47% 37.5% 29.4% 62.5% 82.3%

35

36

37 Conclusion PPD intoxication is a life threatening condition with significant morbidity and mortality in children Clinical manifestations and outcomes are similar to reports from adult literature The mortality rate of PPD intoxication can be decreased by early recognition, prompt referral and aggressive supportive treatment.

38

39 Thank You El-Tigani M A Ali Einas G Hassan Maysoon A M Ali Ikhlas A. Mohamed Nazik A E

40