Management and Sequelae of a 41-Year-Old Jehovah’s Witness With Severe Anhydrous Ammonia Inhalation Injury:

Polycyclic aromatic hydrocarbons and their metabolites in bronchoalveolar lavage and urine samples from patients with inhalation injury throughout their hospitalization: A prospective pilot study

BACKGROUND

Specific toxic compounds, such as polycyclic aromatic hydrocarbons (PAHs) and their metabolites, may affect the inhalation injury (INHI) grade, patients' status, and prognosis for recovery. This pilot prospective study aimed to: i) evaluate the suitability of bronchoalveolar lavage (BAL) for determination of PAHs in the LRT and of urine for determination of hydroxylated metabolites (OH-PAHs) in patients with INHI, ii) describe the dynamic changes in the levels of these toxic compounds, and iii) correlate these findings with clinical variables of the patients with INHI.

METHODS

The BAL and urine samples from 10 patients with INHI were obtained on Days 1, 3, 5, 7, and 14 of hospitalization, if possible, and PAHs (BAL) and OH-PAHs (urine) were analyzed using chromatographic methods (GC-MS and HPLC).

RESULTS

Concentrations of analyzed PAHs were in most cases and time points below the limit of quantification in BAL samples. Nine OH-PAHs were detected in the urine samples; however, their concentrations sharply decreased within the first three days of the hospitalization. On Day 14, the total amount of OH-PAHs in urine was higher in surviving patients with High-grade INHI (≥3) than in those with Low-grade INHI (<3, p = 0.032). Finally, a significant correlation between certain OH-PAHs and clinical variables (AST/ALT, TBSA, ABSI) from Day 1 of the hospitalization was observed (p<0.05).

CONCLUSIONS

BAL samples are not suitable for the analysis of PAHs. However, the OH-PAHs levels in urine can be measured reliably and were correlated with several clinical variables. Moreover, High-grade INHI was associated with higher total concentrations of OH-PAHs in urine.

Cadmium Dicyanoaurates and Their Reaction with Ammonia

The synthesis and crystal structures of two anionic cadmium dicyanoaurate coordination polymers, [nBu4N]6[(Cd4Cl4)2(Au(CN)2)12][CdCl4] (TCCA) and [nBu4N]2[Cd(Au(CN)2)4], and their reaction with ammonia vapour is reported. TCCA and the isostructural [nBu4N]6[(Cd4Br4)2(Au(CN)2)12][CdBr4] form 3-D arrays with [Cd4X4]4+ (X=Cl, Br) cubane clusters linked from each octahedral Cd(II) centre by three bridging [Au(CN)2]- units. TCCA reacts with ammonia with concentrations of 1000 ppm or higher to give a product with a quantum yield of 0.88, while [nBu4N]2[Cd(Au(CN)2)4], which forms a 2-D anionic Cd[Au(CN)2]2 sheet structure with axially pendant [Au(CN)2]- units, reacts with concentrated ammonia vapour to generate Cd(NH3)2[Au(CN)2]2; this has a similar 2-D sheet structure but with axial NH3 units. Vibrational spectroscopy illustrated that the reaction of both Cd/[Au(CN)2]-based materials with ammonia proceeded by breaking Cd-NC bonds. For [nBu4N]2[Cd(Au(CN)2)4], this results in decomposition into [nBu4N][Au(CN)2] ⋅ 0.5H2O and Cd(NH3)2[Au(CN)2]2, while the reaction of ammonia with TCCA is reversible by heating the ammonia-bound sample above 110 °C. Cd[Au(CN)2]2 can be prepared by thermal removal of NH3 units from Cd(NH3)2[Au(CN)2]2.

Targeting gut microbial nitrogen recycling and cellular uptake of ammonium to improve bortezomib resistance in multiple myeloma

The gut microbiome has been found to play a crucial role in the treatment of multiple myeloma (MM), which is still considered incurable due to drug resistance. In previous studies, we demonstrated that intestinal nitrogen-recycling bacteria are enriched in patients with MM. However, their role in MM relapse remains unclear. This study highlights the specific enrichment of Citrobacter freundii (C. freundii) in patients with relapsed MM. Through fecal microbial transplantation experiments, we demonstrate that C. freundii plays a critical role in inducing drug resistance in MM by increasing levels of circulating ammonium. The ammonium enters MM cells through the transmembrane channel protein SLC12A2, promoting chromosomal instability and drug resistance by stabilizing the NEK2 protein. We show that furosemide sodium, a loop diuretic, downregulates SLC12A2, thereby inhibiting ammonium uptake by MM cells and improving progression-free survival and curative effect scores. These findings provide new therapeutic targets and strategies for the intervention of MM progression and drug resistance.

Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome Caused by Anhydrous Ammonia Burns: Two Case Reports

Acute anhydrous ammonia burns are relatively rare but lethal and often occur as a mass occupational incident worldwide. Anhydrous ammonia mainly leads to severe inhalation injury and skin/mucosa wound because of its high water solubility and strong alkalinity. Acute respiratory distress syndrome (ARDS) induced by inhalation injury is the main cause of death. Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, has been recommended as the salvage treatment for severe ARDS based on low-level evidence. However, the application of ECMO in ammonia burns is still limited. Here, we presented two cases of anhydrous ammonia burn patients, one 62-year-old man with 15% total body surface area (TBSA) and one 47-year-old man with 27% TBSA, accompanying severe inhalation injury. They both developed severe ARDS and started vv ECMO on 3, 6, and 15 days after injury, respectively. ECMO lasted 118, 247, and 72 h, respectively. All ECMO were successfully weaned off although only one patient survived. Meanwhile, one patient had the coagulopathy complication of ECMO, mainly bleeding, deep vein thrombosis, and hemolysis. In conclusion, this report provided evidence for use of ECMO as supportive care in ammonia burn patients with severe ARDS.

Ammonia exposure by intratracheal instillation causes severe and deteriorating lung injury and vascular effects in mice

OBJECTIVE

Ammonia (NH₃) is a corrosive alkaline gas that can cause life-threatening injuries by inhalation. The aim was to establish a disease model for NH₃-induced injuries similar to acute lung injury (ALI) described in exposed humans and investigate the progression of lung damage, respiratory dysfunction and evaluate biomarkers for ALI and inflammation over time.

METHODS

Female BALB/c mice were exposed to an NH₃ dose of 91.0 mg/kg·bw using intratracheal instillation and the pathological changes were followed for up to 7 days.

RESULTS

NH₃ instillation resulted in the loss of body weight along with a significant increase in pro-inflammatory mediators in both bronchoalveolar lavage fluid (e.g. IL-1β, IL-6, KC, MMP-9, SP-D) and blood (e.g. IL-6, Fibrinogen, PAI-1, PF4/CXCL4, SP-D), neutrophilic lung inflammation, alveolar damage, increased peripheral airway resistance and methacholine-induced airway hyperresponsiveness compared to controls at 20 h. On day 7 after exposure, deteriorating pathological changes such as increased macrophage lung infiltration, heart weights, lung hemorrhages and coagulation abnormalities (elevated plasma levels of PAI-1, fibrinogen, endothelin and thrombomodulin) were observed but no increase in lung collagen. Some of the analyzed blood biomarkers (e.g. RAGE, IL-1β) were unaffected despite severe ALI and may not be significant for NH₃-induced damages.

CONCLUSIONS

NH₃ induces severe acute lung injuries that deteriorate over time and biomarkers in lungs and blood that are similar to those found in humans. Therefore, this model has potential use for developing diagnostic tools for NH₃-induced ALI and for finding new therapeutic treatments, since no specific antidote has been identified yet.

Quantitative proteomic analysis of trachea in fatting pig exposed to ammonia

Ammonia (NH₃) is considered as the main pollutant in livestock houses and air environment, and its adverse effects on animal and human health have attracted widespread attention. However, trachea proteomics respond to NH₃ is lacking, which is crucial to understanding how NH₃ induces respiratory damage. In this study, we performed labeled quantitative proteomic (TMT-MS) analysis in the trachea of fatting pigs exposed to NH₃ for 30 days. The proteomic results were then validated by Immunohistochemistry (IHC) and Parallel Reaction Monitoring (PRM). The results showed that a total of 126 differentially abundant proteins (DAPs) were identified (fold change <0.83 or > 1.2 and P < 0.05), including 70 differentially up-regulated proteins (DUPs) and 56 differentially down-regulated proteins (DDPs). These proteins were mainly located in intracellular regions and involved in immune response, metabolism and protein synthesis. The results of DAPs (EHHADH, RPL28, SLC25A6, TUBB6, CD14, CTSS, RPS11, RPL19, SLC25A5, RPS8, FABP3, RPL21, RPL34, RPL32, PDIA3, FBP1, HSPH1, SAR1A and SEC24C) verified by IHC and PRM were consistent with the proteomic results. The results of this study provided a basis and a novel insight for understanding the mechanism of NH₃-induced tracheal injury. SIGNIFICANCE: Ammonia (NH₃) is considered as the main pollutant in livestock houses and air environment, and its adverse effects on animal and human health have attracted widespread attention. However, trachea proteomics respond to NH₃ is lacking, which is crucial to understanding how NH₃ induces respiratory damage. Therefore, in this study, labeled quantitative proteomics (TMT-MS) was used to detect trachea tissue samples from finishing pigs in NH₃ exposure group and control group, and PRM method was used to further verify the highly abundant proteins in NH₃ exposure samples, so as to identify new diagnostic markers for NH₃ poisoning. The results of this study provided a basis and a novel insight for understanding the molecular pathological mechanism of NH₃-induced tracheal injury.

