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Yu Z, Zhao E, Shi Q, Yuan Y, Ma J, Zhou L, Duan Y, Zhou Y. Identification of a murder caused by brodifacoum poisoning based on clinical examinations and LC-MS/MS results. Int J Legal Med 2024; 138:1323-1328. [PMID: 38438570 DOI: 10.1007/s00414-024-03198-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/15/2024] [Indexed: 03/06/2024]
Abstract
Brodifacoum exerts its antagonistic effect against the metabolism of vitamin K, an essential component in the synthesis of blood coagulation factors. This effect ultimately hinders the blood's capacity to clot effectively, rendering it a commonly employed rodenticide. Instances of lethal poisonings are exceedingly rare owing to expeditious medical intervention and treatment. Within this report, we present a case of brodifacoum-induced homicide, wherein the patient exhibited distinct clinical examinations and symptoms. Moreover, the patient's blood sample exhibited a noteworthy brodifacoum concentration of 0.681 µg/mL even after a period of 43 days following the incident of poisoning. Although an autopsy was not conducted due to religious restrictions, we endeavor to reasonably deduce the cause of death and furnish corroborative evidence for clinical diagnosis, treatment, and forensic examination in instances involving brodifacoum poisoning.
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Affiliation(s)
- Zhonghao Yu
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Erjuan Zhao
- Hubei Chongxin Forensic Center, Wuhan, 430415, China
| | - Qing Shi
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yuhao Yuan
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jinghong Ma
- Hubei Chongxin Forensic Center, Wuhan, 430415, China
| | - Luwang Zhou
- Chaisang District Public Security Bureau of Jiujiang City, 332100, Jiujiang, China
| | - Yijie Duan
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Yiwu Zhou
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Spadetto L, Gómez-Ramírez P, Zamora-Marín JM, León-Ortega M, Díaz-García S, Tecles F, Fenoll J, Cava J, Calvo JF, García-Fernández AJ. Active monitoring of long-eared owl (Asio otus) nestlings reveals widespread exposure to anticoagulant rodenticides across different agricultural landscapes. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 918:170492. [PMID: 38307270 DOI: 10.1016/j.scitotenv.2024.170492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
The widespread use of anticoagulant rodenticides (ARs) poses a worldwide threat to farmland wildlife. These compounds accumulate in tissues of both target and non-target species, potentially endangering both direct consumers and their predators. However, investigations on ARs in blood of free-ranging predatory birds are rare. Here, the long-eared owl (Asio otus) has been used as a model predator to assess AR exposure in different agricultural landscapes from a Mediterranean semiarid region. A total of 69 owlets from 38 nests were blood-sampled over 2021 and 2022, aiming to detect AR residues and explore factors that determine their exposure, such as land uses. In addition, prothrombin time (PT) test was conducted to assess potential effects of AR contamination. Overall, nearly all the samples (98.6 %) tested positive for at least one compound and multiple ARs were found in most of the individuals (82.6 %). Among the ARs detected, flocoumafen was the most common compound (88.4 % of the samples). AR total concentration (ΣARs) in blood ranged from 0.06 to 34.18 ng mL-1, detecting the highest levels in the most intensively cultivated area. The analysis of owl pellets from 19 breeding territories showed relevant among-site differences in the contribution of rodents and birds into the diet of long-eared owls, supporting its high dietary plasticity and indicating AR presence at multiple trophic levels. Moreover, a positive and significant correlation was found between ΣARs and PT (Rho = 0.547, p < 0.001), which demonstrates the direct effect of ARs on free-living nestlings. Our results provide a preliminary overview of AR exposure in a little-studied owl species inhabiting agricultural and rural landscapes. Despite the low detected levels, these findings indicate widespread exposure -often to multiple compounds- from early life stages, which raises concern and draws attention to an ongoing and unresolved contamination issue.
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Affiliation(s)
- Livia Spadetto
- Toxicology Research Group, Faculty of Veterinary, Campus de Espinardo, University of Murcia, 30100 Murcia, Spain
| | - Pilar Gómez-Ramírez
- Toxicology Research Group, Faculty of Veterinary, Campus de Espinardo, University of Murcia, 30100 Murcia, Spain.
| | - José Manuel Zamora-Marín
- ULULA Association for Owl Study and Conservation, 30100 Murcia, Spain; Department of Applied Biology, Centro de Investigación e Innovación Agroalimentaria (CIAGRO-UMH), Miguel Hernández University of Elche, Elche, Spain; Department of Zoology and Physical Anthropology, Faculty of Biology, University of Murcia, 30100 Murcia, Spain
| | - Mario León-Ortega
- ULULA Association for Owl Study and Conservation, 30100 Murcia, Spain
| | - Sarah Díaz-García
- ULULA Association for Owl Study and Conservation, 30100 Murcia, Spain
| | - Fernando Tecles
- Interdisciplinary Laboratory of Clinical Analysis (Interlab-UMU), Veterinary School, Regional Campus of International Excellence 'Campus Mare Nostrum', University of Murcia, 30100 Murcia, Spain
| | - José Fenoll
- Instituto Murciano de Investigación y Desarrollo Agrario y Alimentario, IMIDA, 30150 Murcia, Spain
| | - Juana Cava
- Instituto Murciano de Investigación y Desarrollo Agrario y Alimentario, IMIDA, 30150 Murcia, Spain
| | - José Francisco Calvo
- Department of Ecology and Hydrology, Faculty of Biology, University of Murcia, 30100 Murcia, Spain
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He QK, Wu YH, Lu XY, Liu MW. Rodenticide poisoning leading to cerebral hemorrhage: A case report. Medicine (Baltimore) 2024; 103:e36971. [PMID: 38363928 PMCID: PMC10869089 DOI: 10.1097/md.0000000000036971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 12/22/2023] [Indexed: 02/18/2024] Open
Abstract
RATIONALE Anticoagulant rodenticides (ARs) are a substantial fraction of murine types. AR poisoning causes bleeding from the skin, mucous membranes, and multiple organs. However, reports of AR-induced cerebral hemorrhage are scarce. PATIENT CONCERNS A 40-year-old male presented with dizziness, headache, and limb weakness for 5 days and with coagulopathy. Two days prior to the onset of these symptoms, the patient was exposed to dead mice. DIAGNOSES Rodenticide intoxication-induced cerebral hemorrhage. INTERVENTIONS Vitamin K1 infusion, administration of dehydrating agents to reduce intracranial pressure, and correction of acid-base and electrolyte imbalances. OUTCOMES After 9 days of treatment, the patient's symptoms were relieved, and reexamination revealed that coagulation parameters returned to normal levels. The patient was eventually discharged for observation with oral vitamin K1. CONCLUSIONS Rodenticide poisoning can lead to intracerebral hemorrhage, and treatment with vitamin K1 infusion is effective. LESSON Rodenticide poisoning-induced cerebral hemorrhage is rarely reported. Because its symptoms are nonspecific, it is easy to miss the diagnosis or misdiagnose. When patients present with direct and indirect symptoms such as dizziness, headache, and limb weakness, rodenticide poisoning should be considered. Coagulation function and head computed tomography or magnetic resonance imaging examination should be performed at the earliest to confirm the diagnosis and provide timely treatment.
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Affiliation(s)
- Qian-kun He
- Department of Neurology, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
| | - Yuan-hua Wu
- Department of Neurology, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
| | - Xiao-ying Lu
- Department of Neurology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Ming-wei Liu
- Department of Emergency Medicine, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
- Department of Emergency Medicine, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou, China
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4
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Tran MH, Mathur G, Barnhard S, Schwartz J. Historic and emerging trends in transfusion medicine: Maintaining relevance as a specialty. Transfusion 2023; 63:2341-2350. [PMID: 37921092 DOI: 10.1111/trf.17588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/05/2023] [Accepted: 10/08/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Minh-Ha Tran
- Department of Pathology and Laboratory Medicine, Irvine School of Medicine, University of California, Irvine, California, USA
| | - Gagan Mathur
- Department of Pathology and Laboratory Medicine, Irvine School of Medicine, University of California, Irvine, California, USA
| | - Sarah Barnhard
- Department of Pathology and Laboratory Medicine, Davis School of Medicine, University of California, Sacramento, California, USA
| | - Joseph Schwartz
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida, USA
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5
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Wu Y, Ye X, Jiang L, Wang A, Wang J, Yao W, Qin Y, Wang B. Developmental toxicity induced by brodifacoum in zebrafish (Danio rerio) early life stages. Birth Defects Res 2023; 115:318-326. [PMID: 36326103 DOI: 10.1002/bdr2.2118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The present study mainly focused on the assessment of developmental toxicity induced by exposure to brodifacoum (BDF) in zebrafish at early life stages. MATERIAL AND METHODS Zebrafish embryos were exposed to 0.2, 0.4, and 0.8 mg/L of BDF from 6 to 96 hr post-fertilization (hpf), and the toxic effects of BDF on early embryonic development were investigated in terms of morphological changes, oxidative stress, and alterations in heart development-related genes. RESULTS The experimental results showed that BDF significantly decreased the heart rate, survival rate, body length, and spontaneous movements of zebrafish embryos at 0.8 mg/L, and the morphological developmental abnormalities were also observed at 96 hpf. In addition, exposure to BDF significantly increased oxidative stress levels in zebrafish embryos by increasing the enzymatic activities of catalase (CAT), superoxide dismutase (SOD), and malondialdehyde (MDA) levels, and decreased glutathione (GSH) levels. Furthermore, BDF treatment-induced alterations in the expression levels of the heart development-related genes (gata4, sox9b, tbx2b, and nppa). CONCLUSION Results from this study indicated that exposure to BDF could lead to marked growth inhibition and significantly alter the activities of antioxidant enzymes in zebrafish embryos. Moreover, BDF exposure exhibited severe cardiotoxicity and significantly disrupted heart development-related genes. The results indicated that BDF could induce developmental and cardiac toxicity in zebrafish embryos.
