Case files of the medical toxicology fellowship at the New York City poison control: bromism: forgotten, but not gone

Unexplained Bromide Toxicity Presenting as Hyperchloremia and a Negative Anion Gap

A high serum bromide level can cause erroneously high serum chloride levels measured through routine assays. Here, we describe a case of pseudohyperchloremia in which routine labs showed a negative anion gap and elevated chloride levels measured with ion-selective assay. The serum chloride level was found to be lower when measured with a chloridometer that employs a colorimetric method of quantification. The initial serum bromide level was elevated at 1100 mg/L that was confirmed by repeating the test that again showed an elevated level of 1600 mg/L and appeared to cause erroneous hyperchloremia when using conventional serum chloride quantification methods. Our case highlights lab errors and factitious hyperchloremia as a cause of the negative anion gap caused by bromism, even without a clear history of bromide exposure. The case also underscores the importance of chloride measurement using both colorimetric methods and ion-selective assay in the case of hyperchloremia.

Cerebral excitability in pup rats prenatally exposed to 1-bromopropane is suppressed by bromide accumulated in the brain

Previously, we reported that prenatal exposure to 1-bromopropane (1-BP) causes the accumulation of bromide (Br-) in the brain of rat pups. Here, we aimed to investigate the effects of Br- accumulation in rat pups prenatally exposed to 1-BP vapor. Dam rats were exposed to 1-BP (400 or 700 ppm; 1-BP group) by inhalation, or to NaBr (20 mM; Br- group) in drinking water during gestation days 1-20. We also analyzed pentylenetetrazole (PTZ, 60 mg/kg, ip)-induced behavioral changes in pups prenatally exposed to 1-BP or Br- on postnatal day (PND) 14. PTZ-induced epileptic convulsions were inhibited in both 1-BP (700 ppm) and Br- groups. The inhibition of neuronal excitability induced by Br- was evaluated electrophysiologically using the hippocampal slices obtained from PND14-16 pups. PTZ (2 mM) failed to induce epileptiform discharge in the presence of 1.2 mM Br- in the slices obtained from the control group. However, it induced epileptiform discharge following the removal of Br-, by perfusing artificial cerebrospinal fluid into the slices obtained from the Br- group. Our results indicate that Br- accumulates in the brain of neonatal rat pups prenatally exposed to 1-BP vapor suppressed neuronal excitability.

Pseudohyperchloremia and Negative Anion Gap - Think Salicylate!

BACKGROUND

Pseudohyperchloremia results in a very low or negative anion gap. Historically, the most common cause of this artifact was bromide poisoning. Bromide salts have been removed from most medications and bromism has become very uncommon. More recently, the introduction of chloride ion selective sensing electrodes (Cl-ISE) has generated a new cause of pseudohyperchloremia-salicylate poisoning. We describe 5 such patients and quantitate the error generated by this measurement artifact.

METHODS

The magnitude of artifactual hyperchloremia generated by high salicylate levels was quantified in 5 patients by measuring chloride concentration with several Cl-ISEs from different manufacturers and with Cl-ISEs of different "ages," and comparing these results to measurements with a chloridometer (coulometric titration), which is free of the salicylate artifact.

RESULTS

Cl-ISEs from different manufacturers generated a wide range of artifactual chloride concentration elevation. Furthermore, the same Cl-ISE generated increasingly severe pseudohyperchloremia as it was repeatedly reused over time and "aged."

CONCLUSIONS

Salicylate interferes with measurement of the blood chloride concentration when a Cl-ISE is used. The severity of this artifact is related to the salicylate level, the specific Cl-ISE, and the "age" of the electrode. Toxic blood salicylate levels can generate marked pseudohyperchloremia, and consequently, an artifactual very small or negative anion gap. The large anion gap metabolic acidosis typical of salicylate poisoning is masked by this artifact. Salicylate has become the most common cause of pseudohyperchloremia, and physicians should immediately consider salicylate poisoning whenever the combination of hyperchloremia and a very small or negative anion gap is reported by the laboratory.

