Severe hyperammonemia from intense skeletal muscle activity: A rare case report and literature review

RATIONALE

Adult hyperammonemia is most often the result of hepatic dysfunction. Hyperammonemia in the setting of normal hepatic function is a much less common phenomenon and has usually been associated with medications and certain disease states. Here, we present an unusual case of severe hyperammonemia caused physiologically by intense muscle activity in a patient lacking any evidence of liver disease.

PATIENT CONCERNS

A 36-year-old woman was brought to the emergency department for a suicide attempt after being found covered in Lysol and Clorox germicidal bleach. She was noted to be in a state of violent psychosis with extreme agitation and had to be sedated and intubated for airway protection.

DIAGNOSIS AND INTERVENTIONS

Initial labs revealed hyperammonemia, lactic acidosis, and anion gap metabolic acidosis. Aminotransferases, bilirubin, and creatine kinase (CK) were normal. Renal function, prothrombin time, activated partial thromboplastin time, and international normalized ratio were also unremarkable and remained so at 24 hours. Ethyl alcohol, acetaminophen, salicylate, and valproic acid were all undetectable in blood. She received 2 doses of lactulose overnight, with a subsequent bowel movement. Next day, her mentation, serum ammonia level, and lactic acid level were back to normal, and she was extubated. Aminotransferases and CK levels were elevated but improved with supportive care. A detailed history and relevant biochemical investigations were unremarkable for any other etiology of hyperammonemia including the common inborn errors of metabolism (IEM). The combination of clinical findings of extreme skeletal muscle activity along with hyperammonemia and lactic acidosis, and subsequently rhabdomyolysis in the setting of unremarkable history and otherwise normal hepatic function strongly suggest the myokinetic origin of hyperammonemia in the patient.

OUTCOME

The patient recovered well with supportive care and was discharged on day 5.

LESSONS

This unique case illustrates the important role of skeletal muscle in the human metabolism of ammonia. In our discussion, we also elucidate the underlying pathophysiology, with the objective of improving clinician understanding of various differential diagnoses.

Autopsy report for chemical burns from cresol solution

Cresol, which is used as a disinfectant and insecticide, has erosive effects on epidermal and epithelial tissues in the body. Oral exposure causes gastrointestinal corrosive injuries as a direct chemical burn. We report herein a case of suicidal poisoning by ingestion of cresol solution. An octogenarian man with depression was found dead approximately 14 h after exposure to less than 500 mL of saponated cresol solution. Macroscopically, corrosive lesions such as red-to-brown-colored epithelium and edematous thickening of walls were seen in the skin, mouth, oral cavity, esophagus, and stomach. Histopathologically, coagulative necrosis and vascular dilatation were detected from mucosal to muscular layers in the esophagus, stomach, and duodenum. Congestive edema of the lungs, edematous changes in the brain, and proximal tubular necrosis of the kidneys were seen, suggesting acute circulatory disturbance due to shock. This human case offers valuable information on the direct irritation and shock induced by systemic exposure to corrosive substances.

Identification of estrogenic/anti-estrogenic compounds in diesel exhaust particulate extract

Diesel exhaust particulate extract (DEPE) was obtained from diesel exhaust particulates with Soxhlet extraction using dichloromethane. After separating DEPE into 11 fractions by liquid-liquid extraction, the neutral fraction (N) showed anti-estrogenic activity and the weak acid (phenol) fraction (WA(P)) showed estrogenic and anti-estrogenic activities by a yeast two-hybrid assay system expressing human estrogen receptor alpha. Both fractions were thoroughly fractionated by silica gel column chromatography and reversed-phase HPLC. In the WA(P) fraction, 3-methyl-4-nitrophenol and 2,6-dimethyl-4-nitrophenol were identified by LC-MS/MS as estrogenic compounds. This is the first study to identify 2,6-dimethyl-4-nitrophenol in DEPE and the first study to show that it is an estrogenic compound. In the N fraction, 1-hydroxypyrene was also identified by LC-MS/MS as an anti-estrogenic compound.

