Evaluation of potential gastrointestinal carcinogenicity associated with the ingestion of asbestos

The inhalation of asbestos, depending on the fiber type and dose, may be associated with the development of mesothelioma and other asbestos-related diseases. However, little is known about the potential adverse effects associated with the ingestion of asbestos. Evidence of asbestos fibers released from asbestos-cement pipes used in water distribution systems has led to concerns of potentially contaminated drinking water. The purpose of this study is to determine whether ingestion of asbestos fibers may lead to cancerous effects on the gastrointestinal (GI) tract. Data from animal and human studies were analyzed using a weight-of-evidence approach to evaluate the potential risk of GI cancers associated with asbestos ingestion. Seventeen human and 23 animal studies were identified and evaluated in this study. Animal studies were conducted in multiple species with inconsistent dosing protocols. Overall, animal studies reported that the asbestos fibers, irrespective of fiber type and dose, failed to produce any definitive GI carcinogenic effect. The 17 identified human epidemiological studies reported the ingestion of asbestos-contaminated water with concentrations from 1 to 71,350 million fibers per liter (MFL). A majority of the epidemiology studies reported statistically significant increases in multiple GI-specific cancers. However, these findings are confounded due to several critical study limitations including flawed study design, small sample size, selection bias, lack of individual exposure history, lack of adequate latency, and the inability to account for confounders including occupational history, diet, and smoking history. Based on our weight-of-evidence assessment, there is insufficient evidence of causality between the ingestion of asbestos and an increased incidence of GI cancers.

Eucalyptus Oil-Induced Seizures in Children: A Single-Center Prospective Study

Objective

Eucalyptus oil (EO) is known to have proconvulsant properties. EO is present in many over-the-counter preparations and used orally or topically to treat many ailments. In this study, we seek to describe clinical features, neuroimaging, and electroencephalographic findings and follow up outcome in children with eucalyptus oil-induced seizures (EOIS).

Materials and methods

This was a single-center prospective observational study, conducted at a tertiary care hospital from South India over a period of two years. Children (up to 18 years of age) with a first afebrile seizure or breakthrough seizures with preexisting epilepsy and with a recent exposure to EO were included. Data from all the children including demographic data, exposure to EO, mode of exposure, time to onset of seizures in relation to exposure, duration of seizure, type of seizure, investigations, and antiepileptic drug therapy were noted. All the patients were followed up for recurrence of seizures for six to nine months. 

Results

During the study period of two years, a total of 17 children met the inclusion criteria, with a median (range) age of 3.75 years (23 - 150 months) and 10 (59%) were male. Only one patient had breakthrough seizures and all other 16 children had a first episode of seizure. All the children had generalized tonic-clonic seizures with median duration of three minutes (30 sec - 30 minutes). The median (range) interval between EO exposure and the onset of seizures was 20 minutes (10 - 120 minutes). All the children had taken EO drops orally mixed in either water or milk in different amounts. All the patients' brain neuroimaging was normal. All the patients had normal electroencephalography except for four children. Only five patients were treated with antiepileptic drugs for two weeks and one patient with preexisting epilepsy was continued on the same antiepileptic drug. None of the patients had a recurrence of seizures during the follow-up period of six to nine months.

Conclusion 

EOIS is an underrecognized and rare entity of seizures in children. EOIS can occur as first seizures or as breakthrough seizures in preexisting epilepsy patients. Despite the previous case reports in the literature quoting the seizurogenic potential of EO, this awareness is lacking in both clinicians and parents. We also recommend clinicians inquire about exposure to EO while approaching a child with first afebrile seizures or breakthrough seizures, which can prevent unnecessary investigations and long-term antiepileptic drug therapy.

