Citation Information :
Chatterjee A, Ansar M, Chandra A, Chakraborty U, Dasgupta S. An Overview of Paraquat Poisoning: A Review. Bengal Physician Journal 2024; 11 (1):24-29.
Poisoning by pesticides is the major public health problem in low-income and middle-income countries, and it is responsible for almost 20% of global suicides in the last decade. Paraquat (PQ) is a toxic bipyridyl compound commonly used in agriculture and it has potential ill-effects with high fatality if ingested even in very small amounts. The mode of poisoning is usually suicidal or accidental. Paraquat poisoning is still a nuisance faced in the rural and semiurban areas, attributable to wide availability and easy access to the poison as well lack of knowledge among the common people regarding its life-threatening effects. Paraquat is partially absorbed from the gastrointestinal tract and the toxic effects are mainly mediated by the production of reactive oxygen species (ROS) causing cell damage. It acts as a corrosive and erodes the gastrointestinal tract but majority of deaths occur due to acute lung injury (ALI). Renal failure and consequent multiorgan dysfunction are also common. The mainstay of management is supportive with paucity of human data on role of antioxidants and immunosuppressives. This review gives a comprehensive outlook on PQ poisoning, the probable mechanisms, available treatment options, and plausible recommendations while managing PQ toxicity.
Boedeker W, Watts M, Clausing P, et al. The global distribution of acute unintentional pesticide poisoning: Estimations based on a systematic review. BMC Public Health 2020;20(1):1875. DOI: 10.1186/s12889-020-09939-0.
Gawarammana IB, Buckley NA. Medical management of paraquat ingestion. Br J Clin Pharmacol 2011;72(5):745–757. DOI: 10.1111/j.1365-2125.2011.04026.x.
Bonneh-Barkay D, Reaney SH, Langston WJ, et al. Redox cycling of the herbicide paraquat in microglial cultures. Brain Res Mol Brain Res 2005;134(1):52–56. DOI: 10.1016/j.molbrainres.2004.11.005.
Castello PR, Drechsel DA, Patel M. Mitochondria are a major source of paraquat-induced reactive oxygen species production in the brain. J Biol Chem 2007;282(19):14186–14193. DOI: 10.1074/jbc.M700827200.
Adam A, Smith LL, Cohen GM. An assessment of the role of redox cycling in mediating the toxicity of paraquat and nitrofurantoin. Environ Health Perspect 1990;85:113–117. DOI: 10.1289/ehp.85-1568326.
Kratsovnik E, Bromberg Y, Sperling O, et al. Oxidative stress activates transcription factor NF-kB-mediated protective signaling in primary rat neuronal cultures. J Mol Neurosci 2005;26(1):27–32. DOI: 10.1385/jmn:26:1:027.
Schoonbroodt S, Piette J. Oxidative stress interference with the nuclear factor-kappa B activation pathways. Biochem Pharmacol 2000;60(8):1075–1083. DOI: 10.1016/s0006-2952(00)00371-3.
Smith LL, Lewis CP, Wyatt I, et al. The importance of epithelial uptake systems in lung toxicity. Environ Health Perspect 1990;85:25–30. DOI: 10.1289/ehp.85-1568342.
Houzé P, Baud FJ, Mouy R, et al. Toxicokinetics of paraquat in humans. Hum Exp Toxicol 1990;9(1):5–12. DOI: 10.1177/0960327190009 00103.
Kevin N. Baer, Paraquat, Editor(s): Philip Wexler, Encyclopedia of Toxicology (Second Edition), Elsevier, 2005, pp. 329–330, ISBN 9780123694003. Available from: https://doi.org/10.1016/B0-12-369400-0/00722-5.
Delirrad M, Majidi M, Boushehri B. Clinical features and prognosis of paraquat poisoning: A review of 41 cases. Int J Clin Exp Med 2015;8(5):8122–8128. PMID: 26221379.
Dinis-Oliveira RJ, Duarte JA, Sánchez-Navarro A, et al. Paraquat poisonings: Mechanisms of lung toxicity, clinical features, and treatment. Crit Rev Toxicol 2008;38(1):13–71. DOI: 10.1080/10408440701669959.
Rahmani AH, Forouzandeh H, Tadayon Khatibi M. Medical management and outcome of paraquat poisoning in Ahvaz, Iran: A hospital-based study. Asia Pac J Med Toxicol 2015;4(2):74–78. Available from: https://doi.org/10.22038/apjmt.2015.5086.
