patients commonly present with acute cholinergic crisis , intermediate syndrome , or delayed polyneuropathy . they may also present with pancreatitis or hepatitis . here
a 75-year - old homemaker presented to our emergency department following deliberate self - harm consuming around 100 ml chlorpyrifos along with small amount of kerosene .
she was known to have systemic hypertension and was not on any treatment for the same .
pulse rate was 120 beats / min and irregular . rest of the examination was normal .
electrocardiogram showed rate 140/min , electrical alternans , multifocal ventricular ectopics , ventricular reentrant beats , ventricular couplets , and prolonged qt interval ( corrected qt = 512 ms ) .
transtubular potassium gradient was 6.85 , and urine analysis revealed inappropriately raised urinary ph ( 7.5 ) with positive urine anion gap all suggestive of distal renal tubular acidosis .
however , her cholinergic symptoms subsided , and potassium values started improving once atropinization was attained .
blood gas analysis , urine potassium excretion , urine ph , and urine anion gap done were normal with serum potassium 4.5 meq / l .
they inhibit acetylcholinesterase enzyme reversibly as well as irreversibly producing excess of acetylcholine in neuromuscular junction .
hence , usually , clinical presentation of organophosphates includes excessive muscarinic symptoms such as increased salivation , lacrimation , urination , diarrhea , gastrointestinal cramps , emesis , and nicotinic symptoms such as tachycardia , hypertension , mydriasis , fasciculation , and weakness . rarely may they present with intermediate syndrome or delayed polyneuropathy .
. it may be intense sympathetic activity due to nicotinic effect producing tachycardia and hypertension or muscarinic activity producing bradycardia and hypotension .
third case , they may present with polymorphic ventricular tachycardia with prolonged qt in early phase of toxicity which is attributed to rise in free fatty acid levels by some authors .
however , in all studies , echocardiogram was normal showing no permanent damage to heart .
cardiac injury is a strong predictor of mortality in organophosphate poisoning , and direct myocardial injury is maximum in acute early phase of severe organophosphate poisoning .
potassium value if <3 meq / l is known to present with multifocal ventricular ectopics , ventricular reentrant beats , ventricular couplets , and prolonged qt interval . in our patient
, cardiac arrhythmias may be due to either organophosphate poisoning or hypokalemia or both combined .
our patient had severe hypokalemia which was evaluated and detected to be due to distal renal tubular acidosis .
transient distal tubular acidosis may be seen in paraproteinemia , medullary sponge kidney , nephrocalcinosis , obstructive uropathy , and autoimmune diseases .
there was one reported case where distal tubular acidosis was detected with accidental kerosene ingestion .
however , that patient also had concomitant ingestion of metformin in a high dose which produced lactic acidosis and acute renal failure . however , in our case , very minimal amount of kerosene has been ingested which can not explain her tubular acidosis .
hence , the same may be attributed to organophosphates itself as it completely improved after atropinization .
toluene poisoning presenting with transient distal renal tubular acidosis was reported , which has been attributed to impaired active hydrogen ion transport and hydrogen ion back diffusion .
the same mechanism may be the cause of transient distal renal tubular acidosis due to organophosphate poisoning also though conclusive proof is yet to be availed .
hence , it is better to know about all atypical presentations and expected complications of its toxicity .
although neurological complications are quite well described , many others such as pancreatitis , hepatitis , and cardiac toxicities are seldom accounted .
we are presenting this case just to open up possibility of a rare complication of organophosphate poisoning , distal renal tubular acidosis which should be thought of in the presence of persistent hypokalemia refractory to treatment .
 renal complications due to organophosphate poisoning are very rare . 
 we are presenting a unique case of transient distal renal tubular acidosis due to organophosphate poisoning , which to the best of our knowledge is the first of its kind . 
 an elderly female after deliberate self - harm with ingestion of chlorpyrifos had multiple ventricular arrhythmias due to hypokalemia secondary to distal renal tubular acidosis which improved completely after treatment . 
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