Ashar A.
Acute Angioedema in Paraphenylenediamine poisoning.
J Pak Med Assoc Jan ;53(3):120-1.

A 14 year old African female was referred with acute progressive orofacial swelling of 3-4 hours duration. Initial history did not reveal any underlying medical cause. Her pulse was 120/minute, blood pressure 110/60 and respiratory rate 28/minute. The patient had non-tender, nonpitting oedema of bilateral submandibular and submental areas. The edematous floor of the mouth was raised above the mandibular occlusal level and the swollen tongue was pushed against the palate. She was able to maintain her airway and tracheostomy was not considered essential. A diagnosis of acute angioedema was made. Intravenous hydrocortisone sodium succinate 200mg and oral Chlorpheniramine maleate 4mg were administered. Subsequently the patient was also noted to have rigidity, tenderness and painful movements of both the lower limbs, as well as, hoarseness of the voice. Routine blood tests showed the following abnormal values: white cell count 25x109/1, Glucose 15.2 mmol/l, Potassium 5.8 mmol/l, Creatinine Kinase (CK) 4380u/l, Aspartate aminotransferase (AST) 1455u/1. Alanine aminotransferase (ALT) 246 u/l and creatinine 200mmg/dl. Arterial blood gases (pH 7.34, P0, 84.5 mm Hg, PC02 29.3 mmHg, S02 84.5% and HC03 15.8mm/I) showed mild metabolic acidosis. Urinalysis showed coffee brown urine which tested positive for blood, myoglobin arid protein. On further interrogation it was revealed that patient had ingested some non-branded hair dye. Blood, urine and solid sample of the ingested material were found to be positive for paraphenylenediamine using chemical spot test and thin layer chromatography. A diagnosis of acute PPD poisoning with oro-facial angioedema, rhabdomyolysis, acute liver and renal impairment was made.

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