An unconscious man with profound drug-induced hypoglycaemia

Introduction

Hypoglycaemia has been reported as an unusual complication of tramadol use and in a few cases of tramadol poisoning, but the exact mechanism is not known.

Case description

An ambulance crew was dispatched to an unconscious 46-year old man. A glucometer point-of-care measurement revealed a profound hypoglycaemia (1.9 mmol/L). Treatment with intravenous glucose was started and the patient was transported to the hospital. The patient had several episodes of pulseless electrical activity requiring cardiopulmonary resuscitation in the ambulance and upon arrival in the hospital. Despite continuous glucose infusion the hypoglycaemia was difficult to correct during the next few hours and the patient developed hypokalaemia. Further investigation to identify the cause of hypoglycaemia revealed that insulin and C-peptide were inappropriately raised. A toxicological investigation revealed the presence of tramadol and its metabolites in lethal concentrations. Also acetaminophen, ibuprofen and lormetazepam were present. Ethanol screening was negative (< 0.1 g/L) and no sulfonylurea were detected. The patient developed multiple organ failure, but eventually recovered.

What happened

The hypoglycaemia was caused by inappropriate stimulation of insulin secretion in a patient intoxicated with tramadol. The sudden hypokalaemia was caused by a massive intracellular shift of potassium in response to the hyperinsulinemia, triggered by the intravenous administration of glucose.

Main lesson

To our knowledge, we are the first to document a significant rise in endogenous insulin production in a hypoglycaemic patient presenting with tramadol intoxication. Our observation suggests that hyperinsulinemia could be the cause of the hypoglycaemia associated with tramadol use.

Gliotoxin and bis(methylthio)gliotoxin are not reliable as biomarkers of invasive aspergillosis

BACKGROUND

Invasive pulmonary aspergillosis (IPA) remains a life-threatening opportunistic infection, but can be difficult to diagnose. New biomarkers are therefore needed. Gliotoxin (GT), a secondary metabolite of Aspergillus fumigatus, and bis(methylthio)gliotoxin (bmGT), a degradation product of GT, have been proposed as potential biomarkers. However, these findings have yet to be confirmed.

OBJECTIVES

To identify the diagnostic potential of GT and bmGT in serum and bronchoalveolar lavage fluid (BALf) in haematology patients compared to galactomannan (GM).

MATERIALS AND METHODS

We prospectively collected culture supernatant, serum and BALf from patients with culture-positive IPA and measured GT and bmGT concentrations using ultra high-performance liquid chromatography-quadrupole time of flight mass spectrometry. Galactomannan was detected using a commercially available enzyme immunoassay.

RESULTS

We included 18 patients with proven (n = 6) and probable (n = 12) IPA, all with positive cultures for Aspergillus fumigatus. BmGT was only detected in serum from one patient (5.6%), whereas GM was positive (optical density ≥ 0.5) in 11/18 patients (61.1%, P = 0.002). We could not find GT in any serum sample. In BALf, bmGT was detected in 8/18 patients (44.4%) and GT in 9/18 patients (50%), compared to GM (optical density ≥ 1.0) in all patients (100%).

CONCLUSIONS

Gliotoxin and bis(methylthio)gliotoxin had a very poor performance for diagnosing IPA. As other biomarkers are more sensitive and easier to detect, we would not recommend serum or BALf GT/bmGT to be used in the diagnosis of IPA.

An abrupt rise of coagulation error messages on ACL TOP automated analysers

Introduction

Blood coagulation tests (BCT) are very important for clinicians to diagnose bleeding or thrombotic disorders and to monitor anticoagulant therapy.

Case description

On a Saturday morning, a laboratory technician noted an abrupt rise in the number of coagulation error messages on our ALC TOP analysers. Visual inspection revealed the presence of partially and/or fully clotted citrate tubes and prompted the clinical biologist to further investigate a potential preanalytical cause.

Considered causes

Partially or fully clotted blood in citrate tubes can have multiple causes including improper mixing of the tube, under- or overfilling or combining blood samples from different tubes into one citrate tube.

What happened

The affected citrate tubes originated mostly from the same clinical departments. Moreover, all the affected tubes shared the same lot number (1 of 7 in use at the time). Visual inspection of 7 unopened boxes of 100 citrate tubes of this lot number revealed one box with nine completely empty and two partially filled tubes and one box with two partially filled tubes. No under-filled tubes were found in the other 5 boxes.

