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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 13  |  Issue : 2  |  Page : 130-131

Hand sanitizer: A double-edged sword used in the COVID-19 pandemic


Department of Medicine, Lady Hardinge Medical College, New Delhi, India

Date of Submission28-Oct-2021
Date of Decision21-Nov-2021
Date of Acceptance08-Dec-2021
Date of Web Publication30-Mar-2022

Correspondence Address:
Dr. Ramesh Aggarwal
Room-114, New Academic Block, Department of Medicine, Lady Hardinge Medical College, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injms.injms_127_21

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  Abstract 


The COVID-19 pandemic has taught us the emphasis of personal hygiene which was long being ignored. Measures such as hand sanitizer which were predominantly used in health-care facilities in the past have seen recent surge in its usage everywhere. The availability of hand sanitizer in almost all the settings in this pandemic including the household has heralded a new step in personal hygiene. People across the world are using hand sanitizer everywhere. As much is known about its beneficial effect in preventing the spread of pathogens, its injudicious use has resulted in discovering its adverse effect if misused. We hereby present a case where the patient with Type 1 diabetes mellitus presented with hand sanitizer ingestion. This case highlights the unwanted effects and lethality of hand sanitizer if used in an unintended manner and hence alert us for its judicious use in the pandemic.

Keywords: COVID-19, diabetes, hand sanitizer


How to cite this article:
Sidharth S, Aggarwal R, Ghotekar L H, Margekar SL, Kumar O. Hand sanitizer: A double-edged sword used in the COVID-19 pandemic. Indian J Med Spec 2022;13:130-1

How to cite this URL:
Sidharth S, Aggarwal R, Ghotekar L H, Margekar SL, Kumar O. Hand sanitizer: A double-edged sword used in the COVID-19 pandemic. Indian J Med Spec [serial online] 2022 [cited 2022 May 23];13:130-1. Available from: http://www.ijms.in/text.asp?2022/13/2/130/341110




  Introduction Top


COVID-19 pandemic has resulted in maintaining social distancing and the use of hand sanitizers to avoid the spread of virus. There has been a recent surge in the production of hand sanitizers to combat the rising demand. Alcohol-based hand sanitizers are liquids, gels, or foams that contain 60%–95% ethyl alcohol (ethanol) or 70%–95% isopropyl alcohol (isopropanol) used to disinfect hands. Most products contain between 60% and 80% alcohol.[1] Inadvertent use of hand sanitizers in daily households has opened a new window in the field of poisoning. The active constituent of sanitizer which is ethanol can be detrimental if taken in overdose. Since ethanol is absorbed rapidly from stomach, the quantity and rapidity of the ingested dose define the extremity of symptoms. Knowing the adverse effects of hand sanitizer ingestion can help the physician in the management and thus prevent this health problem by its appropriate usage.


  Case Report Top


A 30-year-old man with Type 1 diabetes mellitus for 6 years on insulin therapy presented to medical emergency of a tertiary care hospital with drowsiness, frothing from mouth, and vomiting without any history of weakness, seizures, external bleeding, or trauma. On examination, Glasgow Coma Scale score was E2V2M5, P – 92/min, BP – 120/92 mmHg, Spo2 – 96% on room air, blood sugar – 452 mg/dl, and urine ketones – strongly positive. On respiratory examination, bilateral inframammary area coarse crepitations were present suggestive of aspiration. Cardiovascular system was normal. Abdomen was normal. On poking about the history more to ascertain the cause of aspiration, the patient's relatives told about ingestion of 200 ml of hand sanitizer containing 70% ethanol due to domestic fight with his wife. The patient had ingested the sanitizer 30 min before the presentation which had further precipitated diabetic ketoacidosis. ABG - pH-7.077, HCO3 – 5 mEq/L, pco2 –15 mmHg, po2 –119 mmHg, anion gap – 22 mEq/L (8–16), chloride –116 mEq/L, hemoglobin – 14.5 g/dl, total leukocyte count – 8100, differential leukocyte counts – 61/29, platelets – 1.05 L/mm3, urea/creatinine –35/1.0 mg/dl, sodium/potassium – 135/3.7 mEq/L, aspartate transaminase/alanine transaminase – 26/17 U/L, calcium/phosphorus – 9/2.9 mg/dl, total protein – 7.1 g/dl, serum albumin – 4.0 g/dl, amylase – 93, and INR – 0.95. Chest roentgenogram was suggestive of the bilateral middle zone inhomogenous opacities (right >left). The patient was managed on the lines of diabetic ketoacidosis with aspiration and was given oxygen by face mask at 4L/min and started with IV fluids, injection regular insulin 6 units bolus followed by 6 units/h infusion initially. Ryle's tube lavage with activated charcoal was done within 30 min of ingestion of ethanol in emergency with 50 ml of aspirate. Antibiotics with injection ceftriaxone and metronidazole were given. Adequate maintenance fluids and bicarbonate correction were given, and insulin was fixed thereafter. High anion gap metabolic acidosis improved with correction of fluid deficit and bicarbonate with normalization of pH – 7.417, HC03 – 25 mEq/L, and anion gap-12 mEq/L. The patient improved at day 3 after admission with normalization of biochemical parameters. The patient was managed conservatively and discharged with stable vitals and controlled sugar after 1 week of hospital stay.


