Losartan induced fetal toxicity

Losartan is a specific angiotensin II receptor antagonist. Although the teratogenic effects of angiotensin converting enzyme (ACE) inhibitors are well documented there are limited reports of losartan induced fetal toxicity. The authors report a case of incomplete ossification of skull bones, transient oliguria and feed intolerance in a newborn following in-utero exposure to losartan.

[Suicidal poisoning with antihypertensive drugs]

In the period from 1990 to 2002, 201 patients with suicidal antihypertensive drugs poisoning were treated, including 138 women and 63 men from 15 to 84 (mean 36) years old. The main causes of suicides were various kinds of depression (63%) as well as psychopathy and/or sociopathy (16%) and schizophrenia (10%). Twenty eight patients attempted repeatedly to commit suicide. Thirty six persons were poisoned by only antihypertensive drugs, in 165 remaining cases intoxications were mixed including antihypertensive and other different medications. beta-blockers (38.3%), calcium channel blockers (34.8%), angiotensin converting enzyme inhibitors (24.3%) and diuretics (2.5%) were used in suicidal attempts. There were no suicidal poisonings with angiotensin II AT1 receptor antagonists, alpha 1-blockers and imidazole receptor agonists. In the examined group three patients died of cardiogenic shock, electromechanical dissociation and secondary acute respiratory failure resistant to therapy. The drugs used in these cases were propranolol, amlodipine, theophylline, captopril, doxepine, propafenone, furosemide, methimazole and alcohol. Mortality rate in antihypertensive drug poisonings was 1.5%.

[Severe mixed poisoning with diltiazem, potassium and magnesium: a case report]

We report the case of 52-year-old woman, who ingested 3.6 g of diltiazem, 16 g of potassium chloride and 6.5 g of magnesium, in a suicide attempt 4 hours before admission. She developed cardiorespiratory failure, with severe hypotonia and acute renal failure, in ECG third degree atrioventricular block was stated. The highest potassium concentration was 8.0 mmol/l, magnesium 2.15 mmol/l. As a result of multiple pharmacologic intervention, including intravenous fluids, calcium, glucagon, dopamine, dobutamine, norepinephrine, transvenous pacing and peritoneal dialysis (haemodynamic instability makes haemodialysis noneffective) the haemodynamic stabilization of cardiovascular system and normalization of potassium and magnesium concentration were achieved. The diltiazem concentration was measured using liquid chromatography, the result was 0.89 microgram/ml. She was discharged in a good clinical condition on day 26th.

[The use of intra-aortic balloon counterpulsation in the treatment of severe hemodynamic instability from myocardial depressant drug overdose]

A case of refractory hemodynamic instability following metoprolol and diltiazem overdose is reported. Management included intra-aortic balloon counterpulsation as an adjunct to pharmacologic therapy in cardiogenic shock from overdose of myocardial depressant drugs.

[Acute poisoning with cardiovascular drugs: data from Acute Poisoning Ward in Tarnów]

In this paper an analysis of poisonings with cardiovascular drugs treated in the II Ward of Internal Diseases and Acute Poisonings in Tarnów, in the years from 1996 to 2001, is presented. In 6 years 66 patients were treated (4.5% of all treated toxicological cases). The most frequent kind of drugs were antihypertensive drugs (44 cases), mainly beta-blockers--17 cases. No fatalities were observed. Suicidal poisoning with propafenone in 22-year-old man is presented.

Clearance of metformin by hemofiltration in overdose

BACKGROUND

Metformin is prescribed with an increasing frequency for patients with Type II diabetes mellitus; the increasing availability increases the risk of intentional overdoses. Metformin may cause severe lactic acidosis in overdose, especially when accompanied by co-ingestants or other medical conditions that alter lactate handling or metformin elimination. Though the clearance of therapeutic metformin by hemodialysis is known, the clearance in the setting of a large overdose has not been reported.

CASE REPORT

A 58-year-old man with a history of Type II diabetes, hypertension, bipolar disease, and decreased renal function presented after ingestion of approximately 40 500-mg metformin tablets and 20 240-mg diltiazem sustained-release tablets. Clinical manifestations of poisoning included somnolence, hypotension, bradycardia, severe lactic acidosis, and ultimately death. Gastric decontamination was attempted with gastric lavage, multiple dose activated charcoal, and whole bowel irrigation. Hemodynamic support was provided with pressors, glucagon, insulin, and intra-aortic balloon pump. Due to hypotension, continuous renal replacement therapy, rather than hemodialysis, was initiated. Continuous veno-venous hemodialysis was performed with a blood flow of 180 mL/min and dialysate flow of 2.5 L/h. A Multiflow 60 kidney (Cobe) on a Prisma (Cobe) continuous renal replacement therapy machine was used. The initial metformin level was 110 microg/mL (therapeutic range 1-2 microg/mL). By continuous veno-venous hemodialysis, an absolute clearance of 50.4 mL/min was obtained.