Discussion

The blood to additive ratio is crucial for BCT. A sudden rise in clot errors should trigger a thorough investigation to identify the cause.

Main lesson

Laboratories should regularly monitor and evaluate the percentage of clotted samples as a quality indicator at scheduled time points. A problem with the volume of additive in citrate tubes should be considered as a possible cause.

Hemoglobin S monitoring on TOSOH G8 in hemoglobin A1c mode in case of urgent red blood cell exchange

BACKGROUND

Pre- and post-transfusion hemoglobin S (HbS) levels are used to document the efficacy of red blood cell exchange (RCE) in patients with sickle cell disease (SCD). In case of urgent RCE a 24/7 short turn-around time (STAT) analysis, with the ability to identify and quantify HbS, is warranted. The use of TOSOH G8 (Tosoh Europe) is evaluated for this purpose, using the variant HbA1c mode.

METHODS

Analytical performance of the HbS analysis on TOSOH G8 in variant HbA1c mode was evaluated, including assessment of imprecision and linearity for HbS. In addition, a comparison study between TOSOH G8 and Minicap Flex Piercing (FP) system CZE (Sebia) using 32 HbS samples (HbS range: 9%-93%) was carried out to evaluate analytical and clinical concordance.

RESULTS

Total HbS imprecision was 1.77% and 0.31% for a sickle cell trait and a sickle cell anemia sample, respectively. An acceptable linearity (HbS range: 6%-88%) was observed (R²  > .99). Passing-Bablok regression analysis showed a significant proportional bias; however, a good analytical concordance (r > .95) was found. Our results suggested that TOSOH G8 underestimated HbS results compared with those of Minicap FP system (mean difference: -3.54%), especially in samples with a high HbS concentration.

CONCLUSION

Hemoglobin S results obtained with TOSOH G8 in variant HbA1c mode are clinically acceptable to monitor urgent RCE. The observed underestimation will not alter clinical decision-making.

Aberrant glycated haemoglobin (HbA1c) results leading to haemoglobinopathy diagnosis in four Belgian patients

INTRODUCTION

We report four cases in which haemoglobinopathy screening was triggered following aberrant HbA1c analysis. Either the HbA1c assay was unable to produce a quantifiable result or it showed the presence of an extra fraction and/or the result was discordant with the clinical context.

CASE REPORT

In the reported four patients, all from Caucasian, Belgian descent, Hb analysis was performed using cation-exchange high performance liquid chromatography. If necessary, additional Hb electrophoresis was carried out to establish a preliminary (biochemical) diagnosis. Definitive diagnosis was obtained for every sample through DNA-analysis. Three patients were carriers of Hb J-Toronto and one of Hb Stanleyville-II.

DISCUSSION

This report underlines the importance of correct interpretation of HbA1c results to avoid mismanagement of (diabetic) patients. Since neither the RBC indices, the clinical context, nor the ethnicity of these patients was suspicious for an underlying haemoglobinopathy, the aberrant HbA1c result was the only indicator for further investigation. Laboratory personnel and clinicians should be aware of the possibility of uncommon, sometimes clinically unsuspected, Hb variants to cause aberrant HbA1c values, even in populations with low prevalence for haemoglobinopathies. Further analysis should be prompted to obtain definitive diagnosis. Alternative methods for monitoring glycaemic control should be used.

Evaluation of the Sebia Minicap Flex Piercing capillary electrophoresis for hemoglobinopathy testing

INTRODUCTION

Capillary zone electrophoresis (CZE) at alkaline pH is one of the techniques used for hemoglobinopathy screening. In this study, an evaluation of the performance of a lower throughput CZE instrument, the Sebia Minicap Flex Piercing system, for this purpose is reported for the first time.

METHODS

The analytical performance of the Sebia Minicap Flex Piercing system was evaluated. Furthermore, a method comparison between the Sebia Minicap Flex Piercing and two HPLC methods, that is, the Bio-Rad Variant Classic(™) and the Bio-Rad D-10(™) systems was performed by measuring samples with and without clinically relevant hemoglobin disorders.

RESULTS

The analytical performance was acceptable for the determination of HbA, HbA2, HbS, and HbF, with an imprecision ≤2.0%. Method comparison showed a linear correlation for HbA2, HbF, and HbS measurements. Clinical concordance was acceptable when comparing CZE and HPLC.

