Successful management with hemoperfusion and antidotal therapy of severe combined dichlorvos and rodenticide poisoning: a case report

This case report presents a rare instance of combined dichlorvos (organophosphate) and brodifacoum (rodenticide) poisoning. By analyzing the clinical presentation and therapeutic course, we aim to provide insights into the challenges and management strategies associated with multi-agent toxic exposures. A 73-year-old male with a history of hypertension and depression was admitted after ingesting approximately 150 mL of dichlorvos and 10 mL of brodifacoum. He underwent 18 days of comprehensive treatment, including gastric decontamination with induced emesis and activated charcoal, administration of specific antidotes (a total of 1189 mg atropine, 21.8 g pralidoxime iodide, and 660 mg vitamin K1), and extracorporeal detoxification via hemoperfusion and hemofiltration. Supportive care involved infection control, nutritional supplementation, and monitoring of coagulation and electrolyte status. The patient developed early complications, including hematemesis, epistaxis, and persistent coagulopathy, as well as transient alterations in consciousness and cholinesterase levels below 200 U/L. With prompt and aggressive intervention, his clinical condition gradually stabilized, and he was discharged in good condition. Follow-up revealed coagulopathy, with deep vein thrombosis requiring oral anticoagulation. Combined organophosphate and rodenticide poisoning presents a complex toxicological scenario, characterized by overlapping and synergistic effects on the nervous and coagulation systems. Cholinesterase levels below 200 U/L may serve as a critical marker of severity in patients without pre-existing liver disease. Hemoperfusion effectively facilitates toxin clearance, though adjustments to pralidoxime iodide dosing may be warranted during extracorporeal therapy. Following blood purification therapy, no toxin was detected in the patient’s plasma, and long-term coagulation abnormalities associated with super warfarin exposure were not observed in this case. Additionally, electrolyte disturbances and myocardial biomarkers such as myoglobin and troponin require close observation, as they may reflect ongoing systemic injury. While this case highlights several clinical considerations, further studies are needed to establish standardized protocols for managing multi-toxin exposures of this nature.