CONCLUSION

Metformin was cleared by the continuous veno-venous hemodialysis modality of continuous renal replacement therapy in this metformin overdose. Although a fatal outcome occurred in this patient, its utility in other patients with metformin overdose should be investigated.

Cardiovascular depression resulting from atenolol intoxication

A case of massive atenolol ingestion leading to hypotension in association with PR and QRS interval prolongation on the electrocardiogram is presented. These clinical findings are identical to those attributed to the membrane-stabilizing activity of propranolol and other lipophilic beta-blockers. It is commonly believed that hydrophilic agents such as atenolol lack this activity. A review of the literature reveals that hydrophilic beta-blockers may have membrane-stabilizing activity, though much higher concentrations are required to produce this action in comparison with lipophilic agents. This case and a review of the literature provides a potential pathophysiological basis for atenolol-induced haemodynamic depression.

Using trade names: a risk factor for accidental drug overdose

Medication errors due to the exclusive use of trade names of drugs may lead to life-threatening complications. We report the case of a patient with verapamil overdose as a result of this. This case illustrates that the use of trade names, omitting the international nonproprietary names of the active moiety, carries the risk of serious adverse drug events by overdose.

A case of suicide by ingestion of sodium nitroprusside

The study reports a case of suicide by ingestion of sodium nitroprusside which resulted in acute cyanide poisoning. Analyses carried out on body fluid yielded the quantitation of total (5.00 mg/L) and free (3.30 mg/L) cyanide in blood and of methemoglobin (blood = 10.5%). At the scene, some solid reddish-brown material was found in a glass, which on toxicological analysis was found to contain sodium nitroprusside; about 9 g of the same substance was identified in stomach contents. The detection and quantification of cyanide and methemoglobin in biological samples from the case indicated that the lethal effect was due to both metabolic products (cyanide and methemoglobin).

A 1000-fold overdose of clonidine caused by a compounding error in a 5-year-old child with attention-deficit/hyperactivity disorder

A 5-year-old child who weighed 17.5 kg received 50 mg of clonidine. The amount ingested was confirmed by analysis of the suspension administered (clonidine HCl 9.78 mg/mL). To our knowledge, this represents the largest ingestion in a child and the largest ingestion on a milligram per kilogram basis in the medical literature. The child's initial presentation included hyperventilation, an unusual feature of clonidine toxicity. The child was discharged without sequela 42 hours after admission. A serum concentration of clonidine 17 hours postingestion was 64 ng/mL, the highest reported to date in a pediatric patient. The intoxication was traced to a pharmacy compounding error in which milligrams were substituted for micrograms. Increased prescribing of clonidine in young children coupled with the requirement to compound clonidine in a suspension and the narrow therapeutic index suggests that the frequency of severe ingestions in children will increase in the future.

[Deep hypotension with transient oliguria and severe heart failure in course of acute intentional poisoning with amlodipine]

A case of acute poisoning with amlodipine with deep hypotension, transient oliguria and clinical signs of acute heart failure was described. A woman of 23 years swallowed intentionally 60 tablets of amlodipine (600 mg). After eleven hours of ingestion she was admitted to Warsaw Poison Control Centre. She was in severe clinical condition; tachycardia and deep hypotension were the prominent signs of poisoning. There was not CNS depression. Intensive treatment with i.v. catecholamines (dopamine, norepinephrine), crystalloids (with continuous control of central venous pressure), and i.v. calcium salts (with control of plasma calcium concentration) was started immediately. The patient did not improve but got worse. Acute heart failure developed, especially of left ventricle, so i.v. crystalloids were stopped and dubutamin, morphine, nitroglycerin and glucagon were introduced. Because of oliguria and insufficient effect of high doses of furosemide four-hours hemodiafiltration was set in. The patient's condition slowly improve after third and forth day of hospitalization. The systolic blood pressure rose, heart work was really better and on sixth day--the stabilization of diastolic blood pressure was definitely achieved. The patient was discharge in good condition with heart ejection fraction of 65% measured echocardiographically.

[Attempted suicide with sustained release diltiazem]

A 15-year-old woman was admitted to the intensive care unit after intentional auto-intoxication with 10 tablets of 200 mg diltiazem sustained release. She developed hypotension and became oliguric. This was followed by metabolic acidosis. Maximum plasma lactate concentration was 10 mmol/l and the highest measured plasma diltiazem level was 500 micrograms/l. The occurrence of pulmonary oedema due to adult respiratory distress syndrome (ARDS) was striking and the patient required mechanical ventilation for a period of three days as a result of this. After five days in the intensive care unit, she was transferred to a psychiatric hospital in a good physical condition. Sustained release diltiazem intoxications have previously been described on five occasions.