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Affiliation(s)
- Yuanzhao Wu
- Key Laboratory of Drug Prevention and Control Technology of Zhejiang Province Zhejiang Police College, Hangzhou, Zhejiang Province, PR China
| | - Xinyu Ye
- Key Laboratory of Drug Prevention and Control Technology of Zhejiang Province Zhejiang Police College, Hangzhou, Zhejiang Province, PR China
| | - Linyi Jiang
- Key Laboratory of Drug Prevention and Control Technology of Zhejiang Province Zhejiang Police College, Hangzhou, Zhejiang Province, PR China
| | - Anli Wang
- National Engineering Laboratory of Intelligent Food Technology and Equipment, Zhejiang Key Laboratory for Agro-Food Processing, Fuli Institute of Food Science, College of Biosystems Engineering and Food Science, Zhejiang University, Hangzhou, Zhejiang Province, PR China
| | - Jiye Wang
- Key Laboratory of Drug Prevention and Control Technology of Zhejiang Province Zhejiang Police College, Hangzhou, Zhejiang Province, PR China
| | - Weixuan Yao
- Key Laboratory of Drug Prevention and Control Technology of Zhejiang Province Zhejiang Police College, Hangzhou, Zhejiang Province, PR China
| | - Yazhou Qin
- Key Laboratory of Drug Prevention and Control Technology of Zhejiang Province Zhejiang Police College, Hangzhou, Zhejiang Province, PR China
| | - Binjie Wang
- Key Laboratory of Drug Prevention and Control Technology of Zhejiang Province Zhejiang Police College, Hangzhou, Zhejiang Province, PR China
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6
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Lee KI, Lin JH, Chu YJ, Deng JF, Chu WL, Hung DZ. Rat Bait, Not Healthy Rice! TOXICS 2023; 11:60. [PMID: 36668786 PMCID: PMC9860557 DOI: 10.3390/toxics11010060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 06/17/2023]
Abstract
Bromadiolone, a potent, long-acting anticoagulant rodenticide is frequently tinted to a red or pink color and mixed with cereals as rat bait. Six peoples working in a small factory suffered from a severe bleeding tendency several weeks after consuming a rice meal that was tainted with bromadiolone mistaken to be healthy food. High serum levels of bromadiolone and excessive bleeding were found in these individuals, and they needed vitamin K1 therapy for weeks. These cases indicated that long-acting anticoagulant rodenticide might induce cumulative toxicity in repeated, low-dose exposure, and the blood levels of bromadiolone might be an indicator for antidote therapy if available.
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Affiliation(s)
- Kuan-I Lee
- Department of Emergency, Buddhist Tzu Chi General Hospital, Taichung Branch, Taichung 42721, Taiwan
| | - Jing-Hua Lin
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan
| | - Yen-Jung Chu
- Department of Emergency Medicine, China Medical University Hospital, Taichung 40447, Taiwan
| | - Jou-Fang Deng
- Division of Clinical Toxicology & Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Wei-Lan Chu
- Division of Clinical Toxicology & Occupational Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Dong-Zong Hung
- Division of Toxicology, China Medical University Hospital, Taichung 40447, Taiwan
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7
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Invasive rodent eradication on islands: assessment and mitigation of human exposure to rodenticides. Biol Invasions 2022. [DOI: 10.1007/s10530-022-02940-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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8
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Toxicology Case Presentations. Vet Clin North Am Small Anim Pract 2022; 53:175-190. [DOI: 10.1016/j.cvsm.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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9
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Guodong L, Jieyi W, Xiaobo P, Xiaoxia L, Zhongying L, Zhiguo P, Zewu Q, Jianguang D. Retrospective analysis of clinical characteristics of and treatment strategies for patients with long-acting anticoagulant rodenticide poisoning. Basic Clin Pharmacol Toxicol 2022; 131:74-82. [PMID: 35470573 DOI: 10.1111/bcpt.13734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/20/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Long-acting anticoagulant rodenticide (LAAR) poisoning remains a serious public health problem. The aim of this study was to explore the clinical characteristics of different LAARs and a method of making a decision on the VK1 treatment course and the time to stop VK1 treatment safely. METHOD This retrospective study compared the clinical characteristics of two LAARs poisoning patients and used multivariate regression method to explore the relationship between blood LAAR concentration and vitamin K1 dose/treatment time. RESULT A total of 115 patients with LAAR poisoning were included in this study after screening. Of these, 50 patients attempted to commit suicide. The median LAAR concentration of the patients at admission was 409 (157-1174) ng/mL, and the VK1 treatment duration was 14 (8-34) days. The total VK1 treatment time in patients with LAAR poisoning was positively correlated with admission LAAR concentration. During the maintenance treatment period, the VK1 dosage was positively correlated with blood LAAR concentration. CONCLUSION Low dose of VK1 during the maintenance period is indicative of the blood LAAR concentration being relatively low. This provides a basis for judging the LAAR content in the body during the maintenance treatment period.
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Affiliation(s)
- Lin Guodong
- Department of Critical Care Medicine, General Hospital of Southern Theater Command of PLA, Guangzhou, China.,Department of Hematology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Wu Jieyi
- Department of Anaesthesiology, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Peng Xiaobo
- Department of Hematology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Lu Xiaoxia
- Department of Hematology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Liu Zhongying
- Department of Hematology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Pan Zhiguo
- Department of Critical Care Medicine, General Hospital of Southern Theater Command of PLA, Guangzhou, China
| | - Qiu Zewu
- Department of Hematology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Dong Jianguang
- Department of Hematology, The Fifth Medical Center of PLA General Hospital, Beijing, China
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10
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Zhu L, Liu L, Du L, Hao J, Ma J, Zhu J, Gong W. Establishment and Validation of Anticoagulant Rodenticides in Animal Samples by HPLC-MS/MS, Focusing on Evaluating the Effect of Modified QuEChERS Protocol on Matrix Effect Reduction. ACS OMEGA 2022; 7:18146-18158. [PMID: 35664579 PMCID: PMC9161422 DOI: 10.1021/acsomega.2c01863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/06/2022] [Indexed: 06/15/2023]
Abstract
A rapid, accurate, and selective analytical method to simultaneously quantify 13 anticoagulant rodenticides in animal biological samples was developed using high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) coupled with electrospray ionization (ESI) in negative mode. Samples were extracted and purified based on a modified QuEChERS (quick, easy, cheap, effective, rugged, safe) sample preparation technique. The sample pH and the type of extraction solvent and cleanup sorbent used to estimate the procedure's effectiveness were optimized. To improve the matrix effects and obtain acceptable recoveries for 13 rodenticides, 0.1 mL/g biological sample and 1 mL acetonitrile (or acetonitrile: EtOAc = 1:1/(v:v)) extraction followed by Florisil/HC-C18/anhydrous Na2SO4 (NaCl) cleanup under alkaline conditions was fully validated and shown to be selective, precise, accurate, and linear in the range from 1 to 100 ng/mL (g). The mean recoveries were between 52.78 and 110.69%, while the limits of detection and quantification ranged from 0.05 to 0.5 and 0.1-1 ng/mL (μg/kg), respectively. Ideal soft matrix effects (≤20%) were observed for the vast majority of rodenticides (>95%) showing either suppression or enhancement. This method meets international criteria and is capable of simultaneously identifying and quantifying anticoagulant rodenticides in animal blood and tissues and can be suitable for the detection of poisoning cases in the field of forensic or public health.
