F. Lee Cantrell

Palytoxin poisoning after dermal contact with zoanthid coral.

BACKGROUND Palytoxin is most commonly reported after ingestion of seafood. We report a case of palytoxin poisoning from dermal absorption with local toxicity from zoanthid coral in a patient with intact skin. CASE REPORT A 25-year-old previously healthy woman handled a zoanthid coral from a home aquarium without any barrier protection. The patient manifested neurologic symptoms of perioral paresthesia and dysguesia. In addition, there was local dermatologic toxicity that persisted for several days. The patient was treated supportively with corticosteroids and a histamine antagonist. CONCLUSION We report a case of palytoxin poisoning from dermal absorption after handling a zoanthid coral. Palytoxin is a potent marine toxin that affects the sodium-potassium ATPase (adenosinetriphosphatase) pump and can cause multiple clinical effects, including paresthesia, dysguesia, hypertension, respiratory depression, coma, and death.

Envenomation by the Mexican beaded lizard: a case report.

Background: Envenomations by venomous lizards are rare. A single report of envenomation by a Mexican beaded lizard (Heloderma horridum) has been published. Further, anaphylaxis secondary to lizard envenomation has only been reported with the Gila monster. We report an envenomation that resulted in both systemic toxicity and anaphylaxis. Case Report: A 40-year-old male was bitten on his hand by a captive Mexican beaded lizard. The patient experienced severe local pain, dizziness, vomiting, and diaphoresis. Upon arrival to the hospital, he was lethargic, vomiting, and in severe pain with marked swelling of his hand, lips, and tongue. His blood pressure was 110/63 mm/Hg with a pulse of 60 beats/minute. The patients oxygen saturation decreased to 55%, and he required oxygen, although cyanosis was not observed. He was treated with normal saline, diphenhydramine, methylprednisolone, famotidine, ondansetron, morphine, and hydromorphone. The patient was admitted to intensive care where he continued to complain of severe pain requiring morphine. Local X-ray revealed only soft tissue swelling. Remarkable initial laboratory values included WBC 18,500 k/mm3 with 80% segs. Over the next eight hours, the patients symptoms gradually improved. He had persistent local swelling at the bite site along with erythematous streaking up the forearm. He had an uneventful hospital course until his eventual discharge the following day. Conclusion: Significant envenomations by members of the Helodermatidae family are rare. Systemic toxicity usually resolves within one to two days with supportive care. Prior envenomations may predispose patients to anaphylactic reactions.

Central α-2 Adrenergic Eye Drops : Case Series of 3 Pediatric Systemic Poisonings

Three pediatric patients presented with systemic central &agr;-2 agonist poisoning-2 cases of bradycardia and apnea resulting from ingestion of ingestion of apraclonidine, with 1 case requiring intubation, and 1 case of bradycardia and altered mental status requiring intensive care monitoring resulting from therapeutic ophthalmic application of brimonidine. Pediatric poisonings involving central &agr;-2 adrenergic agonists have been well described, particularly with the prototypical agent clonidine. Characteristic symptoms include sympatholytic effects such as central nervous system depression, respiratory depression, hypotension, bradycardia, miosis, hypothermia, and hyporeflexia. Although structurally similar to clonidine, these compounds are presumed to be safer for pediatric use because they are more polar and less lipophilic than clonidine, thereby limiting their ability to cross the blood-brain barrier and reducing incidence of centrally mediated effects. Systemic toxicities of &agr;-2 agonist ophthalmic preparations in pediatric patients are similar to those seen with clonidine poisonings. Symptomatic patients should be treated in the same manner as patients with clonidine poisoning. Treatment of systemic poisoning is primarily supportive. Periodic tactile stimulation seems to be an effective nonpharmacological intervention to improve &agr;-2 adrenergic agonist-induced central nervous system depression and respiratory depression. Intubation should be considered when tactile stimulation is not effective.