Goudarzi F, Armandeh J, Jamali K, et al. Mortality analysis of patients with paraquat poisoning treated at two university hospitals in Shiraz, Iran. Asia Pac J Med Toxicol 2014;3(4):141–145. DOI: 10.22038/apjmt.2014.3730.
Sabzghabaee AM, Eizadi-Mood N, Montazeri K, et al. Fatality in paraquat poisoning. Singapore Med J 2010;51(6):496–500. PMID: 20658110.
Chandra A, Shah KA, Mahato S, et al. Paraquat poisoning. BMJ Case Rep 2021;14(11):e246585. DOI: 10.1136/bcr-2021-246585.
Zhou Q, Kan B, Jian X, et al. Paraquat poisoning by skin absorption: Two case reports and a literature review. Exp Ther Med 2013;6(6): 1504–1506. DOI: 10.3892/etm.2013.1320.
Hedaiaty M, Sabzghabaee AM, Gheshlagh F, et al. Paraquat poisoning management in Iran (Isfahan): Devising a protocol. J Adv Med Med Res 2016;16(5):1–10. DOI: 10.9734/BJMMR/2016/23987.
Wang L, Huang J. Paraquat induces acute respiratory distress syndrome by promoting the lung epithelial-mesenchymal transition. Int J Clin Exp Med 2017;10(1):657–665. ISSN: 1940-5901/IJCEM0038259.
Agarwal R, Srinivas R, Aggarwal AN, et al. Experience with paraquat poisoning in a respiratory intensive care unit in North India. Singapore Med J 2006;47(12):1033–1037.
Lee EY, Hwang KY, Yang JO, et al. Predictors of survival after acute paraquat poisoning. Toxicol Ind Health 2002;18(4):201–206. DOI: 10.1191/0748233702th141oa.
Sandhu J, Dhiman A, Mahajan R, et al. Outcome of paraquat poisoning. A five year study. Indian J Nephrol 2003;13(2):64–68. DOI: 10.4103/0971-4065.34870.
Banday T, Bhat Sadaf B, Bhat Sabreen B. Manifestation, complications and clinical outcome in paraquat poison: A hospital based study in a rural area of Karnataka. J Environ Occup Sci 2014;3(1):21–24. DOI: 10.5455/jeos.20140127031530.
Jyothsna P, Vinapamula KS. Urine sodium dithionite test: A useful clinical test for paraquat poisoning. J Clin Sci Res 2020;9(3):184–185. DOI: 10.4103/JCSR.JCSR_1_20.
Scherrmann JM, Houze P, Bismuth C, et al. Prognostic value of plasma and urine paraquat concentration. Hum Toxicol 1987;6(1):91–93. DOI: 10.1177/096032718700600116.
Blake DK, Gallagher RT, Woollen BH. Improved methods for the analysis of paraquat in biological fluids. Chromatographia 2002;55(Suppl 1):S183–S185. DOI: 10.1007/BF02493377.
Jones AL, Elton R, Flanagan R. Multiple logistic regression analysis of plasma paraquat concentrations as a predictor of outcome in 375 cases of paraquat poisoning. QJM 1999;92(10):573–578. DOI: 10.1093/qjmed/92.10.573.
Liu XW, Ma T, Li LL, et al. Predictive values of urine paraquat concentration, dose of poison, arterial blood lactate and APACHE II score in the prognosis of patients with acute paraquat poisoning. Exp Ther Med 2017;14(1):79–86. DOI: 10.3892/etm.2017. 4463.
Zhou DC, Zhang H, Luo ZM, et al. Prognostic value of hematological parameters in patients with paraquat poisoning. Sci Rep 2016;6:36235. DOI: 10.1038/srep36235.
Roberts DM, Wilks MF, Roberts MS, et al. Changes in the concentrations of creatinine, cystatin C and NGAL in patients with acute paraquat self-poisoning. Toxicol Lett 2011;202(1):69–74. DOI: 10.1016/j.toxlet.2011.01.024.
Hoet PH, Demedts M, Nemery B. Effects of oxygen pressure and medium volume on the toxicity of paraquat in rat and human type II pneumocytes. Hum Exp Toxicol 1997;16(6):305–310. DOI: 10.1177/096032719701600602.
Okonek S, Setyadharma H, Borchert A, et al. Activated charcoal is as effective as fuller's earth or bentonite in paraquat poisoning. KlinWochenschr 1982;60(4):207–210. DOI: 10.1007/BF01715588.
