Luciane C.R. Fernandes

Poisoning by illegal rodenticides containing acetylcholinesterase inhibitors (chumbinho): a prospective case series

Objective. To describe a prospective case series of poisonings caused by ingestion of illegal rodenticides containing acetylcholinesterase inhibitors, mainly “chumbinho,” followed-up by the Campinas PCC for a period of 1 year. Case series. Seventy-six cases were included, of which 53.9% were males. Age ranged from 2 to 74 years (median = 36 years). The main circumstances leading to poisoning were intentional (suicide attempts 92.1%; homicide attempts 5.3%), and 65.8% were admitted less than 2 hours after ingestion. Most of the patients (96.1%) showed cholinergic muscarinic manifestations, particularly salivation (86.8%), myosis (77.6%), sweating (50%), and bronchorrhea (35.5%). Atropine was used in 82.9% of patients (median = 2 days), intubation and mechanical ventilation in 46.1% (median = 3 days), and the median length of the hospital stay was 4 days. Plasma samples obtained upon admission in 59 cases revealed (LC-MS/MS): aldicarb (55), carbofuran (2), aldicarb and carbofuran (1), no active component (1). In most of the plasma and urine samples collected upon admission, the highest concentrations (ng/mL) obtained were for the active metabolite aldicarb sulphoxide (plasma, median = 831, IIQ = 99.2–2885; urine, median = 9800, IIQ = 2000–15000) than aldicarb (plasma, median = 237, IIQ = 35.7–851; urine, median = 584, IIQ = 166–1230), indicating rapid metabolism. The excretion of aldicarb and its metabolites was rapid since these compounds were rarely detected in plasma samples 48 hours after admission. Sequential cholinesterase analysis in 14 patients revealed almost complete reactivation in the first 48 hours post-admission, compatible for poisoning by carbamates. Based on the Poisoning Severity Score, the cases were classified as asymptomatic (5.3%), minor (11.8%), moderate (35.5%), severe (43.4%), and fatal (3.9%). Conclusions. Most poisonings involved aldicarb and resulted from suicide attempts; the poisonings were generally severe, with a mortality of 3.9%. Aldicarb was rapidly absorbed, metabolized, and excreted.

Compartment syndrome after Bothrops jararaca snakebite: monitoring, treatment, and outcome

Objective. To report the outcome of a patient who developed compartment syndrome after Bothrops jararaca snakebite. Case report. A 39-year-old male was admitted 5 h after being bitten on the lower right leg. Physical examination revealed tense swelling, ecchymosis, hypoesthesia, and intense local pain that worsened after passive stretching, limited right foot dorsiflexion, and gingival bleeding. The case was classified as moderate/severe and eight vials of bothropic antivenom (AV) were infused 1 h postadmission. The main laboratory findings upon admission were incoagulable blood (incoagulable PT, aPTT, and INR), thrombocytopenia, serum creatine kinase (CK) of 580 U/L (reference value < 170 U/L), and a serum venom level of 33.7 ng/mL (ELISA; cutoff = 2.3 ng/mL). High anterior compartment pressure (60 mmHg) was identified 8 h post bite, with progressively lower pressures after AV administration and limb elevation (36 mmHg; 19 h post bite). However, moderate pain and limited foot dorsiflexion persisted. In addition, there was a progressive increase in serum CK (6,729 U/L; 45 h post bite), as well as marked edema and hemorrhage of the anterior compartment detected by magnetic resonance imaging (MRI) at 48 h post bite. A fasciotomy done after a further increase in intracompartmental pressure (66 mmHg, 57 h post bite) revealed hemorrhage/necrosis of the anterior tibial muscle that subsequently required partial resection. The patient developed a local infection (day 15 post bite) and a permanent fibular palsy. Conclusion. Compartment syndrome is an unusual but severe complication of snakebites. MRI, in conjunction with subfascial pressure measurements, may be useful in the diagnosis of compartment syndrome after snakebites.

Compartment Syndrome After Bothrops Jararaca Snakebite: Monitoring, Treatment, And Outcome.

