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 Table of Contents  
CASE REVIEW
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 91-94

A rare case of suicide attempt by subcutaneous self-injection of kerosene: A case report and review of literature


1 Department of General Surgery, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
2 Department of General Surgery, King Fahad Specialist Hospital, Dammam, Kingdom of Saudi Arabia
3 Department of General Surgery, King Fahad Military Medical Complex, Dammam, Kingdom of Saudi Arabia
4 Department of General Surgery, Dammam Medical Complex, Dammam, Kingdom of Saudi Arabia

Date of Web Publication2-Apr-2018

Correspondence Address:
Dr. Mohammed Yousef Aldossary
Department of General Surgery, King Fahad Specialist Hospital, Dammam
Kingdom of Saudi Arabia
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DOI: 10.4103/jhs.JHS_156_17

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  Abstract 


Kerosene is one of the most widely used sources of energy in developing countries. Modes of accidental exposure include inhalation, ingestion and through skin or eye contact. There have been few cases reported in literature where kerosene was injected intravenously and subcutaneously with differing outcomes ranging from mild irritation to serious necrotising fasciitis. It remains challenging to predict the outcome of patients who inject kerosene through a non-venous route as it is difficult to establish the accuracy of tissue layer affected by the injection. The aim of this study is to analyse all the case studies presented with attempt of suicide by self-injection of kerosene, to establish a method of management available in this rare presentation.

Keywords: Kerosene, subcutaneous injection, suicide attempt


How to cite this article:
Alquraish FA, Aldossary MY, Almuhsin AM, Alkhlaiwy OY, Alghamdi AM. A rare case of suicide attempt by subcutaneous self-injection of kerosene: A case report and review of literature. J Health Spec 2018;6:91-4

How to cite this URL:
Alquraish FA, Aldossary MY, Almuhsin AM, Alkhlaiwy OY, Alghamdi AM. A rare case of suicide attempt by subcutaneous self-injection of kerosene: A case report and review of literature. J Health Spec [serial online] 2018 [cited 2018 Dec 18];6:91-4. Available from: http://www.thejhs.org/text.asp?2018/6/2/91/229024




  Introduction Top


Kerosene is a refined petroleum product also known as coal oil. It is an aromatic hydrocarbon-containing paraffin complexes and is commonly used in developing countries as a source of energy.[1],[2] Modes of accidental exposure include inhalation, ingestion, and through skin or eye contact.[1] The potential effect of kerosene following exposure is well established.[1] Effects include confusion cough sore throat and headache.[1] There is, however, limited literature regarding intentional exposure of kerosene by subcutaneous and bloodstream routes in the form of committing suicide attempt by self-injection which represent a serious emergency medical event. However, there is paucity in literature regarding the intentional implication of exposure by sub-cutaneous and bloodstream means. Reporting of such cases is crucial to mandate appropriate management in hospital settings. We present a case report of self-exposure to kerosene through a subcutaneous route. An extensive case review is performed. We aim to establish methods of management available in this rare presentation.


  Case Report Top


A 30-year-old male prisoner presented to the emergency department 2 days following a suicide attempt where he injected 6 ml of kerosene subcutaneously in his left cubital fossa. Since exposure, his symptoms deteriorated from mild injection site tenderness to diffused left upper limb swelling associated with erythema, severe pain in his limb, and decreased the range of motion. Systematically, he was complaining of subjective fever. Psychological history was significant for low mood and loss of interest over the past few days. He was otherwise previously well, with no known medical or psychological conditions. On physical examination, the patient was calm and oriented to time, place, and person. His vitals were within normal limits except for the temperature of 38.7°C. Local examination of left arm showed diffuse swelling with generalised erythema [Figure 1]. Peripheral pulses were palpable. However, the capillary refill was difficult to pinpoint. Local hotness was noticed, and a global decreased in the range of motions secondary to pain. Systemic examination was unremarkable. Laboratory revealed marked leucocytosis white blood count was 15.6 × 109/L, neutrophil count was 12.95 × 109/L. All other laboratory results were within normal limits.
Figure 1: Left arm showed diffuse swelling with generalised erythema

