PROPHYLAXIS KILLS

Abstract

Introduction

Isoniazid toxicity is a rare presentation in emergency department. It has high mortality rate hence prompt treatment with appropriate antidote is vital

Case description

A 28-year-old Indonesian woman who was previously well, was brought to emergency department (ED) with sudden onset of seizure. She was brought in by prehospital team who witnessed an ongoing seizure at her resident. At scene, they found empty strips of medication next to the patient. The medication was prescribed to her prophylactically as her newborn baby was diagnosed to have pulmonary tuberculosis. Upon arrival to ED, she was stuporous, tachypneic and had another episode of generalized tonic clonic seizure. We established a diagnosis of refractory status epilepticus and intubated her for airway protection. Initial point of care test showed severe metabolic acidosis with normal capillary blood sugar level. There was no evidence of leukocytosis or any electrolytes abnormalities. We identified the empty strips of medication as isoniazid with a total of three grams assumed to be ingested. She was started on 3g of intravenous pyridoxine due to limited availability in our Centre. Police report was made and further history from the husband revealed that she ingested total of five grams of isoniazid. Initial head CT was normal. She was admitted to medical ward and required repeated bolus of intravenous pyridoxine. Her condition continued to deteriorate, and she succumbed to death after few days. 

Discussion

Isoniazid toxicity is commonly intentional. Its incidence in our country is unknown and associated with high mortality and morbidity. Unexplained seizures with severe metabolic acidosis should raise a suspicion of toxic ingestion of substances. Even though it is rare, hospital should reserve adequate amount of antidote. 

Conclusion

A detailed history and high level of suspicion is important for proper diagnosis and treatment of isoniazid toxicity.