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Affiliation(s)
- Lei Zhu
- Institute
of Forensic Medicine and Laboratory Medicine, Jining Medical University, Jining 272067, China
| | - Li Liu
- Institute
of Forensic Medicine and Laboratory Medicine, Jining Medical University, Jining 272067, China
- School
of Pharmacy, Shandong University of Traditional
Chinese Medicine, Jinan 250355, China
| | - Le Du
- Institute
of Forensic Medicine and Laboratory Medicine, Jining Medical University, Jining 272067, China
| | - Jingmei Hao
- Institute
of Forensic Medicine and Laboratory Medicine, Jining Medical University, Jining 272067, China
| | - Jianhua Ma
- Institute
of Forensic Medicine and Laboratory Medicine, Jining Medical University, Jining 272067, China
| | - Jun Zhu
- Institute
of Forensic Medicine and Laboratory Medicine, Jining Medical University, Jining 272067, China
| | - Wenjing Gong
- Institute
of Forensic Medicine and Laboratory Medicine, Jining Medical University, Jining 272067, China
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11
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Caroline K, Emmanuelle J, Christophe Z, Ramy A, Marie L. Covert poisoning with difenacoum: diagnosis and follow-up difficulties. Clin Chem Lab Med 2022; 60:e213-e215. [PMID: 35621008 DOI: 10.1515/cclm-2022-0314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/16/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Kitel Caroline
- Univ. Lille, CHU Lille, Institut d'Hématologie-Transfusion, Pôle de Biologie Pathologie Génétique, Lille, France
| | | | - Zawadzki Christophe
- Univ. Lille, CHU Lille, Institut d'Hématologie-Transfusion, Pôle de Biologie Pathologie Génétique, Lille, France
| | - Azzouz Ramy
- CHU de Lille, Centre antipoison et de Toxicovigilance de Lille, Lille Cedex, France
| | - Lenski Marie
- Univ. Lille, CHU Lille, Institut Pasteur de Lille, ULR 4483 - IMPECS - Impact de l'environnement chimique sur la santé, Lille, France
- CHU Lille, Unité Fonctionnelle de Toxicologie, Lille, France
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de Genover Gil A, Gonzalez Suarez GM, Moret Puig C, Hurtado Ganoza A. Superwarfarin poisoning: challenges still remain. BMJ Case Rep 2022; 15:e248385. [PMID: 35584857 PMCID: PMC9119149 DOI: 10.1136/bcr-2021-248385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2022] [Indexed: 11/04/2022] Open
Abstract
Superwarfarin (long-acting anticoagulant rodenticide) poisoning should be suspected in unexplained bleeding with prolonged prothrombin time, especially in the absence of another explanation. Diagnosis and treatment of this intoxication remain a challenge as the direct analysis of superwarfarin in serum is not always possible. Therefore, toxin bioavailability remains unknown and close monitoring and treatment for long periods are required to avoid serious bleeding complications. Here, we discuss a case of suspected superwarfarin poisoning to highlight the challenges in early diagnosis and the challenges we encountered in treatment management and ensuring compliance for long periods.
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Affiliation(s)
| | | | - Carla Moret Puig
- Haematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain
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13
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Factor-guided diagnosis of coagulopathy associated with coumarin-contaminated synthetic cannabinoids: A case report. Am J Emerg Med 2022; 58:350.e5-350.e6. [DOI: 10.1016/j.ajem.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/01/2022] [Accepted: 05/05/2022] [Indexed: 11/24/2022] Open
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14
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Navon L, Moritz E, Austin C, Wahl M, Aks S, Layden J. The Public Health Response to a Large Poisoning Outbreak Involving an Illicit Substance: Synthetic Cannabinoids Contaminated With a Long-Acting Anticoagulant Rodenticide, Illinois, March-July, 2018. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 26:E1-E7. [PMID: 30969282 PMCID: PMC10926914 DOI: 10.1097/phh.0000000000001002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
During March-July 2018, the Illinois Department of Public Health responded to an acute outbreak of severe coagulopathy among patients with recent synthetic cannabinoid use. Toxicological testing indicated that cases were exposed to brodifacoum, a long-acting anticoagulant rodenticide. A total of 174 confirmed and probable cases, including 5 deaths, were linked to this outbreak. On the basis of the experience of responding to this complex outbreak, we recommend several steps for consideration to improve health department preparation for acute outbreaks involving illicit substances including strengthening communication between public health and law enforcement agencies, reviewing legal authority to investigate noninfectious acute disease outbreaks, continuing strong partnerships with state poison control centers, partnering with substance abuse and mental health agencies to provide services to patients, and determining health department ability to rapidly enter into public-private partnership agreements.
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Affiliation(s)
- Livia Navon
- Illinois Department of Public Health, Chicago and Springfield, Illinois (Ms Navon and Drs Moritz, Austin, and Layden); Division of State and Local Readiness, Center for Preparedness and Response (Ms Navon), and Epidemic Intelligence Service (Dr Moritz), Centers for Disease Control and Prevention, Atlanta, Georgia; Illinois Poison Center, Illinois Health and Hospital Association, Chicago, Illinois (Dr Wahl); and Cook County Health and Hospitals System, Chicago, Illinois (Dr Aks)
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15
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Competitive tight-binding inhibition of VKORC1 underlies warfarin dosage variation and antidotal efficacy. Blood Adv 2021; 4:2202-2212. [PMID: 32433747 DOI: 10.1182/bloodadvances.2020001750] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/24/2020] [Indexed: 11/20/2022] Open
Abstract
Dose control of warfarin is a major complication in anticoagulation therapy and overdose is reversed by the vitamin K antidote. Improving the dosage management and antidotal efficacy requires mechanistic understanding. Here we find that effects of the major predictor of warfarin dosage, SNP -1639 G>A, follow a general correlation that warfarin 50% inhibitory concentration decreases with cellular level of vitamin K epoxide reductase (VKORC1), suggesting stoichiometric inhibition. Characterization of the inhibition kinetics required the use of microsomal VKORC1 with a native reductant, glutathione, that enables effective warfarin inhibition in vitro. The kinetics data can be fitted with the Morrison equation, giving a nanomolar inhibition constant and demonstrating that warfarin is a tight-binding inhibitor. However, warfarin is released from purified VKORC1-warfarin complex with increasing amount of vitamin K, indicating competitive inhibition. The competition occurs also in cells, resulting in rescued VKORC1 activity that augments the antidotal effects of vitamin K. Taken together, warfarin is a competitive inhibitor that binds VKORC1 tightly and inhibits at a stoichiometric (1:1) concentration, whereas exceeding the VKORC1 level results in warfarin overdose. Thus, warfarin dosage control should use VKORC1 level as a major indicator, and improved antidotes may be designed based on their competition with warfarin.
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16
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Fasih A. Lethal coagulopathy resulting from the consumption of contaminated synthetic cannabinoids: the story of a public health crisis. J Public Health (Oxf) 2021; 43:e1-e6. [PMID: 31242305 DOI: 10.1093/pubmed/fdz067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 05/26/2019] [Indexed: 01/21/2023] Open
Abstract
In March 2018, Illinois saw the outbreak of an unprecedented public health crisis, which manifested as the development of a potentially lethal coagulopathy associated with the consumption of synthetic cannabinoids. This outbreak impacted a reported 174 patients, and was responsible for the deaths of five patients. While events unfolded, it was uncovered that the coagulopathy was not caused directly by the consumption of synthetic cannabinoids, but by the contamination of these products with Brodifacuom, bromadiol and difenacoum, potent Vitamin K antagonists that are the active ingredient in most rodenticides. This article chronicles the first reported instance of clinically significant Long Acting Anticoagulant Rodenticide poisoning on such a widespread and uniform scale, and examines the challenges posed to the providers and Public Health authorities tasked with the management of this outbreak. Crisis preparedness determines mitigation, response and recovery during trying times. It is prudent that healthcare agencies engage in collective measures to establish preparedness plans and build up their capacity to respond to health-related crises such as the one faced by Illinois in early 2018. By examining the solutions developed to tackle each unique challenge, the objective of this article is to lay a framework for action and response to similar public health crises.
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Affiliation(s)
- Anum Fasih
- Department of Family Medicine, The University of Illinois, College of Medicine at Peoria. Peoria, IL, USA
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Jamous MA, Jbarah OF, Alomari AA, Mohamed Alwani M, Obeidat O. Rare manifestation of Bromadiolone toxicity as intracranial hemorrhage. BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Lu A, Yuan F, Yao Y, Wen W, Lu H, Wu S, Wang L. Reversible leukoencephalopathy caused by 2 rodenticides bromadiolone and fluoroacetamide: A case report and literature review. Medicine (Baltimore) 2021; 100:e25053. [PMID: 33655984 PMCID: PMC7939157 DOI: 10.1097/md.0000000000025053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/04/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE With the easy access, rodenticide poisoning has been a public health problem in many countries. Characteristics of central nervous system (CNS) lesions induced by rodenticides are scarcely reported. PATIENT CONCERNS We presented a case of a 40-year-old man with seizure and consciousness disorder, coagulation dysfunction, and symmetric lesions in white matter and corpus callosum. DIAGNOSIS He was diagnosed with rodenticide poisoning due to bromadiolone and fluoroacetamide. INTERVENTIONS He was treated with vitamin K, hemoperfusion, acetamide, and calcium gluconate. OUTCOMES His leukoencephalopathy was reversed rapidly with the improvement of clinical symptoms. LESSONS This report presented the impact of rodenticide poisoning on CNS and the dynamic changes of brain lesions, and highlighted the importance of timely targeted treatments.
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Affiliation(s)
- Aili Lu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Nosal DG, Feinstein DL, van Breemen RB. Chiral liquid chromatography-tandem mass spectrometry analysis of superwarfarin rodenticide stereoisomers - Bromadiolone, difenacoum and brodifacoum - In human plasma. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1165:122529. [PMID: 33486217 PMCID: PMC7875153 DOI: 10.1016/j.jchromb.2021.122529] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 12/28/2020] [Accepted: 01/02/2021] [Indexed: 01/08/2023]
Abstract
Superwarfarins are second-generation long-acting anticoagulant rodenticides that can cause unintended human and wildlife toxicity due, in part, to their prolonged half-lives. Commercially available superwarfarin rodenticides are synthesized as racemates with two asymmetric carbons, producing four stereoisomers. To support studies of human plasma half-lives of individual superwarfarin stereoisomers, a method was developed based on LC-MS/MS to separate and quantify stereoisomers of the commercially important superwarfarins bromadiolone, difenacoum and brodifacoum. Human plasma samples were prepared using protein precipitation and centrifugation. Chiral-phase HPLC separation was carried out on-line with tandem mass spectrometric quantitative analysis of the eluting stereoisomers using selected-reaction monitoring with positive ion electrospray on a triple quadrupole mass spectrometer. All four stereoisomers of each superwarfarin were resolved within 12.5 min with calibration curves spanning 2-3 orders of magnitude and lower limits of quantitation between 0.87 and 2.55 ng/mL. This method was used to determine the half-lives of superwarfarin stereoisomers in plasma from patients who had inhaled synthetic cannabinoid products contaminated with superwarfarins. These data may be used to guide the development of safer next generation anticoagulant rodenticides stereoisomers.