A fatal case of saponated cresol ingestion

We describe here a case of suicidal poisoning by saponated cresol ingestion. A 41 year-old male was found unconsciousness in a park in the early morning, and an empty bottle of saponated cresol was found beside him. His death was confirmed approximately 2 hours later, despite attempts at resuscitation and intensive care. The autopsy revealed severe morphological damage of the upper gastrointestinal tract and congestion of the lung. We also observed by histopathological examination severe lung edema and severe erosion of the esophagus and stomach. Toxicological analysis also identified a high concentration of cresol isomer in the blood and gastric contents. The cause of death was given as cresol poisoning, based on the results of the autopsy and toxicological examination.

Effects of chlorine and its cresylate byproducts on brain and lung performance

Chlorine and potassium cresylate spilled from a train wreck forced evacuation of nearly 1000 people in and near the town of Alberton, Montana, in 1996. Because respiratory and other symptoms persisted in this population, neurobehavioral and pulmonary functions were evaluated in a cohort of exposed vs. unexposed individuals. Ninety-seven subjects were tested 7 wk after exposure. Three years later, 36 of the original subjects were retested, along with 21 new patients exposed in the same incident. These 57 were compared with 22 unexposed individuals. Twenty-six neurobehavioral functions were tested, and spirometry was performed on each subject. At 7 wk postexposure, patients showed significant differences in 5 neurobehavioral functions (i.e., balance, simple reaction time, abnormal visual quadrants, vocabulary, and information), compared with the unexposed individuals recruited in 1999. Patients' Profile of Mood States scores and frequencies of 35 symptoms were also elevated, compared with the unexposed group. At 3 yr postexposure, patients exhibited differences in 7 additional neurobehavioral functions (i.e., choice reaction time, balance with eyes open, color errors, visual fields, Culture Fair, and verbal recall). Respiratory symptoms were increased, but pulmonary functions did not change. Exposure to chlorine and potassium cresylate produced neurobehavioral impairments that have been observed to increase across 3 yr. Spills in heavily populated areas could injure thousands, overwhelming medical facilities.

Determination of phenol and o-cresol by GC/MS in a fatal poisoning case

A fatality due to the ingestion of solution containing phenol and o-cresol is described. The pathological findings were typical of acute substantial poisoning. Blood, urine and stomach content were obtained during post mortem examinations. Phenol and o-cresol were identified using GC/MS. The extractions from autopsy materials were obtained as follows: by gel permeation with cyclohexane/dichloromethane from stomach content, by solid phase extraction (SPE) from urine and by deproteinization with acetonitrile from blood. The phenol and o-cresol concentrations in the samples were found, respectively, as follows: 115.0 and 5.0 microg/g in the stomach contents, 58.3 and 1.9 microg/ml in the blood, 3.3 and 20.5 microg/ml in the urine. Distributions of phenol in fatal poisonings have been reported, but, usually, colorimetry was used as the analytical method and it cannot exclude the interference of other phenolic compounds.

Hepatocellular injury with hyperaminotransferasemia after cresol ingestion

A 42-year-old man attempted suicide by ingesting about 150 mL of a saponated cresol solution containing about 50% cresol. His serum aminotransferase concentrations were elevated, and a coagulopathy was present at the time of admission, 15 hours after ingestion. The hyperaminotransferasemia and coagulopathy worsened on the second day, but resolved thereafter with supportive therapy. Histologic examination of a biopsy specimen obtained on the 14th day demonstrated focal dropout of hepatocytes (which were replaced by reticulin and collagen fibers), ballooning or hydropic degeneration of hepatocytes, and rapid regeneration with small hepatocytes in the periportal zones as well as in the centrilobular zones. A rapid onset of illness with periportal hepatocellular injury is inconsistent with damage due to a hepatotoxic metabolite of p-cresol produced by cytochrome P450, which has been suggested by studies in vitro. A direct transient noxious effect mediated via the portal or arterial circulation may be involved in hepatic injury after cresol ingestion.