Clinical presentation, diagnosis and management of aerodigestive tract foreign bodies in the paediatric population: Part 2

Children, especially toddlers, because of their behaviour, physiology and anatomical characteristics such as oral exploration of their surroundings, have a tendency to place objects in their mouth. Therefore, ingestion or aspiration of foreign bodies (FBs) in children is a potentially life-threatening and common problem seen across the world. In this second part of our pictorial review on ingested and aspirated FBs, we focus on the paediatric population, reviewing the current literature and examining the epidemiology, clinical presentation, anatomic considerations, appropriate imaging modalities, key imaging characteristics associated with clinically relevant FBs in the emergency department (ED) and current management protocols.

Caustic ingestions over 10 years in Victoria, Australia: High rates in migrants and women

OBJECTIVES

Caustic ingestion is relatively common in developing countries and can result in life-threatening sequelae. There is limited understanding of the epidemiology and incidence in Australia. This statewide 10 year audit aims to investigate this further.

METHOD

A retrospective review was conducted over ten years (2007-2016), including all admissions to hospitals in Victoria. This includes a population of 5.9 million people and 22 hospitals.

RESULTS

384 cases of caustic ingestion were admitted to hospital between January 2007 and December 2016. The overall incidence was 7 cases/million/year. This cohort included 217 females (56.5%), 193 overseas born patients (50.2%) and 196 people (51%) with a history of mental illness. The countries of birth with the highest incidence of caustic ingestion were Ethiopia, 11 patients (227 cases/million/year, RR 31.7, p < 0.0001), Sudan, 11 patients (161 cases/million/year, RR 22.6, p < 0.0001), India, 38 patients (27 cases/million/year, RR 3.9, p < 0.0001). All had a significantly higher incidence than the Australian-born population of only 6.5 cases/million/year (RR 0.4, p < 0.0001). Of those born in India, Sudan and Ethiopia, rates of females were considerably higher than males (72% females). The overall mortality rate in this cohort was 2.3%.

CONCLUSIONS

Caustic ingestion remains a significant cause of morbidity and health expenditure in Victoria, particularly amongst vulnerable groups such as recent female migrants from areas in Africa and India. The high frequency of events seen in migrant populations highlights the significant need for awareness of risks in these groups for development of possible prevention strategies which are required. This article is protected by copyright. All rights reserved.

Emerging Mechanisms of Endocytosis in Toxoplasma gondii

Eukaryotes critically rely on endocytosis of autologous and heterologous material to maintain homeostasis and to proliferate. Although mechanisms of endocytosis have been extensively identified in mammalian and plant systems along with model systems including budding yeast, relatively little is known about endocytosis in protozoan parasites including those belonging to the phylum Apicomplexa. Whereas it has been long established that the apicomplexan agents of malaria (Plasmodium spp.) internalize and degrade hemoglobin from infected red blood cells to acquire amino acids for growth, that the related and pervasive parasite Toxoplasma gondii has a functional and active endocytic system was only recently discovered. Here we discuss emerging and hypothesized mechanisms of endocytosis in Toxoplasma gondii with reference to model systems and malaria parasites. Establishing a framework for potential mechanisms of endocytosis in Toxoplasma gondii will help guide future research aimed at defining the molecular basis and biological relevance of endocytosis in this tractable and versatile parasite.

Casein-enhanced uptake and disease-modifying bioactivity of ingested extracellular vesicles

Extracellular vesicles (EVs) from cardiac stromal cells, developed as therapeutic candidates, improve dystrophic muscle function when administered parenterally, but oral delivery remains untested. We find that casein, the dominant protein in breast milk, enhances the uptake and bioactivity of ingested heart‐derived EVs, altering gene expression in blood cells and enhancing muscle function in mdx mice with muscular dystrophy. Thus, EVs, administered orally, are absorbed and exert disease‐modifying bioactivity in vivo. Formulating EVs with casein enhances uptake and markedly expands the range of potential therapeutic applications.