Look What I Found! Poison Hunting on eBay®

Background. Many substances deemed too dangerous for commercial use are still available to the general public. The purchase of these substances may potentially place members of the general public at risk for serious poisonings. This study was designed to document the large variety of dangerous poisons readily available on a popular online auction Web site. Methods. Over a 10-month period, the online auction Web site eBay® was searched daily using the terms “poison” and “contents.” Product name, active ingredients, what form the product is in, amount in container, and relative toxicity rating [Clinical Toxicology of Commercial Products, Gosselin, et al. ] were recorded. If available, pictures of the products were saved. Results. One hundred twenty-one individual products were identified. Fifty-five were in solid/tablet form, 37 were powders, and 29 were liquids. Product containers were full for 56 items and partially full for 65. Twenty-four products contained ingredients rated as “supertoxic” and included strychnine (10), arsenic trioxide (8), cyanide (2) and nicotine, pilocarpine, phosphorus, powdered conium maculatum (1 each). Sixty-three products contained “extremely toxic” ingredients including thallium, picrotoxin, soluble barium, antimony, mercury, arsenates, podophyllin, fluoride, zinc phosphide, atropine, scopolamine, and plant extracts of gelsemium, aconite, larkspur, and croton. Twenty-one products contained “very toxic” ingredients including lead, copper, camphor, caffeine, theobromine, creosote, pyrogallic acid, sparteine, quinine, lindane, warfarin, phenol, and digitalis. The remaining 13 were “moderately-slightly toxic.” Conclusion. While the viability of the labeled ingredients could not be verified, the transportation, handling, and potential utilization of these dangerous poisons by the general public could result in serious poisonings.

An observational case series of dabigatran and rivaroxaban exposures reported to a poison control system

OBJECTIVE Characterize clinical presentations and outcomes of dabigatran and rivaroxaban exposures reported to a poison control system. METHODS Data for cases of dabigatran and rivaroxaban exposures called into the California Poison Control System from January 2011 to July 2013 were collected. Data collected included patient demographics, type of exposure, medication, dosage, vital signs, laboratory values, interventions, outcomes, and disposition. Exclusion criteria included confirmed nonexposures or miscoded cases. RESULTS A total of 56 cases were identified, with 7 excluded, leaving 37 dabigatran and 12 rivaroxaban cases. Children age 12 years or less accounted for 5 dabigatran and 2 rivaroxaban cases. Bleeding was reported in 15 dabigatran cases. There were 4 cases of acute self-harm overdose with dabigatran ranging from 1800 to 3900 mg. Mild bleeding was reported in only one of these overdose cases. There were 2 fatal hemorrhages in dabigatran cases, both in chronic therapeutic dosing. Bleeding was reported in 5 rivaroxaban cases, all in patients with chronic exposure; no deaths were reported. There were no adverse outcomes in pediatric patients. Coagulation parameters did not correlate well with bleeding. CONCLUSIONS In our series, the greatest risk of adverse events was in patients chronically taking these agents, irrespective of excess dosing. Acute self-harm ingestions and accidental pediatric ingestions had few adverse effects, although massive overdose can lead to abnormal coagulation studies. It does not appear that single low-dose ingestions of either medication will lead to clinically significant bleeding. It may be possible to manage some pediatric exposures and most accidental ingestions with observation.

A Poison Center's Ten-year Experience with Flumazenil Administration to Acutely Poisoned Adults

BACKGROUND The frequency of seizures among acutely poisoned adults who are administered flumazenil has not been well established. STUDY OBJECTIVE The objectives of the study were: to determine the frequency of seizures among acutely poisoned adults administered flumazenil; to identify factors associated with seizures; and to determine the mental status of subjects before and after administration of flumazenil. METHODS This study was a historical case series of acutely poisoned adults reported to a poison control system from 1999 to 2008. Included cases were those involving administration of flumazenil to subjects who were ≥ 18 years of age. Both genders were included. Variables collected included: presence of seizure or death, exposure to a pro-convulsant drug, and mental status before and after flumazenil administration. RESULTS Over the 10-year period studied, 904 cases were identified that met inclusion criteria. Thirteen subjects (1.4%) developed seizures after flumazenil was administered. One death occurred. There were 293 subjects exposed to a pro-convulsant drug, and 8 of these had seizures after flumazenil administration. Development of seizures after flumazenil administration was significantly associated with exposure to a pro-convulsant drug (odds ratio 3.41; 95% confidence interval 1.13-10.72). Mental status before and after flumazenil administration was available for 546 subjects (60.3%). Of these, 291 (53.3%) became awake after administration of flumazenil. CONCLUSIONS Flumazenil administration to acutely poisoned adults resulted in a low frequency of seizures and death. Development of seizures was associated with exposure to a pro-convulsant drug. More than half of the subjects for whom mental status was recorded became awake after receiving flumazenil.