CONCLUSIONS

Lower throughput CZE using the Sebia Minicap Flex Piercing can be used for precise and accurate first line screening and follow-up of hemoglobinopathies.

Deproteination of whole blood for LC-MS/MS using paramagnetic micro-particles

OBJECTIVES

Liquid chromatography tandem mass spectrometry has become increasingly popular in clinical laboratories over the last decade due to the inherent sensitivity and specificity of the technology. Nevertheless, full automation and hence application in routine laboratories is still hampered by laborious and difficult-to-automate sample pre-treatment protocols. Functionalized paramagnetic micro-particles could simplify sample pre-treatment and ease automation. We evaluated the applicability of a pre-commercial, straightforward paramagnetic micro-particle based kit for the lysis and deproteination of whole blood for the LC-MS/MS analysis of everolimus and compared the performance to our routine protein precipitation method.

DESIGN AND METHODS

Samples were prepared for LC-MS/MS everolimus analysis on an Acquity UPLC chromatographic system coupled to a TQD mass spectrometer (both Waters Ltd.) using a pre-commercial MagSi-TDMprep kit and a routine protein precipitation respectively. Both pre-treatment methods were validated for imprecision, accuracy, linearity, limit of quantification, matrix effect, recovery and process efficiency. A method comparison (n=63) between both pre-treatment methods was performed.

RESULTS

Imprecision and bias were within pre-defined criteria (15%) for both pre-treatment methods. Both methods were linear from 1.2 to 14.8μg/L with a limit of quantification of 0.6μg/L. Process efficiency was on average 65% for protein precipitation pre-treatment and was substantially higher for the MagSi-TDMprep method (85%). A Passing-Bablok regression showed no significant difference between the two pre-treatment methods.

CONCLUSION

For everolimus in whole blood, the MagSi-TDMprep sample pre-treatment was applicable and comparable to protein precipitation for LC-MS/MS with the possible advantage of easier automation.

Ecstasy intoxication as an unusual cause of epileptic seizures in young children

In light of the widespread use of ecstasy, it is surprising that only few cases of intoxicated young children have been reported. Patients almost invariably present with convulsions accompanied by sympathetic signs and symptoms such as hyperthermia. Two new cases of toddlers intoxicated with ecstasy are described. The first patient, a 19-month-old boy, presented with convulsions but no sympathetic signs. The pediatrician's suspicion was raised because of the absence of a postictal state. The second patient, a 20-month-old girl, had a more typical presentation with convulsions and hyperthermia. Her story illustrates the fact that immunoassays for toxicological screening can easily miss traces of additional illicit drugs present in the urine such as cocaine. The presence of other illicit drugs provides clues to the child's risky environment and should lead to further investigation. Finally, we review the available literature on ecstasy intoxication to summarize the key presenting manifestations.

Copper deficiency in patients with cystinosis with cysteamine toxicity

OBJECTIVES

To assess whether copper deficiency plays a role in the recently described cysteamine toxicity in patients with cystinosis, and to examine whether polymorphisms in copper transporters, lysyl oxidase, and/or type I procollagen genes could be responsible for the occurrence of cysteamine toxicity in a small subset of patients with cystinosis.

STUDY DESIGN

Thirty-six patients with cystinosis were included: 22 with Fanconi syndrome (including 7 with cysteamine toxicity), 12 after renal transplantation, 1 receiving hemodialysis, and 1 with ocular cystinosis. Serum copper and ceruloplasmin levels and urinary copper/creatinine ratio were measured. Genes ATP7A and CTR1 (encoding copper transporters), LOX (encoding lysyl oxidase), and COL1A1 and COL1A2 (encoding type I procollagen) were analyzed in patients with (n = 6) and without (n = 5) toxicity. Fibroblast (pro)collagen synthesis was compared in patients with (n = 3) and those without (n = 2) cysteamine toxicity.

RESULTS

All 22 patients with Fanconi syndrome had increased urinary copper excretion. Serum copper and ceruloplasmin levels were decreased in 9 patients, including all 7 patients with cysteamine toxicity. No specific sequence variations were associated with toxicity. All fibroblasts exhibited normal (pro)collagen synthesis.

CONCLUSION

Patients with cystinosis with cysteamine toxicity demonstrate copper deficiency. This can cause decreased activity of lysyl oxidase, the enzyme that generates the aldehydes required for collagen cross-linking. Thus, copper supplementation might prevent cysteamine toxicity.