Magnet Ingestion in Children Management Guidelines and Prevention

Purpose: Foreign body ingestion is common in children, and most foreign bodies pass spontaneously without causing serious injuries. Ingestion of multiple high-power magnet pieces is unique and increases the risk of morbidity and mortality. The longer the duration of ingestion, the increased likelihood of complications. Various management options have been reported, and there is no consensus on the ideal management which necessitates the need for a practical algorithm. The incidence of magnet ingestion has been increasing and directly related to the laws and recalls. The aim of this review is to provide an easy and practical pathway for management and to highlight the preventive rules of the legislations and recalls. Methods: PubMed/MEDLINE, the Cochrane Database of Systematic Reviews, and the list of references from all identified complete publications were searched for all publications in English-language for pediatric magnet ingestion. Conclusion: Practical and time-saving management pathways are recommended to minimize the risk of complications. Preventive rules and recalls are important for eliminating the availability of these hazardous magnets. Public awareness about the unique risks posed by these magnets if ingested is important.

Migration of an ingested fishbone to the uterine wall: A case report

This paper reports the first case of the removal of an ingested fishbone from the uterus. A 77-year-old woman presented with a 3-day history of lower abdominal pain. An abscess-like lesion in the posterior wall of the uterus was revealed by transvaginal ultrasonography and pelvic magnetic resonance imaging. Moreover, a curvilinear calcium density in the anterior uterine wall was revealed by abdominal computed tomography. A recto-sigmoidal perforation and uterine abscess were suspected. Thus, hysteroscopic drainage of the abscess was performed. Hysteroscopy revealed a fishbone partially embedded in the myometrium. Its removal resulted in full recovery. This study believed that adhesions between the uterus and rectosigmoid colon after partial gastrectomy for gastric cancer may have limited abdominal symptoms by limiting the leakage of intestinal fluids. Although rare, it should be considered that migration of a fishbone into the uterus could occur.

Alpha Spectrometry of Radon Short-Lived Progeny in Drinking Water and Assessment of the Public Effective Dose: Results from the Cilento Area, Province of Salerno, Southern Italy

Radon is a naturally occurring radioactive gas present in the hydrosphere, lithosphere and atmosphere abundantly. Its ionizing radiation provides the largest human internal exposure by inhalation and ingestion to natural sources, constituting a serious health hazard. The contribution to total exposure is mainly due to inhalation, as ingestion by food or drinking water is typically very small. However, because of public health concerns, the contributions from all these sources are limited by regulations and remedial action should be taken in the event that the defined threshold values are overcome. In this paper, the first campaign of measurements to control the radon activity concentration in drinking water from public water supplies in the province of Salerno, south Italy, is described. The results represent a main reference for the area, as it was never investigated before. The purpose of this survey was to contribute to data compilation concerning the presence of radon-222 in groundwater in the Campania region and to determine the associated risk for different age groups. The maximum radon activity concentrations and the related total annual public effective dose turned out to be lower than the threshold values (100 Bq/l and 0.1 mSv/y, respectively) indicated by international guidelines and the national regulation, showing that the health risks for public consumption can be considered negligible.

Risk of toxicity from pediatric topical salicylate ingestions

INTRODUCTION

Suspected pediatric ingestions of greater than or equal to one teaspoon topical salicylate analgesic are recommended by poison control centers to be managed at healthcare facilities. This cutoff is applied for both liquid and non-liquid (cream, ointment, gel) formulations.

METHODS

California poison control cases involving topical salicylate exposures in children less than 6-years-old who were evaluated at a health care facility between 2003 and 2018 were analyzed.

RESULTS

Of 599 patient cases, the majority described no or minor symptoms, with gastrointestinal distress being the most common. Signs of salicylate toxicity (metabolic acidosis, tachypnea) occurred in six cases. Seven patients were hospitalized, six of whom were exposed to liquid preparations.

DISCUSSION

In line with previous research, liquid salicylate preparations were more frequently associated with the signs of salicylate toxicity and hospitalization.

CONCLUSION

There was a low frequency of severe side effects and low hospitalization rates among those referred to a healthcare facility, especially for non-liquid topical salicylate ingestions.

