David P. Betten

Massive Honey Bee Envenomation-Induced Rhabdomyolysis in an Adolescent

Massive envenomations by honey bees are capable of causing multiorgan dysfunction as a result of the direct toxic effects of the large venom load received. Although all varieties of honey bee have the potential for these attacks, the Africanized honey bee (Apis mellifera scutellata) is the most commonly implicated subspecies. In the United States, the Africanized strain is found primarily in the southwestern states and is known for its highly defensive behavior if disturbed. Mechanisms behind the multiorgan dysfunction produced by these mass envenomations are not clearly understood. We present a case of a 13-year-old male who was stung by ∼700 honey bees and developed progressive upper-body swelling and systemic manifestations of mass envenomation including rhabdomyolysis, renal insufficiency, and a transient transaminase elevation.

Antidote Use in the Critically Ill Poisoned Patient

The proper use of antidotes in the intensive care setting when combined with appropriate general supportive care may reduce the morbidity and mortality associated with severe poisonings. The more commonly used antidotes that may be encountered in the intensive care unit ( N -acetylcysteine, ethanol, fomepizole, physostigmine, naloxone, flumazenil, sodium bicarbonate, octreotide, pyridoxine, cyanide antidote kit, pralidoxime, atropine, digoxin immune Fab, glucagon, calcium gluconate and chloride, deferoxamine, phytonadione, botulism antitoxin, methylene blue, and Crotaline snake antivenom) are reviewed. Proper indications for their use and knowledge of the possible adverse effects accompanying antidotal therapy will allow the physician to appropriately manage the severely poisoned patient.

A retrospective evaluation of shortened-duration oral N-acetylcysteine for the treatment of acetaminophen poisoning

IntroductionThe use of less than the traditional 72-hour course of oral N-acetylcysteine has been an alternative treatment option following potentially toxic acute and chronic acetaminophen ingestions felt to be at low risk of developing hepatotoxicity. While clinical experience with shortened treatment duration is extensive, there are few studies evaluating the effectiveness and extent to which these regimens may be used.MethodsA large statewide poison center database was reviewed for all acetaminophen exposures involving potentially toxic acute and chronic ingestions, in addition to those taking place at unknown times. Patients were identified who met laboratory criteria for early N-acetylcysteine (NAC) discontinuation (APAP < 10 μm/mL, INR ≤ 1.3, and AST/ALT ≤ 60 IU) after a minimum of a 140-mg/kg oral NAC loading dose and 5 additional 70-mg/kg doses over 20 hours. A further search of the poison center database was conducted for individuals who received shortened-course (20–48 hours) oral NAC treatment who developed subsequent hepatotoxicity or death.ResultsOf 3303 individuals with potentially toxic acetaminophen ingestions, 1932 met criteria for early NAC discontinuation. Mean treatment duration was 36.4±7.7 hours (acute=37.3±7.6 hours; chronic=34.8±7.4 hours; unknown=35.2±7.6 hours). The poison center database search identified no short-course eligible subjects who developed subsequent hepatotoxicity or death following ≤48 hours of oral NAC.ConclusionTreatment with shortened-course oral NAC in patients meeting criteria for early discontinuation may be an effective treatment option in a sizeable proportion of individuals with potentially toxic acetaminophen ingestions.

Systemic fluoride poisoning and death from inhalational exposure to sulfuryl fluoride

We report a poisoning death from inhalational exposure to the gas fumigants chloropicrin and sulfuryl fluoride. The patient displayed both local irritant effects of chloropicrin and systemic effects of sulfuryl fluoride. The clinical course, marked by initial hypocalcemia, delayed onset of ventricular dysrhythmias, and death, is consistent with fluoride being the predominant mechanism of toxicity with sulfuryl fluoride.

Traumatic Retropharyngeal Hematoma in a Patient Taking Clopidogrel

The development of a retropharyngeal hematoma may lead to acute airway compromise requiring emergent airway stabilization. We describe the development of a retropharyngeal hematoma in an elderly woman who sustained a fall from standing approximately 10 hours prior to symptom onset who was taking the antiplatelet agents clopidogrel and aspirin. This delayed onset of rapid airway compromise secondary to a retropharyngeal hematoma following a fall in a patient taking clopidogrel is an unusual and potentially life threatening event.

Agranulocytosis occurrence following recent acute infectious mononucleosis

Abstract Infectious mononucleosis secondary to Epstein‐Barr virus typically follows a relatively benign and self‐limited course. A small subset of individuals may develop further progression of disease including hematologic, neurologic, and cardiac abnormalities. A mild transient neutropenia occurring during the first weeks of acute infection is a common finding however in rare cases a more profound neutropenia and agranulocytosis may occur up to 6 weeks following the onset of initial symptoms. We describe the case of an 18‐year‐old woman who presented 26 days following an acute infectious mononucleosis diagnosis with agranulocytosis and fever. No source of infection was identified and the patient had rapid improvement in her symptoms and resolution of her neutropenia. The presence of fever recurrence and other non‐specific symptoms in individuals 2–6 weeks following acute infectious mononucleosis symptom onset may warrant further assessment for this uncommon event.