An autopsy case of poisoning by massive absorption of cresol a short time before death

A 65-year-old male patient who was hospitalized with schizophrenia died about 15 min later after ingestion of a large volume of saponated cresol solution in a mental hospital. Fatal levels of free p- and m-cresol in the heart blood were detected at 458.8 and 957.3 microg/ml, respectively, which far exceeded the fatal levels determined previously. The levels in the heart muscle, liver and spleen tissues were also extremely high, and there was 250 ml of cresol-odor-emitting fluid in the stomach. The levels of glucuronic-acid-conjugated p- and m-cresols in the heart blood were 38.2 and 85.6 microg/ml, respectively. Although the high levels of cresols in the heart blood may be due to diffusion from the stomach contents, it is surmised that the essential levels of free and conjugated forms in blood were at least 99 and 240 microg/ml, respectively, considering the results of postmortem examinations and some case reports. It was concluded that about 340 microg/ml of the total cresols was absorbed in a very short period following oral ingestion of saponated cresol solution in this case.

Suspected cresol poisoning in cattle presented for slaughter

Cresol poisoning was suspected in agroup of cattle presented for slaughter at a federaly inspected plant in Illinois. Four cattle died shortly after being unloaded at the slaughter facility, while another animal died after being returned to the feedlot of origin in Iowa. The clinical signs in the affected cattle were lethargy, depression, ataxia, leg weakness, sternal recumbency, dehydration, and severe bloating. Metacresol (3-methyl phenol), commonly found in disinfectants used to clean and sanitize farm equipment and barns, was detected in rumen content from 4 necropsied animals ranging from 25.3 to 52.6 ppm. The exact source of exposure was not identified, but was probably accidental on the farm of origin or on the trailers used for animal transit to the slaughter plant.

Acute respiratory distress syndrome following cutaneous exposure to Lysol: a case report

Lysol (mixed cresols) is a brand of popular detergent commonly used to disinfect toilets and floors in Taiwan. We report a patient with acute respiratory failure immediately following chemical burns caused by skin contact with Lysol solution. On admission, chest radiography showed bilateral diffuse pulmonary infiltrates and an arterial blood gas analysis disclosed hypoxemia refractory to a high concentration of oxygen by inhalation. Under the impression of acute respiratory distress syndrome, our patient was admitted to the intensive care unit for respiratory care. Poor clinical improvement was noted, despite aggressive respiratory therapy. High-dose steroid therapy (hydrocortisone 30 mg/kg/day) was administered from the seventh day after mechanical ventilation began and the ratio of arterial partial pressure of oxygen to fractional concentration of oxygen in inspired gas improved thereafter. The amount of steroid was gradually tapered to the maintenance dose and the patient was successfully weaned from the ventilator after a 93-day course of mechanical ventilation.

Concentrated cresol intoxication

Cresol, a commonly used disinfectant, may cause gastrointestinal corrosive injury, central nervous system and cardiovascular disturbances, and renal and hepatic injury following intoxication. We report a case of acute severe cresol poisoning after a suicide attempt with ingestion of a cresol-soap solution used as a toilet disinfectant. A 44-y-old male was found unconscious after ingesting 300 ml of 50% cresol-soap solution. Endotracheal intubation, gastric lavage and activated charcoal were given immediately which reversed his conscious. He had dermal burns, esophageal and gastric erosion, pneumonia, mixed metabolic acidosis and respiratory aklalosis, renal and liver function impairment, leucocytosis and dark urine. Acute renal failure and hemolysis developed, but he recovered after hemodialysis and intensive supportive care. Urine levels of p-cresol, m-cresol, o-cresol and phenol were respectively 2083, 2059, 125 and 68 mg/g creatinine at 7 h post-ingestion. Though the amount cresol claimed ingested by the patient (150 g) far exceeded the reported lethal dose (30-60 g), and multiple complications developed after massive ingestion, this patient recovered. The renal, pulmonary and hematological effects in this patient might have resulted from the direct toxicity of cresol and its metabolites.