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Affiliation(s)
- Daniel G Nosal
- Linus Pauling Institute, Department of Pharmaceutical Sciences, Oregon State University 2900 SW Campus Way, Corvallis, OR 97331, USA
| | - Douglas L Feinstein
- Department of Anesthesiology, University of Illinois at Chicago, 835 South Wolcott Ave, MC513, E720, Chicago, IL 60612, USA
| | - Richard B van Breemen
- Linus Pauling Institute, Department of Pharmaceutical Sciences, Oregon State University 2900 SW Campus Way, Corvallis, OR 97331, USA.
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Li Q, Yu W, Qu Y, Wang JQ, Mao N, Kang H. Acute toxic encephalopathy following bromadiolone intoxication: a case report. BMC Neurol 2021; 21:8. [PMID: 33407227 PMCID: PMC7789786 DOI: 10.1186/s12883-020-02034-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 12/22/2020] [Indexed: 11/25/2022] Open
Abstract
Background Clinically, bromadiolone poisoning is characterized by severe bleeding complications in various organs and tissues. Bromadiolone-induced toxic encephalopathy is extremely rare. Here, we report a special case of bromadiolone-induced reversible toxic encephalopathy in a patient who had symmetrical lesions in the deep white matter. Case presentation A 23-year-old woman mainly presented with dizziness, fatigue, alalia and unsteady gait after the ingestion of bromadiolone. The laboratory examinations showed normal coagulation levels. Brain magnetic resonance imaging (MRI) showed apparent diffusion restriction in the bilateral deep white matter. The clinical manifestations and MRI alterations were reversible within one month of treatment with vitamin K. The neuropsychological assessment showed no neurodegenerative changes at the 2-year follow-up. Conclusion With the increased use of bromadiolone as a rodenticide, more cases of ingestion have been reported annually over the past several years. Bromadiolone-induced toxic encephalopathy has no special clinical manifestations and is potentially reversible with timely treatment. Because of the reversible restricted diffusion on diffusion-weighted images (DWI) and low apparent diffusion coefficient (ADC) values, transient intramyelinic cytotoxic oedema is thought to be the cause rather than persistent ischaemia. The underlying pathophysiological mechanism is still unknown and may be coagulant-independent. This clinical case extends the current knowledge about neurotoxicity in cases of bromadiolone poisoning and indicates that MRI is useful for the early detection of bromadiolone-induced toxic encephalopathy.
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Affiliation(s)
- Quan Li
- Department of Emergency, Affiliated Yantai Yuhuangding Hospital of Qingdao University, 264000, Yantai, China
| | - Wei Yu
- Department of Emergency, Affiliated Yantai Yuhuangding Hospital of Qingdao University, 264000, Yantai, China
| | - Yun Qu
- Department of Emergency, Affiliated Yantai Yuhuangding Hospital of Qingdao University, 264000, Yantai, China
| | - Jin-Qiu Wang
- Department of Neurology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Ning Mao
- Department of Radiology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Hai Kang
- Department of Emergency, Affiliated Yantai Yuhuangding Hospital of Qingdao University, 264000, Yantai, China. .,Department of Neurology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China. .,Department of Radiology, Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China.
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Kumar S, Bhagia G. Brodifacoum-Laced Synthetic Marijuana Toxicity: A Fight Against Time. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e927111. [PMID: 33132381 PMCID: PMC7647932 DOI: 10.12659/ajcr.927111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Patient: Male, 30-year-old Final Diagnosis: Brodifacoum toxicity Symptoms: Abdominal pain Medication:— Clinical Procedure: — Specialty: Hematology • Toxicology
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Carelli C, Fais P, Freni F, Moretti M, Vignali C, Morini L. Importance of segmental hair analysis in a suspected case of attempted homicide by flocoumafen and difenacoum. Forensic Sci Int 2020; 316:110466. [DOI: 10.1016/j.forsciint.2020.110466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
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Foti F, Sica S, Alma E, De Cristofaro R, Mores N, Vetrugno G. Sudden nasal bleeding and brodifacoum: A case of accidental exposure or attempted homicide? Leg Med (Tokyo) 2020; 47:101772. [PMID: 32771937 DOI: 10.1016/j.legalmed.2020.101772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/15/2020] [Accepted: 07/31/2020] [Indexed: 11/29/2022]
Abstract
A 50-year-old man was admitted to the emergency department with abrupt massive epistaxis. An accurate anamnesis and physical evaluation could not reveal any other anomalies, while coagulation tests showed potentially life threatening prolonged prothrombin time, with activated partial thromboplastin and thrombin time, with fibrinogen and antithrombin III within limits. Despite the prompt pharmacological and compressive local treatment, bleeding continued and the patient was therefore hospitalized. Highly specific coagulation and toxicological testing-among others high-performance liquid chromatography assessment on plasma-were performed, leading to the unexpected identification of brodifacoum. Police and criminal justice authorities revealed the source of exposure to brodifacoum after several months of investigation, residing in his everyday life. Brodifacoum is a long-lasting anticoagulant, acting as a vitamin K antagonist, and belongs to the family of superwarfarins. Brodifacoum use is authorized as rodenticide in many countries worldwide, but has been reported as cause of severe coagulopathies in humans, both intentional or involuntary, even consumed as a contaminant of herbal drugs, such as cannabis. The original contribution of this case to the knowledges of human brodifacoum intoxication resides in the multidisciplinary approach and the collaborative interplay of clinical and toxicology experts as well as judicial authorities.
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Affiliation(s)
- Federica Foti
- Risk Management Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Simona Sica
- Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eleonora Alma
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome - Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raimondo De Cristofaro
- Servizio Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome-Università Cattolica S. Cuore, Rome, Italy
| | - Nadia Mores
- Unit of Pharmacovigilance, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Vetrugno
- Risk Management Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Healthcare Surveillance and Bioethics, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
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Feinstein DL, Nosal DG, Ramanathan S, Zhou J, Chen L, Hershow RC, van Breemen RB, Wright E, Hafner JW, Rubinstein I. Effects of vitamin K1 treatment on plasma concentrations of long-acting anticoagulant rodenticide enantiomers following inhalation of contaminated synthetic cannabinoids. Clin Toxicol (Phila) 2020; 58:716-724. [PMID: 31736367 PMCID: PMC7583456 DOI: 10.1080/15563650.2019.1687903] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/21/2019] [Accepted: 10/25/2019] [Indexed: 12/30/2022]
Abstract
Background: An outbreak of synthetic cannabinoid (SC)-associated coagulopathy and bleeding in Illinois, USA was determined to be due to inhalation of SC contaminated with brodifacoum (BDF), difenacoum (DiF), and bromadiolone (BDL), highly potent long-acting anticoagulant rodenticides (LAARs). Treatment with high-dose vitamin K1 (VK1) prevented mortality; however, plasma LAAR levels were not measured risking recurrence of coagulopathy and bleeding due to premature discontinuation. The goal of this study was to determine if plasma LAAR levels were reduced following standard of care treatment to normalize coagulopathy.Methods: Blood samples were collected from a cohort of 32 patients, and ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis used to quantify plasma LAAR levels including enantiomers.Results: BDF was detected in 31 samples; 30 also contained DiF and 18 contained BDL. Initial plasma levels were 581 ± 87, 11.0 ± 1.9, and 14.9 ± 5.9 ng/mL for BDF, DiF, and BDL, respectively (mean ± SE). At discharge plasma, BDF levels remained elevated at 453 ± 68 ng/mL. Plasma half-lives for BDF, DiF, and BDL were 7.5 ± 1.3, 7.2 ± 1.9, and 1.8 ± 0.3 days, respectively. The half-life for trans-BDF enantiomers (5.7 ± 0.8 days) was shorter than for cis-enantiomers (7.6 ± 1.9 days). BDF half-lives were shorter, and coagulopathy normalized faster in patients receiving intravenous VK1 as compared to oral VK1. Patients prescribed VK1 at discharge had fewer re-admittances.Conclusions: These results demonstrate that plasma LAAR levels at discharge were elevated in poisoned patients despite normal coagulation, and that the route of VK1 administration affected LAAR pharmacokinetics and INR normalization. We propose plasma LAAR levels and coagulation be monitored concomitantly during follow-up of patients with LAAR poisoning. KEY POINTSIn patients treated with high-dose vitamin K1 for LAAR poisoning, plasma levels remained 40-fold above safe levels upon discharge from hospital.LAAR half-lives, normalization of coagulopathy, and readmittances were reduced by treatment with intravenous vitamin K1.
