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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2013  |  Volume : 24  |  Issue : 3  |  Page : 553-556
Acute renal failure and intravascular hemolysis following henna ingestion

Department of Internal Medicine, Royal Commission Medical Center, Yanbu, Al-Sinaiyah, Kingdom of Saudi Arabia

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Date of Web Publication24-Apr-2013


The powder of henna plant (Lawsonia inermis Linn.) is extensively used as a decorative skin paint for nail coloring and as a hair dye. Most reports of henna toxicity have been attributed to adding a synthetic dye para-phenylenediamine (PPD). PPD is marketed as black henna added to natural henna to accentuate the dark color and shorten the application time. PPD toxicity is well known and extensively reported in medical literature. We report a case of a young Saudi male who presented with characteristic features of acute renal failure and intravascular hemolysis following ingestion of henna mixture. Management of PPD poisoning is only suppor­tive and helpful only if instituted early. Diagnosis requires a high degree of clinical suspicion, as the clinical features are quite distinctive.

How to cite this article:
Qurashi HE, Qumqumji AA, Zacharia Y. Acute renal failure and intravascular hemolysis following henna ingestion. Saudi J Kidney Dis Transpl 2013;24:553-6

How to cite this URL:
Qurashi HE, Qumqumji AA, Zacharia Y. Acute renal failure and intravascular hemolysis following henna ingestion. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2021 Dec 7];24:553-6. Available from: https://www.sjkdt.org/text.asp?2013/24/3/553/111065

   Introduction Top

Para-phenylenediamine (PPD), a derivative of para-nitroaniline, has been used for dyeing furs, photochemical measurements, and oxidi­zing hair dyes. Chemically, it is an aromatic diamine-related aniline. Although uncommon in the West, both accidental and intentional ingestion of PPD is frequently reported from Africa, the Middle East, and the Indian sub­continent, where PPD is commonly mixed with henna, which is traditionally applied to color the palms of hands and dye the hair. The toxicity of PPD includes skin irritation, contact dermatitis, chemosis, lacrimation, or even per­manent blindness, due to local contact. Inges­tion of PPD produces two types of toxic effects. The first consists of rapid development of severe edema of the face, neck, pharynx, tongue, and larynx with respiratory distress, often requiring tracheostomy. In the later phase, hemolysis, rhabdomyolysis, and acute tubular necrosis supervene.

We report a case of henna ingestion presen­ting with features of PPD poisoning.

   Case Report Top

A 32-year-old male patient was brought to the emergency room with history of feeling unwell, anorexia, general fatigability, and ab­dominal bloating for three days. One day prior to admission, he noticed yellowish discoloration of the sclera and dark-colored urine. Symptoms started after ingestion of large amounts of boiled henna bought from a herbal medicine shop. The patient took it as a remedy for his chronic bloating and constipation, rela­ted to long history of irritable bowel syndrome.

On presentation, the patient was ill-looking, fully conscious, oriented, and deeply jaun­diced, with henna staining over the hands and feet. Temperature was 37°C, blood pressure 169/110 mmHg; pulse rate 98 beats/min, and oxygen saturation was 83%. Chest and cardio­vascular systems were unremarkable. The ab­domen was soft, distended, had a tympanic note on percussion; there was mild epigastric tenderness. There was no organomegaly or lower limb edema. His urine was observed to be dark black in color.

The patient was managed supportively. The next day, he was noticed to be more distressed and deeply jaundiced. Hemoglobin dropped to 8.8 g/dL. The serum creatinine increased more than double, although the urine volume was adequate. Urine analysis showed one to three white blood cells (WBCs)/hpf, one to two red blood cells (RBCs)/hpf, and moderate number of epithelial cells.

The patient was shifted to the intensive care unit for close observation. His renal function continued to deteriorate. Hemoglobin dropped to 7.5 g/dL. Further laboratory workup was done [Table 1].
Table 1: Serial laboratory investigation reports in the study patient.

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He was transfused with packed RBCs and started on hemodialysis (HD). The patient re­mained well on HD; parameters for hemolysis dropped and the hemoglobin stabilized at 9.5 g/dL. He was discharged home on day 13 and continued on HD for a total period of 17 days. In six weeks' time, patient was well with full clinical and biochemical recovery.

