Girish Thunga

Effectiveness of hemodialysis in acute dapsone overdose-a case report.

The use of dapsone is increasing even though overdose is rarely reported and physicians must be aware of its toxicity and management. Mortality can occur due to methemoglobinemia and hemolytic anemia. Although activated charcoal and methylene blue are recommended, the use of hemodialysis is reported only in few studies. Literature on the kinetic profile indicates that 50% to 80% of dapsone is protein bound and indicates a possibility to dialyze the unbound form. This study describes a case of deliberate severe dapsone overdose with cyanosis, methemoglobinemia, and hemolytic anemia, which improved after repetitive hemodialysis.

Demographics, clinical characteristics and management of herbicide poisoning in tertiary care hospital

Herbicide poisoning is most common method of suicide in India and it is associated with high morbidity and mortality. Among different herbicidal poisonings the most predominantly found poisonings are paraquat and glyphosate. These compounds are highly toxic and their poisonings require proper management techniques. High fatality is seen in these cases which are mainly due to its inherent toxicity and lack of effective treatment. Common symptoms of these poisonings includes gastrointestinal corrosive effects with mouth and throat, epigastric pain and dysphagia, acid-base imbalance, pulmonary edema, shock and arrhythmia. Long term health effects include pulmonary fibrosis, renal failure, hepatic failure, heart failure, multi-organ failure or death. No proven antidote exists for these poisonings. So the treatment is mainly supportive. Initially gastric lavage or whole-gut irrigation using adsorbents such as Fuller′s earth, bentonite or activated charcoal is recommended. In case of renal failure hemodialysis or hemoperfusion may be considered. However novel approaches like treatment with N-acetylcysteine, vitamin C, vitamin E, cyclophosphamide may also be helpful.

Profile of acute mixed organophosphorus poisoning

Organophosphorus (OP) pesticide self-poisoning is a major clinical and public health problem across much of rural Asia and responsible for two thirds of suicidal deaths. However, clinical reports or evidence for the management of mixed poisoning are lacking. Patients are often treated based on the type of symptoms they exhibit, and there are no specific guidelines available to treat mixed poisoning. In this case series, we report 3 acute OP poisoning cases with mixed poisons such as organochlorine, fungicide, copper sulfate, and kerosene. All 3 patients were treated successfully, with a greater focus on OP poisoning with pralidoxime and atropine infusion along with standard decontamination procedures. Because patients developed complications due to the concomitant poisons ingested, they were later treated symptomatically, and in one case, D-penicillamine was administered as antidote for copper poisoning. Mixed poisoning especially with OP compounds makes the diagnosis difficult because the clinical symptoms of OP predominate, whereas damage produced by other pesticides is late to develop and often neglected. Common treatment procedures are focused mainly on the OP poisoning ignoring the complications of other concomitant pesticides ingested. Treating physicians should be prepared and consider the possibility of mixed poisoning prevalent in that region before initiating therapy.

Role of high-dose corticosteroid for the treatment of leptospirosis-induced pulmonary hemorrhage.

Leptospirosis is a zoonotic disease of worldwide distribution caused by spirochetes of the genus Leptospira. Leptospirosis is a common disease, highly prevalent in human populations but most often unidentified. The International Leptospirosis Society estimates that disease incidence ranges are 0.1 to 1.0 per 100 000 in temperate climates and 10 to 100 per 100 000 in humid tropics.1 In India, outbreaks have been increasingly reported since 1980s, especially from the states of Gujarat, Kerala, Karnataka, Maharashtra, Orissa, and Tamil Nadu.2 Outbreaks mostly occur as a result of heavy rainfall and consequent flooding, usually during monsoons.3 The clinical manifestation of leptospirosis varies from inapparent infection to fulminant fatal disease. Pulmonary complications for patients with leptospirosis are also relatively common, reported in 17% to 70% of patients in several large studies.4 Although these manifestations are usually mild, recent studies suggest that pulmonary involvement is frequently the most dramatic feature of leptospiral infection. Accordingly, severe pulmonary manifestations of leptospirosis are becoming more prevalent, with pulmonary hemorrhage being the most predominant cause of death in leptospirosis. The hemorrhagic potential of leptospirosis was first reported by Weil in 1886.5 The intense intra-alveolar hemorrhages seem to be unique for leptospirosis. Previous literature on diffuse alveolar hemorrhage heavily emphasizes the causal role of vasculitides.6 Use of steroids is rarely reported in leptospirosis-associated pulmonary hemorrhages. Here, we report a case of leptospirosis with pulmonary hemorrhage that was successfully treated with a high intravenous dose of methylprednisolone.

Atorvastatin-Induced Acute Pancreatitis

Atorvastatin-induced acute pancreatitis (AP) is one of the rare adverse effects available in the literature. We report a case of 53-year-old patient developed AP after treatment with atorvastatin monotherapy which resolved after drug withdrawal. Extensive workup on AP failed to reveal any other etiology for it. To our knowledge, this is one of the rare case reports of AP caused due to atorvastatin monotherapy and it further strengthens the fact that statins may cause AP. There is need of continued reporting of such a rare adverse effect of atorvastatin for increasing awareness and to manage and avoid the same.