Ethylene glycol poisoning presenting with a falsely elevated lactate level

Early diagnosis of ethylene glycol poisoning is crucial in order to prevent morbidity and mortality. However, diagnosis can sometimes be delayed because of the false elevation of lactate in some chemistry analyzers as a result of the interference of glycolate, a metabolite of ethylene glycol. We present a case of ethylene glycol poisoning presenting with a falsely elevated lactate level on a blood gas analyzer in the emergency department. Given the fact that nowadays there is a marked increase in use of point-of-care analyzers, one should be aware of possible false readings since they use different methods of measuring compared with clinical chemistry analyzers. On the other hand, measuring a "lactate gap" using two different technologies, only one of which is sensitive to glycolate, could be a clinically efficient way to make the diagnosis of advanced ethylene glycol poisoning in the emergency department or other critical care setting.

Profiling the spatial concentration of allethrin and piperonyl butoxide using passive sorptive sampling and thermal desorption capillary GC-MS

Spatial concentration distribution of a chemical in an indoor environment is an important factor in the evaluation of chemical nuisances. However, straightforward techniques for the determination of this distribution are not very common and usually limited in their application. Sorptive sampling using polydimethylsiloxane-coated stir bars and the combination of active and diffusive sampling were shown to allow uncomplicated spatial concentration profiling of multiple compounds in an indoor environment. The validity of the approach was demonstrated in the analysis of the spatial concentration distribution of a pyrethroid insecticide in a common bedroom. The relative concentrations of allethrin and piperonyl butoxide were profiled throughout the room upon the application of an insecticide vaporizer.

Domestic sampling: exposure assessment to moth repellent products using ultrasonic extraction and capillary GC-MS

Moth repellent agents are considered major contributors to indoor air pollution. In this study, the chemical contamination of clothes due to their direct or indirect exposure to moth repellent agents such as p-dichlorobenzene, naphthalene and camphor were investigated. Cotton cloths were used as clothing simulant. They were analyzed using ultrasonic extraction followed by GC-MS analysis. Extrapolated results indicate that a regular cotton shirt indirectly exposed to these chemicals in a storage cabinet can contain up to 7, 3 and 7.5mg of p-dichlorobenzene, naphthalene and camphor, respectively, even after one-hour of airing. Passive sorptive sampling using polydimethylsiloxane-coated stir-bars and ultrasonic extraction followed by GC-MS analysis was used to monitor the concentration distribution in a wardrobe.

Safety of alternative medicines reconsidered: lead-induced anaemia caused by an indian ayurvedic formulation

We report two cases of Belgian women diagnose with a lead poisoning. Both patients presented with abdominal pain and a normochromic normocytic anaemia. The diagnosis was based on the clinical symptoms, the anaemia, the basophilic stippling of erythrocytes and the elevated blood lead level Upon further questioning, both patients reported the use of Ayurvedic medications. Toxicological analysis of the different pills revealed that, in both, the same orange-red pills contained a remarkably high amount of lead. Cases of lead poisoning associated with the use ofAyurvedic formulations are emerging around the world. However, to our knowledge, these are the first reported cases in Belgium.

Determination of polydimethylsiloxane-air partition coefficients using headspace sorptive extraction

Polydimethylsiloxane-air partition coefficients (K(PDMS-A)) were determined using direct headspace analysis and headspace sorptive extraction (HSSE) with polydimethylsiloxane-coated (PDMS) stir bars. The partition coefficients were investigated for three compounds, p-dichlorobenzene (PDCB), naphthalene and camphor, all of which sublimate at room temperature and find use as moth repellents. In order to determine the K(PDMS-A) values of these compounds, the air concentration and the concentration present on PDMS, both at equilibrium, were measured. The results indicate that PDMS-air partition coefficients are proportional to octanol-air partition coefficients. Thus, the latter could be used to estimate the extraction efficiency of PDMS for these compounds in air. Alternatively, octanol-air partition coefficients for organic compounds could be estimated from the PDMS-air partition coefficient values. As expected, the PDMS-air (or octanol-air) partition coefficient increased with decreasing temperature. Importantly, the partition coefficients determined at saturated vapor pressures were lower than the values determined at lower analyte concentrations, with the differences being greater for compounds with larger partition coefficients. Consequently, caution should be exercised when applying K(PDMS-A) values determined at high analyte concentrations to measurements at lower concentrations, especially when the partition coefficients are large.

