DR. SHEETAL KAMAT MBBS,DNB Internal Medicine - API ...

DR. SHEETAL KAMAT
MBBS,DNB Internal Medicine
MALLIGE MEDICAL CENTRE

Miss G a 28 years lady, presented with alleged
history of consumption of 120ml of Vasmol33.
� She had history of pain in legs, thighs,
swelling of neck and passing dark colored
urine.
� O/E: Afebrile, Neck swelling present, mouth
opening reduced, voice normal.
� Vitals – Normal, Systems - NAD, no muscle
tenderness .
� Urine (on Foley’s) – Brown colored.

Investigations - At admission –
� Hb 14.4Gm/dl, TC-22,700 N90% L7%E3%
Platelet Count-4.7lakhs
RFT- Blood Urea-23, Sr Cr-1.2;Serum
electrolytes –Na-137,K-4.7; LFT-Bilirubin-
normal, SGOT/SGPT-1150/160, ALP, GGT,
Protein – normal
LDH-15290iu/l(235-470),
CPK TOTAL-1,85,700 (upto 200)

� Serumcalcium-8.1mg/dl
PT, PTT, ABG –pH-7.41,pCO2-26.2,pO2-
185,cHCO3-16.3 spO2-99.6% CXR – normal
ECG - normal. Urine routine- color –brownish,
pH-acidic, protein-++, microscopy-RBC-nil,
WBC-3-4, Myoglobin-nil.
� Based on this she was initiated on IV fluids,
alkaline diuresis, hydrocortisone and antihistaminics
for cervico facial edema. She
developed worsening respiratory distress
requiring intubation for airway protection.

� She had ongoing rhabdomyolysis-Repeat CPK
TOTAL was 2,02,300iu/l and with OLIGURIA
(urine output

� Hair dye poisoning is emerging as an important
etiological factor in suicide in developing
countries.
� Hair dyes are divided into five categories-
1.Gradual hair coloring
2.Vegetable hair dyes
3.Temporary dyes
4.Semi permanent dyes
5.Permanent dyes-oxidative and progressive.
� Vasmol 33 belongs to oxidative group of
permanent hair dye. It contains PPD 4%, Sodium
EDTA, Resorcinol, Liquid Paraffin.

� PATHOGENESIS- Vasmol33 contains
1. PPD paraphenylene diamine it is a coal tar
derivative which on oxidation produces
Brondrowski base which is allergic ,mutagenic
and highly toxic.
� Poisoning with PPD produces characteristic
features of severe angio edema, rhabdomyolysis
and intra vascular hemolysis culminating in ARF.
� Respiratory syndrome –Inflammatory oedema
involving crico pharynx and larynx.
� 2.Sodium EDTA- produces hypocalcemia.
� 3.Resorcinol – Corrosive ,methaemoglobinemia
and renal toxicity.

� PPD brings about rhabdomyolysis by
promoting calcium release and leakage of
Calcium ions from SER followed by continous
contraction and irreversible change in muscle
structure .Rhabdomyolysis is the main cause
for ARF and morbidity mortality are high
once ARF develop. Severe hypocalcemia is
seen during oliguric phase.
� Other features are myocarditis and
arrythmias

� The characteristic features of angio edema
with stridor , rhabdomyolysis with chocolate
colored urine and acute renal failure this
combination is suggestive of hair dye
poisoning.
� Mortality rates are 0.03-60%.
� High index of suspicion and early institution
of therapy has known to prevent acute renal
failure and significantly reduce mortality
rate.