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Case Series: Organophosphate Contamination of Camel’s Mammary Glands Affects Human Health

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Case Series: Organophosphate Contamination of Camel’s Mammary Glands Affects Human Health

Abstract

In this case series, we present 2 cases of previously healthy farmers, who presented with symptoms of a cholinergic crisis that developed several hours after ingestion of camel milk. The initial case was treated with supportive medical care without using antidote as no history of direct exposure to pesticides was available.The second case presented with symptoms of cholinergic crisis that developed several hours after the ingestion of camel milk. Clinical features included slurred speech, headache, vomiting, diarrhea, frequent ­micturition, muscle fasciculation, chest discomfort, and atrial fibrillation. The patient developed bradycardia that responded to intravenous atropine. Routine investigations were unremarkable, but acetylcholinesterase and pseudocholinesterase levels were both low. The patient was managed with intravenous fluids, analgesia, atropine, and pralidoxime, which were administered when he developed respiratory symptoms secondary to excessive secretions. The following day, the patient was asymptomatic and discharged. On the medical history, the patient denied any other ingestion including food and drink or potential organophosphate exposure on the day of symptom onset. Application of organophosphate pesticides to the mammary glands of camels has been used for many decades against Sarcoptes scabei cameli, a mite that causes a dermal infestation in camels similar to human scabies infections.
Educational Corner – Case Report
Dubai Med J
Case Series: Organophosphate
Contamination of Camel’s Mammary
Glands Affects Human Health
Maryam Saif Al Ali
a Jasem Al Shamsi
a Saweera Sabbar
b
aEmergency Department, Rashid Hospital Trauma Center, Dubai Health Authority, Dubai, United Arab Emirates;
bEmergency Department, Cleveland Clinic, Abu Dhabi, United Arab Emirates
Received: October 29, 2019
Accepted: July 19, 2020
Published online: September 7, 2020
Maryam Saif Al Ali
Emergency Department, Rashid Hospital Trauma Center
Dubai Health Authority, PO Box-4545
Dubai (United Arab Emirates)
Maryamsaif86 @ gmail.com
© 2020 The Author(s).
Published by S. Karger AG, Basel
karger@karger.com
www.karger.com/dmj
DOI: 10.1159/000510263
Keywords
Organophosphate · Pesticides · Cholinergic toxicity ·
Camel milk
Abstract
In this case series, we present 2 cases of previously healthy
farmers, who presented with symptoms of a cholinergic cri-
sis that developed several hours after ingestion of camel
milk. The initial case was treated with supportive medical
care without using antidote as no history of direct exposure
to pesticides was available.The second case presented with
symptoms of cholinergic crisis that developed several hours
after the ingestion of camel milk. Clinical features included
slurred speech, headache, vomiting, diarrhea, frequent
micturition, muscle fasciculation, chest discomfort, and atri-
al fibrillation. The patient developed bradycardia that re-
sponded to intravenous atropine. Routine investigations
were unremarkable, but acetylcholinesterase and pseudo-
cholinesterase levels were both low. The patient was man-
aged with intravenous fluids, analgesia, atropine, and prali-
doxime, which were administered when he developed respi-
ratory symptoms secondary to excessive secretions. The
following day, the patient was asymptomatic and dis-
charged. On the medical history, the patient denied any oth-
er ingestion including food and drink or potential organo-
phosphate exposure on the day of symptom onset. Applica-
tion of organophosphate pesticides to the mammary glands
of camels has been used for many decades against Sarcoptes
scabei cameli, a mite that causes a dermal infestation in cam-
els similar to human scabies infections.
© 2020 The Author(s)
Published by S. Karger AG, Basel
Introduction
Camel milk is one of the famous and common tradi-
tional drinks in Arabian Gulf countries as it is considered
to be beneficial in many aspects. Several studies have
shown that it is effective in improves general well-being,
promotes body natural defenses by enhancing immunity,
and can provide part of the daily nutritional needs for
both adults and children [1–3].
Some of the Bedouins (Arab people who have histori-
cally inhabited the desert region) would apply organo-
phosphate-like substances to the mammary gland of the
camels before milking them in order to protect it from
mites. Such intervention when done might result in the
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Al Ali/Al Shamsi/Sabbar
Dubai Med J
2
DOI: 10.1159/000510263
cholinergic crises to people drinking the milk if the mam-
mary gland was not washed and cleaned well prior to
milking.
We present here 2 cases of organophosphate toxicity
among patients presenting with history of drinking cam-
el milk. We aim to red-flag the importance of asking
about traditional use of organophosphate substances pri-
or to milking the camel when dealing with symptoms of
cholinergic crisis in emergency setting.
Case Report/Case Presentation
Case 1
A 45-year-old Asian man presented to emergency department
(ED) with generalized body weakness, dizziness, sweating, abdom-
inal pain, passing urine, and loose watery stool. All the symptoms
started immediately after the ingestion of fresh camel milk in a
farm. The patient admitted that he never drank camel milk before.