Serotonin Syndrome Associated With Vilazodone Overdose in a 22-Month-Old Treated With Dexmedetomidine

BACKGROUND

Vilazodone was approved by the U.S. Food and Drug Administration in 2011 as a treatment for major depression disorder. Vilazodone is a selective serotonin reuptake inhibitor and 5-HT1A agonist used in the treatment of depression in adults. Vilazodone increases the availability and activity of serotonin and its neural pathways. Vilazodone blocks the serotonin reuptake pump and desensitizes serotonin receptors (especially 5HT1A autoreceptors), therefore increasing serotonergic neurotransmission. Its partial agonist actions at presynaptic somatodendritic 5HT1A autoreceptors theoretically enhance serotonergic activity, contributing to antidepressant actions. There are limited reports exploring its effects in children after unintentional ingestion. Typical adult dosing is titrated from an initial dose of 10 mg up to a maximum dose of 40 mg daily. Serotonin syndrome classically manifests with restlessness, hyperthermia, tachycardia, mydriasis, and increased tone, and is typically treated with benzodiazepines, cyproheptadine, and supportive care. Dexmedetomidine has also been used in case reports to treat serotonin syndrome.

CASE REPORT

We report the case of a toddler with a laboratory-confirmed vilazodone overdose exhibiting symptoms of serotonin syndrome, including restlessness, hyperthermia, mydriasis, dystonia, agitation, seizure-like activity, roving eye movement, tachycardia, and elevated creatine kinase. The patient was admitted and initially treated with supportive care and lorazepam per recommendations of the poison center, which did not recommend cyproheptadine use. On decompensation with suspected serotonin syndrome, the patient was treated with dexmedetomidine. In addition, urine toxicology screening (Amphetamines II assay; Roche, Indianapolis, IN) was positive for amphetamines; however, confirmatory testing (gas chromatography-mass spectrometry) was negative. The patient improved and was discharged after returning to her baseline status at 74 h post ingestion. Importantly, this patient did not require intubation and mechanical intubation, in spite of the large amount of vilazodone ingested. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With increasing prescription of vilazodone, emergency physicians should have a high level of suspicion so as not to miss this toxidrome. The possibility of false-positive amphetamine screenings when an overdose of vilazodone is suspected should be investigated. Finally, systematic evaluation of the use of dexmedetomidine as treatment for serotonin syndrome or vilazodone ingestion should be done to confirm efficacy.

Management of button batteries in the upper gastrointestinal tract of children: A case-series study

Button batteries are the second most frequently-ingested foreign bodies and can lead to serious clinical complications within hours of ingestion. The purpose of this study was to analyze the outcomes of 14 children with button batteries lodged in the upper gastrointestinal tract.Totally 14 children with button batteries lodged in the upper gastrointestinal tract were included. The diagnosis was made primarily by the history of button battery ingestion, physical examination and chest-abdomen X-ray examination.The button batteries lodged in the esophagus were removed by esophagoscope, and those in the gastrointestinal tract were under observation. Among 10 children with batteries in the first esophageal stenosis, 9 were cured and 1 suffered from tracheoesophageal fistula. One case of battery in the second esophageal stenosis was dead due to intercurrent aortoesophageal fistula. Two cases of batteries in the third esophageal stenosis were cured after removal, and 1 case of the battery in the gastrointestinal tract discharged spontaneously.Ingested button batteries are mainly lodged in the esophageal stenoses and are easy to cause esophageal injury and severe complications. Early detection, prompt treatment, strengthening observation and regular follow-up after discharge may help to decrease the incidence of complications and improve the outcomes.

Pediatric ingestions with gummy formulated medications: a retrospective study

CONTEXT

Gummy formulations are widely available with estimated 65% marketed for children. Currently, there are few studies describing children ingesting gummy formulated medications. The aim of this study was to quantify and identify the type of ingestions due to gummy formulated medications, evaluate their clinical significance as defined by adverse outcomes: associated symptoms, emergency department (ED) visits, and hospitalizations.

