Preventable Death in a 2-year-old Male After Ingestion of Weed Killer Stored in an Unlabeled Inappropriate Container

Introduction: Toxic ingestions are infrequent but potentially life-threatening events that can occur in the pediatric population. Toddlers, specifically, are susceptible to unintentional ingestions due to exploratory behaviors and tendency to place objects in their mouth. Inappropriate storage of such objects or substances contribute to these ingestions and can cause serious harm, including death. Below we present a case report of a deadly accidental ingestion of diquat herbicide poisoning in a 2-year-old male.

Case Description: A previously healthy 2-year-old male was taken to a nearby hospital after an unwitnessed ingestion of weed killer (initially thought to contain organophosphate) stored in a water bottle. Ingestion amount was unknown but family stated the container had around 30mL of fluid. The patient presented as somnolent but arousable and was tachycardic and tachypneic. He developed nonbloody nonbilious emesis and soft non-bloody stools. Initial labs showed leukocytosis and hyperchloremia, otherwise normal values. After symptomatic management, he was transferred to a pediatric children’s hospital where he developed oropharyngeal ulcers with no drooling or respiratory distress. Due to suspicion of diquat ingestion, poison control recommended admission to the ICU for observation.

After admission, the patient's clinical course was complicated by hyperchloremic metabolic acidosis (Cl 124 mmol/L, HCO3 13 mEq/L) and acute renal failure (Cr 3.6 mg/dL) while NPO. He was placed on broad spectrum antibiotics due to fever and emesis. Hemodialysis was initiated due to worsening renal function and oliguria. He then developed status epilepticus and subsequently ARDS, requiring antiepileptics, intubation and mechanical ventilation. Due to worsening neurological status confirmed on vEEG, a brain CT was obtained which demonstrated hydrocephalus, diffuse cerebral edema and herniation. Despite neurosurgical interventions, ECMO, and CRRT, he progressed to multi-organ failure. The decision was made with the parents to withdraw life support and the patient passed on the third day of admission.

Discussion: Most deadly toxic ingestions in toddlers are preventable. Exploratory behaviors are common at this age and anticipatory guidance on toddler development and proper storage of household items are key to preventing toxic and deadly ingestions.

Paraquat and diquat, specifically, account for around 5% of herbicide poisoning, but cause more than 50% of herbicide-related deaths. Once ingested, diquat forms reactive oxygen species which lead to cellular damage. Common manifestations and complications include oropharyngeal ulcers, gastrointestinal injury, acute renal failure, ARDS, cerebral infarction, multi-organ failure and death. Management of severe toxicity includes gastric lavage, respiratory support, and elimination via hemoperfusion and hemodialysis.

Conclusion: Many deadly toxic ingestions in the toddler age group can be prevented. This case report highlights the importance of appropriate counseling on normal exploratory behaviors in this age group along with anticipatory guidance on the importance of restricting access to harmful substances at home and how to properly store them.