Species identification of corynebacteria by cellular fatty acid analysis

We evaluated the usefulness of cellular fatty acid analysis for the identification of corynebacteria. Therefore, 219 well-characterized strains belonging to 21 Corynebacterium species were analyzed with the Sherlock System of MIDI (Newark, DE). Most Corynebacterium species have a qualitative different fatty acid profile. Corynebacterium coyleae (subgroup 1), Corynebacterium riegelii, Corynebacterium simulans, and Corynebacterium imitans differ only quantitatively. Corynebacterium afermentans afermentans and C. coyleae (subgroup 2) have both a similar qualitative and quantitative profile. The commercially available database (CLIN 40, MIDI) identified only one third of the 219 strains correctly at the species level. We created a new database with these 219 strains. This new database was tested with 34 clinical isolates and could identify 29 strains correctly. Strains that remained unidentified were 2 Corynebacterium aurimucosum (not included in our database), 1 C. afermentans afermentans, and 2 Corynebacterium pseudodiphtheriticum. Cellular fatty acid analysis with a self-created database can be used for the identification and differentiation of corynebacteria.

Determination of bromophenols as dioxin precursors in combustion gases of fire retarded extruded polystyrene by sorptive sampling-capillary gas chromatography–mass spectrometry

Extruded polystyrene (XPS) is often treated with hexabromocyclododecane (HBCD) as fire retardant (FR). Because of its aliphatic structure, HBCD is not suspected to cause formation of polybrominated dioxins upon combustion. Precursors of polybrominated dioxins, namely bromophenols, were detected during tubular furnace combustion experiments of FR-XPS in combination with sorptive enrichment on polydimethylsiloxane followed by on-line thermal desorption-capillary GC/MS. The highest concentration of mono- and tribromophenols detected were 85.9 and 3.7 mg kg(-1), respectively, at a temperature of 700 degrees C, while a temperature of 500 degrees C yielded the highest concentration of dibromophenols namely 10.4 mg kg(-1). At a combustion temperature of 900 degrees C no bromophenols were detected.

Determination of the enantiomerization energy barrier of some 3-hydroxy-1,4-benzodiazepine drugs by supercritical fluid chromatography

The first-order kinetic equation for irreversible reactions was used to determine the enantiomerization barrier of some of 3-hydroxy-1,4-benzodiazepine enantiomers by supercritical fluid chromatography (SFC). The racemates of lorazepam, oxazepam and temazepam were separated by SFC on chiral (R,R)-Whelk-O1 column with supercritical carbon dioxide containing 12.5% methanol and 0.5% diethylamine as a mobile phase. Peak areas of enantiomers prior to (A(A0), A(B0)) and after the separation (A(A), A(B)), used for calculation of the enantiomerization barrier, were determined by computer-assisted peak deconvolution of peak clusters from the chromatograms. It was demonstrated for the first time that using a model for a four-peak cluster produces height precise results, and most closely approximates the published results. The kinetic equation for irreversible reactions was used to determine apparent enantiomerization rate constants. The dependence of the apparent enatiomerization barrier (deltaG(app)(A-->B), deltaG(app)(B-->A)) on temperature was used to determine apparent activation enthalpy (deltaH(app)(R-->S), deltaH(app)(S-->R)) and entropy (deltaS(app)(R-->S), deltaS(app)(S-->R)) for all studied benzodiazepines.

Evaluation of reversible and irreversible models for the determination of the enantiomerization energy barrier for N-(p-methoxybenzyl)-1,3,2-benzodithiazol-1-oxide by supercritical fluid chromatography

It has been found that the interconversion of enantiomers on a chromatographic column during the separation process can be studied by the first-order kinetic equations derived both for reversible and irreversible reactions in a stationary system if the extent of interconversion is not too high. The equation derived for irreversible reactions gives, however, results also for higher degrees of enantiomerization while that derived for reversible interconversion failed. The irreversible equation was used to determine the enantiomerization barrier of N-(p-methoxybenzyl)-l,3,2-benzodithiazol-l-oxide enantiomers by supercritical fluid chromatography. The racemate of N-(p-methoxybenzyl)-l,3,2-benzodithiazol-l-oxide was separated by supercritical fluid chromatography on the (R,R)-Whelk-Ol column with supercritical carbon dioxide containing 20% methanol as a mobile phase. Peak areas of enantiomers prior to and after the separation used for the calculation of the enantiomerization barrier were determined by computer-assisted peak deconvolution of peak clusters registered on chromatograms using commercial software.

