2016, Volume 32, Number 1, Page(s) 051-053
Clinical and Pathological Findings on Intoxication by Yellow Phosphorus After Ingesting Firework Cracker: A Rare Case of Autopsy
Emine TÜRKMEN ŞAMDANCI1, Ebru ÇAKIR1, Nurhan ŞAHİN2, Candan ELMALI1, Sadegül SAYIN1
1Department of Pathology, İnönü University, Faculty of Medicine, MALATYA, TURKEY
2Department of Pathology, Malatya State Hospital, MALATYA, TURKEY
Keywords: Phosphorus, Hepatic failure, Fatty liver, Autopsy
Yellow phosphorus is a toxic substance used in the production of
firework cracker, fireworks, ammunition and agricultural dung. When
ingested, it shows its effects mainly in the liver, the kidneys, and the
brain. A four-year-old girl had died as a result of acute hepatic failure
caused by ingesting a firework cracker. The case showed high levels
of hepatic enzymes, along with non-specific signs such as nausea,
vomiting and diarrhea. Autopsy revealed diffuse microvesicular
steatosis in the liver and disseminated degeneration in the proximal
tubules of the kidneys. In cases with concomitant hepatorenal failure
and cardiovascular collapse, death is inevitable. However, when only
hepatic failure develops, hepatic transplantation may be lifesaving.
Although intoxication from ingesting yellow phosphorus has a
very high rate of mortality, forensic cases are extremely rare in the
Death resulting from extraordinary causes, such as injuries
caused by firearms or explosives, penetrating stab wounds,
traffic accidents, falls, occupational accidents, intoxication,
electric shock, lightning strikes and mechanic asphyxia, are
considered to be forensic cases. In addition to providing
medical aid to patients in such cases, physicians must
determine whether the cases are forensic and, if they are,
to notify the police as quickly as possible1,2
. For our
case of intoxication from yellow phosphorus following
the ingestion of a firework cracker, the necessary medical
intervention was performed in the emergency department
of our hospital, and the case was recorded as forensic.
Yellow phosphorus is an inorganic substance used in the
production of fireworks, firecrackers, ammunition and
agricultural dung3. Firework cracker is the name of an
entertainment firework used in Turkey. These fireworks are
chocolate brown in color, measure approximately 1 cm in
diameter and emit a popping sound when rubbed against the
ground4. Firework cracker contains yellow phosphorus,
red phosphorus, potassium chloride, iron oxide, silica,
antimony substance and magnesium carbonate, all in
Because this firework can dissolve in fat and bile
approximately 2 to 3 hours after it is absorbed in the
intestines, it starts to accumulate in the liver and leads to acute hepatic failure. The brain, heart, kidneys and
pancreas are also affected, although to a lesser extent5,6.
In cases where there is acute hepatic failure but multi-organ
failure has not yet developed, liver transplantation may be
lifesaving. However, the mortality rate remains very high7.
The histopathological findings of the visceral organs were
presented, along with clinical information, for our pediatric
forensic case, in which acute hepatic failure developed
because of yellow phosphorus after the accidental ingestion
of firework cracker, causing death due to multi-organ
A four-year-old girl with complaints of abdominal pain,
nausea, vomiting and diarrhea was examined in the
emergency department, at İnönü University’s Faculty of
Medicine, in Malatya, Turkey. Her parents reported that she
had ingested firework cracker. She underwent nasogastric
lavage. Foreign bodies observed in her gastric content
included brown pieces that were thought to belong to
firework cracker. In her biochemical tests, aspartate amino
transferase (AST) was 928 u/L (5-40 u/L) and alanine
amino transferase (ALT) was 1043 u/L (7-56 u/L). The
patient had a total bilirubin of 5.74 mg/dl (1.0 mg/dl) and
was rapidly evaluated and diagnosed with acute hepatic
failure. Because this was a case of intoxication, it was at
the same time recorded as a forensic case and forensic
authorities were notified. The general status of the patient,
who was to undergo an immediate hepatic transplantation,
deteriorated within hours and she was hospitalized in the
intensive care unit. The patient developed encephalopathy
and died as a result of cardiovascular collapse before
undergoing liver transplantation. Autopsy was performed
and no macroscopically significant pathological finding
was detected in the organs, except for yellow discoloration
in the liver. For histomorphological examination, tissue
specimens obtained from the brain, liver, lungs, kidneys
and pancreas were fixed in 10% formalin solution.
