Hemoperfusion with Amberlite resin in the treatment of self-poisoning

Human Poisoning from Poisonous Higher Fungi: Focus on Analytical Toxicology and Case Reports in Forensic Toxicology

Several families of higher fungi contain mycotoxins that cause serious or even fatal poisoning when consumed by humans. The aim of this review is to inventory, from an analytical point of view, poisoning cases linked with certain significantly toxic mycotoxins: orellanine, α- and β-amanitin, muscarine, ibotenic acid and muscimol, and gyromitrin. Clinicians are calling for the cases to be documented by toxicological analysis. This document is therefore a review of poisoning cases involving these mycotoxins reported in the literature and carries out an inventory of the analytical techniques available for their identification and quantification. It seems indeed that these poisonings are only rarely documented by toxicological analysis, due mainly to a lack of analytical methods in biological matrices. There are many reasons for this issue: the numerous varieties of mushroom involved, mycotoxins with different chemical structures, a lack of knowledge about distribution and metabolism. To sum up, we are faced with (i) obstacles to the documentation and interpretation of fatal (or non-fatal) poisoning cases and (ii) a real need for analytical methods of identifying and quantifying these mycotoxins (and their metabolites) in biological matrices.

Extracorporeal treatment for tricyclic antidepressant poisoning: recommendations from the EXTRIP Workgroup

The Extracorporeal Treatments In Poisoning (EXTRIP) workgroup was formed to provide recommendations on the use of extracorporeal treatments (ECTR) in poisoning. Here, the workgroup presents its results for tricyclic antidepressants (TCAs). After an extensive literature search, using a predefined methodology, the subgroup responsible for this poison reviewed the articles, extracted the data, summarized findings, and proposed structured voting statements following a predetermined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements and RAND/UCLA Appropriateness Method to quantify disagreement. Blinded votes were compiled, returned, and discussed in person at a meeting. A second vote determined the final recommendations. Seventy-seven articles met inclusion criteria. Only case reports, case series, and one poor-quality observational study were identified yielding a very low quality of evidence for all recommendations. Data on 108 patients, including 12 fatalities, were abstracted. The workgroup concluded that TCAs are not dialyzable and made the following recommendation: ECTR is not recommended in severe TCA poisoning (1D). The workgroup considers that poisoned patients with TCAs are not likely to have a clinical benefit from extracorporeal removal and recommends it NOT to be used in TCA poisoning.

Severe suicidal digoxin toxicity managed with resin hemoperfusion: A case report

Owing to its wide and easy availability, digoxin has got a significant abuse potential and may be used for suicidal purposes. Digoxin-specific antibody (Fab) fragments have become the mainstay of therapy for severe digoxin toxicity and have significantly helped in reducing mortality. However, due to its high cost and limited availability alternative measures may need to be used to manage severe intoxications especially in countries like India, where Fab fragments are unavailable. Here, we present a case of a young female who presented to our casualty with alleged history of consumption of 17.5 mg of digoxin tablets. After admission to ICU, she developed atrioventricular blocks with hemodynamic instability which had to be managed with temporary pacemaker. Her serum digoxin levels were high (12.63 ng/ml) and in the absence of Fab fragments, resin hemoperfusion was done which drastically reduced the serum digoxin levels and reverted the symptoms.