Stir bar sorptive extraction-thermal desorption-capillary GC-MS applied to biological fluids

A new sample preparation method, stir bar sorptive extraction (SBSE), has been evaluated for the enrichment of organic solutes from biological fluids such as urine and blood. In SBSE, a stir bar coated with a polydimethylsiloxane layer is stirred for a given time in the sample. After sampling the stir bar is placed in a thermal desorption unit coupled on-line to capillary gas chromatography-mass spectrometry (SBSE-TD-CGC-MS). The principle and operation of SBSE are presented. Total profiling and target compound analysis have been selected as applications to illustrate the performance of SBSE-TD-CGC-MS (MSD). It is demonstrated that a variety analytes ranging from biological markers (phenols, hormones, fatty acids) to artificial contaminants (recreational drugs, plasticizers) can be enriched with high sensitivity. For polar solutes, in-situ derivatization can enhance both recovery into the polydimethylsiloxane (PDMS) layer and chromatographic analysis. Two types of derivatization have been applied, derivatization with ethyl chloroformate and with acetic acid anhydride. Linearity, detectability, and repeatability are illustrated by the determination of 1-hydroxypyrene in a urine sample from a smoker.

Asymmetric Induction in Intramolecular meta Photocycloaddition: Cyclodextrin-Mediated Solid-Phase Photochemistry of Various Phenoxyalkenes

[reaction: see text]. An approach to the asymmetric intramolecular meta photocycloaddition of phenoxyalkenes is described. The beta-cyclodextrin complexes of several phenoxyalkenes have been synthesized and irradiated in the solid phase. The effect of the CD-hosting on the regio- and enantioselectivity is discussed. Values of ee up to 17% were obtained.

Prevalence of genotypic resistance among antiretroviral drug-naive HIV-1-infected patients in Belgium

OBJECTIVES

To estimate the prevalence and the evolution over time (1995-1998) of genotypic resistance to antiviral drugs in antiretroviral drug-naive HIV-1-infected patients in Belgium.

DESIGN

Belgian Aids Reference Laboratories provided retrospective samples and clinical data from antiretroviral drug-naive HIV-1-infected patients who visited the hospital for the first time in 1995 (n=45), 1997 (n=75) and 1998 (n=111). Genotypic resistance to the three available classes of drugs was monitored using the Line Probe Assay (Innogenetics, Gent, Belgium). Additionally, ARMS-151 was performed for scoring multinucleoside resistance.

RESULTS

The prevalence of genotypic resistance at baseline to nucleoside analogue reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) were each between 10% and 20% for 1995, 1997 and 1998 without an increasing trend over time. For NRTIs, resistance mutations were mainly related to zidovudine in 1995, whereas in 1997 and 1998 baseline resistance was scored for zidovudine, lamivudine or for both drugs simultaneously. No patients displayed the multi-nucleoside resistance Q151M mutation. Baseline resistance mutations to protease inhibitors (PIs) did not rise significantly: 4.4% in 1995, 8% in 1997 and 9.9% in 1998. When scoring any resistance-related mutation, 26.6% displayed genotypic baseline resistance in 1995, 26.6% in 1997 and 31.5% in 1998.

DISCUSSION

The prevalence of genotypic baseline resistance to any drug, as scored with LiPA, in naive HIV-1 patients in Belgium is 29%, with baseline resistance mutations to one or several drugs from all available classes of antiviral drugs. The ability of LiPA to pick up minor variants could be an explanation for the higher overall prevalence we observe, when compared to recent estimates in other countries of 16.3% and 22%, which were based on sequencing methods. According to the European guidelines for resistance testing, resistance testing in Belgium before starting antiviral therapy should be considered.

Prevalence of Genotypic Resistance among Antiretroviral Drug-Naive HIV-1-Infected Patients in Belgium

Objectives

To estimate the prevalence and the evolution over time (1995–1998) of genotypic resistance to antiviral drugs in antiretroviral drug-naive HIV-1-infected patients in Belgium.

Design

Belgian Aids Reference Laboratories provided retrospective samples and clinical data from antiretroviral drug-naive HIV-1-infected patients who visited the hospital for the first time in 1995 ( n=45), 1997 ( n=75) and 1998 ( n=111). Genotypic resistance to the three available classes of drugs was monitored using the Line Probe Assay (Innogenetics, Gent, Belgium). Additionally, ARMS-151 was performed for scoring multinucleoside resistance.

