Poisoning from Ingestion of Fungus-Infected Cicada Nymphs: Characteristics and Clinical Outcomes of Patients in Thailand

The current data regarding poisoning associated with ingestion of fungus-infected cicada nymphs are limited. We performed a retrospective cohort study of patients who ingested fungus-infected cicada nymphs and were referred to the Ramathibodi Poison Center for consultation from June 2010 to June 2022. Thirty-nine patients were included for analysis. Most were men (53.8%). Mean age was 40.2 ± 15.0 years. All nymphs were ingested as a health/food supplement. Thirty-one patients (79.5%) reported gastrointestinal symptoms. Median time from ingestion to symptom onset was 5 h. Twenty-nine patients (74.4%) reported neurological symptoms, including tremor, myoclonus, muscle rigidity, nystagmus/ocular clonus, drowsiness, dysarthria, seizure, and confusion. Some complained of dizziness, urinary retention, and jaw stiffness. Most patients (94.9%) were admitted to the hospital. Median hospital stay was 3 days. Ibotenic acid was detected in the blood and urine samples of one patient. All received supportive care. Four patients developed infectious complications. No deaths occurred. Consuming fungus-infected cicada nymphs may cause poisoning in humans. Gastrointestinal and neurological symptoms were common. Ibotenic acid might be the underlying cause. The main treatment is supportive care and appropriate management of complications. Education of the general public is advocated to prevent the incidence of this type of poisoning.

Comparison between blood hemoglobin concentration determined by point-of-care device and complete blood count in adult patients with dengue

Background

Hematocrit measurement has been an indispensable tool for monitoring plasma leakage and bleeding in dengue patients. However, hematocrit measurement by automated methods is hampered by frequent venipunctures. Utility of point-of-care hemoglobin (POC-Hb) test for monitoring dengue patients has not been established. We evaluated the relationship between hemoglobin measured by POC-Hb testing and hematocrit measured by the automated method in adult dengue patients.

Methodology and principal findings

Adult dengue patients were recruited at two university hospitals in Thailand from October 2019 to December 2020. POC-Hb test was performed using capillary blood simultaneously with venipuncture to obtain whole blood for an automated complete blood count (CBC) analysis. The correlation of hemoglobin and hematocrit measurement was evaluated. A total of 44 dengue patients were enrolled. Twenty-nine patients (65.9%) were female, with a median age of 31 years (interquartile range 22–41). Of the enrolled patients, 30 (68.2%), 11 (25.0%), and 3 (6.8%) were classified as dengue without warning signs, with warning signs, and severe dengue, respectively. Seven patients (15.9%) had hemoconcentration, and five patients (11.3%) had bleeding. A total of 216 pairs of POC-Hb and CBC were evaluated. A significant positive correlation was observed between hemoglobin measured by POC-Hb testing and hematocrit measured by an automated CBC (r = 0.869, p <0.001). Bland-Altman analysis between hemoglobin measured by POC-Hb testing and an automated CBC showed a bias of -0.43 (95% limit of agreement of -1.81 and 0.95). Using the cutoff of POC-Hb ≥20% as a criteria for hemoconcentration, the sensitivity and specificity of hemoconcentration detected by POC-Hb device were 71.4% and 100.0%, respectively.

Conclusions

Hemoglobin measurement by POC-Hb testing has a strong correlation with hematocrit in adult patients with dengue fever. However, the sensitivity in detecting hemoconcentration is fair. The adjunct use of capillary POC-Hb testing can decrease the frequency of venipuncture. Further study in children is encouraged.

The natural history of dengue has the unique characteristic of plasma leakage that results in hemoconcentration as well as vasculopathy and thrombocytopenia that result in bleeding. Therefore, hematocrit monitoring is a crucial tool to guide management in dengue patients. Microhematocrit adjunct with a complete blood count (CBC) to monitor dengue patients were traditionally performed to decrease the frequency of venipuncture. However, microhematocrit is currently less preferred to the point-of-care hemoglobin monitoring tools to measure red cells in other diseases. There has been no study investigating the feasibility of using point-of-care hemoglobin (POC-Hb) to monitor dengue patients. We studied the correlation of hemoglobin measured by POC-Hb testing and hematocrit measured by an automated CBC in adult dengue patients. We were able to show a strong positive correlation between the two measurements (r = 0.869, p <0.001). Using the rise of POC-Hb value of ≥20% above the convalescent value as the criteria for detecting hemoconcentration by POC-Hb testing, measurement of hemoglobin using POC-Hb has a sensitivity of 71.4% for detecting hemoconcentration compared to the traditional hematocrit criteria. Our findings support the use of POC-Hb testing adjunct with a complete blood count to guide fluid management in dengue patients.

