Binh T. Ly

A case of withdrawal from the GHB precursors gamma-butyrolactone and 1,4-butanediol.

We describe a case of withdrawal from the gamma hydroxybutyric acid (GHB) precursors gamma butyrolactone and 1,4-butanediol. Symptoms included visual hallucinations, tachycardia, tremor, nystagmus, and diaphoresis. Administration of benzodiazepines and phenobarbital successfully treated the withdrawal symptoms. As predicted from the metabolism of gamma butyrolactone and 1,4-butanediol to GHB, the symptoms were nearly identical to those reported from GHB withdrawal. Because GHB is now illegal in the United States, individuals have begun abusing the legal and easier to acquire GHB precursors. More frequent cases of both abuse and withdrawal from these GHB precursors can be expected.

Prolonged Coma in a Child Due to Hashish Ingestion with Quantitation of THC Metabolites in Urine

BACKGROUND Cannabinoid-containing substances are commonly abused worldwide. Significant toxicity from these substances is uncommon in adults but can result in significant symptoms in children; these symptoms are usually short-lived. OBJECTIVES To report a case of prolonged mental status alteration of more than 2 days in a child who ingested hashish. CASE REPORT A 14-month-old child presented comatose to a pediatric emergency department after ingestion of hashish; she did not regain consciousness for more than 48 h. Quantitative testing of the childs urine for a tetrahydrocannabinol metabolite revealed a markedly elevated level, the decline of which coincided with the childs clinical improvement. CONCLUSIONS Significant ingestion of cannabinoid-containing substances is capable of causing prolonged symptoms (including coma) in children.

Effect of whole bowel irrigation on the pharmacokinetics of an acetaminophen formulation and progression of radiopaque markers through the gastrointestinal tract

STUDY OBJECTIVES We describe the effects of whole bowel irrigation on a delayed-release acetaminophen preparation. We compare the mechanical effect of whole bowel irrigation on the progression of radiopaque markers through the gastrointestinal tract between an experimental and a control group. METHODS We performed a 2-armed, prospective, randomized, crossover volunteer study. In the experimental phase, subjects were administered a delayed-release acetaminophen preparation (75 mg/kg) along with a capsule containing radiopaque markers. We initiated whole bowel irrigation at 30 minutes after ingestion and continued until the rectal effluent was clear. Serum acetaminophen concentrations were measured at baseline and from 0.5 to 8 hours. Abdominal radiographs were obtained at the completion of whole bowel irrigation. In the control phase, whole bowel irrigation was not performed. The primary outcome measure was the effect on the area under the acetaminophen concentration versus time curve (AUC) between the 2 groups. RESULTS Ten subjects participated in the study. We found an 11.5% reduction in the AUC, with the majority of the effect occurring in the delayed-release portion of the curve after the 2-hour mark. This reduction, however, was not statistically significant. Radiographs obtained at the end of whole bowel irrigation revealed radiopaque markers sequestered in the right hemicolon in 8 of 10 subjects. No discernible pattern was noted in the control arm. CONCLUSION The effect of whole bowel irrigation on reduction of AUC for delayed-release acetaminophen preparation was not statistically significant. Whole bowel irrigation did appear to have a mechanical effect on the progression of radiopaque markers through the gastrointestinal tract, but the clinical significance of this finding is not clear.

Comprehensive analysis of “bath salts” purchased from California stores and the internet

Abstract Study objective. To analyze the contents of “bath salt” products purchased from California stores and the Internet qualitatively and quantitatively in a comprehensive manner. Methods. A convenience sample of “bath salt” products were purchased in person by multiple authors at retail stores in six California cities and over the Internet (U.S. sites only), between August 11, 2011 and December 15, 2011. Liquid chromatography-time-of-flight mass spectrometry was utilized to identify and quantify all substances in the purchased products. Results. Thirty-five “bath salt” products were purchased and analyzed. Prices ranged from

False-Positive Urine Phencyclidine Immunoassay Screen Result Caused by Interference by Tramadol and Its Metabolites

9.95 to 49.99 (U.S. dollars). Most products had a warning against use. The majority (32/35, 91%) had one (n = 15) or multiple cathinones (n = 17) present. Fourteen different cathinones were identified, 3,4-methylenedioxypyrovalerone (MDPV) being the most common. Multiple drugs found including cathinones (buphedrone, ethcathinone, ethylone, MDPBP, and PBP), other designer amines (ethylamphetamine, fluoramphetamine, and 5-IAI), and the antihistamine doxylamine had not been previously identified in U.S. “bath salt” products. Quantification revealed high stimulant content and in some cases dramatic differences in either total cathinone or synthetic stimulant content between products with the same declared weight and even between identically named and outwardly appearing products. Conclusion. Comprehensive analysis of “bath salts” purchased from California stores and the Internet revealed the products to consistently contain cathinones, alone, or in different combinations, sometimes in high quantity. Multiple cathinones and other drugs found had not been previously identified in U.S. “bath salt” products. High total stimulant content in some products and variable qualitative and quantitative composition amongst products were demonstrated.

Recurrent coagulopathy and thrombocytopenia in children treated with crotalidae polyvalent immune fab: a case series.

Phencyclidine is one of the drugs of abuse included in qualitative urine drug screens that are frequently ordered in the emergency department despite concerns about specificity and clinical utility. Many drugs have been described to cause false-positive results for phencyclidine. We present 2 cases of false-positive phencyclidine qualitative urine drug screen results in patients with seizures from tramadol misuse or abuse. The involvement of tramadol and its active metabolite, N-desmethyltramadol, was confirmed by in vitro testing. These cases illustrate that tramadol and its metabolites can trigger a false-positive phencyclidine urine drug screen result in nonfatal cases and highlight the lack of specificity of the phencyclidine qualitative urine drug screen.