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Affiliation(s)
- Douglas L Feinstein
- Jesse Brown VA Medical Center, Chicago, IL, USA
- Department of Anesthesiology, University of Illinois, Chicago, IL, USA
| | - Daniel G Nosal
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Swetha Ramanathan
- Division of Epidemiology and Biostatistics, University of Illinois, Chicago, IL, USA
| | - Jifang Zhou
- College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Luying Chen
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Ronald C Hershow
- Division of Epidemiology and Biostatistics, University of Illinois, Chicago, IL, USA
| | | | - Erik Wright
- Department of Emergency Medicine, University of Illinois, Peoria, IL, USA
| | - John W Hafner
- Department of Emergency Medicine, University of Illinois, Peoria, IL, USA
| | - Israel Rubinstein
- Jesse Brown VA Medical Center, Chicago, IL, USA
- Department of Medicine, University of Illinois, Chicago, IL, USA
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Nosal DG, Feinstein DL, Chen L, van Breemen RB. Separation and Quantification of Superwarfarin Rodenticide Diastereomers-Bromadiolone, Difenacoum, Flocoumafen, Brodifacoum, and Difethialone-in Human Plasma. J AOAC Int 2020; 103:770-778. [PMID: 33241367 PMCID: PMC7372953 DOI: 10.1093/jaoacint/qsaa007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/06/2020] [Accepted: 01/10/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Superwarfarins, second-generation long-acting anticoagulant rodenticides, are 4-hydroxycoumarin analogues of warfarin that contain a large hydrophobic side chain. These compounds contain two chiral centers and are synthesized for commercial use as two pairs of diastereomer. OBJECTIVE To support studies of superwarfarin pharmacokinetics and other efforts to improve clinical care for poisoning victims, a quantitative assay was developed for the measurement of diastereomer of bromadiolone, difenacoum, flocoumafen, brodifacoum, and difethialone in human plasma. METHOD Based on ultrahigh-pressure liquid chromatography-tandem mass-spectrometry (UHPLC-MS/MS), this method was validated according to U.S. Food and Drug Administration (FDA) guidelines. Sample preparation involved simple protein precipitation followed by reversed phase UHPLC, which resolved all five pairs of cis/trans diastereomer in less than 10 min. Superwarfarins were measured using negative ion electrospray followed by selected-reaction monitoring on a triple quadrupole mass spectrometer. RESULTS Calibration curves covered 3-4 orders of magnitude with linear regression coefficients of >0.999. The lower limits of quantitation were from 0.013 to 2.41 ng/mL, and intra-day and inter-day accuracy and precision coefficients of variation were <12%. CONCLUSIONS A 10-min UHPLC-MS/MS assay was developed and validated for the separation and quantitative analysis of the pairs of diastereomer of five superwarfarins in human plasma. HIGHLIGHTS This method was used to identify and measure superwarfarins and their cis/trans diastereomers in plasma obtained from patients treated for coagulopathy following consumption of contaminated synthetic cannabinoid products.
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Affiliation(s)
- Daniel G Nosal
- Oregon State University, Linus Pauling Institute, Department of Pharmaceutical Sciences, 2900 SW Campus Way, Corvallis, OR 97331, USA
| | - Douglas L Feinstein
- University of Illinois at Chicago, Department of Anesthesiology, 835 South Wolcott Ave, MC513, E720, Chicago, IL 60612, USA
| | - Luying Chen
- Oregon State University, Linus Pauling Institute, Department of Pharmaceutical Sciences, 2900 SW Campus Way, Corvallis, OR 97331, USA
| | - Richard B van Breemen
- Oregon State University, Linus Pauling Institute, Department of Pharmaceutical Sciences, 2900 SW Campus Way, Corvallis, OR 97331, USA
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Carlier L, Rex S, Vanassche T, Verelst S, Desmet K, Van Elslande J, Verhamme P, Vandenbriele C. Münchhausen Syndrome: A Case Report of an Unusual Cause of Vitamin K Antagonist Intoxication. A A Pract 2020; 14:e01189. [DOI: 10.1213/xaa.0000000000001189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Kodali S, Rajendran T, Richard IN, Boyapati L, Wong ECC, Avezbakiyev B. Superwarfarin Exposure: An Important Uncommon Cause of Painless Bleeding. J Hematol 2019; 8:155-159. [PMID: 32300463 PMCID: PMC7155811 DOI: 10.14740/jh538] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/12/2019] [Indexed: 11/11/2022] Open
Abstract
Painless bleeding in a patient presenting from the community with elevated coagulation studies rarely makes the physicians suspect superwarfarin or rodenticide poisoning. Although a significant number of superwarfarin exposure cases are diagnosed every year, we believe there appears to be delay in diagnosis and confusion in determining what is the ideal way to treat and monitor these patients during the management. This is the first thorough literature review of all the reported cases of superwarfarin poisoning which also studied the clinical presentation, management and follow-up patterns. We present a 70-year-old man who presented to the emergency room with epistaxis, melena, cola-colored urine with elevated prothrombin time (PT), activated partial thromboplastin time (aPTT) and international normalized ratio (INR). Mixing studies showed complete correction of coagulopathy indicative of factor deficiency. Additional history revealed that the patient had arguments with family member at home and made us suspect superwarfarin exposure. Qualitative brodifacoum testing was positive and was managed with fresh frozen plasma and high doses of vitamin K1 (phytomenadione) with serial monitoring of INR and clinical symptoms. Superwarfarin poisoning should be considered in the differential diagnosis of a patient who presents with above clinical and laboratory profile especially in the absence of any history of coagulopathy or anticoagulant use. We want to raise public and especially physician awareness that history taking, early diagnosis and managing in right clinical setting play a significant role in survival of these patients.
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Affiliation(s)
- Sreenath Kodali
- Division of Hematology/Oncology, Brookdale University Hospital Medical Center, 1Brookdale Plaza, Brooklyn, NY 11212, USA
| | - Tara Rajendran
- Division of Hematology/Oncology, Brookdale University Hospital Medical Center, 1Brookdale Plaza, Brooklyn, NY 11212, USA
| | - Ivan N Richard
- Division of Hematology/Oncology, Brookdale University Hospital Medical Center, 1Brookdale Plaza, Brooklyn, NY 11212, USA
| | - Lakshmi Boyapati
- Division of Hematology/Oncology, Brookdale University Hospital Medical Center, 1Brookdale Plaza, Brooklyn, NY 11212, USA
| | - Edward C C Wong
- Quest Diagnostics Nichols Institute, Chantilly, VA, USA.,George Washington School of Medicine and Health Sciences, Departments of Pediatrics and Pathology, 2300 Eye Street, NW Washington DC, 20037, USA
| | - Boris Avezbakiyev
- Division of Hematology/Oncology, Brookdale University Hospital Medical Center, 1Brookdale Plaza, Brooklyn, NY 11212, USA
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Devgun JM, Rasin A, Kim T, Mycyk MB, Bryant SM, Wahl MS, DesLauriers C, Navon L, Moritz ED, Thompson TM, Swoboda HD, Lu J, Aks SE. An outbreak of severe coagulopathy from synthetic cannabinoids tainted with Long-Acting anticoagulant rodenticides. Clin Toxicol (Phila) 2019; 58:821-828. [DOI: 10.1080/15563650.2019.1690149] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
| | | | | | - Mark B. Mycyk
- Toxikon Consortium, Chicago, IL, USA
- Department of Emergency Medicine, Division of Medical Toxicology, Cook County Health, Chicago, IL, USA
| | - Sean M. Bryant
- Toxikon Consortium, Chicago, IL, USA
- Department of Emergency Medicine, Division of Medical Toxicology, Cook County Health, Chicago, IL, USA
- Illinois Poison Center, Chicago, IL, USA
| | | | | | - Livia Navon
- Illinois Department of Public Health, Springfield, IL, USA
| | - Erin D. Moritz
- Illinois Department of Public Health, Springfield, IL, USA
| | - Trevonne M. Thompson
- Toxikon Consortium, Chicago, IL, USA
- Department of Emergency Medicine, Division of Medical Toxicology, UI Health, Chicago, IL, USA
| | - Henry D. Swoboda
- Department of Emergency Medicine, Division of Medical Toxicology, Rush University Medical Center, Chicago, IL, USA
- Department of Psychiatry, Rush University Medical Center, Chicago, IL, USA
| | - Jenny Lu
- Toxikon Consortium, Chicago, IL, USA
- Department of Emergency Medicine, Division of Medical Toxicology, Cook County Health, Chicago, IL, USA
| | - Steven E. Aks
- Toxikon Consortium, Chicago, IL, USA
- Department of Emergency Medicine, Division of Medical Toxicology, Cook County Health, Chicago, IL, USA
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Love RL, Sharma N, Chong K. Unusual presentation of haemoptysis following accidental inhalation of the 'superwarfarin' rodenticide brodifacoum. BMJ Case Rep 2019; 12:12/11/e230044. [PMID: 31767603 DOI: 10.1136/bcr-2019-230044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Haemoptysis is a worrying symptom for patients and can represent a diagnostic challenge for clinicians. We present the case of a 56-year-old woman who presented to the emergency department with acute haemoptysis and associated sudden-onset dyspnoea. The patient remained haemodynamically stable and there was no demonstrable drop in haemoglobin concentration. Following rigorous investigations, on further questioning, the patient recalled inadvertent inhalation of the rodenticide brodifacoum. This exposure was deemed to represent the cause of their acute haemoptysis, which subsequently fully resolved without intervention.
