A boy ate three laundry pods in one bite.This is what happened to his lungs. “JR” is a 17 year old boy presenting to the emergency room with emesis, respiratory distress, and somnolence. His mother Jane tells the admitting nurse that he had been vomiting, gagging, and struggling to breathe for at least 30 minutes. You see, JR had been participating in a contest with friends, The Forbidden Fruit Challenge, where contenders would take videos of themselves chewing on laundry detergent pods and the person with the most social media likes and comments would win… … nothing. Clearly this was for jokes and memes on behalf of teenagers. Most of them knew this was dangerous and were not actually going to put any laundry detergent in their mouths, but JR was determined. He was going to, as he told his friends, “experience the greatness of laundry pod flavor” and become internet famous. Immediately, after putting three pods in his mouth, he could feel a slight burning sensation waft up into his nose. Huddled over the sink, JR was prepared to spit out the detergent as soon as he started biting. But as he chewed down on the pods. piercing into the vinyl plastic, laundry detergent poured into his mouth. He was suddenly overcome by a severe burning, numbing sensation on his tongue. JR began coughing, retching, with his tongue paralyzed by the sensation. Laundry detergent began to seep down into his throat. In his coughing fit, he aspirated some of the detergent into his trachea, corroding the tissue, compromising part of his airway as the liquid began to drip and ooze into his bronchi. With every cough, more and more detergent was lodged further and further into the airways of his lungs. His mother Jane hears the commotion and rushes to him. She sees him vomiting his gastric contents, which come out with green and blue laundry detergent as he begins foaming at the mouth. As he collapses, he grips his chest and cries out in pain as he feels the detergent set fire to his esophagus, down into his stomach. As he struggles to breathe and is panicked, his lips begin to cyanose, or turn blue. Confused and unaware as to what just happened Jane looks around and sees the plastic wrapping of the laundry pods that JR spit out of his mouth. She calls the poison control center who initially tells her to give her son water and to not induce vomiting, but his cyanose lips prompts a 911 call. In the ambulance JR Becomes more somnolent as he arrives to the emergency room where we are now. Given the patient’s immediate past history, it’s very clear his symptoms are because of laundry detergent pod ingestion but the presentation is multifactorial and there’s a few challenges to consider first. JR is suffering from an early manifestation of caustic esophageal injury. Esophageal referring to the esophagus, the tube that connects the mouth to the stomach. Caustic referring to a burning or corrosion of organic tissue through chemical origin, referring back to the three laundry detergent pods that JR just consumed. There’s a wide variability in the chemical composition of various laundry pods on the market, which brings us to the first challenge. Jane was unsure the brand of pod used in her household. Some are alkaline, or strongly basic, when in solution with water like many other detergents and soaps. These agents can be at least a hundred thousand times more basic than human blood and contact with mucosal surfaces like the esophagus induces liquefactive necrosis. “- osis” meaning abnormal state, “necro-” meaning death, and “liquefactive” meaning as the tissue dies, its sloughs off into a liquid pus, disintegrating the lining of the esophagus as it rolls down into the stomach, causing deep penetration and possible tissue perforation – all of this happening within one second of contact. The pods JR consumed appeared to be acidic in solution, opposite of alkaline, meaning instead they corrode the esophageal lining and instead induce coagulation necrosis, a state of death marked by clotted blood blocking the flow of oxygen and choking the cells to death. But this isn’t the only problem. Because the patient was found gagging and choking, he’s also suffering from upper airway injury, which leads us to the second challenge. JR presents with stridor, a high-pitched wheezing sound caused by disrupted airflow. His breathing is hoarse with coughing and choking, all of which exacerbates his hypoxemia. “hypo-” meaning low, “ox-” referring to oxygen and “-emia” meaning presence in blood. “Low oxygen presence in blood.” Further examination finds that JR has tachycardia. “tachy-” meaning fast and “-cardia” referring to heart rate. It’s measured at a hundred and thirty beats per minute, more than two times that of normal. He’s tachypnic, meaning his respiratory rate is much higher than normal. Both of these are combined with somnolence as JR appears sleepy and lethargic. As the patient workup is continued by the medical team, JR suddenly loses consciousness. Given his hypoxemia, his upper airway distress, the severe tachycardia, and tachypnea, JR is now presenting with imminent respiratory failure. Without immediate airway management, he will go into cardiopulmonary arrest and die instantly. How is it possible that something so candy-like in appearance and so ubiquitous in availability could be this deadly? Well, there’s a few things to consider. First, laundry pod detergent is more concentrated than free liquid product. This one pod is the equivalent of this much free laundry detergent. The interesting thing about detergent is that each molecule has simultaneous affinity for both water and fat. In this small science experiment, I put oil and water together in a jar. You can see that they