Lessons to be learned: a case study approach. Unseasonal severe poisoning of two adults by deadly nightside (Atropa belladonna)

Unseasonal, mid-winter, severe poisoning by deadly nightshade is reported in two adults who simultaneously ate from a pie made of frozen deadly nightshade berries, mistaken at the time of picking for bilberries. Atropine levels are reported in the urine. Physostigmine treatment was ineffective.

Lessons to be learned: a case study approach: prolonged methaemoglobinaemia due to inadvertent dapsone poisoning; treatment with methylene blue and exchange transfusion

The authors present a case of methaemoglobinaemia of acute onset, with an unusually protracted course. The long persistence of this disorder led to a search for the cause which was eventually traced to medication with dapsone. The latter was found to be inappropriately being taken by the patient instead of an antispasmodic that had been prescribed for a spinal condition; this was because the tablets had been incorrectly labelled and dispensed in a pharmacy. The patient took increasing doses of the presumed 'antispasmodic' tablets as they seemed to lack clinical effect, thus further exacerbating the toxic consequences. Moreover, the patient brought his wrongly labelled tablets into hospital and was allowed to use them there, contrary to normal hospital policy. As treatment for the methaemoglobinaemia both bolus and continuous infusions of methylene blue were used, which probably contributed to the severe haemolysis which followed. Furthermore, the development of a rare side effect of dapsone toxicity, namely that of a sensorimotor neuropathy, is reported.

Lessons to be learned: a case study approach. An unusual case of alveolar deposition from swallowing metallic mercury in an attempt at self-poisoning

The authors report a case of deliberate self-poisoning in a drug addict who swallowed elemental mercury: in so doing he inadvertently acquired a permanent diffuse deposition of mercury particles throughout both lung fields. Swallowed mercury should be relatively harmless in small quantity but the high specific gravity and free flowing properties of elemental mercury allowed it to overcome the normal swallowing pathways--such that some of it passed into the bronchial tree instead of passing harmlessly through the gut. In that site its significant vapour pressure, together with its potential for oxidation to inorganic mercury--which may, in turn, be absorbed across the alveolar membrane, gives high potential for mercury poisoning.

Clinical evaluation is better: myoglobin estimation used singly as a discriminant for early acute myocardial infarction does not well identify patients who will benefit from thrombolytic therapy

We have examined the use of serum myoglobin concentration in the management of cases of suspected acute myocardial infarction (AMI). In a series of 51 patients myoglobin, used as a discriminant, correctly identified 97% (28/29) of cases as AMI with one false positive. Initial clinical judgement based on history, examination and the electrocardiogram correctly identified 66% (19/29) of cases with one false positive. These patients were given streptokinase. However, in these further identified AMI patients, 78% (7/9) had small enzyme rises with non-Q wave infarction and/or non-ST elevation and therefore may not have benefited from thrombolytic therapy in contrast to the Q wave/raised ST segment infarcts with large enzyme rises identified by clinical means. Enthusiasm for myoglobin estimation, where used as a discriminant for AMI, as a direct pointer to thrombolysis in the early diagnosis of AMI should be tempered by this finding.

The use of cytokine and C-reactive protein measurements in cerebrospinal fluid during acute infective meningitis

Cerebrospinal fluid (CSF) concentrations of C-reactive protein (CRP), tumour necrosis factor alpha (TNF), interleukin-6 (IL-6), total protein (TP) and white cell count with differential (WCC) have been measured in 24 patients presenting with acute bacterial or viral meningitis and also in a non-infected, non-inflamed control group (n = 24). In acute viral meningitis, CRP levels were not raised when compared to controls and there was a discordance between high levels of the primary inflammatory mediators (IL-6 and TNF) and the low measured CRP levels. CRP levels were raised in cases of bacterial meningitis. A concentration of 100 ng/mL CRP had a sensitivity of 87% for bacterial meningitis. TNF concentrations in the CSF were significantly raised in cases of acute bacterial meningitis (P < 0.001). Smaller but variable elevations were seen in the patients with acute viral meningitis. One patient, who succumbed to bacterial infection, showed low CSF levels of CRP, TNF and WCC but an elevated IL-6 concentration. Another, presenting with low CSF WCC, had raised concentrations of CRP, TNF and IL-6 which pointed to the correct diagnosis of acute bacterial meningitis. The development of methods yielding rapid analysis for these cytokines together with a sensitive assay for CRP in CSF would be a useful adjunct to conventional investigation.

Acute respiratory distress during caesarean section under spinal anaesthesia. A probable case of anaphylactoid reaction to Syntocinon

A case of life-threatening respiratory distress during a Caesarean section under spinal anaesthesia is reported. Possible causes of the event including anaphylactoid reactions and the methods of their diagnosis are discussed. The most likely cause of the episode was felt to be an anaphylactoid reaction to Syntocinon.

Body space measurements in the hyponatraemia of carcinoma of the bronchus: evidence for the chronic 'sick cell' syndrome?

Body space measurements using simultaneous multiple isotope dilution techniques were made in both hyponatraemic and normonatraemic patients with carcinoma of the bronchus and wasting, and compared with those in a group of normal volunteers. Both groups of patients showed osmolal loss from cells. The significance of these findings in relation to the development of hyponatraemia is discussed.

Ectopic release of GHRH and ACTH from an adenoid cystic carcinoma resulting in acromegaly and complicated by pituitary infarction

A 23 year old man presented with a tumour mass in the lung. Subsequent investigation showed ectopic secretion of adrenocorticotrophic hormone (ACTH) and growth hormone releasing hormone (GHRH) from an adenoid cystic carcinoma. The patient progressed to show the clinical effects of long term exposure to high blood levels of both growth hormone and cortisol. The case was complicated by pituitary infarction. The very high blood levels of ACTH, growth hormone (GH) and GHRH proved resistant to treatment with the somatostatin analogue, SMS 201-995, and a possible side effect of the drug is reported. To our knowledge this is the first reported case of ectopic hormone secretion by an adenoid cystic carcinoma.