Genetic determinants of ammonia-induced acute lung injury in mice

In this study, a genetically diverse panel of 43 mouse strains was exposed to ammonia, and genome-wide association mapping was performed employing a single-nucleotide polymorphism (SNP) assembly. Transcriptomic analysis was used to help resolve the genetic determinants of ammonia-induced acute lung injury. The encoded proteins were prioritized based on molecular function, nonsynonymous SNP within a functional domain or SNP within the promoter region that altered expression. This integrative functional approach revealed 14 candidate genes that included Aatf, Avil, Cep162, Hrh4, Lama3, Plcb4, and Ube2cbp, which had significant SNP associations, and Aff1, Bcar3, Cntn4, Kcnq5, Prdm10, Ptcd3, and Snx19, which had suggestive SNP associations. Of these genes, Bcar3, Cep162, Hrh4, Kcnq5, and Lama3 are particularly noteworthy and had pathophysiological roles that could be associated with acute lung injury in several ways.

Bilateral sequential lung transplantation in Jehovah's Witnesses

The ethical concerns of refusing lifesaving treatments after receiving an already limited resource such as a solid organ transplantation in a Jehovah's Witness patient have been discussed in the literature. Many of these studies have concluded that with a multidisciplinary approach, solid organ transplantation is possible in the setting of Jehovah's Witness patients. To date, there are no reported cases of bilateral sequential lung transplantation in the literature. We report two successful cases of bilateral sequential lung transplantation in Jehovah's Witness patients with excellent long-term follow-up.

Zinc Tetracyanoplatinate: A Reversible Luminescence-Based Ammonia Sensor

ZnPt(CN)₄ was shown to be an effective material for ammonia sensing, and can be synthesized using either solution or mechanochemical methods. A combination of luminescence and Raman spectroscopy revealed that multiple species are involved in the reaction between ammonia and ZnPt(CN)₄ . The crystal structure of one of these species, Zn(NH₃ )₂ Zn(NH₃ )₃ (Pt(CN)₄ )₂ , was elucidated. Detection of ammonia vapor down to 50 ppm in air was accomplished by monitoring the luminescence spectrum. The reaction between ZnPt(CN)₄ and ammonia vapor is reversible, and can be cycled multiple times by either flowing air over the material or heating. ZnPt(CN)₄ also has a relatively high thermal stability, decomposing only when heated above 420 °C.

Ammonia toxicity: from head to toe?

Ammonia is diffused and transported across all plasma membranes. This entails that hyperammonemia leads to an increase in ammonia in all organs and tissues. It is known that the toxic ramifications of ammonia primarily touch the brain and cause neurological impairment. However, the deleterious effects of ammonia are not specific to the brain, as the direct effect of increased ammonia (change in pH, membrane potential, metabolism) can occur in any type of cell. Therefore, in the setting of chronic liver disease where multi-organ dysfunction is common, the role of ammonia, only as neurotoxin, is challenged. This review provides insights and evidence that increased ammonia can disturb many organ and cell types and hence lead to dysfunction.

Mass chemical casualties: treatment of 41 patients with burns by anhydrous ammonia

BACKGROUND

This article reports a chemical burn incident that occurred on 31 August 2013 in Shanghai. We describe situations at the scene, emergency management, triage, evacuation, and follow-up of the victims.

METHOD

The scene of the incident and information on the 41 victims of this industrial chemical incident were investigated. The emergency management, triage, evacuation, and hospitalization data of the patients were summarized.

RESULTS

At the time of the incident, 58 employees were working in a closed refrigerator workshop, 41 of whom sustained burns following the leakage of anhydrous ammonia. Ten victims died of severe inhalation injury at the scene, and another five victims died during the process of evacuation to the nearest hospital. After receiving information on the incident, a contingency plan for the burn disaster was launched immediately, and a first-aid group and an emergency and triage group were dispatched by the Changhai Hospital to the scene to aid the medical organization, emergency management, triage, and evacuation. All casualties were first rushed to the nearest hospital by ambulance. The six most serious patients with inhalation injuries were evacuated to the Changhai Hospital and admitted to the burn intensive care unit (BICU) for further treatment, one of whom died of respiratory failure and pulmonary infection.

CONCLUSION

This mass casualty incident of anhydrous ammonia leakage caused potential devastating effects to the society, especially to the victims and their families. Early first-aid organization, emergency management, triage, and evacuation were of paramount importance, especially rapid evaluation of the severity of inhalation injury, and subsequent corresponding medical treatment. The prognosis of ammonia burns was poor and the sequelae were severe. Management and treatment lessons were drawn from this mass casualty chemical burn incident.