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Affiliation(s)
- Ryan Laurence Love
- Department of Respiratory Medicine, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Naveen Sharma
- Department of Radiology, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Katie Chong
- Department of Respiratory Medicine, East and North Hertfordshire NHS Trust, Stevenage, UK
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Spontaneous Hemorrhage Associated With Synthetic Cannabinoid Use. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2019.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Zuo W, Zhang X, Chang J, Ma W, Wei J. Bromadiolone poisoning leading to subarachnoid haemorrhage: A case report and review of the literature. J Clin Pharm Ther 2019; 44:958-962. [PMID: 31556967 DOI: 10.1111/jcpt.13005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/11/2019] [Accepted: 07/05/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Wei Zuo
- Department of Pharmacy Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
| | - Xiao Zhang
- Department of Neurosurgery Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
| | - Jian‐Bo Chang
- Department of Neurosurgery Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
| | - Wen‐Bin Ma
- Department of Neurosurgery Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
| | - Jun‐Ji Wei
- Department of Neurosurgery Peking Union Medical College Hospital Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
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Sachdev S, Boyd R, Grimsey NL, Santiago M, Connor M. Brodifacoum does not modulate human cannabinoid receptor-mediated hyperpolarization of AtT20 cells or inhibition of adenylyl cyclase in HEK 293 cells. PeerJ 2019; 7:e7733. [PMID: 31579608 PMCID: PMC6765355 DOI: 10.7717/peerj.7733] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 08/23/2019] [Indexed: 01/04/2023] Open
Abstract
Background Synthetic cannabinoids are a commonly used class of recreational drugs that can have significant adverse effects. There have been sporadic reports of co-consumption of illicit drugs with rodenticides such as warfarin and brodifacoum (BFC) over the past 20 years but recently, hundreds of people have been reported to have been poisoned with a mixture of synthetic cannabinoids and BFC. We have sought to establish whether BFC directly affects cannabinoid receptors, or their activation by the synthetic cannabinoid CP55940 or the phytocannabinoid Δ9-tetrahydrocannabinol (Δ9-THC). Methods The effects of BFC on the hyperpolarization of wild type AtT20 cells, or AtT20 cells stably expressing human CB1- or CB2- receptors, were studied using a fluorescent assay of membrane potential. The effect of BFC on CB1- and CB2-mediated inhibition of forskolin-stimulated adenylyl cyclase (AC) activation was measured using a BRET assay of cAMP levels in HEK 293 cells stably expressing human CB1 or CB2. Results BFC did not activate CB1 or CB2 receptors, or affect the hyperpolarization of wild type AtT20 cells produced by somatostatin. BFC (1 µM) did not affect the hyperpolarization of AtT20-CB1 or AtT20-CB2 cells produced by CP55940 or Δ9-THC. BFC (1 µM) did not affect the inhibition of forskolin-stimulated AC activity by CP55940 in HEK 293 cells expressing CB1 or CB2. BFC (1 µM) also failed to affect the desensitization of CB1 and CB2 signaling produced by prolonged (30 min) application of CP55940 or Δ9-THC to AtT20 cells. Discussion BFC is not a cannabinoid receptor agonist, and appeared not to affect cannabinoid receptor activation. Our data suggests there is no pharmacodynamic rationale for mixing BFC with synthetic cannabinoids; however, it does not speak to whether BFC may affect synthetic cannabinoid metabolism or biodistribution. The reasons underlying the mixing of BFC with synthetic cannabinoids are unknown, and it remains to be established whether the “contamination” was deliberate or accidental. However, the consequences for people who ingested the mixture were often serious, and sometimes fatal, but this seems unlikely to be due to BFC action at cannabinoid receptors.
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Affiliation(s)
- Shivani Sachdev
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Rochelle Boyd
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia.,Cancer Research Unit, Children's Medical Research Institute, Sydney, NSW, Australia
| | - Natasha L Grimsey
- Department of Pharmacology and Clinical Pharmacology, and Centre for Brain Research School of Medical Sciences, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Marina Santiago
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Mark Connor
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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Lindeblad M, Lyubimov A, van Breemen R, Gierszal K, Weinberg G, Rubinstein I, Feinstein DL. The Bile Sequestrant Cholestyramine Increases Survival in a Rabbit Model of Brodifacoum Poisoning. Toxicol Sci 2019; 165:389-395. [PMID: 29897553 DOI: 10.1093/toxsci/kfy147] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Patients exposed to long acting anticoagulant rodenticides (LAARs) are typically administered large amounts of oral vitamin K1 (VK1) to counteract life-threatening anticoagulant effects. Although VK1 treatment effectively prevents mortality, additional methods are needed to reduce the long duration of VK1 treatment which can last for months at high expense. We developed a model of brodifacoum (BDF) poisoning, one of the most potent LAARs, in adult male New Zealand White (NZW) rabbits. The LD50 for oral BDF was determined to be 192 μg/kg, similar to that calculated for adult rats. However, in contrast to rats, NZW rabbits exhibited severe internal hemorrhage including in the brain, symptoms which mimic what occurs in cases of human poisoning. Similar to warfarin, BDF and other LAARs undergo enterohepatic recirculation which contributes to their long half-lives. We therefore tested effects of cholestyramine (CSA), an FDA-approved bile sequestrant, on BDF-induced mortality. When given daily (0.67 g/kg, oral) starting the day of BDF administration, CSA reduced mortality from 67% to 11%. At the same CSA prevented the increase in clotting time, and reduced the decrease in core body temperature due to BDF. Given its excellent safety record and that it is approved for children older than 6 years, these findings suggest CSA could be considered as an adjunct to VK1 for treatment of LAAR poisoning.
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Affiliation(s)
- Matthew Lindeblad
- Department of Medicinal Chemistry and Pharmacognosy, University of Illinois, Chicago, Illinois 60612
| | - Alexander Lyubimov
- Department of Medicinal Chemistry and Pharmacognosy, University of Illinois, Chicago, Illinois 60612
| | - Richard van Breemen
- Department of Pharmaceutical Sciences, Linus Pauling Science Center, Oregon State University, Corvallis, Oregon 97331
| | - Kamil Gierszal
- Department of Anesthesiology, University of Illinois, Chicago, Illinois 60612
| | - Guy Weinberg
- Department of Anesthesiology, University of Illinois, Chicago, Illinois 60612.,Jesse Brown Veterans Affairs Medical Center, JBVAMC, Research & Development, Chicago, Illinois 60612
| | - Israel Rubinstein
- Jesse Brown Veterans Affairs Medical Center, JBVAMC, Research & Development, Chicago, Illinois 60612.,Department of Medicine, University of Illinois, Chicago, Illinois 60612
| | - Douglas L Feinstein
- Department of Anesthesiology, University of Illinois, Chicago, Illinois 60612.,Jesse Brown Veterans Affairs Medical Center, JBVAMC, Research & Development, Chicago, Illinois 60612
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Bahouth MN, Kraus P, Dane K, Plazas Montana M, Tsao W, Tabaac B, Jasem J, Schmidlin H, Einstein E, Streiff MB, Shanbhag S. Synthetic cannabinoid-associated coagulopathy secondary to long-acting anticoagulant rodenticides: Observational case series and management recommendations. Medicine (Baltimore) 2019; 98:e17015. [PMID: 31490385 PMCID: PMC6739027 DOI: 10.1097/md.0000000000017015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Synthetic cannabinoids have become increasingly popular drugs of abuse due to low cost and inability to detect these substances on routine drug screenings. In the United States, incidence of synthetic cannabinoid contamination with long-acting anticoagulant rodenticides (LAARs) resulting in coagulopathy and bleeding complications has been described.We sought to describe the natural history, management approach, and outcomes of bleeding secondary to synthetic cannabinoid-associated LAAR toxicity in an observational case series of patients evaluated at an urban academic medical system.We conducted an observational study of patients with suspected exposure to LAAR-contaminated synthetic cannabinoids and associated bleeding treated within the Johns Hopkins Health System.In this 16 subject cohort, hematuria was the most common bleeding symptom at presentation. The majority of the cohort (75%) had international normalized ratio (INR) > 9.6 at presentation. Of the 13 patients with brodifacoum testing, 12/13 (92%) were positive. Twelve patients (75%) had at least 1 INR value below 2 within 24 hours of the first INR measurement. Of this cohort, 1/16 (6%) died in hospital. The median length of hospital stay was 4 days, (interquartile range = 3-6). The average cost of pharmacological treatment for coagulopathy during inpatient hospitalization was $5300 (range, $2241-$8086).In patients presenting with unexplained coagulopathy it is important for emergency department providers to consider LAAR intoxication and consider formal testing for brodifacoum to assist with treatment planning. Use of a standardized management algorithm including intravenous/oral vitamin K, judicious use of blood products and close laboratory monitoring is essential to optimizing outcomes.