[Diffuse cerebral atrophy and reversible polyneuropathy in a patient with chronic Bromvalerylurea intoxication: a case report]

A 37-year-old man who had been on bromvalerylurea (BU) medication for 11 years at a maximum dose of 2,400 mg per day for headache therapy was admitted to our hospital due to gait disturbance. He had weight loss and exanthema all over his body. Cognitive dysfunction, intellectual deterioration, attention disturbance, decreased muscle strength, and decreased vibratory sense in the lower limbs were observed. Brain MRI showed diffuse brain atrophy, and a peripheral nerve conduction examination revealed decreased nerve conduction velocity and action potential amplitude in the extremities. We diagnosed him with chronic BU intoxication based on pseudohyperchloremia, BU detected in the blood, and bromide elevation. By discontinuing BU and performing intravenous infusion, neurological symptoms and exanthema were improved, and peripheral nerve conduction examination findings also improved. There are few reports of peripheral neuropathy cases of chronic BU intoxication; herein we report one such case along with previously reported cases.

Census of halide-binding sites in protein structures

Motivation

Halides are negatively charged ions of halogens, forming fluorides (F⁻), chlorides (Cl⁻), bromides (Br⁻) and iodides (I⁻). These anions are quite reactive and interact both specifically and non-specifically with proteins. Despite their ubiquitous presence and important roles in protein function, little is known about the preferences of halides binding to proteins. To address this problem, we performed the analysis of halide–protein interactions, based on the entries in the Protein Data Bank.

Results

We have compiled a pipeline for the quick analysis of halide-binding sites in proteins using the available software. Our analysis revealed that all of halides are strongly attracted by the guanidinium moiety of arginine side chains, however, there are also certain preferences among halides for other partners. Furthermore, there is a certain preference for coordination numbers in the binding sites, with a correlation between coordination numbers and amino acid composition. This pipeline can be used as a tool for the analysis of specific halide–protein interactions and assist phasing experiments relying on halides as anomalous scatters.

Availability and implementation

All data described in this article can be reproduced via complied pipeline published at https://github.com/rostkick/Halide_sites/blob/master/README.md.

Supplementary information

Supplementary data are available at Bioinformatics online.

Challenges and Opportunities in Preclinical Research of Synthetic Cannabinoids for Pain Therapy

Cannabis has been used in pain management since 2900 BC. In the 20th century, synthetic cannabinoids began to emerge, thus opening the way for improved efficacy. The search for new forms of synthetic cannabinoids continues and, as such, the aim of this review is to provide a comprehensive tool for the research and development of this promising class of drugs. Methods for the in vitro assessment of cytotoxic, mutagenic or developmental effects are presented, followed by the main in vivo pain models used in cannabis research and the results yielded by different types of administration (systemic versus intrathecal versus inhalation). Animal models designed for assessing side-effects and long-term uses are also discussed. In the second part of this review, pharmacokinetic and pharmacodynamic studies of synthetic cannabinoid biodistribution, together with liquid chromatography–mass spectrometric identification of synthetic cannabinoids in biological fluids from rodents to humans are presented. Last, but not least, different strategies for improving the solubility and physicochemical stability of synthetic cannabinoids and their potential impact on pain management are discussed. In conclusion, synthetic cannabinoids are one of the most promising classes of drugs in pain medicine, and preclinical research should focus on identifying new and improved alternatives for a better clinical and preclinical outcome.

Approach to the Patient With a Negative Anion Gap

When anion gap calculation generates a very small or negative number, an explanation must be sought. Sporadic (nonreproducible) measurement errors and systematic (reproducible) laboratory errors must be considered. If an error is ruled out, 2 general possibilities exist. A true anion gap reduction can be generated by either reduced concentrations of unmeasured anions such as albumin or increased concentrations of unmeasured cations such as magnesium, calcium, or lithium. This teaching case describes a patient with aspirin (salicylate) poisoning whose anion gap was markedly reduced (-47 mEq/L). The discussion systematically reviews the possibilities and provides the explanation for this unusual laboratory result.