The Management of Tricyclic Antidepressant Poisoning

Although there have been descriptive, uncontrolled clinical reports of removal of tablet debris by gastric lavage, there have been no clinical studies that have demonstrated that this has any impact on outcome in patients with tricyclic antidepressant (TCA) poisoning. There is also the possibility that lavage may increase drug absorption by pushing tablets into the small intestine. Furthermore, gastric lavage in patients with TCA poisoning may induce hypoxia and a tachycardia potentially increasing the risk of severe complications such as arrhythmias and convulsions. In view of the paucity of evidence that gastric lavage removes a significant amount of drug and the risk of complications associated with the procedure, the routine use of gastric lavage in the management of patients with TCA poisoning is not appropriate. Volunteer studies have shown generally that activated charcoal is more likely to reduce drug absorption if it is administered within 1 hour of drug ingestion. In the one volunteer study that looked at later administration of activated charcoal, there was a 37% decrease in plasma concentration associated with administration of activated charcoal at 2 hours post-ingestion. There have been no clinical studies that enable an estimate of the effect of activated charcoal administration on outcome in the management of patients with TCA poisoning. Volunteer studies have shown that multiple-dose activated charcoal increases the elimination of therapeutic doses of amitriptyline and nortriptyline, but not of doxepin or imipramine; however, these studies cannot be directly extrapolated to the management of patients with TCA poisoning. There have been no well designed controlled studies that have assessed the impact of multiple-dose activated charcoal in the management of patients with TCA poisoning. Because of the large volume of distribution of TCAs, it would not be expected that their elimination would be significantly increased by multiple-dose activated charcoal.Haemoperfusion, haemodialysis and the combination of these procedures do not result in significant removal of TCAs and are not recommended in the management of patients with TCA poisoning.

Suicidal chloral hydrate poisoning

BACKGROUND

The cumulative reports of chlorate hydrate toxicity suggest an unacceptable risk for this commonly used sleep aid.

CASE REPORT

A 29-year-old male was admitted after ingestion of 70 g of chloral hydrate. He was hypotensive and hypothermic. Spontaneous respiration was insufficient. Fluid resuscitation did not restore adequate blood pressure levels. Low dose catecholamine infusion resulted in ventricular arrhythmias. The patient was treated with combined hemoperfusion and hemodialysis during an eight hour period. During this time, serum concentrations of trichlorethanol fell. Blood pressure and heart rate increased and consciousness was regained without signs of neurological deficits.

CONCLUSIONS

Although outcome was favorable, this case report illustrates the potentially high acute toxicity of chloral hydrate and supports its removal from the market.

In vitro studies of the efficacy of reversed phase silica gel as a sorbent for hemo- and plasmaperfusion

The clearance capacities of reversed phase silica gel, widely used in analytical chemistry, were studied in vitro. The plasma clearances of amitriptyline, quinidine, digoxin, digitoxin, methaqualone, phenobarbital and phenytoin were determined at typical toxic plasma levels. Between 88.8 and 99.5% of the drugs were eliminated from plasma by reversed phase silica gel, which compares favorably with amberlite XAD-4 and coated activated charcoal. The biocompatibility of reversed phase silica gel was also evaluated in vitro. Thrombocytopenia and leukopenia were noted while coagulation parameters, electrolytes, acid-base balance, glucose, urea, creatinine, uric acid, total protein, albumin, bilirubin, cholesterol and triglycerides were not significantly affected. Preliminary results in vitro support the high clearance capacity of reversed phase silica gel and suggest a biocompatibility similar to that of other sorbents currently in use. Further investigation of the clearance capacities and biocompatibility of reversed phase silica gel seems justified.

Acute renal failure following collective intoxication by Cortinarius orellanus

Twenty-six young men with no previous medical history all ingested mushroom soup, exclusively made with Cortinarius orellanus. They were hospitalized 10-12 days after the incident. On admission, 12 patients presented with acute tubulointerstitial nephritis with acute renal failure; 8 required haemodialysis. In addition to symptomatic treatment, 9 patients were given corticosteroids. In this group of 12 patients, 8 recovered rapidly, and the other 4 suffered from chronic renal failure for several months. In the other group of 14 patients, initial leukocyturia was observed in 12 cases, although renal function remained normal during a one-year follow-up. Hepatic acetylation and hydroxylation tests performed after 6 months in 22 patients did not provide any explanation for the strong individual sensitivity to the renal toxicity of this fungus.

Intoxication by Cortinarius orellanus: detection and assay of orellanine in biological fluids and renal biopsies

A woman suffering from acute tubulo-interstitial nephritis was admitted to the hospital ten days after deliberate intoxication by ingestion of Cortinarius orellanus. Orellanine, the main toxin responsible for orellanine poisoning, was detected in biological fluids and renal biopsies. It was assayed by direct spectrofluorimetry on two-dimensional thin-layer chromatograms after specific photodecomposition into orelline. The orellanine concentration was 6.12 mg/l in the plasma (10 days after ingestion). Orellanine levels in renal biopsies were 7 micrograms per 25 mm3 of the first biopsy (13 days after ingestion) and 24 micrograms per 8 mm3 of the second biopsy (6 months later).