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Affiliation(s)
| | | | | | | | - William Tsao
- Department of Neurology, Johns Hopkins School of Medicine
| | | | - Jagar Jasem
- Department of Hematology, Johns Hopkins Hospital
| | | | - Evan Einstein
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
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35
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Production of a specific monoclonal antibody and a sensitive immunoassay for the detection of diphacinone in biological samples. Anal Bioanal Chem 2019; 411:6755-6765. [DOI: 10.1007/s00216-019-02051-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/21/2019] [Accepted: 07/24/2019] [Indexed: 12/14/2022]
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36
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Ross CH, Singh P, Simon EL. Hemorrhagic Soft Tissue Upper Airway Obstruction From Brodifacoum-Contaminated Synthetic Cannabinoid. J Emerg Med 2019; 57:47-50. [DOI: 10.1016/j.jemermed.2019.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/27/2019] [Accepted: 03/04/2019] [Indexed: 10/26/2022]
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37
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Rubinstein I, van Breemen R, Nosal DG, Weinberg G, Hershow RC, Feinstein DL. Should Cytochrome P450 Inducers be Used to Accelerate Clearance of Brodifacoum from Poisoned Patients? Drugs R D 2019; 19:67-71. [PMID: 30689138 PMCID: PMC6380967 DOI: 10.1007/s40268-019-0261-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A recent multi-state outbreak of life-threatening bleeding following inhalation of synthetic cannabinoids has been attributed to contamination with the long-acting anticoagulant rodenticide (LAAR) brodifacoum, a second-generation, highly potent, long-acting derivative of the commonly used blood thinner warfarin. While long-term treatment with high-dose vitamin K1 restores coagulation, it does not affect brodifacoum metabolism or clearance, and, consequently, brodifacoum remains in the human body for several months, thereby predisposing to risk of bleeding recurrence and development of coagulation-independent injury in extrahepatic tissues and fetuses. This has prompted the evaluation of pharmacological measures that accelerate brodifacoum clearance from poisoned patients. Since the induction of certain cytochrome P450 (CYP) enzymes accelerates warfarin metabolism, using CYP inducers, such as phenobarbital, to accelerate brodifacoum clearance seems plausible. However, unlike warfarin, brodifacoum does not undergo significant metabolism in the liver, nor have the effects of phenobarbital on vitamin K1 metabolism been previously determined. In addition, the safety of phenobarbital in brodifacoum-poisoned patients has not been established. Therefore, we propose that CYP inducers should not be used to accelerate the clearance of brodifacoum from poisoned patients, but that alternative approaches such as reducing enterohepatic recirculation of brodifacoum, or using lipid emulsions to scavenge brodifacoum throughout the body, be considered.
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Affiliation(s)
- Israel Rubinstein
- University of Illinois, 835 South Wolcott Ave, MC513, E720, Chicago, IL, 60612, USA
- Jesse Brown VA Medical Center, Chicago, IL, USA
| | | | - Daniel G Nosal
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Guy Weinberg
- University of Illinois, 835 South Wolcott Ave, MC513, E720, Chicago, IL, 60612, USA
- Jesse Brown VA Medical Center, Chicago, IL, USA
| | - Ronald C Hershow
- University of Illinois, 835 South Wolcott Ave, MC513, E720, Chicago, IL, 60612, USA
| | - Douglas L Feinstein
- University of Illinois, 835 South Wolcott Ave, MC513, E720, Chicago, IL, 60612, USA.
- Jesse Brown VA Medical Center, Chicago, IL, USA.
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Luc SA, Whitworth MM, King SE. Effects of Obesity on Warfarin Reversal With Vitamin K. Clin Appl Thromb Hemost 2019; 25:1076029618824042. [PMID: 30808216 PMCID: PMC6714928 DOI: 10.1177/1076029618824042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Phytonadione (vitamin K1, VK) is fat soluble and may be sequestered by adipose tissue, thus potentially altering drug distribution in obese patients requiring warfarin reversal. This single-center retrospective cohort study aimed to determine the effects of obesity (defined as body mass index [BMI] ≥ 30 kg/m2) on warfarin reversal following administration of VK in adult patients. The primary outcome was complete or partial warfarin reversal (defined as an international normalized ratio [INR] ≤ 2.0) within 72 hours post-VK administration. Of 688 identified patients, 215 were included in primary INR analysis. Mean BMIs for obese (n = 84) and nonobese (n = 131) patients were 37.3 and 24.3 kg/m2 ( P < .001), and mean baseline INRs were 4.73 and 4.42 ( P = .534), respectively. Within 72 hours post-VK administration, 70% and 69% of the obese and nonobese groups, respectively, achieved complete or partial warfarin reversal ( P = .904). Multiple logistic regression determined baseline INR and concomitant fresh frozen plasma administration to be factors influencing warfarin reversal. These findings do not suggest obesity is significantly associated with a decreased likelihood of warfarin reversal within 72 hours post-VK administration.
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Affiliation(s)
- Stanley A Luc
- 1 Department of Pharmacy, Broward Health Medical Center, Fort Lauderdale, FL, USA
| | - Maegan M Whitworth
- 2 Department of Pharmacy Practice, Texas Tech University Health Sciences Center School of Pharmacy, Amarillo, TX, USA
| | - Shawna E King
- 3 Providence Alaska Medical Center, Anchorage, AK, USA
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39
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Bad weed: synthetic cannabinoid–associated coagulopathy. Blood 2019; 133:902-905. [DOI: 10.1182/blood-2018-11-876839] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 01/07/2019] [Indexed: 01/28/2023] Open
Abstract
Abstract
Recent multistate outbreaks of coagulopathy caused by brodifacoum-tainted synthetic cannabinoids or “fake weed” highlight the public health impact of long-acting anticoagulant rodenticides (LAARs). Patients presenting with this syndrome have had recent exposure to synthetic cannabinoids, evidence of isolated vitamin K antagonism with or without bleeding, and detectable levels of brodifacoum and other LAARs in circulation. This article will provide information on synthetic cannabinoids, LAARs, and coagulopathic manifestations arising from use of adulterated synthetic cannabinoids and their management.
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40
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Feinstein DL, Gierzal K, Iqbal A, Kalinin S, Ripper R, Lindeblad M, Zahkarov A, Lyubimov A, van Breemen R, Weinberg G, Rubinstein I. The relative toxicity of brodifacoum enantiomers. Toxicol Lett 2019; 306:61-65. [PMID: 30779948 DOI: 10.1016/j.toxlet.2019.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/25/2019] [Accepted: 02/15/2019] [Indexed: 10/27/2022]
Abstract
Brodifacoum (BDF) is a potent, long-acting anticoagulant rodenticide that can cause fatal poisoning in humans. The chemical structure of BDF includes 2 chiral carbons, resulting in 2 pairs of diastereomers, BDF-cis (R/S and S/R) and BDF-trans (R/R and S/S). However, the relative potency of these molecules is not known. The purpose of this study was to compare the in vitro and in vivo toxic effects of the 2 BDF diastereomer pairs. In adult Sprague-Dawley rats BDF-cis was significantly more toxic than BDF-trans (LD50 values of 219 versus 316 μg/kg, respectively) while racemic BDF had intermediate potency (266 μg/kg). In adult New Zealand white rabbits, BDF-cis had a longer half-life than BDF-trans which could contribute to its observed increased toxicity. Lastly, BDF-cis (10 μM), but not BDF-trans, damaged cultured SH-SY5Y human neuroblastoma cells by attenuating mitochondrial reductive capacity. Taken together, these data suggest that different toxic manifestations of BDF poisoning in mammals could be attributed, in part, to differences in relative enantiomer concentrations present in racemic formulations of this commercially-available toxicant.
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Affiliation(s)
- Douglas L Feinstein
- Department of Anesthesiology, University of Illinois, Chicago, IL, 60612, USA; Jesse Brown VA Medical Center, Chicago, IL, 60612, USA.
| | - Kamil Gierzal
- Department of Anesthesiology, University of Illinois, Chicago, IL, 60612, USA.
| | - Asif Iqbal
- Department of Pharmacology, University of Illinois, Chicago, IL, 60615, USA.
| | - Sergey Kalinin
- Department of Anesthesiology, University of Illinois, Chicago, IL, 60612, USA
| | - Richard Ripper
- Department of Anesthesiology, University of Illinois, Chicago, IL, 60612, USA; Jesse Brown VA Medical Center, Chicago, IL, 60612, USA.
| | - Matthew Lindeblad
- Department of Pharmacology, University of Illinois, Chicago, IL, 60615, USA.
| | - Alexander Zahkarov
- Department of Pharmacology, University of Illinois, Chicago, IL, 60615, USA.
| | - Alexander Lyubimov
- Department of Pharmacology, University of Illinois, Chicago, IL, 60615, USA.
| | | | - Guy Weinberg
- Department of Anesthesiology, University of Illinois, Chicago, IL, 60612, USA; Jesse Brown VA Medical Center, Chicago, IL, 60612, USA.
| | - Israel Rubinstein
- Jesse Brown VA Medical Center, Chicago, IL, 60612, USA; Department of Medicine, University of Illinois, Chicago, IL, 60612, USA.
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41
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Shanbhag S, Dane KE, Streiff MB. "The 700-Dollar Vitamin": The Epidemic of Synthetic Cannabinoid-Associated Coagulopathy. A Case Study of Excessive Generic Drug Prices in the American Health Care System. Mayo Clin Proc 2019; 94:199-201. [PMID: 30711118 DOI: 10.1016/j.mayocp.2018.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 10/04/2018] [Accepted: 10/09/2018] [Indexed: 11/19/2022]
Affiliation(s)
| | - Kathryn E Dane
- The Johns Hopkins Hospital Department of Pharmacy, Baltimore, MD
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42
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Boyack I, Opsha O. Coagulopathic hemorrhage with use of synthetic cannabinoids. Am J Emerg Med 2019; 37:374.e3-374.e4. [DOI: 10.1016/j.ajem.2018.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 10/09/2018] [Accepted: 10/11/2018] [Indexed: 12/26/2022] Open
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Boels D, Chhun S, Meyer G, Lelièvre B, Souday V. Clinical consequences related to a defective elimination of clobazam caused by homozygous mutated CYP2C19 allele. Clin Toxicol (Phila) 2019; 57:743-747. [PMID: 30696292 DOI: 10.1080/15563650.2018.1550198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction: Voluntary drug intoxication with benzodiazepines is common and in most cases without consequences. We report an interesting case of voluntary drug intoxication with clobazam (CLB) in a patient with a homozygous mutated CYP2C19 genotype. Case report: A 63-year-old Caucasian man was admitted to an intensive care unit for voluntary drug intoxication with CLB (1200 mg) complicated by prolonged hospitalization (46 days). The levels of CLB and N-desmethylclobazam (NCLB) in plasma were initially 8.3 and 14.8 mg/L. The persistence of a high concentration of NCLB (14.3 mg/L on day 30) suggested a lack of elimination. A homozygous mutated allele of CYP2C19*2 without enzyme activity was discovered. To overcome this phenotype, NCLB metabolism was induced by administering 100 mg of phenobarbital for 10 days, allowing patient improvement. Discussion: NCLB is the major active metabolite of CLB with a longer half-life and much higher steady-state plasma concentrations compared to the parent drug. The half-life elimination of CLB is 18 h that of NCLB is between 40 and 50 h. However, there is considerable inter-individual variation in the metabolism of CLB and of the report NCLB/CLB under the dependence of genotype of CYP2C19. These polymorphisms are not generally well-known by physicians and may lead to severe poisoning.