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Imaging performed, an X-ray of the left arm with multiple views [Figure 2]a, [Figure 2]b, [Figure 2]c showed, diffuse soft-tissue swellings, and no subcutaneous gas was identified. A provisional diagnosis of cellulitis was made. The patient was admitted and was managed with arm elevation, analgesia, and IV clindamycin 600 mg three times daily for 5 days and switched to oral. The patient condition improved and he was discharged after 5 days. Three weeks after discharge, a follow-up appointment revealed complete resolution of patient symptoms with no complication.
Figure 2: (a-c) Multiple hand X-ray views showed diffuse soft-tissue swellings, and no subcutaneous gas was identified

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Analysis of the literature review

There are limited reported cases of kerosene injection, making up a total of nine publications [Table 1]. Most reported cases are in Arab countries (KSA, Jordan, Iraq) (15 cases).[2],[3],[4],[5],[6] Iraq is the highest of Arab countries (11 cases).[4] The difficulty arises in management as cases are unique to each exposure in terms of dose injected, site of intended versus actual injection, and quantification of the exact dose of exposure. The lethal dose of kerosene for 70 kg adult is 100 ml.[7] Only 12.9% (4 cases) had reported the exact dose of kerosene that was used. Routes of kerosene exposure included: Intradermal, subcutaneous and intravenous [Chart 1]. Superficial skin contact with kerosene may cause dryness scaling and dermatitis.[8] Injection of kerosene presents with a more severe clinical presentation in the form of local unspecified inflammation, aggregation of neutrophils and soft tissue necrosis. This was demonstrated in two histopathology specimens of debrided necrotic tissue in two reported cases.[2],[3] Intradermal injection has been reported in 32% of cases (10 cases).[4] All treated medically as a case of panniculitis and skin ulceration [Chart 2]. Patients recovered without complications except one who has developed injection site fibrosis and contracture in the wrist and hand.
Table 1: Publications on kerosene poisoning

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The subcutaneous injection was reported in 12.9% of cases (4 cases) including our case.[2],[5] Three of them developed tissue necrosis requiring surgical debridement [Chart 2]. Kerosene was injected intravenously in 41.9% of cases (13 cases),[5],[8],[9],[10] 11 of the 13 patients were managed medically [Chart 2], 10 patients requiring intensive care input with cardiorespiratory support. Five out of the 10 patients injected more than 5 ml died. Only one patient, who injected an unknown dose of kerosene, developed tissue necrosis required surgical intervention. Non-specific route of kerosene injection was reported in 4 cases (12.9%) [Chart 1], all required surgical debridement [Chart 2].[3],[6],[11] Overall, 87% of cases have mental strain as a driving force of this self-harming behaviour (27 cases). Clinical presentations of kerosene injection are mainly cutaneous and soft-tissue injury ranging from cellulitis panniculitis ulcers and tissue necrosis. One study has demonstrated the ability of kerosene to produce an abscess. Neural injury has been reported in two cases.[9],[11] Temperature was commonly reported reaching up to 39°C. Severe systematic effect of kerosene has been reported in 10 cases mainly in patient who injected more than 5 ml of kerosene intravenously.[10] Most of cases have normal chemical and biochemical lab results except for leucocytosis, which was found in some cases reaching up to 23.[12] The percentage is low for patient who required surgical intervention 29% (9 cases) [Chart 2].[2],[3],[5],[6],[9],[11]


  Discussion Top


Management of patient presenting with kerosene injection depends on the clinical manifestations. Majority of patients will recover with conservative treatment (requiring analgesia, anti-inflammatory, and antibiotic).[13] However, surgical opinion should always be sought, especially in patients who present with tissue necrosis.[14] Multidisciplinary approach is required in patient who presents with systemic effect of kerosene in an intensive care unit, especially those who injected more than 5 ml intravenously.[15] After recovery, patient should be followed by psychiatrist to prevent further incidents.[16] Psychological intervention is necessary to reduce the chances of the patient trying to commit suicide.[17] Follow-up is needed by physician and patient should be educated about late kerosene effects which were reported in some cases such as injection site chronic ulcers and necrosis.[18] Medical solutions to incidences of kerosene injection are the most common means through which the condition is handled.[12] Injecting oneself with kerosene leads to the manifestation of tissue necrosis and ulcers. Some IV injections may not present with any clinical symptoms.[19]


