Introduction
The dichlorophenoxyacetic acid (2, 4 D) is a systemic herbicide, belonging to the group of phytohormones. Its ingestion with suicidal intent can cause severe poisoning and death. We report two cases of deliberate intoxication by (2 4 D) complicated by refractory shock leading to death after 24 hours of the poisoning
Case report 1
A 32 year old men treated for depression, was admitted to the emergency department for a deliberate intoxication by herbicides five hours ago. The examination at admission showed an unconscious patient (GCS=8) with myosis, fever 40 °C, tachypnea 36 C/ min with tracheobronchial congestion and pulmonary rales sounding both hemifields, systolic blood pressure was at 80 mmHg, requiring intravenous fluids. Laboratory tests revealed rhabdomyolysis with CPK at 19366μg/l (113 times normal), a positive troponin 0.7 ng/ml, renal failure (urea 1,23 g/l, creatinine 26 mg/l), metabolic acidosis (pH 7.19, bicarbonate levels to 9 mEq/l) and decreased prothrombin time (PT 49 %). Toxicological analysis revealed 2, 4 D in the urines and blood. Echocardiography has objectified a normal left of ventricular size with preserved systolic function and hyperkinetic. Despite a blood filling with vasoactive drugs (norepinephrine up to 1 μg/kg/min), the hemodynamic status deteriorated rapidly with persistence of severe acidosis, leading to death 24 hours after admission
Case report 2
F C aged 19 years old women; unmarried with no pathological history, pregnant at 21 weeks of gestation with a concept of poisoning. She presented generalized tonic-clonic seizures without recovery of consciousness in inter-critical. At admission, the examination objectified an unconscious patient with GCS at 9, blood pressure at 120/70 mmHg; a fever, gynecological exam was normal; otherwise neurological examination has objectified hypotonia of four members with osteotendinous reflexes vivid. Laboratory tests has showed a reduced kidney function (urea at 0,79 g/l and creatinine at 16 mg/l), CPK 903μg/l, a negative troponin. The initial toxicology research by colorimetric and immunochromatographic method was negative. A MRI was normal. The patient was then expelled a dead fetus born with aggravation of renal function (urea at 1,36 g/l and creatinine at 19 mg/l) and rhabdomyolysis, CPK at 4000 μg/l and troponin at 3 ng/ml. A toxicological screening by HPLC DAD revealed the presence of a 2-4 D in the blood and urine. The evolution was marked by hemodynamic status deteriorated with severe acidosis leading to death of the patient
Conclusion
2-4D poisoning is rare; it is responsible for a high mortality rate. In our context, the commercial availability of this product becomes worrying, justifying the use of a wide prevention program to inform the public and the authorities of the danger of this herbicide