Acute 2,4-dichlorophenoxyacetic acid herbicide poisoning in rural India: clinical spectrum, multiorgan toxicity, and outcomes in an eight-patient observational study

Acute poisoning with 2,4-dichlorophenoxyacetic acid (2,4-D), a commonly available chlorophenoxy herbicide, represents an emerging toxicological challenge in rural agricultural settings yet remains underreported in intensive care literature. We conducted a retrospective observational study of eight consecutive patients with suspected acute 2,4-D ingestion admitted to a rural tertiary-care center in India to characterize clinical presentation, organ toxicity, management, and outcomes. The cohort demonstrated a wide clinical spectrum, ranging from mild gastrointestinal illness to rapidly progressive multiorgan dysfunction. Severe toxicity was characterized by early hypotension, profound metabolic acidosis, central nervous system depression, rhabdomyolysis, and acute kidney injury requiring renal replacement therapy. Notably, one patient developed electrocardiographic changes and echocardiographic myocardial dysfunction progressing to cardiogenic shock, highlighting potential cardiac involvement that may be underrecognized in phenoxy herbicide poisoning. Management was largely supportive and included hemodynamic stabilization, ventilatory support, urinary alkalinization, and dialysis in selected cases. Overall mortality was 50%, with adverse outcomes associated with early hemodynamic instability and multisystem involvement at presentation. These findings expand the limited clinical literature on 2,4-D toxicity from low-resource settings and emphasize the need for heightened clinical suspicion, early aggressive supportive care, and improved toxicovigilance. Larger prospective studies are warranted to clarify predictors of severity and optimize management strategies for chlorophenoxy herbicide poisoning. • Severe 2,4-D poisoning showed a high mortality rate with multiorgan involvement. • Early hypotension and metabolic acidosis were strong markers of poor outcome. • Myocardial dysfunction may represent an underrecognized feature of toxicity. • Rhabdomyolysis and acute kidney injury were common in critically ill patients. • Supportive intensive care and urinary alkalinization remain key management strategies.