He denied any chest pain, shortness of breath, fever, or loss of con-
sciousness. The patient’s companion did not notice any abnormal
movement of the body (e.g., seizures). The patient was a farmer
who had no significant medical or surgical history. He denied hav-
ing any drug allergies, he denied smoking, alcohol consumption or
use of any unlawful drugs. On physical exam, the vital signs were
as follows: blood pressure 137/90, pulse rate 90 beat per minute,
respiratory rate 20 breaths per minute, oxygen saturation 99% in
room air, temperature 34.9 celcius, and random blood sugar −158
mg/dL. The patient was profusely sweating, looking anxious, hav-
ing dysarthria, but no tongue bite was evident. The patient had
urinary and fecal incontinence. There were no rashes on his body,
and no other clinical findings were present on systemic examina-
tion except for generalized weakness. Laboratory test was unre-
markable except for hypokalemia (potassium level 2.6 mmol/L),
electrocardiogram showed normal sinus rhythm, and computed
tomography (CT) brain with contrast showed left middle cerebral
artery to be hyper-dense, suspecting acute thrombosis. Despite
such results from the brain CT, cerebrovascular accident was kept
as one of the differential diagnoses but not primary since the over-
all picture was suggesting a cholinergic toxidrome. The patient was
admitted under observation, and he was managed with intrave-
nous fluids and given potassium chloride replacement because of
his hypokalemia, and he was improved gradually with complete
recovery and discharged.
Case 2
A 30-year-old Asian man presented to the ED with slurred
speech, headache, vomiting, loose motion, frequent urination, and
chest discomfort. All the symptoms started on the same day of in-
gestion fresh farm camel milk. The patient complained of not feel-
ing well and having headache, vomiting, diarrhea, and frequent
urination. He also had chest discomfort and palpitation. The pa-
tient’s friends also noticed that the patient had left-sided body
weakness. He was a farmer who had no significant medical or sur-
gical history. He denied having any drug allergies, he denied smok-
ing, alcohol consumption or use of any unlawful drugs. On ex-
amination, vital blood pressure was 105/77, pulse rate 102 beat per
minute, RR 20 breaths per minute, oxygen saturation 99% in room
air, temperature 35.4 celcius, random blood sugar −221 mg/dL,
and electrocardiogram was also taken initially which showed atri-
al fibrillation. The patient was conscious, alert, but irritable. Sys-
temic examination was normal except for an irregular heartbeat.
Pupils were 2 mm and reactive. During the assessment, he passed
urine over the bed and after few minutes, the patient’s heart rate
dropped to 30 beats/min, and he complained of feeling dizzy. So
atropine 0.5 mg IV was administered, and his heart rate increased.
Neurological examination showed no focal neurological defect.
During his ED stay, the patient was noted to have some fascicula-
tion and muscle twitching. Laboratory tests were unremarkable,
and CT brain was normal. The patient was managed with IV fluids,
atropine, and pralidoxime which were administered when he de-
veloped respiratory symptoms secondary to excessive secretions.
His symptoms improved accordingly, and he was discharged the
following day. As the patient was noticed to have cholinergic toxi-
drome after camel milk ingestion and no other direct exposure to
an organophosphate source was reported, serum pseudocholines-
terase and acetylcholinesterase levels were sent, and the result was
low serum pseudocholinesterase 0.3-kU/L (normal-5.3–12.9) and
acetylcholinesterase (HB) 0.15 – delta-pH/h (normal 0.55–0.85)
which confirmed our diagnosis. Both patients were followed up,
and they did not have any health complaints after hospital dis-
charge.
Discussion
Organophosphate can be found in pesticides, medica-
tion, plants, chemical weapons, or occupational sub-
stances. Toxicity can happen from intentional ingestion,
medication noncompliance, dermal exposure, or inhala-
tion. Organophosphate toxicity results from inhibiting
acetylcholinesterase which results in the accumulation of
acetylcholine at the muscarinic and nicotinic receptors.
Clinical presentation of toxicity varies with duration,
route of exposure, and type of agents. The primary symp-
toms might be secondary to the widespread of acetylcho-
line in the central nervous system which will manifest as
headache, confusion, seizure, vertigo, or coma. Other
presentations can be secondary to the involvement of
muscarinic receptors (DUMBBELLS = Diarrhea, Urina-
tion, Miosis, Bradycardia, Bronchorrhea, Emesis Lacri-
mation, Lethargic, Salivation). Nicotinic receptor in-
volvement will manifest as fasciculation, mydriasis,
tachycardia, hypertension, seizure, tremor weakness, and
paralysis. Diagnosing organophosphate toxicity can be
made by clinical suspicion from patient history and phys-
ical examination. Specific test of pseudocholinesterase
and acetylcholinesterase level, which will be low in or-
ganophosphate toxicity, is confirmatory. Management of
patients presenting with organophosphate toxicity in-
cludes resuscitation and supportive care, decontamina-
Farmers Are at Risk of Pesticide Toxicity
from Camel Milk
3
Dubai Med J
DOI: 10.1159/000510263
tion of the patient by removing the clothes, and washing
the skin and using the antidote (e.g., atropine and prali-
doxime).