   Discussion Top

In 1924, Nott described the first cases of systemic toxicity with hair dye in a saloon owner in the United Kingdom. [1] Hair dye poi­soning is an uncommon form of intoxication in the West, although it is fairly common in some other parts of the world such as Africa and Asia. The main component of the hair dye is PPD. Hair dye containing PPD is widely used by women in Sudan and Morocco for hair coloring and is added to henna to accentuate the dark color and shorten the application time. PPD and its metabolites are allergenic, mutagenic, and highly toxic, [2] and clinical presen­tation of PPD intoxication is usually domi­nated by acute severe angioedema, rhabdomyolysis, intravascular hemolysis, and acute renal failure (ARF). Our patient did not have angioedema, but had the latter three com­plications. In the absence of laboratory facili­ties for testing of PPD by chemical spot test or thin layer chromatography, the characteristic clinical picture with history of henna ingestion is considered as enough evidence for PPD poisoning. [3]

The absence of characteristic angio-neurotic edema in the presented case does not argue against the diagnosis of PPD poisoning since this feature is reported in variable proportion in many described series of PPD poisoning. [4]

The symptoms are considered to be dose related and ingestion of large amounts of PPD results in higher mortality and morbidity. Onset of symptoms after ingestion of the dye is about 4-6 h. [5] A large amount will cause death within the first 6-24 h due to angio-neurotic edema or cardiotoxicity leading to fatal arrhythmias. [6] A moderate dose will cause ARF within the first week. [7] Angio-neurotic edema is considered as immediate-type hypersensitivity reaction, possibly IgE mediated. Less common complications of PPD toxicity that are reported include severe myocardial necro­sis leading to cardiogenic shock, severe aplastic anemia, optic atrophy, and severe contact dermatitis. Hemolysis, methemoglobinemia, and direct toxic action of the chemical or its meta­bolic product on the renal parenchyma are sug­gested to be the most likely factors leading to ARF. [8]

Recovery from ARF is invariable if adequate care is taken, and there are few or no clinical or histological residual effects. [9] Chronic renal failure and chronic contact dermatitis are re­ported in few cases with PPD poisoning. [10]

There is no specific antidote for PPD and treatment is supportive. Accidental poisoning is likely to happen in communities where tradi­tional healers prescribe henna as a remedy for certain diseases since it is marketed unlabeled. According to literature review, this is the first case of PPD poisoning reported in a Saudi pa­tient; all cases reported from Saudi Arabia are expatriates (African and Indian). The case is special, also concerning the cause of exposure as most cases reported are either due to local application of henna, suicidal attempt, or acci­dental exposure in children. The deliberate intake of henna in this patient is probably rela­ted to local Saudi culture and public beliefs about the benefits of henna. Public attention should be drawn to this poisoning.

Primary care physicians, intensive care phy­sicians, and nephrologists need to be aware about the clinical manifestations and manage­ment of this condition. Early institution of dia­lysis is associated with reduction of mortality.

   References Top

1.NottNott HW. Systemic poisoning by hair dye. Br Med J 1924;1:421-2.  Back to cited text no. 1
2.Avijit H. Adverse reactions to henna. Indian J Pharmacol 2002;34:436-7.  Back to cited text no. 2
  Medknow Journal  
3.Bhargava P. Paraphenylene Diamine-Induced Acute renal failure: Prevention is the key. J Postgrad Med 2008;54:60-1.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Avenbukh Z, Modai D, Lenovy, et al. Ann. Fr Anesth reanim 2000;19:105-7.  Back to cited text no. 4
5.Ashraf W, Dawling S, Farrow LJ. Systemic Paraphenylenediamine (PPD) poisoning: A case report and review. Hum Exp Toxicol 1994;13:167-70.  Back to cited text no. 5
6.Bowen DA. A Case of Phenylenediamine Poisoning. Med Sci Law 1963;2:216-9.  Back to cited text no. 6
7.Suliman SM, Homeida M, Aboud OI. Paraphenylene-diamine induced acute tubular necrosis following hair dye ingestion. Hum Toxicol 1983;2:633-5.  Back to cited text no. 7
8.Chugh KS, Malik GH, Singahal PC. Acute renal failure following paraphynylene diamine (Hair Dye Poisoning: Report of Two Cases. J Med 1982;13:131-7.  Back to cited text no. 8
9.Suliman SM, Fadlalla M, Nasr Mel M, et al. Poisoning with hair-dye containing paraphenylene diamine: Ten years experience. Saudi J Kidney Dis Transpl 1995;6:3:286-9.  Back to cited text no. 9
10.Brown JH, McGeown MG, Conway B, Hill CM. Chronic renal failure associated with topical application of paraphenylene-diamine. Br Med J Clin Res Ed 1987;294:155.  Back to cited text no. 10

Correspondence Address:
Hala E. A. Qurashi
Department of Internal Medicine, Royal Commission Medical Center, Yanbu, Al-Sinaiyah
Kingdom of Saudi Arabia
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DOI: 10.4103/1319-2442.111065

PMID: 23640630

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