Marked increases of aminotransferase levels after cresol ingestion

A 26-year-old woman developed marked increases in levels of aminotransferases about 24 hours after ingestion of 70 mL of 50% cresol. Responding to supportive measures, the patient recovered without any significant complications. Cresol and/or its metabolite may have caused transient hepato-cellular injury in this patient. In cresol poisoning, hepato-cellular injury can manifest even after a 24-hour asymptomatic period.

A computer-aided 3-D geometry of acute and chronic zonal necrosis: three-D tangent counting applied in an attempt to re-examine the structure of the human liver

In an attempt to examine the feasibility of the acinar concept in the liver of humans, the spatial distribution of zonal necrosis and its relation with the blood vessels were studied in terms of 3-D tissue microstructure. The material was five autopsy livers, two from patients of acute cresol intoxication and three with long-standing heart failure. Examined were: 1) whether the surviving areas (zones 1, 2) in acute zonal necrosis have surfaces convex toward the necrotic zone 3 as illustrated in the acinar schema, and 2) whether the necrosis extends as slender "s eeves" so as to reach the portal tracts and create portal-central (P-C) bridging, leaving zones 1 and 2 as a spheroid parenchymal clump. These were examined on serial histological sections of the livers, which were subjected to 3-D reconstruction with the aid of a computer system. The geometric properties of the interfaces between the surviving and necrotic areas were analyzed by 3-D tangent counting technique of DeHoff modified for 3-D application. It was shown by reconstruction that necrosis was uniformly distributed around the hepatic venules. In acute cases, tangent counting showed that the surfaces of the surviving areas were mainly concave toward necrosis. In contrast, in chronic cases, the surfaces became mainly convex as a result of parenchymal regeneration. At no place, in acute or chronic cases, was necrosis shown to reach the portal tracts, and because of this, neither acini nor their agglomerates revealed themselves as a separate unit. All these findings contradict what one expects would be, so long as based on the assumption of the acinar model.

Gas chromatographic determination of cresols in the biological fluids of a non-fatal case of cresol intoxication

A simple and rapid method for analysis of free and conjugated cresols in biological fluids was developed. Prior to and following freeing of the conjugated cresols by acid hydrolysis in a sealed ampoule, free cresols were extracted by Extrelut column extraction, determined by gas chromatography, and confirmed by gas chromatography-mass spectrometry. In a non-fatal case of cresol intoxication a 46-year-old male had ingested about 100 ml of a saponated cresol soap solution. The concentrations of xylenol (2,4- and/or 2,5-dimethylphenol) and p- and m-cresol in the serum sample collected on admission were 15.8 micrograms/g, 43.3 micrograms/g and 73.8 micrograms/g, respectively. The total cresol concentration of 117 micrograms/g in the serum is within the range of fatal concentrations, and it is suspected therefore that the patient's recovery was due to adequate therapy alone.

Triorthocresyl phosphate poisoning--a review of human cases

Since the end of the nineteenth century, numerous cases of triorthocresyl phosphate (TOCP) poisoning due to accidental contamination of drink, food or drugs have been reported. Following the ingestion of preparations contaminated by TOCP, gastrointestinal symptoms may occur and after an interval of ten to twenty days, a well-known delayed neurotoxicity gradually develops. In general, the initial symptoms are pain and paresthesia in the lower extremities. In most cases, muscle weakness progresses rapidly developing into a striking paralysis of the lower extremities with or without an involvement of the upper extremities. Severe cases show pyramidal signs. The histopathological findings show axonal degeneration in the peripheral nerves and degenerative changes in the anterior horn cells. Degenerative change also occurs in the lateral and dorsal tracts of the spinal cord. The cardinal therapy is physical rehabilitation.

