A retrospective study of mushroom poisoning in Iran

The objective of this study was to describe the pattern of mushroom poisoning in adults admitted to the Loghman Hakim Hospital Poison Center from 1992 to 2002. All patients ≥ 12 years of age were included in the study. The frequency of mushroom poisoning with respect to age, sex, season, reason, place of residence, latent phase, clinical and laboratory findings, treatment, and outcome of patients was investigated. Of the 72 421 poisoning cases admitted to Loghman-Hakim Hospital Poison Center from 1992 to 2002, only 37 were poisoned by consumption of toxic mushrooms. As some of the patients' files were incomplete, only 25 files were included in the study. Of this number, 68% were male. The patients' age ranged between 12 and 65 years, with a mean of 31 years of age. All cases were accidental and mostly from Tehran (36%) and the northern provinces (rainy woodlands) of Iran (32%). Autumn was the most common season for poisoning with a frequency of 80%. The latent phase of poisonings was between 0.5 and 12 hours. The most frequently reported symptoms were vomiting (84%), nausea (60%), abdominal pain (60%) and diarrhea (40%). Jaundice was observed in 44% of cases, with a 50% rate of hepatic encephalopathy. A total of 66% of patients were discharged and the duration range of hospitalization was 1-12 days.

In conclusion, people should be more informed of the dangers posed by wild mushrooms. Training of physicians and nurses in the accurate diagnosis and management of patients poisoned with poisonous mushrooms would improve the rate of survival.

A simplified acute physiology score in the prediction of acute organophosphate poisoning outcome in an intensive care unit

Organophosphate poisoning (OPP) occurs frequently and accounts for a large number of intoxication cases treated in intensive care units (ICU). Poisoning by these agents is a serious public health problem. Among pesticides, OPs are the main cause of poisoning and death in Loghman-Hakim Poison Center of Tehran, Iran. The aim of this study was to determine the impact of the Simplified Acute Physiology Score (SAPS II) in the prediction of mortality in patients with acute OPP requiring admission to the ICU of Loghman-Hakim Hospital Poison Center over a period of 12 months. This study was a prospective, case-control of records of patients with acute OPP admitted to the ICU between January 2006 and December 2006. The Demographic data were collected and SAPS II score was recorded. During the study period, 24 subjects were admitted to the ICU with acute OPP. All 24 patients (15 male) required endotracheal intubation and mechanical ventilation in addition to gastric decontamination and standard therapy with atropine and oximes and adequate hydration. Of these, 24 patients, eight (five male) died. SAPS II score was significantly higher in the non-survival group than the survival group. Mortality following acute OPP remains high despite adequate intensive care and specific therapy with atropine and oximes. One-third of the subjects needing intensive care die within the hospitalization period. SAPS II scores calculated within the first 24 hours were recognized as good prognostic indicator among patients with acute OPP that required ICU admission. It is concluded that SAPS II score above 11 within the first 24 hours is a predictor of poor outcome in patients with acute OPP requiring ICU admission. Human & Experimental Toxicology (2007) 26, 623—627

Blood β-glucuronidase as a suitable biomarker at acute exposure of severe organophosphorus poisoning in human

Organophosphorus compounds are known to cause the selective release of liver microsomal β-glucuronidase into plasma. Organophophoruses may induce nitrosative stress leading to the generation of nitrogen free radicals and alterations in scavengers of free radicals in many biological systems. In this study, we investigate how acute human organophosphorus intoxication is associated with changes of blood nitric oxide, total thiol molecules, and activities of the acetylcholinesterase and β-glucuronidase. A total of 21 acute organophosphorus-poisoned patients were recruited into study and were divided into two groups of mildly (13) and severely affected (9); 26 age-matched healthy volunteers were recruited as control group. Results indicated that both mildly and severely affected patients had lower acetylcholinesterase activities as compared to controls. The extent of acetylcholinesterase reduction in the severely affected patients was higher than that of mildly affected patients. A significant increase in serum β-glucuronidase was observed only in severely affected patients as compared to controls. Both mildly and severely affected patients had lower plasma total thiol molecules as compared to controls. The extent of reduction of total thiol molecules in the severely affected patients was higher than that of mildly affected patients. No significant difference was observed in plasma total nitric oxide of controls and patients. It is concluded that nitrosative stress has a minor role in toxicity of organophosphorus, whereas blood β-glucuronidase is very sensitive biomarker at high exposure of severe organophosphorus poisoning.

Acute inhalation exposure to titanium ethanolate as a possible cause of metal fume fever

Occupational inhalation exposure to noxious agents is not uncommon. Herein, we present a 26-year-old male student who had accidental acute inhalation exposure to a large quantity of titanium ethanolate and hydrogen chloride in chemistry lab. He was referred to the emergency department of our hospital with low-grade fever, dyspnea, headache, fatigue and myalgia. After 24 hrs of symptomatic treatment (oxygen therapy and acetaminophen), the fever was subsided and the patient discharged home in a good clinical condition. The presented symptoms could be interpreted as a form of metal fume fever. It can therefore be concluded that organo-metallic compound of titanium metal may have the potential to produce metal fume fever in human.

