Acute multiple organ failure with imidacloprid and alcohol ingestion

Imidacloprid [1-(6-chloro-3-pyridylmethyl)-N-nitroimidazolidin-2-ylideneamine] belongs to a relatively new class of insecticidal chemistry, the chloronicotinyl neonicotinoid compounds. Animal studies indicate relatively low toxicity to mammals due to nicotinic receptor resistance. Human poisoning is usually mild, and reports are quite limited. Here, we report a case of ingestion of alcohol with an insecticide containing imidacloprid. Clinical manifestation included mild disorientation, followed by bradycardia, ventricular arrhythmia, and cardiopulmonary arrest. Acute multiple organ failure, including oliguric kidney injury, acute lung injury, hypotension, and metabolic acidosis developed within hours of ingestion. Renal replacement therapy, including intermittent hemodialysis and continuous venovenous hemodialysis, quickly corrected the metabolic acidosis with better blood pressure. Despite original belief that imidacloprid has low mammalian toxicity, there is increasing evidence that imidacloprid may cause heart, kidney, and other organ damages and even death besides gastrointestinal irritation and neurological symptoms. The role of aldehyde oxidase, imidacloprid metabolites, and ethanol alcohol consumption in the pathogenesis of imidacloprid toxicity needs further study.