Acute tricresylphosphate intoxication in childhood

Tricresylphosphates (TCP) have been responsible for a large number of epidemic and individual intoxications since the recognition, in 1899, that phospho-creosote was the cause of paralysis in patients being treated for tuberculosis. Although children are mentioned as being among the victims of epidemic intoxication, no well documented reports of acute tricresylphosphate ingestion in childhood are available in the literature. We report a case of severe intoxication in a 4 1/2-year-old child following ingestion of a lubricant containing TCP. Clinical findings in this child were typical of previously reported acute ingestions in adults: acute gastro-intestinal symptoms, delayed cholinergic crisis and neurological toxicity. Previous literature is reviewed briefly and discussed.

Repeated facial palsies after chlorocresol inhalation

A 42-year-old woman who experienced more than 50 attacks of left-sided facial palsies after exposure to chlorocresol was studied. Only muscles around the left side of the mouth were affected. On neurophysiological testing during chlorocresol provocation the only abnormality was a loss of motor units during maximal contraction of the left orbicularis oris muscle. This could be explained by a peripheral as well as a central effect. Extensive electrophysiological examination without chlorocresol provocation excluded a preexisting generalised nerve disorder and other diagnostic procedures did not give evidence of pathology involving the left facial nerve. A hyperreactive mechanism causing a transient block of the left facial nerve is proposed.

A fatal case of creosote poisoning

A case of fatal creosote poisoning is described. On presentation, extensive oropharyngeal ulceration was noted and gastric lavage withheld. Post-mortem examination showed an intact oesophagus and stomach.

Acute Heinz-body anemia due to severe cresol poisoning: successful treatment with erythrocytapheresis

A patient with massive intravascular Heinz-body hemolytic anemia associated with the presence of bizarre-looking erythrocytes following the oral ingestion of approximately 100 mL of "penetrating oil", a petroleum distillate containing 85% kerosene, 12% cresol and 2% surfactant, is described. He was treated successfully with immediate erythrocytapheresis and forced diuresis.

Homicidal intoxications by lye- and parachlorcresol-containing disinfectants

In a nursing section for 54 senile, demented inpatients for the period of 3 months, a casual worker committed homicide in 11 cases and attempted homicide in 16 cases by peroral application of lye- and parachlorcresol-containing disinfectants. Autopsies had been performed in nearly all of the fatal cases without detection of the true causes of death. The fatal intoxications could be verified through reexamination of the lung slides and through gas chromatography/mass spectrometry of the formalin-fixed tissue specimens.

Acute toxicity of tri-ortho-cresyl phosphate in sheep and swine

Tri-ortho-cresyl phosphate (TOCP) was given orally or by subcutaneous (SC) injection to sheep and swine. Sheep given oral doses of 100, 200, or 400 mg of TOCP/kg of body weight developed an acute intoxication characterized by diarrhea dehydration, metabolic acidosis, and death within 6 days. Daily SC injections of TOCP in sheep caused either death or delayed neurotoxicosis depending upon the dosage. Increase of aspartate aminotransferase activity approximately 24 hours before the animal died and histopathologic changes confirmed that liver injury had occurred. Swine dosed with 100 to 1,600 mg of TOCP/kg had minimal signs of acute toxicosis, but developed severe delayed neurotoxicosis in approximately 15 days. Those given a 800 mg/kg dose by the oral route or SC injection had severely decreased serum acetylcholinesterase activity. In the swine which were euthanatized at 7 days after treatment, histopathologic examinations revealed no lesions (although the nervous system was not examined, because clinical neurologic signs were normal).

Tri-cresyl phosphate neuropathy in Sri Lanka: a clinical and neurophysiological study with a three year follow up

Clinical and neurophysiological findings in twenty patients intoxicated with tri-cresyl phosphate following consumption of contaminated gingili oil are reported. Marked distal axonopathy, high incidence of pyramidal tract dysfunction and minimal sensory abnormalities were the cardinal features. Despite pronounced motor weakness in the early stages, the patients showed remarkable improvement during a three year follow up.