Intestinal obstruction in acute inhalational toluene 2,4-diisocyanate gas toxicity

The isocyanates are widely used as precursors of polyurethane products, as well as carbamate insecticides. Toluene 2,4-diisocyanate (TDI) is one of the most important commercially used isocyanates. Humans may be exposed to TDI by inhalation, ingestion, dermal and eye contact. TDI is a powerful irritant to the mucosal membranes of the gastrointestinal and respiratory tracts, eyes and the skin. Pulmonary manifestations, especially occupational asthma, are the predominant manifestations after TDI toxicity. Herein, we present intestinal obstruction as an extraordinary manifestation of acute TDI toxicity after occupational exposure. TDI toxicity may cause intestinal obstruction.

Effectiveness of fresh frozen plasma as supplementary treatment in organophosphate poisoning

With the establishment of the inadequate efficiency of atropines and oximes in reducing morbidity and mortality of patients poisoned by organophosphates, more attention is given to using other methods such as Fresh Frozen Plasma (FFP) as a bioscavenger to mop up organophosphate toxins. This randomized clinical trial was conducted on 56 organophosphate poisoned patients who were randomly assigned to the FFP and control groups in order of admission. The routine treatment in both groups included atropine and, in moderate to severe cases of poisoning, pralidoxime. The FFP group received four packs of FFP as stat dose at the beginning of treatment. No significant difference was seen between the two groups on the atropine and pralidoxime dosage, hospitalization length and mortality. The present study showed that using four packs of FFP as stat dose at the onset of treatment had no significant effect on the clinical course of organophosphate poisoned patients.

Antidepressant self-poisonings in iran

Introduction

Tricyclic antidepressants (TCAs) are more likely to cause cardiovascular and neurological toxicity than compared to Selective Serotonin Reuptake Inhibitors (SSRIs).

Objectives

In a prospective hospital-based cohort study, we addressed the question of severity and outcome of antidepressant self-poisonings in patients who attended the Loghman-Hakim Hospital Poison Center. The severity was judged by impairment of consciousness, the outcome criteria were the requirement of inpatient treatment and endotracheal intubation as well as mortality. The aim of the study was to find out if TCA intoxications require more therapeutic efforts than SSRI intoxications.

Methods

From 28 March to 20 May 20 2006, all patients presented to the Poison Center were documented using preformatted forms by three trained nurses blinded to any study hypotheses. From 3.578 intoxications, a number of 334 patients with antidepressant or lithium self-poisoning was identified (9.3% of all poisoning cases; 233 females, 101 males; median age 24 years, min 13, max 70).

Results

As compared to SSRI single-substance intoxications (n = 17), TCA single-substance intoxications (n = 73) were associated with (1) a significantly lower level of consciousness (p = 0.005); (2) a significantly higher admission frequency (80.8% vs. 35.3%; p < 0.001) and (3) a higher intubation frequency (13.7% vs. 0%; p = ns). SSRI multiple-substance intoxications were associated with a significantly lower level of consciousness than SSRI single-substance intoxications (p = 0.042), while there was no significant difference between TCA multiple- and single-substance intoxications.

Conclusions

This study suggests that an overdose with SSRIs results in a more favorable clinical outcome than an overdose with TCAs.

A retrospective 7-years study of aluminum phosphide poisoning in Tehran: opportunities for prevention

The objective of this study was to survey aluminum phosphide (AIP) poisoning in a referral poisoning hospital in Tehran servicing an estimation of 10,000,000 populations. Records of all patients admitted and hospitalized during a period of 7 years from January 2000 to January 2007 were collected and analyzed according to gender, age, cause of intoxication, amount of AIP consumed, route of exposure, time between exposure and onset of treatment, signs and symptoms of intoxication at admission, therapeutic intervention, laboratory tests, and outcome. During the studied years, 471 patients were admitted to the hospital with AIP poisoning; 50% of them were men. The overall case fatality ratio was 31%. The mean age was 27.1 years, and most of the patients were between 20 and 40 years old. Self-poisoning was observed in 93% of cases. The average ingested dose was 5.1 g, and most of the patients (73%) consumed 1-3 tablets of AIP. A wide range of symptoms and signs was seen on admission, but the most common one was cardiovascular manifestations (78.12%). The majority (65%) of patients were from Tehran. Poisoning in spring and winter (34% and 24%, respectively) was more common than other seasons. Gastric decontamination with potassium permanganate, and administration of calcium gluconate, magnesium sulfate, sodium bicarbonate, and charcoal were considered for most of the patients. Mean arterial blood pH was 7.23 and bicarbonate concentration was 12.7 mEq/L. One-hundred percent of patients with blood pH <7 died and 100% of patients with blood pH >or= 7.35 survived. Electrocardiogram (EKG) abnormalities were noted in 65.6% of cases. There was a significant difference between survival and non-survival according to pH, HCO(3) concentration, and EKG abnormality. Even without an increase in resources, there appears to be significant opportunities for reducing mortality by better medical management and further restrictions on the AIP tablets usage. Arterial blood pH seems to be a prognostic factor for the outcome of AIP-poisoned patients.