Li Y, Tse ML, Gawarammana I, et al. Systematic review of controlled clinical trials of gastric lavage in acute organophosphorus pesticide poisoning. Clin Toxicol (Phila) 2009;47(3):179–192. DOI: 10.1080/15563650701846262.
Hong SY, Yang JO, Lee EY, et al. Effect of haemoperfusion of plasma paraquat concentration in vitro and in vivo. Toxicol Ind Health 2003;19(1):17–23. DOI: 10.1191/0748233703th171oa.
Van de Vyver FL, Giuliano RA, Paulus GJ, et al. Hemoperfusion-hemodialysis ineffective for paraquat removal in life-threatening poisoning? J Toxicol Clin Toxicol 1985;23(2–3):117–131. DOI: 10.3109/15563658508990622.
Pond SM, Rivory LP, Hampson EC, et al. Kinetics of toxic doses of paraquat and the effects of hemoperfusion in the dog. J Toxicol Clin Toxicol 1993;31(2):229–246. DOI: 10.3109/155636593090 00391.
Koo JR, Kim JC, Yoon JW, et al. Failure of continuous venovenous hemofiltration to prevent death in paraquat poisoning. Am J Kidney Dis 2002;39(1):55–59. DOI: 10.1053/ajkd.2002.29880.
Lin JL, Leu ML, Liu YC, et al. A prospective clinical trial of pulse therapy with glucocorticoid and cyclophosphamide in moderate to severe paraquatpoisoned patients. Am J Respir Crit Care Med 1999;159(2):357–360. DOI: 10.1164/ajrccm.159.2.9803089.
Lin JL, LinTan DT, Chen KH, et al. Repeated pulse of methylprednisolone and cyclophosphamide with continuous dexamethasone therapy for patients with severe paraquat poisoning. Crit Care Med 2006;34(2):368–373. DOI: 10.1097/01.ccm.0000195013.47004.a8.
Afzali S, Gholyaf M. The effectiveness of combined treatment with methylprednisolone and cyclophosphamide in oral paraquat poisoning. Arch Iran Med 2008;11(4):387–391. PMID: 18588370.
Dinis-Oliveira RJ, Remião F, Duarte JA, et al. P-glycoprotein induction: an antidotal pathway for paraquat-induced lung toxicity. Free Radic Biol Med 200615;41(8):1213–1224. DOI: 10.1016/j.freeradbiomed.2006.06.012.
Agarwal R, Srinivas R, Aggarwal AN, et al. Immunosuppressive therapy in lung injury due to paraquat poisoning: A meta-analysis. Singapore Med J 2007;48(11):1000–1005. PMID: 17975689.
Block ER. Potentiation of acute paraquat toxicity by Vitamin E deficiency. Lung 1979;156(3):195–203. DOI: 10.1007/BF02714010.
Redetzki HM, Wood CD, Grafton WD. Vitamin E and paraquat poisoning. Vet Hum Toxicol 1980;22(6):395–397. PMID: 7210466.
Kang SA, Jang YJ, Park H. In vivo dual effects of Vitamin C on paraquat induced lung damage: Dependence on released metals from the damaged tissue. Free Radic Res 1998;28(1):93–107. DOI: 10.3109/10715769809097880.
Korbashi P, Kohen R, Katzhendler J, et al. Iron mediates paraquat toxicity in Escherichia coli. J Biol Chem 1986;261(27):12472–12476. DOI: https://doi.org/10.1016/S0021-9258(18)67111-X.
Hoffer E, Zonis Z, Tabak A, et al. The administration of desferrioxamine to paraquatintoxicated rats. Vet Hum Toxicol 1992;34(4):300–303. PMID: 1509687.
Fürst R, Blumenthal SB, Kiemer AK, et al. Nuclear factorkappa B independent anti-inflammatory action of salicylate in human endothelial cells: Induction of heme oxygenase-1 by the c-jun N-terminal kinase/activator protein 1 pathway. J Pharmacol Exp Ther 2006;318(1):38994. DOI: 10.1124/jpet.106.102251.
Sukumar CA, Shanbhag V, Shastry AB. Paraquat: The poison potion. Indian J Crit Care Med 2019;23(Suppl 4):S263–S266. DOI: 10.5005/jp-journals-10071-23306.
Addo E, Poon-King T. Leucocyte suppression in treatment of 72 patients with paraquat poisoning. Lancet 1986;1(8490):1117–1120. DOI: 10.1016/s0140-6736(86)91836-2.