METHODS

Retrospective study in children aged 0-19 exposed to gummy formulated medications from 2015 to 2017 as identified by calls made to the Regional Poison Control Center (RPCC). A list of potentially toxic gummy formulated medications was compiled and reviewed by medical and clinical toxicologists. We categorized medications into vitamins, minerals and supplements, melatonin, and other. Data collected included: medication name, number of units, age, sex, symptoms described, ED visit, hospitalization, and unintentional or intentional ingestion.

DISCUSSION

Of the 66,059 pediatric exposures received by RPCC, 1143 (1.7%) involved gummy formulated medications of which 1098 were analyzed. Median age was 3 years, 57.7% were males and 7% were symptomatic. Seventy-four percent exposures involved vitamins and 24% melatonin. In comparison to other gummy exposures, those who ingested melatonin had 8.4 times higher odds of being symptomatic (OR: 8.4, 95% CI: 5.1, 14) and 4.8 times higher odds of visiting ED (OR: 4.8, 95% CI: 2.5, 9). The predominant symptoms reported were drowsiness, gastrointestinal upset, and hyperactivity. Two patients were hospitalized who ingested multiple medications, one was unintentional, and one was intentional as a suicide attempt thus admitted for psychiatric stabilization.

CONCLUSIONS

Gummy formulated medications comprised <2% of the total pediatric calls to the RPCC. Although, the occurrence of symptoms is rare, these medications especially those containing melatonin should be safely stored.

Bioaccessibility of Difenoconazole in Rice Following Industry Standard Processing and Preparation Procedures

For pesticide registration a post application assessment is made on the safety of any residue remaining in the edible portion of the treated crop. This assessment does not typically consider the bioaccessibility of pesticide residues. The effects of this on potential exposure to incurred difenoconazole residues passing through the human gastrointestinal tract were studied, including the impact of commodity processing. It has previously been demonstrated that solvent extraction methods have the potential to overestimate the bioaccessible fraction, so in vitro simulated gut systems may offer a better approach to determine residue bioaccessibility to refine the risk assessment process. The bioaccessibility of difenoconazole residues associated with processed rice samples was assessed using in vitro intestinal extraction and colonic fermentation methods. The mean bioaccessibility following intestinal digestion was 33.3% with a range from 13% to 70.6%. Quantification of the colonic bioaccessible fraction was not possible due to compound metabolism. Mechanical processing methods generally increased the residue bioaccessibility, while chemical methods resulted in a decrease. Both mechanical and chemical processing methods reduced the total difenoconazole residue level by ca. 50%.

An Unusually Large Object Removed From the Upper Esophagus in a Patient With Self Harm Syndrome

A 32-year-old female with a history of bipolar disorder and schizophrenia was transported to our tertiary-care hospital after swallowing a large toilet paper holder bracket. Removal of the large foreign body required coordination between anesthesiology, otolaryngology, and trauma surgery. A tracheostomy airway was established, and the object was removed transorally. The object was found to be a toilet paper holder bracket measuring 7.5 cm × 5.4 cm × 5.4 cm with a 2.6 cm screw protruding from the end. A review of articles describing the removal of foreign bodies from the upper aerodigestive tract found our object to be the largest foreign body ingestion described in literature. One report suggested that 18% of adult patients with foreign body ingestions had primary neuropsychiatric disorders. Our patient's psychiatric disorder was a major underlying factor leading to the ingestion, with our patient reporting hallucinations instructing her to ingest household objects.

Laryngeal Edema, Metabolic Acidosis, and Acute Kidney Injury Associated with Large-Volume Kohrsolin TH® Ingestion

BACKGROUND

Glutaraldehyde is a commonly used disinfectant in most hospitals. It is known to be an irritating agent to the airway. With the exception of one small-quantity (75 mL) ingestion, no large-volume ingestion has been previously reported.

