Insecticides are the pesticide group of chemical materials which are known as powerful poisons, used in both agricultural and daily life to destroy harmful pests such as flies and insects. Fly sprays containing D phenothrin and tetramethrin are available in this country as insecticides which though having low toxicity for use in the home and living areas can be life threatening if used for suicide attempts. These types of insecticides are easily accessible to the general public, can be purchased for a low price and are frequently used. Suicide attempts using this form of product are seen less often than those using other insecticides.

Our case, a seventeen year old girl brought to our intensive care unit, sprayed fly-killing insecticide found in the home into a bowl and then tried to self-inject the liquid intravenously. She was not a doctor, nurse or another medical person but she had been taking care of her grandmother with chronic illness. Therefore she was familiar with simple medical interventions.While use of insecticides in such a manner to attempt suicide are rare, the results can range from being limited to cellulitis developing at the injection site, to serious results such as systemic toxicity. Our patient is an interesting study of a rare suicide attempt.

The seventeen year old female patient was brought to the emergency service by her family complaining of nausea thought to be due to food poisoning and was admitted to the intensive care unit after initial intervention. In our hospital, all intoxication cases are admitted to intensive care unit for treatment like food intoxication or drug intoxication. Her general situation was good, she was conscious, oriented and cooperative with respiratory rate of 14/min, fever 36.7 °C, blood pressure 130/80 mmHg, pulse 88/min and peripheral oxygen saturation 98% breathing room air. Detailed physical examination found a possible injection mark and surrounding hyperemia on the left arm antecubital fossa. Questioning the patient again about the possibility of attempted drug injection the patient admitted that she had sprayed the fly-killing spray (containing D phenothrin and tetramethrin) found at home, first spraying into a bowl and injected this liquid material (about 1-2 ml) herself by a syringe to attempt suicide. Using the general approach for intoxication cases for follow-up and treatment the patient was treated with 100% oxygen, fluid treatment, gastric protection, empirical antibiotic, antiseptic dressing of the injection site and urine drainage was monitored. The patient’s blood count, arterial blood gas analysis and biochemical values were within normal levels. On the second day of treatment as a result of orthopedic and general surgical consultations, elevation, dressing, low molecular weight heparin and antibiotherapy were recommended and applied to treat cellulitis developing in the forearm. Additionally a psychiatric consultation advised the patient to apply to the psychiatric department after being discharged. While treatment continued thrombophlebitis developed in addition to cellulitis and the patient was transferred to the vascular surgery department. Afterwards, she responded to treatment, was monitored with no problems, and was discharged at the end of treatment. Informed Consent Form has been taken for this presentation.

Insecticides, a pesticide group of chemical materials, are frequently used throughout the world mainly in agriculture to fight harmful pests. Additional to high effectiveness on the target organisms, low toxicity for other organisms is a frequent reason for choosing to use them [1, 2].

While insecticides generally cause poisoning due to unintentional exposure, they are sometimes intentionally used in suicide attempts. While unintentionally exposed agricultural workers, pesticide workers or people with these chemicals stored inappropriately in the home are known, intentional exposure is generally orally, by inhalation or by skin contact. There are cases in the literature of liquid forms of insecticide being used parenterally for suicide attempts. However there are very rare intoxication cases where the liquid derived from the spray form is injected parenterally. In all cases the clinical tableau varies depending on the type of material used, the method of intake to the body and the amount [3, 4]. Pyrethroid group insecticides are widely available and cheap products. They are divided into two groups, Type I and Type II, depending on their structure and effects at high dose. The main intake method is by inhalation [5]. The intoxication tableau includes toxicity of the gastrointestinal system, the respiratory system and the nervous system and may progress to coma. At the same time, cardiac rhythm disorders may be seen [6]. Though pyrethroids are widely used there is very low incidence of these products causing systemic intoxication [7].

D-phenothrin and tetramethrin are synthetic pyrethroids and are widely used in spray form to kill insects or flies [1, 8]. Our subject sprayed fly-killing spray containing D-phenothrin and tetramethrin into a bowl to collect the liquid. She then put this into an injector and tried to inject herself in a forearm vein of the antecubital fossa. After an amount of liquid was injected into the soft tissue, the area became painful and without telling her family of her actions, the patient told them she felt bad and nauseated. Thinking she had food poisoning her family brought her to the hospital’s emergency service.

Most insecticides found in liquid form on the market have been used by various methods for suicide attempts known in the literature. Soft tissue injections of these insecticides may be limited to local symptoms but may cause systemic toxicity. According to Sabanci a twenty-three years old male patient injected 5 ml of agricultural chemical containing organophosphate into muscle and developed subcutaneous crepitation along with local erythema. The patient responded to treatment for the localized symptoms and systemic toxicity was not observed [4]. Hadimoglu et al. reported another case where local abscess and necrosis was observed with symptoms of systemic toxicity after subcutaneous injection of organophosphate [9]. In the literature in another case where agricultural chemical containing organophosphate was injected intravenously rhabdomyolysis and acute kidney failure developed and the patient required hemodialysis before going into intermediate syndrome [3]. In our country Guloglu et al. reported the case of a twenty-two years old female patient who injected herself with liquid derived from an aerosol spray containing dichlorvos (DDVP) and cellulitis in the form of blisters, fever and edema were observed initially. Afterward continued worsening of the arm led to surgical drainage and the patient responded to treatment; after eight days the patient was discharged [10].

Pyrethroid group insecticides are easily obtained cheap products and intoxication due to intravenous or other parenteral injection type are rare. LoVecchio’s case, published in 2005, explains how a patient self-injected pyrethroid group insecticide intravenously and subcutaneously. After the patient injected 2 ml subcutaneously in the abdomen and 6 ml of the same insecticide intravenously in the arm, only local toxicity symptoms were observed at the injection sites and the patient recovered without consequences.5 Pyrethroids are used widely throughout the world and severe intoxication cases in humans are rare. However while initially systemic indications may not be seen, over hours life-threatening symptoms such as convulsions or coma may develop; the patient may even enter a more serious life-threatening course [11].

In conclusion, with intention of suicide or not, detailed examination of all systems in cases with suspicion of intoxication is fundamental. Examination of the extremities, especially in patients who may not have given a true history, must be carried out to find possible injection sites. In cases of intoxication due to insecticide injection parenterally in addition to local symptoms, it must be kept in mind that late-starting systemic toxic symptoms may develop. Patients should be monitored closely for systemic toxic symptoms in addition to treatment for local symptoms, the main aim of treatment should be life support and appropriate antidote therapy should be administered in cases of systemic toxicity.