Need for an acute poisoning registry data base in India

To the Editor, Acutepoisoningisoneofthecommonreasonsforhospitalisation in developing countries. 1 In countries like India, where the economy is linked substantially to agriculture, thenumberofcasesofacutepoisoningincreaseeveryyear. While in developed countries, the rate of mortality from poisoning ranges from 1% to 2% in developing countries like India, it varies between 15% and 30% and is the fourth mostcommoncauseofmortality,especiallyinruralIndia. 2 The rapid increase in the use of newer chemicals with potentiallyharmfuleffectsisamatterofconcerntothephysician and makes the management more challenging. 3 The monsoon-dependent agricultural practice and socioeconomic factors related to it also play a role in the incidence of acute poisonings. 4 Insufficient regulation for the sale and use of pesticides, lack of surveillance systems, insufficient enforcement regarding safe use of pesticides, lack of training of healthcare professionals regarding the managementaspects,inadequateaccesstoinformationsystem,and poorly maintained or non-existent personal protective equipmentarethemajorfactorsresponsibleforhigherincidence rate of poisoning. 5 Early diagnosis, treatment and prevention are crucial in reducing the burden of poisoning-related injury in any country. 6 A thorough knowledge about the nature andmagnitude of the problem in a particular area is essential for the doctors in hospital practice. In Indiathe exactincidenceofacutepoisoningcannot be defined properly due to under-reporting of cases to Government authorities. India has an over-usage of pesticides, and in particular organophosphate poisoning is most commonly reported in the emergency departments of Indian hospitals. 7 The data from poison information centre of All India Institute of Medical Sciences (AIIMS) reveals that highest incidence of poisoning cases was found in the age group of 14–40 years, with a preponderance of males affected. 8 According to the World Health Organization (WHO), 99% of the fatal poisoning cases occur in developing countries, predominantly among farmers. 4, 9, 10

Pharmacokinetic Potentiation of Mixed Organophosphate and Pyrethroid Poison Leading to Prolonged Delayed Neuropathy

Organophosphate (OP) and mixed pesticide poisoning remains an important cause of hospital admission. Therefore, physician must be aware of atypical presentations of delayed neurological complications of poisoning by taking proper patient history. We report a case of a 23-year-old female who presented with high stepping gait and muscle wasting in hands. Patient history revealed consumption of approximately 4ml of mixed pesticide, consisting of 50% chlorpyrifos with synthetic pyrethroid, 5% cypermethrin. The prolonged and severe nature of delayed peripheral neuropathy, persisting at two years of follow-up, suggests that even small quantities of OP taken in combination with a pyrethroid can result in significant morbidity and is irreversible.

Phenytoin induced Stevens-Johnson syndrome exacerbated by cefepime

Steven Johnson syndrome (SJS) is a rare drug induced mucocutaneous reaction. Here, we present an elaborate report of a 28-year-old female patient who developed Phenytoin induced SJS, which was exacerbated by cefepime.

Factors that Correlate with Poor Glycemic Control in Type 2 Diabetes Mellitus Patients with Complications

Objectives Inadequate glycemic control amongst patients with Type 2 diabetes mellitus (T2DM) indicates a major public health problem and a significant risk factor for the progression and complications caused by diabetes. Glycemic control is the main therapeutic objective for the prevention of organ damage and other complications arising from diabetes. Methods This was a retrospective observational study of T2DM patients with complications, who were aged 40 years and older. The study was conducted retrospectively on medical records (in-patient and out-patient) obtained from a South Indian teaching hospital, Manipal, India. The patients included in the study had fasting blood sugar, postprandial blood sugar and HbA1c measured at least twice during follow-ups the previous year. Patients’ HbA1c levels were categorized into good control ≤7% (≤53mmol/mol), and poor control >7% (>53mmol/mol), and patients’ characteristics were analyzed. Results A total of 657 patients were included in the study. The mean age was 59.67 (SD = 9.617) years, with 152 (23.1%) females and 505 (76.9%) males, and 514 (78.2%) patients had poor glycemic control. Most of the patients were on insulin mono-therapy [n = 271 (42.1%)], about a third of the patients were on combination therapy that included an oral hypoglycemic agent and insulin [n = 236 (36.6%)]. Patients with a history of more than 10 years of diabetes [n = 293 (44.6%)], had a family history of diabetes [n = 256 (39%)] and obesity [n = 95 (14.5%)], all had poor glycemic control. Conclusion This present study indicated a significant association of gender (female), age, high-density lipoprotein level, duration of diabetes and type of medication, with poor glycemic control in T2DM patients that had secondary medical complications.

Evaluation of supportive care management outcomes in cancer chemotherapy: a prospective observational study in a tertiary care teaching hospital in south India

Aims: Evaluation of supportive care management of cancer patients experiencing drug-related problems (DRPs) is a challenge because it might increase the cost due to additional therapy. The main objectives of this study were to estimate chemotherapy-associated drug-related hospital admissions in the department of medical oncology and to estimate the cost of managing chemotherapy-associated DRPs. Settings and Design: This study is a prospective observational study. Subjects and Methods: Patients with chemotherapy-related DRPs were prospectively identified from the patients medical records. The contribution of DRPs and cost incurred due to each hospitalization was assessed. Statistical Analysis Used: Data were analyzed using SPSS® 20.0 version. Results: Out of 55 patients analyzed for DRPs, 25 (45.5%) patients in the age group of 51–60 years experienced DRPs most frequently. Most commonly occurring DRP was adverse drug reactions 42 (76.4%), which were more frequent in females. DRPs were maximum with alkylating agents 15 (27.3%) and the least with hormonal agents 1 (1.8%). The mean length of hospitalization was 9.6 ± 6.5 days. The total direct medical cost was Rs. 31,540 ± 42,476, of which medicine cost accounted for Rs. 16,550 ± 25,404, constituting a major share of the total medical costs. Conclusions: Pharmacists can provide better patient care by identifying and preventing DRPs and reducing drug-related morbidity and mortality.