Fatal Aluminum Phosphide Poisoning in Iran: An 11-Year Statistics and Update on Clinical and Forensic Toxicology Aspects

Background: Aluminum phosphide (AlP), under street name rice tablet, as a cheap and effective pesticide, is frequently used to protect stored crops mainly rice in Iran. AlP is a non-selective pesticide with high fatality potential for non-target species including humans. Phosphine gas (PH3) as main toxic component of AlP tablets, is liberated from the AlP due to contact with moisture and acid which present in air and stomach content. AlP has toxic effects on cardiovascular, respiratory, hepatic, and gastrointestinal system. Although the exact mechanism of AlP is unknown, the major mechanism of PH3 toxicity seems to be the inhibition of cytochrome-c oxidase and induction of the oxidative stress and cell death. In recent decades, due to availability, high toxicity and inexpensiveness of this pesticide, it used as a common agent for committed suicidal poisoning in Iran. In Iran, following high incidence and mortality due to acute AlP poisoning, the importation, distribution, and use of AlP tablets have been banned and excluded from the list of official pesticides since 2007. Unfortunately, fatal AlP poisoning is in the raise in Iran. In this study, we studied the trend of fatal AlP poisoning in an eleven-year period after the ban of this pesticide and reviewed the updated clinical and forensic toxicological aspects of the poisoning in Iran.Methods: In the study, all available data sources such as published articles in PubMed and Google Scholar databases and official reports from the Forensic Medicine Organization of Iran related to AlP fatal poisoning in Iran during 20 March 2008 to 20 March 2019 have been reviewed.Results: During this period, 5782 fatal AlP cases have been reported in Iran. A high increase rate (285%) in fatal AlP cases has been observed (from 214 cases in 2008 to 825 cases in 2019). Most of the victims (63.3%) were male with an age range between 20-30 years old. The incidence of fatal AlP poisoning has been reported from 29 provinces. Tehran, Guilan, Mazandaran, Lorestan, West Azerbaijan, Kermanshah, and Lorestan had a high prevalence of fatal AlP cases in Iran. From forensic toxicology aspect, most of the poisoning (99.8%) was self-poisoning. Five fatal AlP cases were accidental poisoning and five cases were homicidal poisoning. In clinical toxicology viewpoint, in the recent years, there are several studies on AlP poisoning in Iran for investigation of pharmacological agents (e.g. N-acetyl cysteine (NAC), vitamin E, liothyronine, minocycline, melatonin, hydroxyethyl starch, magnetic magnesium nanocarrier, glutathione, vitamin C, vasopressin, milrinone, boric acid, sweet almond oil, acetyl-L-carnitine) and medical procedural modalities (such as fresh red blood cells transfusion, intra-aortic balloon pump, peritoneal dialysis, hyperinsulinemia/euglycemia, hyperbaric oxygenation ) has been suggested to treat AlP poisoning in experimental and clinical settings.Conclusion: AlP poisoning is a major and in the raise cause of chemical self-poisoning fatality in Iran and prevention planning and education for the public and medical care providers considered for countermeasures in this regards.

کلیدواژه ها:

Aluminum phosphide ، Rice Tablet ، Poisoning ، Iran