Tramadol intoxication: a review of 114 cases

Tramadol as a centrally acting analgesic is extensively used in the management of moderate to severe pain. It slightly affects opioid receptors and inhibits the reuptake of norepinephrin and serotonin in the CNS. There are reports about toxicity and abuse of tramadol. The objective of the present study was to evaluate epidemiology of intentional tramadol intoxications. All poisoning cases that admitted to Loghman-Hakim Hospital Poison Center from April to May 2007 were studied. A total of 114 cases (82 men and 32 women) of intentional tramadol intoxications with the median age of 23.66 +/- 6.87 years (range 16-54 years) were identified. Other illicit drugs were found to be used in combination with tramadol in some of the cases, which among them benzodiazepines were the most common. Tramadol overdose has been one of the most frequent causes of drug poisoning in the country in the recent years, especially in male young adults with history of substance abuse and mental disorders. Nausea, vomiting, Central Nervous System (CNS) depression, tachycardia, and seizure are the most common findings in this kind of poisoning. Cardiopulmonary arrest was found as the cause of death in cases who had ingested more than 5000 mg tramadol.

Hyperglycemia in acute aluminum phosphide poisoning as a potential prognostic factor

Aluminum phosphide (AlP) is a solid fumigant widely used in Iran as a grain preservative. When reacted with water or acids, AIP produces phosphine gas, a mitochondrial poison that interferes with oxidative phosphorylation and protein synthesis. Poisoning by AIP is one of the most important causes of fatal chemical toxicity in Iran. There are few studies in the medical literature addressing prognostic factors associated with AlP poisoning. In this prospective study conducted across a 14-month period commencing on 21st March 2006, we enrolled all patients admitted to the ICU of Loghman-Hakim Hospital Poison Center (Tehran, Iran) with AIP poisoning, no history of diabetes mellitus diagnosed before hospitalization, and normal body mass index. We recorded patient-specific demographic information, blood glucose level on presentation (before treatment), arterial blood gas (ABG) analysis, time elapsed between ingestion and presentation, ingested dose, duration of intensive care admission, and outcome data related to each presentation. We enrolled the group of patients who survived the intoxication as a control group and compared their blood glucose levels with those who died because of AlP poisoning. Data were analyzed by Statistical Product and Service Solutions (SPSS) software (Version 12; Chicago, Ilinois, USA) using logistic regression, Pearson correlation coefficient and Student's t-test. P values of 0.05 or less were considered as the statistical significant levels. Forty-five patients (21 women and 24 men) with acute AlP poisoning were included in the study. The mean age was 27.3 +/- 11.5 years (range: 14-62 years). Thirteen patients survived (29%) and 32 expired (71%). AlP poisoning followed deliberate ingestion in all patients. The time elapsed between ingestion and arrival at the hospital was 3.2 +/- 0.4 h. There was no significant difference between survived and non-survived groups according to age, gender, and time to treatment. However, the difference between mean blood glucose levels in survived (143.4 +/- 13.7 mg/dL) and non-survived (222.6 +/- 20 mg/dL) cases was statistically significant (P = 0.021). There was no significant correlation between blood glucose level and time to treatment, age, gender, pH, HCO3 concentration, and ingested dose. Twenty-three (71.9%) of non-survived and four (30.8%) of survived patients had a blood glucose level greater than 140 mg/dL. After adjusting according to age, gender, ingested dose, pH and HCO3 concentration The odds ratio for hyperglycemia as a risk factor for death was 5.7 (CI of 1.4-23.4). In our study, patients who succumbed to AIP poisoning had significantly higher mean blood glucose levels than those who survived. This correlation of hyperglycemic effect and mortality suggests that it may be useful in guiding risk assessment and treatment of AIP poisoning. Management of hyperglycemia may have a useful role in treatment of these patients by allowing increased entrance of glucose into cells and reducing oxygen consumption.

Unintentional poisoning by phosphine released from aluminum phosphide

Aluminum phosphide as a releaser of phosphine gas is used as a grain preservative. In this case report, we describe an accidental severe poisoning in a 35-year-old woman, her 18-year-old daughter, and 6-year-old son caused by inhalation of phosphine gas released from 20 tablets of aluminum phosphide stored in 15 rice bags. The boy died 2 days after exposure before admission to hospital and any special treatment, but the others were admitted 48 h after exposure. They had signs and symptoms of severe toxicity, and their clinical course included metabolic acidosis, electrocardiographic changes, and hypotension. They were treated by intravenous administration of sodium bicarbonate, magnesium sulfate, and calcium gluconate. The patients were discharged after 3 days and followed up for 1 week after discharge. Rapid absorption of phosphine by inhalation, induction of hyperglycemia, and surviving of patients are interesting issues of this case report.