Losartan and fetal toxic effects

We report a case of maternal exposure to the antihypertensive drug losartan during weeks 20-31 of pregnancy. We saw the fetal toxic effects of oligohydramnios (decreased amniotic fluid), fetal pulmonary hypoplasia, fetal hypoplastic skull bones, and subsequent fetal death. This pattern of abnormalities is similar to those seen in exposure to angiotensin-converting-enzyme (ACE) inhibitors during pregnancy, and were probably caused by losartan.

Clonidine toxicity in an adolescent patient

Clonidine is a central acting a2-agonist used primarily as an antihypertensive agent. Recently, it has been used for the treatment of attention deficit hyperactivity disorder in children and adolescents. When taken in excess, it can produce profound CNS depression, apnea, bradycardia and hypotension. A transient period of hypertension can sometimes occur. Treatment is primarily supportive, including respiratory support, atropine for bradycardia, and fluids and dopamine for hypotension. The CNS depression sometimes responds to naloxone. Young children are very sensitive to the toxic effects of clonidine. A case of an 11 year old adolescent who took an overdose of his clonidine is described to illustrate the toxicity of this agent.

Use of clonidine for chemical submission

CASE REPORT

An East-European prostitute in Amsterdam robbed several victims, after having sedated them with clonidine solution (available as plastic ampoules of eyedrops) added to her victims' drinks. One victim was hospitalized. His symptoms included bradycardia, hypotension, hypothermia, pallor, cyanosis, and impaired consciousness. Treatment included isoprenaline for 28 hours. The victim was released from hospital the next day. In court, the female offender confessed and was sentenced to prison for 3 1/2 years. She may have administered doses as high as 8 mg clonidine.

An unusual death by propranolol ingestion

A case of acute intoxication with propranolol is reported. A 60-year-old man was found dead in his car with no evidence of trauma or signs of asphyxia. Near the car, a pharmaceutical box of Inderal, a pharmaceutical formulation containing propranolol, was found. The man was not under therapy with this medication, but circumstantial data suggested the use of this medicine by his sister. High blood levels of propranolol confirmed the suspected drug use and induced us to discuss the probable lethal mechanism of this substance. The analysis of this compound was performed by liquid-liquid extraction followed by gas chromatography/mass spectrometry determination.

Anti-death properties of TNF against metabolic poisoning: mitochondrial stabilization by MnSOD

The cytokine tumor necrosis factor (TNF) is toxic to some mitotic cells, but protects cultured neurons from a variety of insults by mechanisms that are unclear. Pretreatment of neurons or astrocytes with TNF caused significant increases in MnSOD activity, and also significantly attenuated 3-nitropropionic acid (3-NP) induced superoxide accumulation and loss of mitochondrial transmembrane potential. In oligodendrocytes, however, MnSOD activity was not increased, and 3-NP toxicity was unaffected by TNF. Genetically engineered PC6 cells that overexpress MnSOD also were resistant to 3-NP-induced damage. TNF pretreatment and MnSOD overexpression prevented 3-NP induced apoptosis, and shifted the mode of death from necrosis to apoptosis in response to high levels of 3-NP. Mitochondria isolated from either MnSOD overexpressing PC6 cells or TNF-treated neurons maintained resistance to 3-NP-induced loss of transmembrane potential and calcium homeostasis, and showed attenuated release of caspase activators. Overall, these results indicate that MnSOD activity directly stabilizes mitochondrial transmembrane potential and calcium buffering ability, thereby increasing the threshold for lethal injury. Additional studies showed that levels of oxidative stress and striatal lesion size following 3-NP administration in vivo are increased in mice lacking TNF receptors.

A 9-month-old with bradycardia and periodic apnea

The patient was discharged approximately 36 hours after admission to the emergency department. At that time she was awake and alert and responding appropriately to her surroundings. Her vital signs were within normal limits. It took approximately 2 weeks to receive the baby's clonidine level, which was 11.0 ng/mL; the therapeutic level is between 0.5 to 4.5 ng/mL. We came to the conclusion that the babysitter's clonidine patch had accidentally fallen into the playpen, where the baby subsequently sucked on it. To this day, the babysitter denies any involvement. Situations such as this confront emergency nurses every day, and questions arise regarding intent. In this case, the physician interviewed the babysitter and believed that the overdose was unintentional. Once again we are reminded of the fragility of life, the importance of capable, cautious caregivers, and just how easily accidents can happen. What a happy outcome this turned out to be after what appeared to be such a grave medical emergency on presentation!

Delayed hypoglycemia in a child after ingestion of a single glipizide tablet

This is the first report to describe the delayed onset of hypoglycemia in a child after ingestion of one tablet of glipizide. A 2-year-old boy was observed to ingest 5 mg glipizide and 25 mg hydrochlorothiazide. Activated charcoal was administered within 35 minutes of ingestion. Hypoglycemia (serum glucose 49 mg/dL) developed 11 hours later. Emergency physicians must be aware of the potential for delayed hypoglycemia in children with single-tablet ingestions of glipizide. Prolonged monitoring of glucose levels is warranted.