Formalin induced Corrosive Mucosal Injury: A Rare Case Report

 

Stephy Stephen¹, Sajitha Nair², Uma Devi P^3*

¹Student, Pharm D, Department of Pharmacy Practice, Amrita School of Pharmacy,

Amrita Vishwa Vidyapeetham, Kochi - 682041, Kerala, India.

²Professor, Department of Paediatrics, Amrita Institute of Medical Sciences and Research Centre,

Amrita Vishwa Vidyapeetham, Kochi - 682041, Kerala, India.

³Associate Professor, Department of Pharmacology, Amrita School of Pharmacy, Amrita Vishwa Vidyapeetham, Kochi - 682041, Kerala, India.

 

ABSTRACT:

Formalin is an aqueous solution of formaldehyde (37%), which is a pungent and highly reactive gas. Ingestion of formalin is infrequent due to its strong odour and irritant effects. Here, we report a case of accidental ingestion of formalin in a five-year-old child. This child was referred to our hospital with a history of accidental ingestion of 30 mL of formalin at home. Following the intake she developed vomiting and mild abdominal pain. Arterial blood gases at admission were as follows: pH: 7.39, pCO₂: 30.4 mm Hg, pO₂: 102 mm Hg, bicarbonate: 19.8 mmol/L, lactate: 1.2 mmol/L. Routine haematological, liver and kidney investigations revealed no significant abnormality. Oesophago-gastro duodenoscopy indicated corrosive injury to stomach and oesophagus. Supportive care treatment was provided with broad spectrum antibiotics, intravenous fluids, antiemetics, proton pump inhibitors and gastrointestinal mucosal protectant like sucralfate. She showed improvement with the treatment and was later started on a clear liquid diet which gradually advanced to soft diet. Thus, the gastrointestinal system appears to be primarily affected due to formalin intoxication. In the absence of a specific antidote, such poisoning cases need to be treated symptomatically. Prompt supportive treatment can avoid fatal consequences.

 

 

INTRODUCTION:

Formalin is an aqueous solution of formaldehyde (37%), which is a pungent and highly reactive gas.¹ It has wide applications as disinfectant, tissue preservative etc. It is absorbed from all surfaces of the body and affects multiple organ system including gastrointestinal, renal, cardiovascular, respiratory and central nervous system.² Ingestion of formalin is infrequent due to its strong odour and irritant effects. However, few cases of accidental³ or suicidal ingestion of formalin^4,5 have been reported in literature. Here, we report a case of accidental ingestion of formalin in a five-year-old child.

 

CASE REPORT:

A five-year-old developmentally normal, previously asymptomatic girl was referred to our hospital with a

 

history of accidental ingestion of 30 mL of formalin at home. Following the intake she developed vomiting (which had the characteristic smell of formaldehyde) and mild abdominal pain. She was taken to a local hospital, treated symptomatically with intravenous fluids and antiemetic and was then referred to our hospital for further management.

 

On admission she was fully conscious and afebrile. Her oxygen saturation was 98%, pulse rate was 100/minute, respiratory rate was 26/minute and blood pressure was 100/56 mm Hg. On physical examination, her oral mucosa showed minimal whitish slough. Heart sounds were normal with no murmurs. Her abdomen was soft and non-tender with no signs of organomegaly.

 

Arterial blood gases and serum electrolytes at admission were as follows: pH: 7.39, pCO₂: 30.4mm Hg, pO₂: 102 mm Hg, bicarbonate: 19.8 mmol/L, lactate: 1.2 mmol/L, potassium: 4.19mmol/L, sodium: 133.3mmol/L, chloride: 115mmol/L, phosphate: 4.9mg/dL and magnesium: 2.02mg/dL. Her liver and kidney function tests were normal. Routine haematological investigations also revealed no significant abnormality.

 

She was monitored and conservatively managed and paediatric gastro consultation was availed on day 2 and was advised for oesophago-gastro duodenoscopy (OGD) which indicated corrosive injury to stomach and oesophagus. The oesophagus and stomach regions showed erythema and exudates. Erythema of prepyloric area was also observed.

 

Supportive care treatment was provided with broad spectrum antibiotics, intravenous fluids, antiemetics, proton pump inhibitors and gastrointestinal mucosal protectant like sucralfate. She showed improvement with the treatment and was later started on a clear liquid diet which gradually advanced to soft diet. The patient was discharged from the hospital after one week.

 

Barium swallow test performed one month later showed normal filling of lumen, normal peristaltic activity, normal oesophageal emptying time as well as normal relaxation of upper oesophageal sphincter and gastro-oesophageal junction.