The ultrastructure of tricresylphosphate poisoning in primates. 3. Studies on alterations in neuronal soma

This report deals with the ultrastructural changes observed in neurons of the posterior root ganglion of slow loris (Nycticebus coucang) following administration of tricresylphosphate (TCP) 0.2 ml/kg body weight for 10 days. The observed changes involved the rough and smooth endoplasmic reticulum profiles, neurofilaments, Golgi complex as well as lipofuscin pigment. Nissl substance was markedly dispersed to the periphery of the neuron. Membranous profiles of the smooth endoplasmic reticulum were lost. Neurofilaments were markedly increased and manifested neurofibrillary tangles or else were scattered over the cytoplasm. Golgi complexes were dilated and there was a marked increase in lipofuscin. These observations suggest that TCP produces degenerative changes in the organelles of sensory neurons similar to those seen at the height of chromatolysis produced by mechanical interference in the dorsal root ganglia and other neurons.

Acute poisoning due to Wright's vaporizing fluid

A 3-year survey is reported of acute poisoning by Wright's Vaporizing Fluid which covered a change in formulation from 90% cresol to 10% chlorocresol. Of 160 children (average age 2.5 years) and 12 adults, 21.5% had moderate symptoms, 7.5% had severe symptoms and one child died. Where incidents involved the old formulation very few patients escaped without symptoms and over 50% of thm had skin burns or moderate systemic symptoms. With the new formulation over 50% of the patients were asymptomatic and skin burns were uncommon. However there was no significant difference in the incidence of severe systemic symptoms between the formulations. The new formulation appears safer when small amounts of the fluid are ingested, but when larger amounts are involved it is potentially lethal. The case history of the fatal poisoning is presented.

Ultrastructural reactions of spinal ganglia to tri-ortho-cresyl-phosphate: effects of neurotoxicity

The ultrastructure of neurons in spinal ganglia of the domestic fowl poisoned with tri-ortho-cresyl-phosphate (TOCP) shows characteristic changes. The light neurons react to TOCP by a marked increase in the number of neurofilaments. These neurons also contain mitochondria in various degenerative stages. Several of the altered mitochondria show an increasing osmiophilia. Some of the darker neurons display a hypertrophy of the endoplasmic reticulum or a relative increase of neurofilaments. The mitochondria in some of these cells show early stages of degeneration. These changes appear 13 days after TOCP ingestion.

[Incorporation of 2-14C-acetate into the glycolipids of the spinal cord and brain stem of normal guinea pigs and guinea pigs in the paralytic stage of triorthocresylphosphate poisoning]

Paralytical form of chronic intoxication was caused by single intracutaneous administration of tri-O-cresyl phosphate (TOCP)/2=2.2 ml/kg/ into guinea pigs. Within the first 27--33 days after the treatment, the animals with pronounced symptoms of neurotoxic effect of TOCP were subcutaneously administered with 2-14C-acetate/100 mu Ci per 100 g of body weight/2 hrs before decapitation. Purified cerebrosides, gangliosides and acid-soluble fraction, containing 14C-precursors, were isolated and their specific radiactivity was measured in a gas-flow counter. The rate of 14C incorporation into cerebrosides and gangliosides in spinal cord was found to exceed that in brain stem. In paralytical stage of disease, caused by TOCP, synthesis of cerebroside was depressed in spinal cord and in brain stem, according to calculated value for relative specific radioactivity. In spinal cord the rate of 14C incorporation into gangliosides was also decreased. These data suggest that neurtoxic drug TOCP affects metabolic processes both in oligodendroglial cells and in neurons, where ganglioside biosynthesis occurs.