Cyclical konzo epidemics and climate variability

Konzo epidemics have occurred during droughts in the Democratic Republic of Congo (DR Congo) for >70 years, but also in Mozambique, Tanzania, and the Central African Republic. The illness is attributed to exposure to cyanide from cassava foods, on which the population depends almost exclusively during droughts. Production of cassava, a drought-resistant crop, has been shown to correlate with cyclical changes in precipitation in konzo-affected countries. Here we review the epidemiology of konzo as well as models of its pathogenesis. A spectral analysis of precipitation and konzo is performed to determine whether konzo epidemics are cyclical and whether there is spectral coherence. Time series of environmental temperature, precipitation, and konzo show cyclical changes. Periodicities of dominant frequencies in the spectra of precipitation and konzo range from 3 to 6 years in DR Congo. There is coherence of the spectra of precipitation and konzo. The magnitude squared coherence of 0.9 indicates a strong relationship between variability of climate and konzo epidemics. Thus, it appears that low precipitation phases of climate variability reduce the yield of food crops except cassava, upon which the population depends for supply of calories during droughts. Presence of very high concentrations of thiocyanate (SCN(-) ), the major metabolite of cyanide, in the bodily fluids of konzo subjects is a consequence of dietary exposure to cyanide, which follows intake of poorly processed cassava roots. Because cyanogens and minor metabolites of cyanide have not induced konzo-like illnesses, SCN(-) remains the most likely neurotoxicant of konzo. Public health control of konzo will require food and water programs during droughts. [Correction added on 26 February 2015, after first online publication: abstract reformatted per journal style]

Improving lithium therapeutics by crystal engineering of novel ionic cocrystals

Current United States Food and Drug Administration (FDA)-approved lithium salts are plagued with a narrow therapeutic window. Recent attempts to find alternative drugs have identified new chemical entities, but lithium's polypharmacological mechanisms for treating neuropsychiatric disorders are highly debated and are not yet matched. Thus, re-engineering current lithium solid forms in order to optimize performance represents a low cost and low risk approach to the desired therapeutic outcome. In this contribution, we employed a crystal engineering strategy to synthesize the first ionic cocrystals (ICCs) of lithium salts with organic anions. We are unaware of any previous studies that have assessed the biological efficacy of any ICCs, and encouragingly we found that the new speciation did not negatively affect established bioactivities of lithium. We also observed that lithium ICCs exhibit modulated pharmacokinetics compared to lithium carbonate. Indeed, the studies detailed herein represent an important advancement in a crystal engineering approach to a new generation of lithium therapeutics.

Transient neuromyopathy after bromide intoxication in a dog with idiopathic epilepsy

A seven-year old Australian Shepherd, suffering from idiopathic epilepsy under treatment with phenobarbitone and potassium bromide, was presented with generalised lower motor neuron signs. Electrophysiology and muscle-nerve biopsies revealed a neuromyopathy.

The serum bromide concentration was increased more than two-fold above the upper reference value.

Clinical signs disappeared after applying diuretics and reducing the potassium bromide dose rate. This is the first case report describing electrophysiological and histopathological findings associated with bromide induced lower motor neuron dysfunction in a dog.

A systematic review of the safety of potassium bromide in dogs

OBJECTIVE

To critically evaluate and summarize available information on the safety of potassium bromide in dogs.

DESIGN

Systematic review.

SAMPLE

111 references reporting safety information relevant to potassium bromide published between 1938 and 2011.

PROCEDURES

PubMed searches without date limitations were conducted with the terms "potassium bromide" and "sodium bromide" in December 2009 and October 2011. Additional articles were identified through examination of article reference lists and book chapters on seizures in dogs and pharmacology.

RESULTS

Reversible neurologic signs were the most consistently reported toxicoses and were generally associated with adjunctive potassium bromide treatment or high serum bromide concentrations. Dermatologic and respiratory abnormalities were rare in dogs. Insufficient information was available to assess the effects of potassium bromide on behavior or to determine the incidence of vomiting, weight gain, polyphagia, pancreatitis, polyuria, polydipsia, or reproductive abnormalities associated with potassium bromide administration. Evidence suggested that administration of potassium bromide with food may alleviate gastrointestinal irritation and that monitoring for polyphagia, thyroid hormone abnormalities, and high serum bromide concentrations may be beneficial.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that potassium bromide is not an appropriate choice for treatment of every dog with seizures and that practitioners should tailor therapeutic regimens and clinical monitoring to each dog. Abrupt dietary changes or fluid therapy may compromise seizure control or increase the likelihood of adverse events. Availability of an appropriately labeled, approved potassium bromide product could provide better assurance for veterinarians and their clients of the quality, safety, and effectiveness of the product for veterinary use.