 

DISCUSSION:

In this report we describe a case of accidental ingestion of formalin in a child. Cases on formalin ingestion are sparse in literature which can be attributed to its irritating effect and strong odour.

 

Following ingestion, formaldehyde is rapidly converted to formic acid in the body, which may be responsible for the metabolic acidosis that is seen after formalin intoxication. Usually formalin contains methanol as a stabilising agent to prevent polymerization, which could also contribute to the formic acid pool and hence the metabolic acidosis.²

 

Ingestion of formalin has been reported to affect almost all the major systems of our body with the gastrointestinal system being primarily affected. It has been reported to produce erythema, ulcerations and perforations in the gastrointestinal tract. The most common late complication is stricture formation.^{6, 7} Hence, to assess the degree of gastrointestinal damage, oesophago-gastro duodenoscopy was done which revealed corrosive injury to the oesophagus and stomach which was evident as erythema with exudates. The extent of damage is dependent on not only the chemical concentration but also on the exposure duration. Liver and kidney function tests performed in our patient were found to be within the normal limits.

 

Since there are no specific antidotes for the management of formalin poisoning,⁸ the patient was provided symptomatic treatment. Even though activated charcoal can inhibit the furthermore absorption of formalin, however, there is not enough literature to support the fact.⁹ Moreover, it has a potential to obstruct the endoscopic procedure.  In view of the injury to the oesophagus and stomach, the patient was started on a proton pump inhibitor (pantoprazole) and sucralfate to provide protection to the linings of the stomach and hence allow for faster healing of the mucosal membrane. In view of the mucosal damage, antibiotics were also prescribed to avoid the development of infection.

 

The fatal dose of formalin in adults has been reported to be about 60 to 90 ml.² However, in the paediatric age group, the fatal dose may be far less. In an earlier case of homicidal poisoning, approximately 10 to 15 ml of formalin had proved to be fatal in a six-month-old infant.¹⁰ In our case, the child had ingested around 30 ml, however, no fatality was observed which could be due to prompt implementation of symptomatic and supportive treatment.

 

CONCLUSION:

Ingestion of formalin even though infrequent, can affect the major organ systems in the body especially the gastrointestinal system. In the absence of a specific antidote, such poisoning cases need to be treated symptomatically. Prompt supportive treatment can avoid fatal consequences.

 

AUTHOR’S CONTRIBUTION:

We declare that this work was done by the authors named in the article and all liabilities pertaining to claims relating to the content of this article will be borne by the authors. Stephy Stephen collected and prepared the manuscript. Dr Sajitha Nair and Dr Uma Devi P were involved in the critical review of the manuscript.

 

CONFLICT OF INTEREST:

The authors declare that there is no conflict of interest.

 

REFERENCES:

1.      Indian Pharmacopoeia 2018, volume 1. Government of India, Ministry of Health and Family Welfare. 

2.      Pandey CK et al. Toxicity of ingested formalin and its management. Human & Experimental Toxicology 2000; 19(6): 360-6.

3.      Vos H, Luinstra M, Pauw R. Survival of a formalin intoxication: a case report. Netherlands Journal of Critical Care 2017; 25(4): 133-6.

4.      Hungund C et al. Fatal formalin poisoning: A case report. Iranian Journal of Toxicology 2011; 5(1&2): 468-9.

5.      Koppel C et al. Suicidal ingestion of formalin with fatal complications. Intensive Care Medicine 1990; 16(3): 212-4.

6.      Yanagawa Y et al. A case of attempted suicide from the ingestion of formalin. Clinical Toxicology (Philadelphia) 2007; 45(1): 72-6.

7.      Hawley CK, Harsch HH. Gastric outlet obstruction as a late complication of formaldehyde ingestion: a case report. The American Journal of Gastroenterology 1999; 94(8): 2289-91.

8.      Pillay VV. Current views on antidotal therapy in managing cases of poisoning and overdose. The Journal of the Association of Physicians of India 2008; 56: 881-92.

9.      Pillay VV, Sasidharan A, Ramakrishnan UK. Decontamination methods in poisoning revisited. Journal of the Indian Society of Toxicology 2016; 12(1): 22-8.

10.   Beeregowda YC et al. Homicidal acute formalin poisoning in an infant from a rural sericulture family presenting with multisystem failure. Pediatric Emergency Care 2013; 29(5): 653-5.

 

 

 

 

 

Received on 12.06.2019           Modified on 04.07.2019

Accepted on 02.08.2019         © RJPT All right reserved