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The efficacy of low-dose antivenom therapy on morbidity and mortality in snakebite cases

UNLABELLED Similar to the cases seen around the world, snakebite causes mortality and morbidity in Turkey. The venom of different types of snake in the region of Cukurova causes serious systemic and local tissue damage. METHODS We performed this prospective study on 45 patients who complained of snakebite. We grouped the patients according to their clinical presentations to facilitate treatment and follow-up period procedures. RESULTS Whereas the patients with grade 1 envenomation did not receive any antivenom, grades 2 and 3 patients received 2.70 +/- 0.77 and 4.88 +/- 1.65 vials of antivenom, respectively. One of our patients had to undergo finger amputation but there were no deaths. Allergic reactions developed after antivenom therapy in 8 patients (17.8%). CONCLUSIONS When we considered the cost and complications of the antivenom treatment, it was seen that low-dose antivenom treatment effectively treated the patients with venomous snakebite injuries in our region.

Snakebite during pregnancy

Little is known about snakebites during pregnancy and only a few cases have been reported in the literature. The fact that venomous snakebites during pregnancy result in high fetal wastage and may cause maternal mortality makes this an important, albeit, uncommonly encountered entity in emergency medicine. In this paper, we report on the successful treatment of three cases of snakebite in pregnancy.

QTc intervals in drug poisoning patients with tricyclic antidepressants and selective serotonin reuptake inhibitors.

Commonly used agents of drug poisoning among patients who come to the emergency services are tricyclic antidepressants (TCAs). These drugs may cause defect in cardiac conduction due to the slowdown in the cardiac depolarization and expansions in the QT interval. Selective serotonin reuptake inhibitors (SSRIs) are less expansion of the QT period and lower cardio toxic side effects. The aim of this study was to investigate QTc intervals and prognosis of the patients who come to the emergency service due to TCA and SSRI group antidepressant drug poisoning. In a study of 96 patients, 75 of whom were diagnosed to be poisoned by TCAs (TCA group) and 21 by SSRIs (SSRI group) were examined. Electrocardiographic alterations and QTc intervals all of patients were evaluated. QTc intervals of patients in TCA group were determined to be slightly more than those in SSRI group and it was not statistically significant. In the SSRI group, only one patient had QTc period more than 500 milliseconds (520 milliseconds); however, TCA overdose showed 9 (12%) patients with QTc interval over 500 milliseconds, and QTc values of 2 patients were over 600 milliseconds. In our study, it was determined that SSRI group drugs caused similar expansion of the QTc period as TCA drugs but they did not reach high values like TCA drugs, and their OTc intervals stayed in more innocent levels.

Parotitis Due to Organophosphate Intoxication

Acute pancreatitis due to pancreatic exocrine over-secretion induced by organophosphate poisoning has been previously reported but parotid gland involvement has not. This paper describes a case of acute organophosphate-induced parotitis in a patient with pre-existing sialolithiasis. The patient developed bilateral facial swelling in the pre-auricular area extending to the angle of the jaw and also developed elevated serum amylase on the second day of the poisoning. Serum lipase remained normal. Autopsy confirmed parotid gland inflammation and pre-existing ductal lithiasis. This case illustrates that organophosphate-induced parotitis can occur and should be considered in patients with organophosphate poisoning who have hyperamylasemia without elevation in serum lipase.

Myocardial infarction, acute ischemic stroke, and hyperglycemia triggered by acute chlorine gas inhalation

Chlorine is one of the most common substances involved in toxic inhalation. Until now, several accidental exposures have been reported. The damage to the respiratory tract in the immediate phase after exposure to chlorine is well defined. Death occurs particularly due to pulmonary edema with respiratory failure and circulatory collapse. On the other hand, no association with myocardial infarction, acute stroke, severe hyperglycemia, and acute chlorine inhalation has been reported in literature. In the present study, an elderly (74-year-old) and diabetic case with myocardial infarction, acute stroke, hyperglycemia, and respiratory failure associated with acute chlorine intoxication after a diagnosis of acute chlorine poisoning and treatment in the emergency department is reported and the literature is revisited. Physicians should know that in elderly patients with a systemic disease who apply with chlorine gas inhalation, more serious complications along with damage in respiratory tract might be observed.

H-FABP in cases of carbon monoxide intoxication admitted to the emergency room

Introduction: Carbon monoxide (CO) intoxication causes cardiovascular problems as a result of diffuse tissue hypoxia. Cardiac biochemical markers and electrocardiographic changes have been reported in CO intoxications. Human fatty acid-binding protein (H-FABP) has been recently used as a reliable marker in identifying early cardiac damage. In this prospective study, we aimed to investigate the advantages of the use of H-FABP, in evaluating the findings of myocardial ischemia in patients with CO intoxication in our region. Methods: Twenty four successive patients admitted to the emergency department with acute CO intoxication were included in our study. Serum traditional markers and H-FABP were also taken in the earliest period for evaluation of cardiac damage. Results: The creatinine kinase MB (CKMB) levels were positive in 11 of the patients; however, H-FABP and troponin T levels were positive in only 3 of them. One of these subjects had elevated level of H-FABP in the short-term and increasing troponin T level increasing level of troponin T during the follow-up period. Conclusion: The obtained data supports the use of H-FABP, a specific indicator in identifying the cardiotoxicity of CO intoxications at an early phase.