  Discussion Top


Since the COVID-19 pandemic, alcohol-based hand sanitizers have been extensively used as a norm for hand hygiene and personal protection. While washing hands with soap and water is a simple traditional way of cleaning the visible contamination, the use of hand sanitizers has overtaken this standard approach of hand hygiene in the pandemic. Consequently, the easy access to alcohol-based hand sanitizers and its intentional or unintentional ingestion has emerged as a new public health problem in the existing COVID-19 pandemic. The vulnerable population includes children, elderly, and institutionalized groups such as prisoners, psychiatric patients, and alcohol de-addiction groups who are restricted from alcohol. There have been case reports of accidental ingestion of hand sanitizer in children.

The effects of isopropanol are similar to those of ethanol, with clinical effects reported after ingestion of as little as 100 mL of 70% isopropanol solution.[2] Generally, symptoms of alcohol-based hand sanitizer mirrors that of alcohol intoxication appearing within few hours of ingestion. Symptoms range from nausea, vomiting, epigastric pain, hypothermia, cardiac arrhythmia, respiratory, and central nervous system depression to death.[3] Constituents such as ethanol and ethylene glycol cause high anion gap metabolic acidosis due to increase in unmeasured anions. Other causes of high anion gap include acetaminophen, aspirin, methanol, renal failure, lactic acidosis, and diabetic ketoacidosis. In this case, the patient had high anion gap due to both ethanol poisoning and diabetic ketoacidosis, thus precipitating severe acidosis requiring bicarbonate replacement. Management is usually conservative with securing airway, breathing, and maintenance of hemodynamic stability. Insulin may be required in cases of high anion gap metabolic acidosis due to diabetic ketoacidosis which can be precipitated by the hand sanitizer ingestion as was in this case. The combination of increased demand and exposure to alcohol-based hand sanitizers and the negative impacts of the COVID-19 outbreak on mental health, social supports, financial security, and health services are a cause of serious concern.[4]


  Conclusion Top


The recent surge in the use of hand sanitizers particularly households has allowed its access as a new poison. We can prevent this new emerging problem by judicious use of sanitizers. Supervision of vulnerable group with limiting the easy accessibility and proper counseling may be helpful. Recognizing the effects of hand sanitizer poisoning early in course may prevent untoward metabolic derangements and preventable deaths in the vulnerable population. Awareness in the detection and management of hand sanitizer ingestion may help the health-care team to combat this entity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO. Guide to Local Production: WHO-Recommended Handrub Formulations; 2010. Available from: https://www.who.int/gpsc/5may/Guide_to_Local_Production.pdf. [Last accessed on 2020 Aug 13].  Back to cited text no. 1
    
2.
Archer JR, Wood DM, Tizzard Z, Jones AL, Dargan PI. Alcohol hand rubs: Hygiene and hazard. BMJ 2007;335:1154-5.  Back to cited text no. 2
    
3.
Gormley NJ, Bronstein AC, Rasimas JJ, Pao M, Wratney AT, Sun J, et al. The rising incidence of intentional ingestion of ethanol-containing hand sanitizers. Crit Care Med 2012;40:290-4.  Back to cited text no. 3
    
4.
Pierce M, Hope H, Ford T, Hatch S, Hotopf M, John A, et al. Mental health before and during the COVID-19 pandemic: A longitudinal probability sample survey of the UK population. Lancet Psychiatry 2020;7:883-92.  Back to cited text no. 4
    




 

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Abstract
Introduction
Case Report
Discussion
Conclusion
References

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