Fatal Triad: Spontaneous Pneumothorax, Pneumomediastinum, and Pneumorrhachis in a Case of Paraquat Ingestion

Objective: dependency on agriculture and the unregulated sale of paraquat makes it an easy alternative for homicidal and suicidal use in developing nations. it kills by multiorgan failure, predominantly pulmonary fibrosis, and ards. we report a case of alleged paraquat ingestion with spontaneous pneumothorax, spontaneous pneumomediastinum, and pneumorrhachis. aim is to reinforce the importance of a high index of suspicion in early diagnosis when the above findings are present with ards in absence of trauma and a history of alleged substance ingestion. case presentation: a 35-year-old male presented with loose stool occasionally bloody, oral ulcers, yellow discoloration of eyes with fever, and decreased urine output for three days after consuming some substance with his seafood. on examination, he had yellow discoloration of eyes and oral mucosa along with multiple ulcers on the buccal region as well as the dorsum of the tongue and lateral margins with generalized subcutaneous emphysema. in addition, decreased air entry in the bilateral lung field and muffled heart sounds were present. he had an acute hepatorenal failure and severe metabolic acidosis with respiratory failure. urine tested positive for myoglobin and muscle enzymes (creatinine kinase and lactate dehydrogenase (ldh)) were raised. he was intubated and shifted to the intensive care unit. injectable n-acetyl cysteine (nac) for acute liver failure was started with empirical antibiotics and intravenous fluids. we supplemented thiamine and vitamin k, and hemodialysis was done in view of progressive renal failure. radiological evaluation showed spontaneous pneumothorax, pneumomediastinum, and pneumorrhachis which were managed conservatively. his respiratory parameters worsened despite maximal ventilatory support. renal failure and metabolic acidosis worsened in spite of hemodialysis. he succumbed to his illness on day five of admission and seven days after toxin ingestion. conclusion: we recommend that the sale of paraquat be restricted and regulated to avoid its use for suicidal and homicidal purposes. more research is required to find measures to intervene early and prevent pulmonary fibrosis. we propose that paraquat toxicity be considered early in a patient with the triad in an atraumatic setting with acute respiratory distress syndrome (ards).