Awareness of cholinergic crisis after camel milk inges-
tion is important as the practice of applying acaricides
(organophosphate like substance) over the mammillary
gland is used as a standard of care for disease prevention
and treatment in Arabian camels (Psoroptes cameli) [4].
Our report supports another study that presents the effect
of pesticides on farm workers in the United Arab Emir-
ates [5].
Conclusion
Farmers are at risk of pesticide exposure and toxicity
from indirect exposure. A comprehensive history and
physical examination can guide physicians to the correct
diagnosis and proper management of such patients.
Statement of Ethics
The authors believe the importance of obtaining a consent be-
fore publishing a case report, and based on that, multiple attempts
have been tried to communicate with the patient and failed; at the
same time, the authors feel that this case should be published to
raise awareness among farmers regarding the dangers of such
practice through the public health system and to bring the atten-
tion of healthcare providers that cholinergic crisis after camel milk
ingestion in this particular scenario is a possibility.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
The authors did not receive any funding.
Author Contributions
M.S.A.A.: manuscript preparation, literature search, and re-
view. J.A.S.: case presentation, literature search, manuscript prep-
aration, and review. S.S.: case presentation, manuscript review,
and editing.
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ResearchGate has not been able to resolve any citations for this publication.
Article
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Introduction: Camel milk is the closest to a human mother's milk. Camel milk is different from other milks, however, having low sugar and cholesterol, high minerals (sodium, potassium, iron, copper, zinc and magnesium, and vitamin C). The milk is considered have medicinal characteristics as well. This systematic review is aimed at determining and reporting nutritional values and medicinal characteristics of camel milk in children. Methods: The search strategy of the current review is "(camel AND milk) AND (autism OR food allergy OR milk allergy OR children OR diarrhea." The search was conducted via PubMed, Scopus, and Google scholar. Also two Persian scientific databases (SID and Iranmedex) and international congresses were investigated. Full-text papers and abstracts on the topic of camel milk, evaluating nutritional value and medicinal properties, were included in this systematic review. Results: Out of the 472 records found in the resources, 35 related studies were included in the final analysis. The result showed that camel milk is highly nutritious and is safe for consumption by children. Conclusion: It seems that many researchers did not follow a specific guideline for reporting and confirming the therapeutic properties of camel milk in children, but there is evidence denoting the importance, trials, and investigations of its usability and benefits. Camel milk as a supplemental treatment seems less invasive and costly than specialist care, medications, alternative treatments, and behavioral interventions. Based on our findings, camel milk is safer for children, effective in the treatment of autism, improves general well-being, promotes body natural defenses, is a good nutritional source, and can helps the daily nutritional needs of humans.
Article
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Based on literature data, the composition of milk from different ruminants (cow, sheep, goat, buffalo, camel, llama, yak and deer) and equidae (horse and donkey) and of human milk were compared to examine possible nutritional differences. Additionally, the alleged health benefits attributed to some of these milks and the effect of heating are discussed. Very generally, ruminant milk has a lower lactose content, but a higher protein (and casein), fat (with a higher share of saturated and mono-unsaturated fatty acids and a higher cholesterol level), vitamin (except for vitamin C) and mineral content compared to horse or donkey milk. Milk composition may however vary largely, not only between ruminants and non-ruminants, but also between different breeding variants of the same species and between individual animals. Consequently, a constant health promoting potential is, if present, difficult to guarantee. Moreover, differences in milk composition do not only concern the relative proportions of the milk components, but also occur at the molecular level (e.g. monomeric versus dimeric proteins, different amino acid sequence). Pasteurization is not expected to affect the nutritional (or presumed health) benefits significantly, regardless of differences observed in thermostability between components of considered types of milk. Even though the milk composition of some animal species resembles to a great extent the composition of human milk, it is recommended to give either human milk or formula milk to babies and infants. For people suffering from milk allergy, milk other than e.g. bovine milk may offer a solution, but this greatly depends from one person to another.
Pesticide-related health problems and diseases
  • Mmm Beshwari
  • A Bener
  • Aam Een
  • Ama Ehdi
  • H Z Ouda
Beshwari MMM, Bener A, Een AAM, Ehdi AMA, Ouda HZ. Pesticide-related health problems and diseases. Int J Environ Health Res. 1999; 221.
Husbandry guidelines for Arabian camel Camelus dromedarius
  • J Moretti
Moretti J. Husbandry guidelines for Arabian camel Camelus dromedarius. 2008.