don’t mix. But when I add detergent you’ll see that the oil droplets become suspended inside water, forming something called an emulsion. This happens because each detergent molecule has a hydrophilic end. “hydro-” meaning water and “-philic” meaning affinity for. This means that end orients towards and interacts with water only. But the opposite end of the same molecule has a lipophilic end, one that orients towards and interacts with fat only. This is important to note because the mucosal surfaces like the mouth and the esophagus are wet and abundant with water, but they also have an epithelial lining of cells: cells which have an outer membrane made of fat, meaning at a molecular level the detergent has a hydrophilic moiety that latches onto water in the mucosa and a lipophilic end that latches on to the cell membrane. These attractive forces are strong enough for the detergent molecule to rip open the cell membrane, causing the cell to spill out its contents and die. Stripping the epithelium, killing all of the cells, and causing tissue injury. This is what happened to JR’s esophagus. Because of the instant irritation caused by the stripping off of the epithelium Junior started coughing violently But it doesn’t stop there. In this fit, he aspirated droplets of the highly concentrated laundry detergent, which lodged into his trachea as it entered into his airway. The more he coughed, the more smaller droplets lodged deeper into his bronchi, where amounts of detergent entered into his smaller airways. Because the lungs also contain water in the form of moisture, those cells too were torn apart by the detergent. It’s here where his lungs are literally getting stripped of their cell lining as the tissue begins to die. The body detects this and initiates an inflammatory response in the airway in an effort to defend against the injury, meaning his lungs begin to swell with water and white blood cells, exacerbating his respiratory distress and leading to his imminent respiratory failure. This mechanism of laundry pod detergent damage to biologic tissue is generalized to all parts of the human body. The eyes can suffer burns as well as the skin when they come into contact with the highly concentrated detergent. Mild soaps much weaker than laundry detergents can be used to wash hands because skin cells contain keratin, a protein that protects cellular membranes from rupturing on detergent contact. But the soaps will rupture bacterial, viral, and fungal membranes, which typically don’t contain keratin. Similarly, the cells of the eyes, mouth, and throat also don’t contain this protein, so they too would be irritated by these same mild soaps. The concept of surface active detergents with a dual nature in hydrophilicity and lipophilicity is an important physiologic theme in medicine. Ironically, the lungs produce their own detergent called dipalmitoylphosphatidylcholine. This prevents collapse of the small bubbles of the alveoli where oxygen exchange occurs with the blood. Premature babies often experience respiratory distress syndrome from collapsed airways because their bodies don’t develop the capability to produce this surfactant until term. This isn’t in the same league of detergent as contained in the laundry pods and exists inside the alveoli rather than outside, where JR’s damage is occurring. Fats and oils are difficult for the body to digest if not for bile, an emulsifying agent that encapsulates fat globules in a structure that can interact with both water and fat, helping absorption of fat-soluble vitamins as well as digestion of oils. Pharmaceutical dosage forms famously employed detergents in an effort to increase bioavailability, enhance absorption and distribution of drug in the body. Creams and lotions contain emulsified oils that absorbed transdermally into the skin. Inhalers use surfactants to maintain dispersion of the drug for absorption into the lungs. And most recently, liposomal nanoparticles are being researched and engineered for gene therapy and for targeted drug delivery in cancer. These particles can be self forming “in vivo,” or in the body and are not the ethoxylated, sulfated, anionic and non-ionic surfactants of laundry detergent which were specifically formulated and designed to remove grease and stains from clothing. There is no place in or on any part of the human body for any kind of laundry detergent. Ever. For JR, There’s no cure for laundry pod poisoning. The best that can be done in patient is supportive care to alleviate symptoms and monitoring. His airway is stabilized and he’s intubated to prevent respiratory arrest. Because he was shown to have severe circumferential burns to his esophagus, prophylactic antibiotics were given as well as corticosteroids to limit inflammation. Because he’s unable to swallow, he can only be fed intravenously or through a nasogastric tube as his esophageal epithelium begins to heal from the chemical burn injury that it had suffered. This was a tragic case that did not need to happen. Warning labels are prominent on laundry pod packaging. Previously poison call centers have dealt with thousands of cases like this, but mostly in very young children as well as impaired geriatric patients. Make no mistake, one has absolutely nothing to gain from putting laundry detergent in their mouths, and they have everything to lose instead. With supportive care in the intensive care unit in addition to timely monitoring, a strong lesson learned, a story, that’ll never be lived down amongst his friends and an event that he’ll wanna erase from his memory for the rest of his life JR was able to make a recovery from his injuries. Thank you so much for watching. Take care of yourself and be well.