Intoxicacion por alcanfor en pediatria

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Intoxicacion por alcanfor en pediatria

  1. 1. A Cluster of Children With Seizures Caused by Camphor Poisoning Hnin Khine, Don Weiss, Nathan Graber, Robert S. Hoffman, Nora Esteban-Cruciani and Jeffrey R. Avner Pediatrics 2009;123;1269-1272 DOI: 10.1542/peds.2008-2097 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/123/5/1269 PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2009 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from www.pediatrics.org by on August 16, 2010
  2. 2. ARTICLE A Cluster of Children With Seizures Caused by Camphor Poisoning Hnin Khine, MDa, Don Weiss, MD, MPHb, Nathan Graber, MD, MPHc, Robert S. Hoffman, MDc, Nora Esteban-Cruciani, MDa, Jeffrey R. Avner, MDa a Division of Pediatric Emergency Medicine, Department of Pediatrics, Albert Einstein College of Medicine, Children’s Hospital at Montefiore, Bronx, New York; Bureaus of b Communicable Diseases and cEnvironmental and Occupational Disease Epidemiology, Department of Health and Mental Hygiene, New York, New York The authors have indicated they have no financial relationships relevant to this article to disclose. What’s Known on This Subject What This Study Adds It is known that camphor causes seizures. Prior case reports of seizures caused by cam- We discovered that in certain communities, a wide spread use of illegally imported phor containing products had led the FDA to restrict the contents of camphor in over- unregulated camphor in many varied ways and parental unawareness of its toxicity had the-counter products to less than 11%. led to seizures in young children, and under-recognized cause of seizure. ABSTRACT BACKGROUND. Isolated cases of camphor-induced seizures have been reported in young children after gastrointestinal, dermal, and inhalation exposure. In 1982, after a series of unintentional ingestions of camphor products, the US Food and Drug www.pediatrics.org/cgi/doi/10.1542/ peds.2008-2097 Administration restricted the camphor content to 11% in some products intended for medicinal use. Camphor products intended for use as pesticides must be regis- doi:10.1542/peds.2008-2097 tered with the US Environmental Protection Agency. Still, many imported camphor- Key Words camphor, seizure, toxicity containing products fail to meet Food and Drug Administration and Environmental Abbreviations Protection Agency requirements for labeling and content. FDA—Food and Drug Administration OBJECTIVE. To describe a cluster of cases of camphor-associated seizure activity resulting ED— emergency department from the availability of imported camphor products in certain ethnic populations that Accepted for publication Aug 29, 2008 use it as a natural remedy. Address correspondence to Hnin Khine, MD, Children’s Hospital at Montefiore, Pediatric Emergency Medicine, 111 E 210th St, Bronx, METHODS. We present 3 cases of seizures associated with imported, illegally sold cam- NY 10467. E-mail: hkhine@montefiore.org phor in young children who presented to a large, urban children’s hospital in Bronx, PEDIATRICS (ISSN Numbers: Print, 0031-4005; New York, during a 2-week period. Online, 1098-4275). Copyright © 2009 by the American Academy of Pediatrics RESULTS. The children’s ages ranged from 15 to 36 months. Two children ingested camphor, and 1 child was exposed through repetitive rubbing of camphor on her skin. All 3 patients required pharmacologic intervention to terminate the seizures. One patient required bag-valve- mask ventilation for transient respiratory depression. All 3 patients had leukocytosis, and 2 patients had hypergly- cemia. Exposure occurred as a result of using camphor for spiritual purposes, cold remedy, or pest control. After identification of these cases, the New York City Department of Health released a public health warning to keep camphor products away from children. Similar warnings were issued later by other state health departments. CONCLUSIONS. These cases highlight the toxicity associated with camphor usage in the community and that inappro- priate use of illegally sold camphor products is an important public health issue. Camphor may be a common, yet unrecognized, source of seizures in children in certain ethnic populations that use it as a natural remedy. Efforts are needed to educate the communities about the hazards of using camphor products and to limit the illegal availability of these products. Pediatrics 2009;123:1269–1272 S EIZURES ARE A known complication of camphor toxicity and are reported after ingestion, inhalation, and dermal exposure.1–6 In 1982, after the reports of several incidents of camphor toxicity in young children, often involving camphorated oil products (20% camphor), the US Food and Drug Administration (FDA) limited the camphor content of common cold preparations to 11% and restricted the sale of camphorated oil.7 In addition, because of its properties as a toxic, combustible, and irritating substance, which, if ingested, can cause injury, illness, or death, camphor products must comply with the labeling requirements of the New York City Health Code (173.05b). The FDA also requires proper labeling if camphor products are intended for medicinal use, as does the Environmental Protection Agency if camphor products are intended for use as an insecticide or insect repellent. Currently, many camphor-containing products are imported from other countries and sold without proper or complete labeling (Fig 1). Such products are widely available in the community and are being used for medicinal, spiritual, and aromatic purposes as well as for pest control. Because of their wide usage, inadvertent exposure of young children and infants to camphor may represent an under-recognized cause of seizures. In this report, we PEDIATRICS Volume 123, Number 5, May 2009 1269 Downloaded from www.pediatrics.org by on August 16, 2010