Peyote and mescaline exposures: a 12-year review of a statewide poison center database

Background. Peyote, a cactus containing the hallucinogen mescaline, has been used by Native Americans for thousands of years. Illicit use is also known to occur, but reports in the medical literature consist only of isolated case reports. Objectives. We sought to identify characteristics of patients with reported exposure to peyote or mescaline. Methods. We performed a retrospective review of the California Poison Control System database for the years 1997–2008 for all cases of single-substance human exposure using the search terms “peyote” and “mescaline.” Results. There were a total of 31 single-substance exposures to peyote or mescaline. Thirty (97%) exposures were intentional; 30 (97%) exposures were through the oral route, whereas one patient (3%) insufflated mescaline powder. Five patients (16%) were managed at home, whereas the remainder patients were managed in a healthcare facility. Commonly reported effects included hallucinations, tachycardia, agitation, and mydriasis. Vomiting was reported in only one case. Conclusions. Although uncommonly encountered, use of peyote and mescaline was associated with clinically significant effects requiring treatment in a substantial number of patients. Clinical effects were usually mild or moderate, and life-threatening toxicity was not reported in this case series.

Asphyxiation Due to Dry Ice in a Walk-in Freezer

BACKGROUND Exposure to a high concentration of environmental carbon dioxide (CO2) can result in poisoning through direct toxicity and by displacing atmospheric oxygen (O2). Dry ice undergoes sublimation to a gaseous state at -78.5 degrees C (-109.3 degrees F), which is heavier than air and can accumulate in dependent areas. CASE REPORT We report the case of a 59-year-old man found in cardiac arrest shortly after entering a recently repaired walk-in freezer that contained dry ice. First responders and bystanders did not recognize the proximate hazardous environment but were fortunately uninjured. A careful Emergency Department history coupled with rapid case investigation by the Medical Examiners Office led to the determination of the cause of death and the elimination of the ongoing hazard. CONCLUSION This case illustrates the lethal consequences of improper storage of dry ice and the need to consider toxic environmental exposure as a cause of sudden cardiac arrest.

Fatal unintentional overdose of diltiazem with antemortem and postmortem values.

Background. Therapeutic errors involving calcium channel antagonists (CCA) resulting in death rarely have been reported in detail. We report a fatality from an unintentional overdose of sustained-release (SR) diltiazem including antemortem and postmortem blood concentrations. Case Report. A 65-year-old man with aortic stenosis mistakenly took six tablets of diltiazem 360 mg SR. He developed symptoms of toxicity by 7 hours after ingestion. By 10 hours, he went to the emergency department. Despite a prolonged resuscitative attempt, the patient died 17 hours postingestion. An antemortem blood sample drawn 11.5 hours after ingestion was 2.9 mcg/mL. Postmortem gas chromatography of central blood revealed a diltiazem level of 6 mcg/mL and the peripheral blood sample measured 5 mcg/mL. Conclusion. This case suggests that an unintentional overdose with a CCA may be lethal if the patients cardiovascular ability to compensate for the toxic effects is compromised.

Examination of adverse events following black widow antivenom use in california

Objectives. Following widow spider (Latrodectus sp.) envenomation, local pain, erythema, abdominal pain, rigidity, hypertension, and diaphoresis can be seen. While an effective specific antivenom (AV) is available, its use is limited due to concern of possible severe allergic reaction. We performed the current study to determine rate of adverse effects and the efficacy of AV in patients treated for widow spider envenomation. Methods. Observational case series of the California Poison Control System electronic database from January 1999 to December 2009. All cases of widow spider envenomation treated with AV were included. Age, gender, signs, and symptoms, adjunctive therapy, number of vials of AV given, and adverse reaction to AV were recorded. Descriptive statistical methods were used. Results. Ninety-six patients received AV, mean age 26 years (0.12–74 years), 76% male. Following widow spider envenomation generalized pain was reported in 91%, erythema at site in 57%, hypertension (≥ 140/90 mmHg) in 43%, muscle rigidity/cramping in 43%, abdominal pain in 41%, tachycardia (≥ 100 bpm) in 23% and diaphoresis in 21%. No patient required more than one vial of AV. One patient developed urticaria to AV halfway through infusion which was immediately discontinued. Another patient developed generalized flushing following completion of infusion but had no other effects. Two other patients reported myalgia and paresthesia. There were no deaths in any patients receiving AV. There was no shortness of breath or respiratory distress, no hypotension or chest pain following AV administration. All patients reported pain relief with AV and did not require additional AV doses. Conclusions. Our results suggest that Black Widow Spider Antivenin® (Merck) administration is relatively safe with mild to moderate adverse effects seen in only a small percentage of patients. There were no deaths, or severe allergic reactions identified. The retrospective use of poison control system data is a limitation of our study. Further prospective studies are needed to validate our findings and elucidate the full safety profile on this antivenom.