J Indian Acad Forensic Med, 32(2)

ISSN 0971-0973

Case report Suicide by para-phenylenediamine Poisoning

* Dr.Sushil Kumar

Abstract
Twenty three cases of acute para-phenylenediamine poisoning were examined clinically at emergency ward of Rama Medical College Hospital, Kanpur (Uttar Pradesh) irrespective of age, sex and socio-economic strata along with route and manner of administration of the poison. Albuminuria, anaemia, hypocalcemia, leucocytosis, thrombocytopenia, increased serum bilirubin, prolonged bleeding and clotting time alongwith increased levels of liver enzymes and serum creatinine were observed as significant bio-chemical parameters; on investigation in respect to complete haemogram, liver function test, renal function test, serum electrolytes, serum CPK levels and arterial blood gas analysis. The para-phenylenediamine is the ingredient of a traditional cosmetic hair dye available with the trade name Godrej expert powder hair dye, which is orally administered mainly with an intention to commit suicide, sometimes accidentally and very rarely as homicidal poison by hair dye users. The suicidal poisoning is more common in females as compared to males. The systemic toxicity of PPD has serious consequences which may eventually lead to death. The cases are reported with the advice public education and strict control over the sale and distribution of para-phenylenediamine should be done to reduce poisoning by this agent. Key Words: Para-Phenylenediamine, Suicidal Poisoning, Traditional Cosmetic, Hair Dye

Introduction:
Para- phenylendediamine is a poison, semipermanent dye has smaller molecule and is therefore able to penetrate the hair shaft. This Colour will servive repeated washings. Godrej hair dye, supervasmol 33, Paraphenylendiamine, are used for colouring of hair, Pphenylendiamine (PPD) is an organic compound. This derivative of aniline aromatic amine, is a colourless solid when pure. This compound is used in almost every hair dye marketed regardless of brands. The darker the colour, usually, the higher the concentration, some of the so-called Natural and herbal hair colours, while ammonia free contains PPD. Some product sold as henna also contains PPD Particularly black henna. Short exposure to high level of PPD may cause severe dermatitis, eye irritation and tearing, Asthma, renal failure, vertigo tremers, convulsions and coma. Ingestion of PPD produces rapid developments of edema of face, neck, pharynx tongue and larynx with respiratory distress which often needs tracheostomy.

In the later stages Rhabdomyolysis and acute tubular necrosis with acute renal failure and hepatic failure develops.Bleeding tendency (bleeding from gums), sub-cunjunctival hemorrhage and bleeding from mucus membrane also occur.

Material and Method:

Twenty three cases of acute Paraphenylendiamine poisoning admitted to Rama Medical College & Hospital Mandhana Kanpur U.P. were examined irrespective of age, sex, socioeconomic strata Profession along with manner of administration of the poison. Following investigations were done: 1. CBC, BT, CT 2. Renal function tests: a. S. creatinine b. Blood urea c. Urine: Routine and Microscopic 3. Liver function test i. S. Bilirubin ii. SGPT, SGOT 4. Serum electrolytes: a. Serum Sodium b. Serum Potassium c. Serum Calcium 5. CPK 6. Arterial blood gas analysis

Corresponding Author:
*Dr. Sushil Kumar Assistant Professor, Forensic Medicine, Rama Medical College, Kanpur (U.P.)

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ISSN 0971-0973

J Indian Acad Forensic Med, 32(2) was raised in 46.88 percent cases, these patients also have deranged ABG. Albumunaria seen in 50 percent case prolonged BT, CT in 18.75 percent cases, thrombocytopenia in 31.25 percent cases. 6 cases were Refered for dialysis were expired, mortality was 18.75%. mortality was 21.1% is study by Ayoub et al [4, 6] and 41.9 in study by M, Sir Hasim et al and 22% in study by Yagi et al. [6] The mortality was less in our study probably because of ingestion of low amount of dye, and early treatment of patient.