  3. 3. FIGURE 1 Examples of imported camphor products. describe a cluster of camphor-associated seizures linked intractable vomiting. Shortly after arrival in the ED, he to imported camphor products that occurred over a developed a generalized tonic-clonic seizure that was 2-week period at a single hospital in Bronx, New York. treated with 0.1 mg/kg of lorazepam intravenously. Ini- tial vital signs and significant laboratory findings are CASE REPORTS shown in Table 1. Noncontrast computed tomography of the brain was normal. Alcohol, acetaminophen, aspirin, CASE 1. A 15-month-old Hispanic boy with no significant and iron were not detected on a serum toxicology past medical history or recent trauma was brought to the screen. A urine toxicology screen for drugs of abuse was emergency department (ED) for vomiting. He was in his negative. An electrocardiogram showed sinus tachycar- usual state of health until he suddenly dropped to the dia with normal axis and intervals. The parents initially ground and became stiff. Immediately afterward, he had denied any ingestion, however, after additional ques- TABLE 1 Patients’ Initial Vital Signs and Significant Laboratory Findings Case Age, mo Temperature, oF Heart Rate, Respiratory Blood Pressure, Oxygen White Blood Serum Beats per Min Rate, Breaths mm Hg Saturation, %a Cells, 103/uL Glucose, per Min mg/dL 1 15 98.6 160 28 85/54 100 26.6 166 2 22 97.3 218 31 80/38 100 18.6 176 3 36 100.1 169 36 94/58 95 26.5 87 a Blood oxygen saturation as measured by pulse oximetry in room air. 1270 KHINE et al Downloaded from www.pediatrics.org by on August 16, 2010
  4. 4. tioning, the father revealed that he saw the child put a containing products extensively in various ways including cube of “alcanfor” (Spanish for camphor) in his mouth putting “alcanfor” in the vaporizer, placing it in a bowl with 40 minutes earlier. The parents stated that they put water under the crib, hanging camphor tablets in a meshed camphor cubes in a bowl of water just outside the door cloth on the posts of the crib, and spreading crushed tablets to his room to ward off evil spirits. The child was admit- around the house to control roaches. The mother also ted to the inpatient service for 1 day and had an un- reported that 2 of her other children had previously been eventful recovery. In a telephone interview with the diagnosed with a seizure disorder. All 3 children had ex- father 10 weeks after the incident, he stated that the tensive evaluation for seizures in the past, including nor- child had no additional episodes of seizures. The parents mal MRI of the brain and electroencephalograms. The removed all camphor-containing products from the mother also noted that neither of the other siblings had any home. seizures when they lived in the grandmother’s apartment for 1 year in the past. The grandmother would not allow CASE 2. A 22-month-old Hispanic boy was brought to the the mother to use camphor during that time because she ED in status epilepticus with stiffening and mild shaking couldn’t stand the smell. The eldest sibling “outgrew” his of extremities for 1 hour. His parents initially denied seizure disorder around the age of 5 years at which point any preceding illness, ingestion, or trauma. He had a his anticonvulsant medication was discontinued. The pa- history of a febrile seizure 1 month before presentation. tient was discharged from the hospital with no anticonvul- He was afebrile at the time of presentation to the ED. The sant medications. Use of camphor products in the home child was given 2 intravenous doses of lorezapam (each was discontinued. The children’s neurologist had advised 0.1 mg/kg) followed by an intravenous loading dose of the mother to discontinue all anticonvulsant medications 20 mg/kg of fosphenytoin to control his seizures. He for all 3 children. On follow-up 10 weeks after discharge, required bag-valve-mask ventilation secondary to tran- no additional episodes of seizures were reported in any of sient respiratory depression. The initial vital signs and the children. significant laboratory findings are shown in Table 1. These cases were reported to the New York City Poison Liver function tests were normal. A urine toxicology Control Center. In response, the New York City Depart- ment of Health and Mental Hygiene initiated an investiga- screen for drugs of abuse was negative. MRI of the brain tion of the availability of camphor products in local stores was normal except for prominent perivascular spaces of where the products implicated in these cases were pur- unknown significance. After stabilization, the child was chased, surveillance