Levofloxacin-Induced Hepatotoxicity and Death

Drug-induced hepatotoxicity is a major cause of hepatocellular injury in patients admitting to emergency services with acute liver failure. Hepatic necrosis may be at varying degrees from mild elevations in transaminases to fulminant hepatitis, and even death. The case of a 53-year-old female patient with toxic hepatitis due to levofloxacin and multiple organ failure secondary to toxic hepatitis is presented. Patient suffered itching, redness, and rash after receiving a single dose of 750 mg of levofloxacin tablets for pulmonary infection 10 days ago. Skin lesions had regressed within 3 days, but desquamation formed all over the body. After the fifth day of drug intake, complaints of abdominal pain, vomiting, and yellowing in skin color had started. The patient was referred to our emergency department with these complaints 10 days after drug intake. Patient was thought as a candidate for liver transplant, but cardiopulmonary arrest occurred, and the patient died before she could be referred to a transplant center. This case is important because hepatotoxicity and death due to levofloxacin is uncommon in the literature.

Serum IL-6, TNFα levels in snakebite cases occurring in Southern Turkey

Objective The snake species Vipera ammodytes meridionalis and Vipera lebetina obtuse are often seen in Southern Turkey and have venom that causes serious systemic and tissue damage. The aim of our study is to assess the relationship between tumour necrosis factor α (TNFα) and interleukin 6 (IL-6) serum levels, and clinical and laboratory findings in the snakebite patients. Methods 26 patients who had received snakebites were included in a prospective study. Patients were grouped according to their clinical presentations in order to plan treatment. Results TNFα serum levels of most patients who went to the emergency room to receive treatment for snakebite were high. This increase was most likely to be related to the clinical severity of the snakebite and the length of time between the snakebite and their arrival at the hospital. In contrast to TNFα, there was no relationship between serum IL-6 levels and clinical and laboratory parameters. Conclusions Snakebites from Vipera ammodytes meridionalis and Vipera lebetina obtuse lead to increased levels of serum TNFα. However, serum TNFα and IL-6 levels depend on various factors such as the kind of snake, the area the venom was injected into, the amount of venom and the body size of the patients.

H-FABP in the early diagnosis of stroke.

Dear Editor, We have read the study conducted by Wunderlich et al. [1] and published in the journal in 2005, ‘‘Release of braintype and heart-type fatty acid-binding proteins (B-FABP and H-FABP) in serum after acute ischaemic stroke’’. In this study, it was observed that the serum B-FABP and H-FABP levels of 42 consecutive patients admitted within 6 h following ischemic stroke increased within the first 2 h and remained so until the fifth day and that the increase was in parallel with the infarct area of the serum H-FABP, in particular. When we read the above-mentioned study in the journal, we thought that we could possibly use H-FABP in the early diagnosis of stroke patients in our clinic and to this end, we dispatched H-FABP and Troponin I samples from 20 patients with acute stroke. The acute cerebral tomographic findings of all the patients were consistent with their clinical findings. Of those followed-up with the diagnosis of stroke, all but one patient had H-FABP and troponin values within the normal limits, while the serum H-FABP and trop I values were positive in one patient. During follow-up, this patient was observed to have simultaneous SVO and non-Q myocardial infarction. On the other hand, 20 acute myocardial infarction (AMI) patients who applied to the emergency clinic, whom we examined as the control group in the same period, were found to have high values of H-FABP and trop. It was concluded that in the AMI patients in our clinic, H-FABP does not increase in patients with acute stroke and, thus, this method cannot be used in stroke patients as a diagnostic tool. Recently put into use in the diagnosis and prognosis of acute coronary syndrome, H-FABP proved its reliability through the studies conducted [2]. In addition, H-FABP is found in the neuronal cell body and they are rapidly released from damaged cells into circulation and cleared by the kidney with a plasma half-life of 20 min [3]. We observed that the method used for H-FABP in the study published in the journal was different from our method. In the study by Wunderlich et al., serum concentrations of H-FABP were measured with a direct non-competitive sandwich-type ELISA using monoclonal antibodies obtained from HyCult biotechnology (HK 403; Uden, the Netherlands). In our study, on the other hand, the principle of the newly developed whole-blood rapid H-FABP test is based on a dual monoclonal antibody sandwich method using two distinct monoclonal antibodies and a gold label method (CardioDetect combi, cardiac infarction test, Rennesens GmbH, Germany). It was concluded that the higher serum H-FABP levels detected in stroke patients might have resulted from a problem with the method used and further studies are needed to investigate its causes. O. Akpinar (&) Department of Cardiology, Gaziantep 25 Aralik Hospital, Gaziantep, Turkey e-mail: onur_akpinar@yahoo.com

Unusual Electrocardiographic Changes With Propranolol and Diltiazem Overdosage: A Case Report

The therapeutic efficacy and safety of beta-adrenoreceptor-blocking drugs has been well established in patients with angina pectoris, cardiac arrhythmias, and hypertension and reducing the risk of mortality and nonfatal reinfarction on survival of acute myocardial infarction. The calcium antagonists are used for the treatment of patients with angina pectoris, long-term systemic hypertension, and the management of hypertensive emergencies and also for a multitude of other cardiovascular and noncardiovascular conditions. Because adverse cardiovascular effects can occur, however, patients being considered for combination treatment with propranolol and diltiazem must be selected carefully and observed closely. In this article, we present a suicidal case of drug overdose with propranolol and diltiazem with unusual electrocardiographic changes.