Multimodal Management of Moderate-to-Severe Paraquat Poisoning in a Patient with Uncontrolled Type 2 Diabetes: A Case Report.

Abstract

Background: Paraquat poisoning carries a mortality rate of 60 to 90% and has no specific antidote, with outcomes driven largely by ingested dose and the speed of intervention. Management in comorbid patients, and in settings without access to plasma paraquat assays, remains poorly described. Case Presentation: We describe a 45-year-old man with uncontrolled Type 2 Diabetes Mellitus (HbA1c 11.7%) who ingested approximately 34 mg/kg of paraquat ion, placing him in the moderate-to-severe toxicity range by the Proudfoot classification. Plasma paraquat concentration was unavailable, so risk stratification relied on clinical and laboratory parameters, including metabolic acidosis, 3+ proteinuria, and hyperglycemia. He was treated with a four-pillar multimodal protocol: gastrointestinal decontamination with activated charcoal, two cycles of charcoal hemoperfusion at six and sixteen hours post-ingestion, immunosuppression with dose-reduced cyclophosphamide and dexamethasone, and antioxidant support with N-acetylcysteine. Supplemental oxygen was withheld given saturations above 97%, and steroid-induced hyperglycemia superimposed on pre-existing uncontrolled diabetes was managed with a continuous insulin infusion. The patient survived without progression to pulmonary fibrosis or significant renal impairment. Conclusion: This case demonstrates that early, individualized multimodal therapy can achieve survival in moderate-to-severe paraquat poisoning even when plasma paraquat measurement is unavailable and diabetes complicates immunosuppressive dosing, supporting the feasibility of protocol-driven management in resource-limited settings.