of calls to the Poison Control Center, admitted to the inpatient service for observation. On and notification of other health departments across the direct questioning, the father reported that the patient county. Unlabeled and mislabeled products were embar- ate a small piece of “alcanfor” 1 hour before onset of goed and distributors were identified and ordered to recall the symptoms. The product was placed around the any product that was sold. Health alerts, press releases, and apartment to control roaches. The child remained very educational material warned health care providers and the restless and irritable for 12 hours after the reported public to keep all camphor products out of the reach of ingestion and a lumbar puncture was performed to ex- children.8 The New York State Department of Environ- clude infection. Cultures of the blood and cerebrospinal mental Conservation, which enforces pesticide regulations, fluid had no growth. The child was hospitalized for 4 was also notified. Similar warnings were issued by other days and had a slow, but uneventful, recovery. At 10 state health departments.9 weeks after discharge, he had no additional episodes of seizures. DISCUSSION Sporadic cases of camphor toxicity are reported in chil- CASE 3. A 3-year-old Hispanic girl with a history of seizures dren and result from gastrointestinal, pulmonary, and presented after a generalized tonic-clonic seizure that dermal absorption.1–6 Despite attempts by the FDA to lasted 9 minutes. She received rectal diazepam at home restrict and control camphor use, it remains sold over before arrival in the ED. Initial vital signs are shown in the counter as a nonprescription natural remedy. Cam- Table 1. On arrival, she was awake but tired. The physical phor tablets are also sold as a pesticide without proper examination was remarkable for mild tachypnea and registration or labeling as required by the Environmental coarse rales on lung auscultation consistent with a recent Protection Agency. In fact, most reported cases of toxic- diagnosis of pertussis. The child’s past medical history was ity occur in the context of unintentional ingestions of significant for a seizure disorder of unknown etiology di- rubefacients or when a parent mistakenly administers agnosed at 3 months of age. A magnetic resonance angiog- camphorated oil instead of castor oil.10 In 2006, the raphy/MRI of the brain and electroencephalogram per- American Association of Poison Control Centers Toxic formed 2 years before were normal. Until 4 months before, Exposure Surveillance System reported over 7000 single the patient had been treated for seizures with valproic acid. substance exposures because of camphor.7 Although She was admitted to the inpatient service for observation. most exposures were not treated in a health care facility, On direct questioning about camphor use, the mother re- there were reports of both moderate and major toxicity. vealed that she had been rubbing a properly labeled cam- Children are particularly vulnerable to toxicity, because phor ointment over the child’s upper chest, forehead, and camphor is highly lipophilic and is easily absorbed back hourly for 10 hours before the onset of seizure to through the skin and mucous membranes. relieve her cold symptoms. The mother used camphor- Although seizures are a known toxicity of camphor, our PEDIATRICS Volume 123, Number 5, May 2009 1271 Downloaded from www.pediatrics.org by on August 16, 2010
  5. 5. TABLE 2 Parental Reports of Ways in Which Camphor-Containing of camphor toxicity when evaluating new onset seizures in Products Are Being Used young children who otherwise have no risk factors for seizures. 1. Camphor tablet placed in a jar containing water placed outside doors to ward off evil spirits and keep away illness. 2. Camphor tablet in a bowl of water placed over radiator as an air CONCLUSIONS freshener. We have described 3 children with seizures associated with 3. Camphor tablet in a bowl of water placed near a baby crib/bed to relieve toxic exposure to camphor. These cases highlight the tox- common cold symptoms. icity associated with extensive camphor usage in the com- 4. Camphor tablets placed in cheesecloth sacks and used as a bracelet or munity, including treatment of common childhood ail- anklet or placed around young children and babies to help relieve the symptoms of common colds. ments. Our report also calls attention to the use of 5. Camphor tablets placed in mesh bags and hung on each pole of a baby imported camphor products for medicinal purposes and crib to keep baby safe. pest control with potentially high-camphor content and 6. Camphor tablet placed in a vaporizer for a child with upper respiratory the need for restricting the availability of these products. In symptoms to inhale to relieve them of symptoms. certain communities, camphor-containing products have 7. Repetitive rubbing of camphor ointments on babies and children over been used in varied ways for many generations.3,4 The their chest, head, and back to relieve them of common ailments. inappropriate use of camphor and the availability of im- 8. Ingestion of water that had camphor dissolved in it (1 tablet of camphor ported, illegally sold camphor products are important pub- in 1 gallon of water) to relieve gastrointestinal symptoms. lic health issues. Furthermore, although manufacturers 9. Crushed camphor cubes spread around the home to keep away roaches. and distributors are required to register and properly label 10. Camphor used as mothballs in the closets and boxes of stored clothing. 