CASE REPORT

A 59-year-old man presented with history of large-volume (500 mL) consumption of a solution containing 10% glutaraldehyde and developed respiratory distress, as well as gastrointestinal and kidney injury. His ingestion necessitated a feeding jejunostomy tube placement and tracheostomy. His condition improved with supportive care and he was discharged after 1 month with no long-term sequelae. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ingestion of this easily accessible agent, which may initially seem clinically benign, warrants close observation. Emergent airway stabilization and supportive care is crucial to the survival of the patient.

Transformation of Nanomaterials and Its Implications in Gut Nanotoxicology

Ingestion of engineered nanomaterials (ENMs) is inevitable due to their widespread utilization in the agrifood industry. Safety evaluation has become pivotal to identify the consequences on human health of exposure to these ingested ENMs. Much of the current understanding of nanotoxicology in the gastrointestinal tract (GIT) is derived from studies utilizing pristine ENMs. In reality, agrifood ENMs interact with their microenvironment, and undergo multiple physicochemical transformations, such as aggregation/agglomeration, dissolution, speciation change, and surface characteristics alteration, across their life cycle from synthesis to consumption. This work sieves out the implications of ENM transformations on their behavior, stability, and reactivity in food and product matrices and through the GIT, in relation to measured toxicological profiles. In particular, a strong emphasis is given to understand the mechanisms through which these transformations can affect ENM induced gut nanotoxicity.

Assessment of Radiation Dose from the Consumption of Bottled Drinking Water in Japan

Activity concentrations of ²³⁴U, ²³⁵U, ²³⁸U, ²²⁶Ra, ²²⁸Ra, ²²²Rn, ²¹⁰Po, ²¹⁰Pb, ⁴⁰K, ³H, ¹⁴C, ¹³⁴Cs and ¹³⁷Cs were determined in 20 different Japanese bottled drinking water commercially available in Japan. The origins of the mineral water samples were geographically distributed across different regions of Japan. Activity concentrations above detection limits were measured for the radionuclides ²³⁴U, ²³⁵U, ²³⁸U, ²²⁶Ra, ²²⁸Ra and ²¹⁰Po. An average total annual effective dose due to ingestion was estimated for adults, based on the average annual volume of bottled water consumed in Japan in 2019, reported to be 31.7 L/y per capita. The estimated dose was found to be below the recommended World Health Organisation (WHO) guidance level of 0.1 mSv/y for drinking water quality. The most significant contributor to the estimated dose was ²²⁸Ra.

Successful treatment of left subclavian artery penetration due to ingestion of a safety pin by an elderly person

Background

Ingestion cases are increasing in elderly persons. Herein, we report a rare case of ingestion of a safety pin by an elderly person.

Case presentation

The patient was an 87‐year‐old bedridden woman who had fever with left pleural effusion. Chest X‐ray revealed a foreign body, confirmed to be a safety pin, in the cervical esophagus. A contrast multidetector row computed tomography scan revealed that the opened safety pin penetrated the left subclavian artery, leading to the diagnosis of an esophageal foreign body penetrating the left subclavian artery. The safety pin was removed, and the subclavian artery aneurysm caused by the penetration was embolized by interventional radiology. After treatment, she was returned to the nursing home on postoperative day 8.

Conclusion

Penetration by ingestion of a safety pin is rare; in this case, safe treatment was possible due to a team of certified specialist physicians and surgeons.

Disk Battery Ingestion: A Simple User-Guide

INTRODUCTION

Disk Battery Ingestion (DBI) is a cause of access to the emergency department (ED), especially in pediatric age. This problem, if not well managed, may lead to serious injuries, with several complications involving the gastrointestinal and respiratory tract.

OBJECTIVE

The aim of this review is to analyze the literature of the last 25 years to make a decisional flow-chart that may help the emergency physician.

METHODS

For this review, 36 articles have been analyzed (8 articles and 28 case reports), from 1995 to 2019. Data considered from each study included year of publication, type of study, population studied, type of battery, timing of ingestion, treatment, outcomes, complications.