Jamaica ginger paralysis. Forty-seven-year follow-up

In 1930, thousands of Americans were poisoned by an illicit extract of Jamaica ginger ("jake") used to circumvent the Prohibition laws. A neurotoxic organophosphate compound, triorthocresyl phosphate (TOCP), had been used as an adulterant. The earliest reports were of peripheral neuritis, but later it was evident that an upper motor neuron syndrome had supervened. This TOCP poisoning apparently involved various cell groups and tracts in the spinal cord; the lesions was not peripheral at all. We interviewed 11 survivors of the illness residing in eastern Tennessee. Four were carefully examined. The principal findings showed the spasticity and abnormal reflexes of an upper motor neuron syndrome. One patient had mild disease, despite typical findings, and had lived a normal life.

[Intensity of 14C-2-acetate incorporation into guinea pig brain and spinal cord phospholipids and cholesterol under normal conditions and following triorthocresylphosphate poisoning]

A severe form of chronic intoxication was caused in guinea pigs by a single intracutaneous inoculation of triorthocresyl phosphate (TOCP); the intensity of acetate-2(14)C incorporation into the brain stem and spinal cord phospholipids and cholesterol was investigated in vivo. In paralytic stage of the disease incorporation of 14C into phospholipids and cholesterol was found to be markedly depressed; the inhibition of the synthesis of these lipids was observed not only in the most vulnerable lumbo-sacral region of the spinal cord, but also in the brain stem. This finding is in favour of the systemic character of lipid metabolism disorder in the central nervous system and indicates alteration of oligodendrocyte metabolism caused by TOCP.

[Guinea pig brain and spinal cord glycolipids in tricresyl phosphate poisoning]

Experimental neuroparalytic form of chronic intoxication with tricresylphosphate (TCP was induced in adult guinea pigs by means of single intracutaneous administration of TCP (industrial mixture containing 37% of ortho-isomer) at a dose of 2.0-2.2 ml/kg of body weight. Moderate and severe forms of the impairment, accompanied by paresis and paralysis of hind extremities was developed in 66.1% of the treated animals. Content of galactolipids (cerebrosides + sulphatides) and gangliosides was determined in brain stem, lumbar and sacral parts of spinal cord of intact and impaired animals. Content of galactolipids was distinctly decreased in spinal cord (by 22.9%) and in brain stem (9.0%). Total gangliosides were decreased by 19.1% in spinal cord, but its content was altered in brain stem. These alterations appear to reflect destructive processes not only in myelin membranes but also in structure of neurones.

[Dialysis technic for regulation of the internal milieu in acute poisoning]

In 72 patients with acute poisoning (15 patients without unconsciousness with 80% of acute renal and hepatic failure, and 57 patients with unconciousness with 10.5% of acute renal and hepatic failure) the significance of the continuous prolonged haemodialysis lasting on an average 12 hours, respectively 18 hours, with the maximum of 33 and 82 hour, respectively. The duration of the haemodialysis was in close correlation with the pH-value of the blood and the duration of the unconciousness. One half of the unconscious patients suffered from dehydration (of them up to 40.3%), which was valuated by the height of the central venous blood pressure. It was also referred to the necessity of the correction of the potassiaemia and glycaemia.

[Guinea pig brain and spinal cord phospholipids and cholesterol in tricresyl phosphate poisoning]

Chronic intoxication of guinea pigs was induced by intracutaneous inoculation of tricresylphosphate (TCP). The brain stem and spinal cord total phospholipids and total, free and esterified cholesterol were determined during the severe neuroparalytic stage of TCP intoxication. The content of phosphilipids and of total cholesterol was not altered, but cholesterol esters appeared to accumulate both in the brain stem and the spinal cord. Cholesterol esters are characteristic products of degraded myelin sheaths.

Poisoning by cresol

A man aged 32 years who was poisoned with cresol is reported. It is suggested that in the absence of evidence about haemoperfusion over charcoal, forced diuresis is the only effective means of removing cresols from the body. Artifical ventilation controls early respiratory failure, but the patient remains at risk from toxic damage to the myocardium and lungs.