  Conclusion Top


Management of patient presenting with kerosene injection depends on the clinical manifestations. A slight irritation is handled conservatively while surgery is considered in necrotising fasciitis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kerosene. Centers for Disease Control and Prevention; 2014. Available from: https://www.cdc.gov/niosh/ipcsneng/neng0663. [Last accessed on 2017 Nov 27].  Back to cited text no. 1
    
2.
Awe AJ, Soliman MA, Gourdie RW. Necrotizing fasciitis induced by self-injection of kerosene. Ann Saudi Med 2003;23:388-90.  Back to cited text no. 2
    
3.
Qaryoute SM. Skin ulceration induced by kerosene injection. Ann Plast Surg 1984;12:361-3.  Back to cited text no. 3
    
4.
Sharquie KE, Noaimi AA, Younis MS, Al-Sultani BS. Kerosene-induced panniculitis in Iraqi patients. JCDSA 2014;4:323-8.  Back to cited text no. 4
    
5.
Khammash MR, Hussein AD, Musmar M. Management of kerosene injections in the upper limb. Saudi Med J 1997;18:188-90.  Back to cited text no. 5
    
6.
Kafaween HM, Rebehat H, Sweis M, Hawil KN. Necrotising fasciitis induced by self-injection of kerosene. Middle East J Fam Med 2010;8:35-9.  Back to cited text no. 6
    
7.
Patel AL, Shaikh WA, Patel HL, Deshmukh D, Malaviya AP, Janawar P, et al. Kerosene poisoning – Varied systemic manifestations. J Assoc Physicians India 2004;52:65-6.  Back to cited text no. 7
    
8.
Amiri AH, Tarrahi MJ, Rafiei A. Clinical finding and outcome in suicidal attempt due to intravenous injection of kerosene. Pak J Biol Sci 2009;12:439-42.  Back to cited text no. 8
    
9.
Rostami K, Farzaneh E, Abolhassani H. Bilateral deep peroneal nerve paralysis following kerosene self-injection into external hemorrhoids. J Med Case Rep 2010;2010:1-3.  Back to cited text no. 9
    
10.
Jayaprasad S, Metikurke V. An unusual case of suicide attempt using intravenous injection of kerosene. Indian J Psychol Med 2013;35:98-100.  Back to cited text no. 10
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11.
Rubinstein E, Segal P, Tirosh M, Dolev E, Findler G. Kerosene-induced epidural abscesses. Arch Intern Med 1985;145:371.  Back to cited text no. 11
    
12.
Calati R. Psychological Interventions in Suicide. Springer Link. Springer, Cham; 1970. Available from: https://link.springer.com/chapter/10.1007/978-3-319-26282-6_27. [Last accessed on 2017 Nov 27].  Back to cited text no. 12
    
13.
Pease H. Effects of kerosene on the skin. Vet J Ann Com Pathol 1892;35:171-2.  Back to cited text no. 13
    
14.
Jack RL, Williams JM. Attribution and intervention in self-poisoning. Br J Med Psychol 1991;64(Pt 4):345-58.  Back to cited text no. 14
    
15.
Nunn JA. Gasoline and kerosene poisoning in children. JAMA 1934;103:472.  Back to cited text no. 15
    
16.
Belonwu RO, Adeleke SI. A seven-year review of accidental kerosene poisoning in children at Aminu Kano teaching hospital, Kano. Niger J Med 2008;17:380-2.  Back to cited text no. 16
    
17.
Paswan DW. Analysis the clinical profile of children admitted with kerosene poisoning in a tertiary care medical college hospital. JMSCR 2017;5:21423-6.  Back to cited text no. 17
    
18.
Whitten JH. The effects of Kerosene and other petroleum oils on the viability and growth of Zea mais. Bull Illinois State Lab Nat Histo 1914;10:245-73.  Back to cited text no. 18
    
19.
Yates G. Kerosene poisoning in children. JAMA 1956;160:1410.  Back to cited text no. 19
    


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