RESULTS

A decisional flow-chart has been configured. X-ray should be performed as the first step in every stable patient, meanwhile CT scan should be performed in unstable patients. When the battery is still localized in the esophagus, endoscopy should be performed as soon as possible, meanwhile, when the battery is beyond the esophagus, its diameter should be noted before taking a decision.

CONCLUSION

The use of the flow-chart proposed may reduce the risk of worse consequences and severe injuries for the patients, helping the emergency physician in his decisional process.

2018 Annual Report of the University of Kansas Health System Poison Control Center

INTRODUCTION

This is the 2018 Annual Report of the Kansas Poison Control Center at The University of Kansas Health System (KSPCC). The KSPCC serves the state of Kansas 24-hours per day, 365 days a year with certified specialists in poison information and clinical and medical toxicologists.

METHODS

All encounters reported to the KSPCC from January 1, 2018 through December 31, 2018 were analyzed. Data recorded for each exposure included caller location, age, weight, gender, exposure substance, nature of exposure, route of exposure, interventions, medical outcome, disposition, and location of care.

RESULTS

There were 21,072 total encounters, including 20,031 human exposure cases. Calls were received from every county and hospital in Kansas. Most of the exposures involved females (51.5%, n = 10,320) and a child less than 19 year of age (64%, n = 12,865). Medical outcomes were 24.5% (n = 4,912) no effect, 17.7% (n = 3,542) minor effect, 9.1% (n = 1,830) moderate effect, and 2.4% (n = 476) major effect. Seven deaths were reported in 2018. The number of exposure calls from healthcare facilities and severity of medical outcomes increased in 2018 compared to 2017.

CONCLUSION

The 2018 KSPCC annual report demonstrated that the center receives calls from the entire state of Kansas totaling over 20,000 human exposures. While pediatric exposures remain the most common encounter, a trend continued of an increasing number of calls from healthcare facilities and for cases with serious outcomes. This report supported the continued value of the KSPCC to both public and acute health care in the state of Kansas.

Ball Magnets Clicked Together on the Epiglottis

Neodymium ball magnets are commonly ingested by children and are a risk of causing significant morbidity if not addressed appropriately. While most ingested magnets are located distal to the epiglottis in the gastrointestinal tract, they can rarely get lodged across tissues in the mouth and throat such as the epiglottis. Though rare, this represents an impending airway emergency and requires urgent treatment once identified. We present the case of a two-year-old, asymptomatic male who presented after ingesting two neodymium ball magnets that were found to be clicked together across his epiglottis, which were ultimately retrieved by bronchoscopy without complications.

Epsom Salt Ingestion Leading to Severe Hypermagnesemia Necessitating Dialysis

BACKGROUND

Hypermagnesemia is an often overlooked electrolyte abnormality that has a myriad of presenting symptoms. It has been observed after both accidental and intentional ingestions of magnesium-containing compounds, and as in the case presented, Epsom salts, which are primarily magnesium sulfate.

CASE REPORT

A 56-year-old man presented to the emergency department reporting weakness after an ingestion of Epsom salts used as a laxative and was found to be bradycardic and hypotensive. He subsequently developed altered mental status and respiratory depression necessitating intubation. His magnesium level was found to be > 3.91 mmol/L (> 9.5 mg/dL). He was given multiple doses of calcium gluconate and generous i.v. fluids with furosemide, with minimal improvement. However, his magnesium level corrected rapidly after initiation of dialysis, and 3 days later he was discharged home in good condition with normal neurologic function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Keeping a high level of suspicion for, and quickly recognizing, hypermagnesemia allows for prompt initiation of treatment, which can avoid significant hemodynamic or respiratory compromise. Mainstays of treatment are i.v. calcium and i.v. fluids. Loop diuretics may be given as an adjunct as well. Dialysis should be considered in cases of severe hypermagnesemia because it results in rapid correction of magnesium levels.