11. Camphor cubes that are burned as part of religious rituals. any product that may be harmful, this was not the case with many of the camphor products cited in our report. Continued efforts are needed to educate communities about the hazards of using camphor products and to limit cases raise the possibility that camphor toxicity in children the availability of illegal products. Finally, we highlight occurs more commonly than recognized, especially in how a healthy partnership between primary care providers communities where cultural practices support its wide- and the Department of Health can function to improve spread use. Young children and infants are particularly at community health. risk based on the misperception that camphor has medic- inal properties. Illegally sold camphor products are widely available in grocery stores, fruit stands, Botanicas (a retail REFERENCES store that sells folk medicine), independent pharmacies, 1. Spyker DA, Cantilena LR Jr, Green J, Rumack BH, Heard SE. and discount stores. The use of camphor products to treat 2006 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS). Clin common childhood illnesses is particularly concerning in Toxicol (Phila). 2007;45(8):815–917 these cases, because the products were not properly labeled 2. Gouin S, Patel H. Unusual cause of seizure. Pediatr Emerg Care. to warn parents about the potential for harm, and the 1996;12(4):298 –300 content of these products is unknown. Table 2 lists the 3. Love JN, Sammon M, Smereck J. Are one or two dangerous? ways in which parents of our patients described the use of Camphor exposure in toddlers. J Emerg Med. 2004;27(1):49 –54 camphor-containing products in their homes. 4. Manoguerra AS, Erdman AR, Wax PM, et al, and the American We suspect that camphor usage in the community is Association of Poison Control Centers. Camphor poisoning: an largely unrecognized and that parents fail to mention this evidence-based practice guideline for out-of-hospital manage- exposure when accessing health care services. Further- ment. Clin Toxicol (Phila). 2006;44(4):357–370 more, the potential toxic effects are unknown to its users. 5. Ragucci KR, Trangmar PR, Bigby JG, Detar TD. Camphor in- gestion in a 10-year-old male. South Med J. 2007;100(2): With the exception of the initial case (case 1), the infor- 204 –207 mation of camphor exposure became apparent only after 6. Ruha AM, Graeme KA, Field A. Late seizure following inges- direct questioning of the parents. Although seizures may be tion of Vicks VapoRub. Acad Emerg Med. 2003;10(6):691 the first manifestation of camphor toxicity, they may not 7. New drugs: camphorated oil drug products for human use. Fed occur until 90 minutes after exposure, and symptoms may Regist. 1982;47:11716 –11720 persist for up to 24 hours.3,11 Therefore, it is possible that 8. New York City Department of Health and Mental Hygiene. the association of camphor and seizures may not be appar- Health Department warns parents to keep camphor products ent to caregivers. If unidentified by the caretaker, the use of away from children. Available at: www.nyc.gov/html/doh/ camphor as a natural treatment during a child’s febrile html/pr2008/pr006-08.shtml. Accessed February 5, 2008 illness may mistakenly lead to the common diagnosis of a 9. Maryland Department of Agriculture Pesticide Regulation Sec- tion. MDA stops sale of unregistered camphor products being simple febrile seizure rather than toxicity from the cam- sold as pesticides. Available at: www.mda.state.md.us/ phor exposure. The third case in our series highlights the article.php?i 9151. Accessed February 5, 2008 possibility that ongoing exposure of camphor may lead to 10. Bridge CK. Hazards of camphorated oil. CMAJ. 1995;153(7): recurrent seizures if not considered in the initial differential 881 diagnosis. In this family, the patient and siblings were 11. Liebelt EL, Shannon MW. Small doses, big problems: a selected diagnosed with a seizure disorder leading to extensive eval- review of highly toxic common medications. Pediatr Emerg uations as noted. Therefore, physicians should be cognizant Care. 1993;9(5):292–297 1272 KHINE et al Downloaded from www.pediatrics.org by on August 16, 2010
  6. 6. A Cluster of Children With Seizures Caused by Camphor Poisoning Hnin Khine, Don Weiss, Nathan Graber, Robert S. Hoffman, Nora Esteban-Cruciani and Jeffrey R. Avner Pediatrics 2009;123;1269-1272 DOI: 10.1542/peds.2008-2097 Updated Information including high-resolution figures, can be found at: & Services http://www.pediatrics.org/cgi/content/full/123/5/1269 Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Therapeutics & Toxicology http://www.pediatrics.org/cgi/collection/therapeutics_and_toxico logy Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtml Reprints Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml Downloaded from www.pediatrics.org by on August 16, 2010

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