Toxic properties of the mushroom Cortinarius orellanus. I. Chemical characterization of the main toxin of Cortinarius orellanus (Fries) and Cortinarius speciosissimus (Kühn & Romagn) and acute toxicity in mice

The toxins of the mushrooms Cortinarius orellanus (Fries) and Cortinarius speciosissimus (Kühn & Romagn) were isolated by extraction procedures and Sephadex chromatography. All intermediate and end products of the purification process were tested in mice for acute toxicity after oral and i.p. administration. In both species a fluorescent main toxin and a nonfluorescent compound of minor toxicity were found. The main toxin of both species was identified by mass spectrometric and nuclear magnetic resonance analyses as the 2,2'-bipyridine-3,3',4,4'-tetrol-1,1'-dioxide, which is identical to orellanine. The purified compound was toxic when administered either orally or i.p. When given orally the LD50 was 33 mg/kg body weight in mice. The oral LD50 of Cortinarius orellanus (2.20 g dried mushroom/kg) and of Cortinarius speciosissimus (3.12 g/kg) depended on the orellanine content (14 mg/g in Cortinarius orellanus and 9 mg/g in Cortinarius speciosissimus). The second toxic component was ineffective in mice when given orally. It caused acute toxicity when administered i.p., but toxicity was low when compared to the main toxin. Thus it appears to be of minor importance. Intraperitoneal testing of both isolated toxins and of the extract containing the whole toxic potential of the mushrooms revealed that toxicity, time dependency and expression of toxicosis is accounted for by the sum of these two toxins. No peptidic main toxin as described by other mycologists could be detected.

Mushroom poisoning caused by species of the genus Cortinarius Fries

Symptomatology, clinical characteristics and pathogenesis of mushroom poisoning caused by Cortinarius species are surveyed. The isolation of a bipyridine--orellanine--from Cortinarius orellanus is held to be responsible for the nephrotoxicity of this species as well as the closely related C. speciosissimus. The present knowledge on the toxicity of structurally related and well-known bipyridines such as paraquat and diquat is brought up and found comparable to orellanine toxicity. Pharmacokinetic experiments on the nephrotoxic bipyridines suggest that haemoperfusion is a rational therapy of intoxicated persons, even several days after mushroom ingestion.

The influence of haemoperfusion on white cells, immunoglobulin concentrations and the complement system in the treatment of intoxications

The influence of haemoperfusion on some immunological parameters was investigated in a pilot study involving two groups of three patients each. In columns containing cellulose-coated activated charcoal or polystyrene resin a temporary reduction of the total white cell number, particularly involving the segmented and band neutrophils, was demonstrated. Cellulose-coated activated charcoal and, to a lesser extent, polystyrene resin induced activation of the complement system using C3d as a parameter. An appreciable decrease of immunoglobulin or complement levels could not be demonstrated in either column.

Treatment of antidepressant poisoning with resin hemoperfusion

1 The object of this study was to evaluate hemoperfusion in tricyclic antidepressant (TCA) poisoning. 2 Eight patients with severe TCA-poisoning and one patient with maprotiline poisoning were treated with resin hemoperfusion (HP). All patients were in Grade III or Grade IV coma with a QRS interval of 100 ms or greater. Hemoperfusion was started and continued until a satisfactory clinical response was obtained or for up to a maximum of 4 h. 3 Clearance values and extraction ratios were calculated during HP. The extraction ratio for all drugs was high (0.91-0.98) showing an effective clearance of these drugs from the blood compartment. After termination of HP a rebound effect of blood concentrations was seen in five cases. The total amount of the drug recovered was in no case greater than 3.1% of the estimated amount ingested. 4 It is therefore difficult to ascribe the clinical improvement seen in these patients during HP to the removal of significant amounts of the drug taken.