Case Presentation: Background: Diquat is an active ingredient found in many herbicides, it is rare but a serious cause of poisoning.1 Diquat poisoning often occurs as a result of an accident or suicide attempt.2 Despite its potency, diquat poisoning is relatively rare, with only 30 cases reported in the United States between 1968 and 1999.3 However, the mortality rate was strikingly high.3 Because these cases are rare, we have a limited understanding of their clinical manifestations and treatment options. Most case reports focus on diquat ingestion, which typically damages the gastrointestinal tract, kidneys, lungs, liver, and heart, with kidney injury being the most common.4 This case, however, involves a novel mode of poisoning, an intramuscular injection resulting in both expected and unexpected symptoms. Case Presentation: A 26-year-old transgender male with a history of depression came to the emergency department after attempting suicide by injecting himself with 7.5 ml of herbicide containing diquat dibromide. He injected herbicide into his arm and leg intramuscularly. Upon arrival, he was feeling extremely hot and sweaty and was experiencing palpitations, nausea, and vomiting. His blood pressure was 137/89 mmHg, heart rate was 107 bpm, respiratory rate was 24 breaths per minute, SpO2 was 99% on room air, and temperature of 36.7°C. He was sweating and agitated but was alert, and oriented, and no signs of neurological deficits were observed. Poison control was contacted, and they recommended prolonged observation and supportive care. The patient was started on normal saline and given anti-emetics. As his agitation worsened, he was given IV lorazepam and was subsequently admitted to the medicine for further monitoring. The patient became more agitated and non-responsive to commands, suggesting neurological involvement. Repeat vitals indicated hypertension, tachycardia, and an increase in temperature. Subsequent lab results showed a dramatic rise in white blood cells, creatinine, liver enzymes, and lactic acid, signaling a systemic inflammatory response and multi-organ dysfunction. EKG showed sinus bradycardia. Poison control recommended transfer to the ICU, NAC protocol initiation, and Decadron administration. The patient was eventually intubated due to declining mental status and transferred to a specialized poison control center.
Discussion: Diquat dibromide is a highly toxic herbicide that generates free radicals and leads to severe cellular damage and multi-organ failure.5 Diquat poisoning is mostly fatal, with the kidneys most affected.4 This case is interesting due to the unique method of poisoning, which bypassed the gastrointestinal tract but led to systemic toxicity. The patient’s symptoms, such as diaphoresis, palpitations, nausea, and neurological decline, align with existing literature.6 However, the mode of poisoning presented significant challenges in management. Despite early consultation with poison control,8 delayed ICU admissions may have impacted the patient’s care. The effectiveness of dialysis and hemoperfusion in such cases remains debatable.8
Conclusions: Given the high mortality associated with diquat poisoning and the absence of specific antidotes, swift recognition and aggressive supportive care are crucial. This case highlights the importance of early ICU admission, poison control consultation, and prompt initiation of symptomatic treatments to enhance patient outcomes.