Results:
Sr. No. 1 2 3 4 5 6 7 8 9 10 11 Biochemical Parameter Raised total Leucocyte counts Raised Liver enzymes: SGPT, SGOT Raised serum creatinine Hypocalcemia Raised Bilirubin Reduced Hemoglobin Prolonged BT and CT Thrombocytopenia Blood urea ABG Derangement Albuminuria Percentage of cases shown derangement 78.125 62.5 46.88 37.5 68.75 31.25 18.75 31.25 46.8 46.8 50

Conclusion:
The systemic effects of PPD poisoning have serious consequences which may eventually lead to death. The Lethal dose of PPD is not known; estimates from 7-10 grams. The mechanisms of acute tubular necrosis are many. The most of the injuries resulting from hypoxia dehydration, intravascular haemolysis, Methaemoglobinaemia and direct toxic actions of chemical or its by products on the renal tubules.This study showed that PPD poisoning was fatal in about 18.75 percent cases. The poisoning of PPD was not more common in this region previously. Previously cases of Celphos poisoning were more but due to the strict control of sale of Celphos, poisoning of hair dye (PPD) is more common these days. The controlled supervision over selling of hair dye is necessary to stop PPD poisoning. We recommend that the selling of hair dye containing PPD should be banned and public education programme should be initiated in this regard so that mortality from PPD may be prevented, because availability of PPD in home causes easy accessibility of this poison.

Discussion:
Hair dye containing PPD is used for hair colouration and is added to Henna to accentuate the colour when used on the skin. Over-doses with this chemical is common, and can be fatal if taken in large quantities. Death is usually caused by angioneurotic edema or arrhythmias due to direct cardiotoxicity of PPD cases of poisoning of PPD which develops renal failure require dialysis. The cause of renal injury is probably direct nephrotoxicity of compound. Rhabdomyolysis caused by PPD is also a cause of ARF in these patients. The lethal dose of PPD is not known; estimates vary from 7-10 grams. The characteristic chocolate brown colour of the urine could be confirmative evidence of hair dye poisioning in individual with the poisioning of PPD (Presence of hair dye in urine can be confirmed by this layer chromatography in the lab). First case of systemic toxicity with PPD was described by the Nott in 1924 in the owner of a hair saloon. [7] A report from Sudan described a series of 18 cases of acute hair dye poisoning. Sood et al and Chug et al have reported hair dye poisoning from India. [8, 9] Clinical studies were also done by Ansory et al 1983, [1] Fathi et al 1995, [2] Kamil and Devidson 1996, [3]Yagi et al 1996, [5] Ababou et al 1995, Ayuoub Filali, Llham Semlali 2006. [4] All our patient took poison intentionally with a suicidal intent. In the study of Ayoub et al & Yagi et al few cases were accidental but most of the cases were seen with suicidal intent. [4, 6] In our study entire poisioning was by Ingestion. The toxic effects of PPD are many. The most explainable in the combined effect to kidney resulting from hypoxia, dehydration, intravascular hemolysis, methemoglobinea and a direct toxic effect of the chemical or its by products on the renal tubules. Rhabdomyolysis may also contribute to renal failure. [10, 11] In our study total leucocutes count was raised in 78.125 percent cases 62.5 cases were raised liver enzymes, S. creatinine and blood urea

References:
1. El. Ansary, E.H., Ahmed, M.K., Clague H.W., (1983). Systemic toxicity of paraphyelendiamine. Lancet, I, 1341. 2. Fatihi, E., Laraki, M., Zaid, D., Benaguida, M., (1995). Toxicite systemique de la paraphenylene diamine a propos de 13 cas. Rea Urg 4, 671-673. 3. Kamil A., A.A. Davidson. N.m., (1996). A woman who collapsed after painting her soles. Lancet B: 658. 4. Ayoub Filali, Llham Semlali et al. A retrospective study of acute systemic poisoning of paraphenylendediamine in Morocco. African Journal 2006. Vol-3, Num, 1, 2006, pp. 142-149. 5. Yagi H.I., El Hindi, A.M., Diab, A., Elshikh, A.A., (1996). Paraphenylendediamine induced optic atrophy following hair dye poisoning. Hum exp Toxicol 15:617-618. 6. Yagi H.I., El Hindi, A.M., Khalil, S.I. (1991). Acute poisoning from hair dye. East Afr. Med. J. 68: 404-411. 7. Nott HW. Systemic poisoning by hair dye. The Br Med J 1924; 1:421-2. 8. Sood AK, Yadav SP, Sood S et al. Hair dye poisoning. J Assoc Physicians lnd 1996; 44 (1):69. 9. Chugh KS, Malik GH, Singhal PC. Acute renal failure following paraphenylenediamine (hair dye) poisoning. Report of 2 cases. Journal of Medicine 1982; 131-7. 10. Gabow PH, Kachny WD, Kelleher SP. The spectrum of rhabdomyolysis. Medicine 1982; 61:14-52. 11. Suliman SM, Homedia M Aboval Ol. Paraphenylenediamine induced acute tubular necrosis following hair dye ingestion Human Toxicol 1983; 2:633-5.

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