Aluminium Phosphide (ALP) Poisoning - Complete Answer

1. Clinical Features

Basic Pharmacology (Context)

Symptoms (Dose-Dependent)

• Nausea, vomiting (early and profuse)
• Burning pain in the epigastrium
• Garlicky/fishy odor from breath (pathognomonic - due to phosphine)
• Intense thirst and diarrhea
• Dizziness, headache, fatigue
• Tightness in the chest, dyspnea
• Ataxia, numbness, paresthesia, tremors, diplopia
• Jaundice, muscular weakness

• Cardiovascular: Hypotension, sinus tachycardia, arrhythmias (VT, VF), heart block, bradycardia, myocardial damage, pericarditis, congestive cardiac failure, cardiogenic shock
• ECG changes: ST depression, T-wave inversion, prolonged QT, bundle branch block
• Respiratory: ARDS (Adult Respiratory Distress Syndrome), pulmonary edema - phosphine directly irritates pulmonary parenchyma when inhaled
• CNS: Excitement and agitation (restlessness - as in this case), convulsions, coma
• Renal: Oliguria, acute renal failure
• Metabolic: Hypocalcemia (tetany), metabolic acidosis, hypoglycemia
• Hematological: Bleeding diathesis (rarely)
• Skin: Cold, clammy skin in terminal stages

• The Essentials of Forensic Medicine and Toxicology, 36th ed. (2026), p. 499
• P C Dikshit Textbook of Forensic Medicine and Toxicology, p. 573-574

2. Treatment

Gastric Decontamination

• Gastric lavage with 3-5% sodium bicarbonate solution, 1% copper sulphate, or 1% potassium permanganate, OR mineral/coconut oil - these convert residual ALP to phosphate and slow phosphine release
• Note: Recent studies have debated gastric lavage because adding moisture to residual tablets in the stomach accelerates phosphine release; however, lavage with oil (coconut oil or liquid paraffin) is currently favored as it retards the hydrolysis reaction
• Keep patient under observation for delayed symptoms even after initial apparent recovery (ALP adheres to gastric mucosa)

Cardiovascular Support

• IV fluids (cautious - risk of pulmonary edema) and vasopressors (dopamine infusion - low dose to maintain perfusion)
• Magnesium sulphate IV/IM: 3 g bolus, then 6 g infusion over 24 hours for 5-7 days - corrects arrhythmias and cardiac dysfunction
• Calcium salts IV - to correct hypocalcemia and stabilize cardiac membranes

Respiratory Support

• Oxygen inhalation
• Artificial ventilation/mechanical ventilation for ARDS
• Steroids (to combat pulmonary edema)

Metabolic Correction

• Sodium bicarbonate 50 mEq IV every 15 minutes until arterial bicarbonate > 15 mmol/L - corrects metabolic acidosis
• Antibiotics to treat secondary infection

Adjuncts (evidence-based additions)

• IV N-acetylcysteine (antioxidant - limited evidence)
• Melatonin and Vitamin E (antioxidants - limited evidence from Rosen's Emergency Medicine)
• Monitoring: Serial ECG, electrolytes, ABG, renal function

What NOT to do

• Emesis induction is contraindicated (risk of aspiration and rapid deterioration)
• Avoid adding unnecessary water to the GI tract

• P C Dikshit, p. 573-574
• Rosen's Emergency Medicine - Concepts and Clinical Practice
• The Essentials of Forensic Medicine and Toxicology, 36th ed. (2026)

3. Postmortem Appearances

External

• Cyanosis (peripheral and central)
• Froth over the mouth and nostrils (in some cases) - from pulmonary edema
• Garlicky/fishy smell on opening the body cavity - this is the most distinctive finding; phosphine gas is detectable at autopsy

Internal - Gross Findings

• All internal organs congested with evidence of petechial hemorrhages (widespread)
• Lungs: Congested and edematous - pulmonary edema well established; frothy fluid in airways
• Stomach/GI tract:
  • Garlic odor on opening the stomach
  • Grayish-black residues of the poison sticking to the gastric mucosa
  • Gastric mucosal congestion, erosions, and necrosis
• Liver: Congested; findings similar to phosphorus poisoning (periportal necrosis); even necrobiosis of liver
• Kidneys: Congested, may show features of acute tubular necrosis
• Brain: Congested; cerebral edema
• Spleen: Congested
• Heart: Myocardial damage, focal myocardial necrosis (subendocardial ischemia)
• Color of postmortem staining: Yellow/dark discoloration is characteristic (similar to phosphorus poisoning)

Microscopy (Histopathology)

• Widespread congestion in liver, lungs, kidneys, spleen, and brain
• Focal myocardial necrosis
• Gastric mucosal necrosis
• Hepatic necrosis (periportal pattern)
• Alveolar edema and hemorrhage in lungs
• According to a 2025 systematic review and meta-analysis of 2,450 autopsies, multiorgan congestion was the most prevalent finding in ALP-related deaths

Chemical Analysis

• Stomach contents: Characteristic garlic odor; silver nitrate paper test shows blackening
• Blood/urine: Phosphine (hypophosphite) can be detected in urine
• Toxicological analysis is the primary identification method

• P C Dikshit Textbook of Forensic Medicine and Toxicology, p. 575
• Parikh's Textbook (zinc phosphide - analogous findings), p. 607
• The Essentials of Forensic Medicine and Toxicology, 36th ed. (2026)

4. Medicolegal Aspects

Manner of Death

Why It Is Forensically Important

• ALP is labelled as "an agent of sure death" - mortality is extremely high (often >70%) even with treatment
• A single tablet (or even part of one) can cause death
• It is easily available and cheap - widely available in rural agricultural areas, sold over the counter
• Its resemblance to a "medicinal tablet/pill" (greyish, 3 g tablet in sealed packet) facilitates both suicidal and homicidal misuse
• Called "Rice Tablet" in colloquial usage (as in this case) - tablets are kept in grain storage

Medicolegal Points

1. Certifying cause of death: The cause of death is "acute aluminum phosphide poisoning" leading to "cardiac failure/cardiovascular collapse" - must be stated in the death certificate
2. Manner: The case must be reported as a medicolegal case; manner determined by circumstantial evidence (suicide note, domestic quarrel, etc.)
3. Dowry deaths: When used homicidally in dowry death context, charges under IPC Section 304B (dowry death) or 302 (murder) apply
4. Smell at autopsy: The characteristic garlic odor from the stomach and body cavities at autopsy is itself a strong diagnostic clue - the forensic pathologist should note it
5. Evidence collection: Stomach contents, sealed packet remnants, urine for phosphine metabolites - send for chemical analysis
6. Reporting: All medicolegal autopsies of ALP poisoning deaths should be reported to the police under CrPC
7. Drastic rise in incidence: Dramatic increase in mortality statistics especially in northern India over the past 25+ years - it is a major public health and forensic problem

• P C Dikshit Textbook of Forensic Medicine and Toxicology, p. 574-575
• Parikh's Textbook of Medical Jurisprudence, p. 679
• The Essentials of Forensic Medicine and Toxicology, 36th ed. (2026), p. 499-500

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