Association of soluble human leukocyte antigen-G with acute tubular necrosis in kidney transplant recipients

BACKGROUND

Human leukocyte antigen (HLA)-G is a nonclassical HLA class I molecule that displays strong immune-inhibitory properties and has been associated with allograft acceptance. However, there are conflicting data on the correlation of soluble HLA-G (sHLA-G) and acute rejection and no data on the correlation with acute tubular necrosis in kidney transplantation.

OBJECTIVE

To evaluate the association of sHLA-G level in early post-transplant period and allograft rejection/ and acute tubular necrosis (ATN) in kidney transplant recipients.

METHODS

The sera procured before transplantation and serially on day 3 and day 7 after transplantation from 76 kidney transplant recipients were analyzed for the level of sHLA-G by enzyme-linked immunosorbent assay.

RESULTS

The levels of sHLA-G from three serial sera did not differ between patients with acute rejection and patients without rejection. However, the sHLA-G levels on day 3 post-transplant and day 7 post-transplant in patients with ATN were significantly higher than that in patients without ATN (16.3 vs 9.85 U/ml, p = 0.018, for day 3 post-transplant and 12.47 vs 5.42 U/ml, p = 0.044, for day 7 post-transplant). In addition, the ROC analysis of sHLA-G for identifying patients with ATN showed that the area under curve was 0.67 (95% confidence interval 0.54-0.80).

CONCLUSIONS

There was no significant difference for sHLA-G levels between patients with acute rejection and without rejection. Interestingly, high levels of sHLA-G in day 3 and day 7 after transplantation were associated with acute tubular necrosis. Our findings raise the question whether the increased levels of sHLA-G in patients with acute tubular necrosis after transplantation might be a result of ischemia and reperfusion injury.

Pharmacokinetics of mitragynine in man

BACKGROUND

Kratom, known botanically as Mitragyna speciosa (Korth.), is an indigenous tree in Southeast Asia. Kratom is currently easily available worldwide via special shops and the Internet to use as a drug of abuse, opioid alternative, or pain killer. So far, the pharmacokinetics of this plant has been studied only in animals, and there is no such study in humans. The major abundant active alkaloid in Kratom, mitragynine, is one of the promising new chemical substances to be developed as a new drug. The aim of this study was to examine the pharmacokinetics of mitragynine and assess the linearity in pharmacokinetics in chronic users.

METHODS

Since Kratom is illegal in Thailand, studies in healthy subjects would be unethical. We therefore conducted a prospective study by enrolling ten chronic, regular, healthy users. We adjusted the steady state in each subject by giving a known amount of Kratom tea for 7 days before commencement of the experiment. We admitted and gave different oral doses to subjects to confirm linearity in pharmacokinetics. The mitragynine blood concentrations at 17 times points and the urine concentrations during the 24-hour period were collected and measured by liquid chromatography-tandem mass spectrometry method.

RESULTS

Ten male subjects completed the study without adverse reactions. The median duration of abuse was 1.75 years. We analyzed one subject separately due to the abnormal behavior of blood concentration. From data of nine subjects, the pharmacokinetic parameters established were time to reach the maximum plasma concentration (0.83±0.35 hour), terminal half-life (23.24±16.07 hours), and the apparent volume of distribution (38.04±24.32 L/kg). The urine excretion of unchanged form was 0.14%. The pharmacokinetics were observed to be oral two-compartment model.

CONCLUSION

This was the first pharmacokinetic study in humans, which demonstrated linearity and was consistent with the oral two-compartment model with a terminal half-life of about 1 day. The pharmacokinetic linearity and parameters reported are necessary pharmacological information of Kratom, and there is a possibility for it to be developed medically as a pain killer or better opioid substitute in the future.