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Affiliation(s)
- David Boels
- a Centre Antipoison et de ToxicoVigilance, CHU d'Angers , Angers , France.,b Service de Pharmaco-Toxicologie Clinique , CHU Nantes , Nantes , France
| | - Stéphanie Chhun
- c AP-HP, Laboratoire d'Immunologie Biologique, INEM U1151 , Hôpital Necker-Enfants Malades, Université Paris Descartes , Paris , France
| | - Géraldine Meyer
- a Centre Antipoison et de ToxicoVigilance, CHU d'Angers , Angers , France
| | | | - Vincent Souday
- e Département de Réanimation Médicale et de Médecine Hyperbare , CHU d'Angers , Angers , France
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VKORC1 and VKORC1L1 have distinctly different oral anticoagulant dose-response characteristics and binding sites. Blood Adv 2019; 2:691-702. [PMID: 29581108 DOI: 10.1182/bloodadvances.2017006775] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 01/22/2018] [Indexed: 01/11/2023] Open
Abstract
Vitamin K reduction is catalyzed by 2 enzymes in vitro: the vitamin K 2,3-epoxide reductase complex subunit 1 (VKORC1) and its isozyme VKORC1-like1 (VKORC1L1). In vivo, VKORC1 reduces vitamin K to sustain γ-carboxylation of vitamin K-dependent proteins, including coagulation factors. Inhibition of VKORC1 by oral anticoagulants (OACs) is clinically used in therapy and in prevention of thrombosis. However, OACs also inhibit VKORC1L1, which was previously shown to play a role in intracellular redox homeostasis in vitro. Here, we report data for the first time on specific inhibition of both VKOR enzymes for various OACs and rodenticides examined in a cell-based assay. Effects on endogenous VKORC1 and VKORC1L1 were independently investigated in genetically engineered HEK 293T cells that were knocked out for the respective genes by CRISPR/Cas9 technology. In general, dose-responses for 4-hydroxycoumarins and 1,3-indandiones were enzyme-dependent, with lower susceptibility for VKORC1L1 compared with VKORC1. In contrast, rodenticides exhibited nearly identical dose-responses for both enzymes. To explain the distinct inhibition pattern, we performed in silico modeling suggesting different warfarin binding sites for VKORC1 and VKORC1L1. We identified arginine residues at positions 38, 42, and 68 in the endoplasmatic reticulum luminal loop of VKORC1L1 responsible for charge-stabilized warfarin binding, resulting in a binding pocket that is diametrically opposite to that of VKORC1. In conclusion, our findings provide insight into structural and molecular drug binding on VKORC1, and especially on VKORC1L1.
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45
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Superwarfarin (Long-Acting Anticoagulant Rodenticides) Poisoning: from Pathophysiology to Laboratory-Guided Clinical Management. Clin Biochem Rev 2019; 40:175-185. [PMID: 31857739 DOI: 10.33176/aacb-19-00029] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Superwarfarins are long-acting anticoagulant rodenticides developed from warfarin. The mechanism of action is by inhibition of vitamin K epoxide reductase, resulting in the inability of the body to recycle vitamin K. Deficiency of vitamin K thereafter leads to inability for the body to synthesise vitamin K-dependent coagulation factors, factor II, VII, IX, and X, leading to prolonged prothrombin time. Due to the bulky aromatic sidechains, superwarfarins have a much longer half-life when compared to warfarin, and exposure to superwarfarins results in a prolonged period of anticoagulation which can result in clinical bleeding. Diagnosis is straightforward in patients with known history of superwarfarin exposure but has proved difficult for patients who did not report superwarfarin intake. Superwarfarin poisoning should therefore be suspected in all patients with unexplained prolongation of prothrombin time, and can be confirmed by their detection in serum. Treatment for superwarfarin poisoning includes rapid correction of factor deficiencies with either 4-factor prothrombin complex concentrate or fresh frozen plasma in patients with active bleeding, and high dose vitamin K therapy given multiple times per day for a prolonged period of weeks to months.
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Abstract
How to cite this article: D'Silva C, Krishna B. Rodenticide Poisoning. Indian J Crit Care Med 2019;23(Suppl 4):S272–S277.
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Affiliation(s)
- Carol D'Silva
- Department of Critical Care Medicine, St. John's National Academy of Health Sciences, Bengaluru, Karnataka, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St. John's National Academy of Health Sciences, Bengaluru, Karnataka, India
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47
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Tran MH, Perez-Alvarez I, Swaroop B. Synthetic cannabinoid: an unexpected cause of coagulopathy. Transfusion 2018; 58:2743-2744. [DOI: 10.1111/trf.14821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/01/2018] [Accepted: 06/04/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Minh-Ha Tran
- University of California Irvine Medical Center; Orange CA
| | | | - Bindu Swaroop
- University of California Irvine Medical Center; Orange CA
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48
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Vitamin K epoxide reductase: moving closer to nature. Blood 2018; 132:1867-1869. [DOI: 10.1182/blood-2018-08-869578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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49
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Rubinstein I, Feinstein DL. Comment on: Pesticide-Poisoned Patients: Can They Be Used as Potential Organ Donors? J Med Toxicol 2018; 14:331-332. [PMID: 30276621 DOI: 10.1007/s13181-018-0682-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 09/06/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- Israel Rubinstein
- Department of Medicine, Jesse Brown VA Medical Center, University of Illinois at Chicago, Chicago, IL, 60612, USA.
| | - Douglas L Feinstein
- Department of Anesthesiology, Jesse Brown VA Medical Center, University of Illinois at Chicago, Chicago, IL, 60612, USA
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50
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Kelkar AH, Smith NA, Martial A, Moole H, Tarantino MD, Roberts JC. An Outbreak of Synthetic Cannabinoid-Associated Coagulopathy in Illinois. N Engl J Med 2018; 379:1216-1223. [PMID: 30280655 DOI: 10.1056/nejmoa1807652] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In March and April 2018, more than 150 patients presented to hospitals in Illinois with coagulopathy and bleeding diathesis. Area physicians and public health organizations identified an association between coagulopathy and synthetic cannabinoid use. Preliminary tests of patient serum samples and drug samples revealed that brodifacoum, an anticoagulant, was the likely adulterant. METHODS We reviewed physician-reported data from patients admitted to Saint Francis Medical Center in Peoria, Illinois, between March 28 and April 21, 2018, and included in a case series adult patients who met the criteria used to diagnose synthetic cannabinoid-associated coagulopathy. A confirmatory anticoagulant poisoning panel was ordered at the discretion of the treating physician. RESULTS A total of 34 patients were identified as having synthetic cannabinoid-associated coagulopathy during 45 hospitalizations. Confirmatory anticoagulant testing was performed in 15 of the 34 patients, and superwarfarin poisoning was confirmed in the 15 patients tested. Anticoagulant tests were positive for brodifacoum in 15 patients (100%), difenacoum in 5 (33%), bromadiolone in 2 (13%), and warfarin in 1 (7%). Common symptoms at presentation included gross hematuria in 19 patients (56%) and abdominal pain in 16 (47%). Computed tomography was performed to evaluate abdominal pain and revealed renal abnormalities in 12 patients. Vitamin K1 (phytonadione) was administered orally in all 34 patients and was also administered intravenously in 23 (68%). Red-cell transfusion was performed in 5 patients (15%), and fresh-frozen plasma infusion in 19 (56%). Four-factor prothrombin complex concentrate was used in 1 patient. One patient died from complications of spontaneous intracranial hemorrhage. CONCLUSIONS Our data indicate that superwarfarin adulterants of synthetic cannabinoids can lead to clinically significant coagulopathy. In our series, in most of the cases in which the patient presented with bleeding diathesis, symptoms were controlled with the use of vitamin K1 replacement therapy. The specific synthetic cannabinoid compounds are not known.
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Affiliation(s)
- Amar H Kelkar
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
| | - Nichole A Smith
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
| | - Annia Martial
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
| | - Harsha Moole
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
| | - Michael D Tarantino
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
| | - Jonathan C Roberts
- From the Departments of Medicine (A.H.K., N.A.S., A.M., H.M., M.D.T.) and Pediatrics (M.D.T., J.C.R.), University of Illinois College of Medicine at Peoria, and the Bleeding and Clotting Disorders Institute (M.D.T., J.C.R.) - both in Peoria
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