A retrospective review of California poison control system data of sibutramine exposures

Objectives: Recurrent signs and symptoms after initial treatment and control of coagulopathy and thrombocytopenia after American pit viper (crotaline) envenomations have been previously described in patients treated with Crotalidae polyvalent immune Fab antivenom (FabAV). The significance and necessity of treatment of these recurrent abnormalities are uncertain. Our goal was to further characterize recurrent coagulopathy or thrombocytopenia in pediatric patients. Methods: All cases presenting to our Toxicology Consult Service, which covers 6 hospitals in a metropolitan area, from May 2007 to April 2008 with recurrent coagulopathy after initial control with FabAV were included and retrospectively reviewed. Results: Four cases of pediatric patients are presented who presented with recurrent coagulopathy and/or thrombocytopenia after initial control with FabAV. The patients were all treated with delayed administration of FabAV with variable results. Blood products administered without concurrent FabAV were of limited use. The laboratory abnormalities took up to 18 days to resolve in one case. One patient developed hemodynamically significant spontaneous bleeding. Conclusions: The cases presented here suggest administration of FabAV may correct delayed coagulopathy associated with crotaline envenomations. The first 3 cases illustrate that in the face of severe derangements in laboratory values, most envenomated patients treated with FabAV do not develop significant bleeding. These cases may respond to additional antivenom alone. However, case 4 illustrates that hemodynamically significant spontaneous bleeding can occur. Until more data are available, readministration of FabAV is a reasonable first-line therapy for delayed coagulopathy associated with crotaline envenomations.

Internet-purchased ibogaine toxicity confirmed with serum, urine, and product content levels

Introduction. Sibutramine is a centrally acting neurotransmitter reuptake inhibitor used for the treatment of obesity. In doses of 10–15 mg/day, sibutramine has been shown to promote modest weight loss; however, the literature devoted to characterizing overdoses and abuses of sibutramine is limited. Methods. We queried and retrospectively reviewed the California Poison Control System database between January 1998 and August 1, 2008. This was an observational case series. Results. A total of 62 cases were identified. Forty-four (71%) of our study subjects were females. Twenty-three patients (37%) were between 8 months and 2 years of age; 17 patients (27%) were between 31 and 50 years. The doses ranged from 2.5 to 75 mg. A total of 27 patients (44%) were referred to a medical center. In general, medical outcomes were minor. Twenty-five (40%) patients had no effects reported; 30 patients (48%) reported minor effects; and three patients (5%) had moderate effects. There were no major effects or deaths reported. In 58 (94%) patients, the ingestion was unintentional. Thirty-two (52%) cases resulted in the recommendation of observational therapy only as their management strategy. Of the patients who did experience adverse effects, cardiovascular side effects were the most common. In particular, tachycardia (nine patients, 14.5%) was the most notable, followed by chest pain (four patients, 6.5%). Six patients (10%) reported central nervous system side effects. Gastrointestinal side effects occurred in four patients (6.5%). The dose ingested did not appear to correlate with the clinical effects observed. Discussion. Sibutramine ingestion resulted in no serious effects or deaths on our retrospective case series. Mild to moderate effects that were rarely reported included tachycardia, chest pain, agitation, irritation, dizziness, vertigo, nausea, and vomiting.

Orbeez: the magic water absorbing bead--risk of pediatric bowel obstruction?

UNLABELLED Ibogaine, a psychotropic indole alkaloid, is gaining popularity among medical subcultures for its purported anti addictive properties. Its use has been associated with altered mental status, ataxia, gastrointestinal distress, ventricular arrhythmias, and sudden and unexplained deaths.Its pharmacokinetics in toxic states is not well understood. Case report:A 33-year-old man overdosed on ibogaine in an attempt to quit his use of heroin. He developed altered state of consciousness, tremor, ataxia,nausea, vomiting, and transient QT interval prolongation, which all remitted as he cleared the substance. Ibogaine was confirmed in his urine and serum with a peak serum concentration of 377 ng/mL. Nonlinear elimination kinetics and a formula match to its active metabolite noriobgaine were observed as well. CONCLUSION This case presents the unique description of serial serum concentrations as well as urine and product-confirmed ibogaine toxicity with transient toxin-related QT interval prolongation.

A Retrospective Poison Center Review of Varenicline-Exposed Patients

Objectives In December 2012, the U.S. Consumer Product Safety Commission recalled the water-absorbing toy WaterBalz after reports of small intestine obstruction after ingestion by children. Orbeez, another water-absorbing bead, remains available and is marketed as a children’s toy. We sought to determine the extent to which Orbeez enlarge in various liquid media and the potential risk for bowel obstruction. Methods Three Orbeez beads were added to 210 mL of the following liquid media: room temperature tap water, whole milk, simulated gastric fluid, GoLytely (polyethelyelene glycol, 3350 and electrolytes), and vodka (40% ethanol by volume). Diameters before exposure to media were measured using a caliper to the nearest 0.1 mm and again at 1, 2, 4, 6, 12, and 24 hours. Ten beads were then added to the beads already immersed in simulated gastric fluid and water and observed for an additional 72 hours (96 hours total) for clumping or increase in diameter. Clumping was defined as two or more beads remaining persistently adherent to one another despite gentle circular movement (swirling) of the liquid. Results Growth in each of the media was observed. Growth in simulated gastric fluid was minimal, whereas the beads were observed to be the largest after 24 hours in vodka. Clumping of the beads was not observed to occur. Conclusions Orbeez beads enlarge to a different extent in different liquid media. It is unlikely that Orbeez beads would expand to sizes or demonstrate clumping that would be concerning for intestinal obstruction.