Results

The prevalence of genotypic resistance at baseline to nucleoside analogue reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) were each between 10% and 20% for 1995, 1997 and 1998 without an increasing trend over time. For NRTIs, resistance mutations were mainly related to zidovudine in 1995, whereas in 1997 and 1998 baseline resistance was scored for zidovudine, lamivudine or for both drugs simultaneously. No patients displayed the multi-nucleoside resistance Q151M mutation. Baseline resistance mutations to protease inhibitors (PIs) did not rise significantly: 4.4% in 1995, 8% in 1997 and 9.9% in 1998. When scoring any resistance-related mutation, 26.6% displayed genotypic baseline resistance in 1995, 26.6% in 1997 and 31.5% in 1998.

Discussion

The prevalence of genotypic baseline resistance to any drug, as scored with LiPA, in naive HIV-1 patients in Belgium is 29%, with baseline resistance mutations to one or several drugs from all available classes of antiviral drugs. The ability of LiPA to pick up minor variants could be an explanation for the higher overall prevalence we observe, when compared to recent estimates in other countries of 16.3% and 22%, which were based on sequencing methods. According to the European guidelines for resistance testing, resistance testing in Belgium before starting antiviral therapy should be considered.

Inhibition of acetylcholine esterase and choline esterase by benzethonium chloride and avoidance of the benzethonium chloride carry-over inhibitory effect

It has been shown that benzethonium chloride produces linear mixed-type inhibition of choline esterase and acetylcholine esterase. These enzymes also show-reagent-carry-over inhibition if the enzyme activities are measured in plastic cuvettes in which previously protein has been determined by the alkaline benzethonium chloride method. Choline esterase is about 10-fold more sensitive to benzethonium chloride than acetylcholine esterase. With acetylthiocholine as substrate Michaelis-Menten constants for choline esterase and acetylcholine esterase are 85 mumol/l and 102 mumol/l, respectively. Carry-over inhibitory effect of benzethonium chloride can be avoided by washing the cuvettes, after protein determination by the benzethonium chloride method, with 5 ml/l Triton X-100, 5 ml/l Tween 20 or 10 g/l sodium dodecyl sulphate. The latter has a disadvantage in that it precipitates out at low temperatures. The dry slide method (Johnson & Johnson) for serum choline esterase is free of the inhibitory effect until the concentration of benzethonium chloride in the sample reaches about 200 mumol/l.

Quantitation of paraquat in serum by HPLC

An HPLC method for the quantitation of paraquat in urine was applied to serum. Sample preparation consisted of ion-pair extraction on disposable cartridges of end-capped octadecyl silica. The paraquat thus extracted, was quantitated by HPLC using 1,1'-diethyl-4,4'-dipyridyl dichloride as an internal standard. Relatively small sample volumes (1 mL serum) were required. Within- and between-assay coefficients of variation for the HPLC technique were 2.9% and 4.0%, respectively, at low paraquat serum concentration (0.4 microgram/mL), and 2.4% and 3.2% at high paraquat serum concentration (4.0 micrograms/mL). The between-assay coefficient of variation for the total procedure, including the extraction, was 5.6% at low concentration (0.4 microgram/mL). Serum concentration levels down to 0.025 microgram/mL could be quantitated. The technique was checked for interference from muscle relaxants (pancuronium bromide and vecuronium bromide) and from anticoagulants (heparin and K2EDTA). No interference was observed.

Diminished sedation during diazepam treatment for chloroquine intoxication

We report a case of a woman hospitalized after chloroquine overdose whose whole blood concentration on admission was 7.87 micrograms/ml. High blood concentrations of chloroquine induce cardiotoxicity and have been associated with death when they exceed 3.0 micrograms/ml. Early administration of massive doses of diazepam has been described to reduce the mortality due to chloroquine toxicity, but the protective mechanism has remained unknown. This patient was treated with diazepam (2.0 mg/kg over 30 min followed by a dosage of 1.0 to 2.0 mg/kg over 24 h), yet she remained awake despite the high plasma concentrations of diazepam and nordiazepam which would normally be associated with sedation. This suggests an antagonistic effect of chloroquine on the benzodiazepine-induced sedation due to an interaction between these drugs at their site of action.