In the microscopic examination, congestion was noted
in the brain, lungs and pancreas. In the hepatic sections,
nearly all the hepatocytes showed macrovesicular and
microvesicular vacuolization (Figure 1). Diffuse vacuoles,
located in the hepatocytes, were positively stained with Oil
Red O (Figure 2). There was no necrosis and inflammation
in the liver. Periodic acid Schiff (PAS) and d- PAS did not
reveal any metabolic substance accumulation. In sections of
the kidney, the proximal tubular epithelium had generally
fallen into in the lumen and showed a vacuolar appearance
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|Figure 3: Vacuolar degeneration in the proximal tubular
epithelium of the kidney (H&E, x400).
Yellow phosphorus is a toxic substance used in the
production of firework cracker, fireworks, ammunition and
. Yellow phosphorus intoxication is seen
in developing countries, but rarely reported in developed
countries. In developing countries, the intoxication
generally results from unintentional oral ingestion9,10
Our case was intoxicated after she ingested firework cracker
while she was playing.
The literature includes limited information about the
damage yellow phosphorus can cause to tissue, although
some case reports and a few experimental animal studies
have shown it as a cause of acute hepatic failure11. In
some articles published under the topic of substance
intoxication affecting the liver, yellow phosphorus is
cited as an etiologic substance. In our case, the changes
caused by yellow phosphorus in organs other than the
liver, such as the brain, lungs, heart and kidneys, were
macroscopically and microscopically examined. Orally
ingested yellow phosphorus is rapidly absorbed through
the gastrointestinal system and approximately 70% is
accumulated in the liver within 2 to 3 hours. It accumulates
to a lesser extent in the heart (12%), kidneys (4%), pancreas
(0.4%), and brain (0.39%), and also leads to damage in
those organs12. Histopathological changes, in our
case, were mainly detected in the liver and kidneys. No
significant pathological change, other than congestion, was
observed in the brain, lungs, pancreas and heart. As seen
in the literature, marked histomorphological appearance,
correlated with the clinical hepatic and renal findings,
supported the fact that yellow phosphorus showed a
greater accumulation in liver and kidneys. Again, the lack
of a remarkable microscopic change in the heart and other
organs was consistent with the literature and was directly
proportional to the amount of yellow phosphorus digested.
In addition, the fact that the patient died within hours may
explain why few morphological changes were observed in
organs other than the liver and kidneys.
Serious intoxication resulting from this substance follows a
course that is accompanied by multi-system organ failures
and has a mortality rate between 20% and 50%12,13. In
our case of intoxication resulting from yellow phosphorus
and multiple organ failure, mainly of the liver, the course
rapidly led to the patient’s death.
Although yellow phosphorus has no antidote, supportive
therapy is given14. Our case underwent gastric lavage
and was given supportive therapy to maintain the fluidelectrolyte balance. As liver transplantation can be
lifesaving, in spite of the high rate of mortality in cases that
develop acute hepatic failure15, our patient died before
hepatic transplantation could be performed.
Deaths, such as those resulting from murders, injuries
caused by firearms, explosives and all other types of
devices, traffic accidents, battery burns, falls, intoxication,
electric shock and suicide attempts, that are presented to
emergency departments at hospitals and health institutions
are considered to be forensic cases16. The case presented
here was considered a forensic case because of the
intoxication. The legal authorities were notified and an
autopsy was performed at the request of the prosecution.
It is important to note that the firework cracker, which is
produced and sold unchecked and used as amusement
for children who live mainly in regions with lower sociocultural
level, is one of the most common and fatal cause of
fulminant hepatic failure. This report aimed at highlighting
the importance of considering substance intoxications as
forensic cases, of examining histomorphological changes
caused in some tissues by yellow phosphorus intoxication,
which has a high mortality, and of looking at the role of
social factors in yellow phosphorus intoxication.
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