Objective. To report the outcome of a patient who developed compartment syndrome after Bothrops jararaca snakebite. Case report. A 39-year-old male was admitted 5 h after being bitten on the lower right leg. Physical examination revealed tense swelling, ecchymosis, hypoesthesia, and intense local pain that worsened after passive stretching, limited right foot dorsiflexion, and gingival bleeding. The case was classified as moderate/severe and eight vials of bothropic antivenom (AV) were infused 1 h postadmission. The main laboratory findings upon admission were incoagulable blood (incoagulable PT, aPTT, and INR), thrombocytopenia, serum creatine kinase (CK) of 580 U/L (reference value < 170 U/L), and a serum venom level of 33.7 ng/mL (ELISA; cutoff = 2.3 ng/mL). High anterior compartment pressure (60 mmHg) was identified 8 h post bite, with progressively lower pressures after AV administration and limb elevation (36 mmHg; 19 h post bite). However, moderate pain and limited foot dorsiflexion persisted. In addition, there was a progressive increase in serum CK (6,729 U/L; 45 h post bite), as well as marked edema and hemorrhage of the anterior compartment detected by magnetic resonance imaging (MRI) at 48 h post bite. A fasciotomy done after a further increase in intracompartmental pressure (66 mmHg, 57 h post bite) revealed hemorrhage/necrosis of the anterior tibial muscle that subsequently required partial resection. The patient developed a local infection (day 15 post bite) and a permanent fibular palsy. Conclusion. Compartment syndrome is an unusual but severe complication of snakebites. MRI, in conjunction with subfascial pressure measurements, may be useful in the diagnosis of compartment syndrome after snakebites.

Human accidents involving Rhinocricus spp., a common millipede genus observed in urban areas of Brazil

Objective. The most important millipede species causing accidents in Brazil is Rhinocricus padbergi (order Spirobolida, family Rhinocricidae), a vegetarian scavenger distributed from Central to South America. Eleven clinical cases of dermal and oral accidental exposures to secretions from Rhinocricus spp. milipedes are described. Case series. Eleven cases of skin and oral involvement after accidental contact with the secretions of Rhinocricus spp. in patients from 1to 46 years are detailed. Ten of the 11 accidents involved the feet and in 1 child the mouth. Mild pain was reported in two of the cases, and a transient local burning sensation was described by most of the patients. Three reported no pain or any sensation at all. What was observed in all patients was a dark reddish or blackish staining of the skin simulating inflammatory or even necrotic lesions, which resolved naturally after some weeks. Conclusion. Despite the necrotic appearance of Rhinocricus spp. skin lesions, only a very mild inflammation and no necrosis occur. Analysis of the content of 50 glands of these animals captured in the southeast region of Brazil identified 2-methil-1,4-benzoquinone and 3,3a,4,5-tetrahydro-1H-pyrrolo-[2,3-b] pyridine-2,6-dione as the substances responsible for the lesions. Benzoquinones are strongly irritant and persistent compounds, working very well as insect repellents and are toxic to a great variety of other parasites and pathogens. They also have tanning properties. No systemic toxic effects have been described so far after skin contact with benzoquinones or Rhinocricus species.

Serotonin syndrome following sibutramine poisoning in a child, with sequential quantification of sibutramine and its primary and secondary amine metabolites in plasma

Objective. To report a case of serotonin syndrome (SS) after sibutramine overdose in a child. Case report. A 4-year-old girl was admitted 25 h after accidentally ingesting approximately 27 pills of sibutramine (15 mg, ∼23 mg/kg). The child developed clinical features suggestive of SS, including diaphoresis, tachycardia, hypertension, agitation, insomnia, incoordination, hypertonia (lower limbs ≫ upper limbs), and hallucinations. Serum creatine phosphokinase levels reached a peak on day 3 (2,577 U/L, reference value <145), suggesting mild rhabdomyolysis. No relevant changes were detected in other laboratory examinations or in the electrocardiogram throughout the period of hospitalization. The quantification of sibutramine and the active metabolites, M1 (mono-desmethyl sibutramine) and M2 (di‐desmethyl sibutramine), by liquid chromatography/electrospray ionization tandem mass spectrometry in six sequential samples collected from 25 to 147 h post-ingestion revealed a nonlinear decrease in the log-scale plasma concentrations. Treatment was only supportive and involved prolonged sedation to control the agitation, sleeplessness, and hypertension; no cyproheptadine was used. The patient was discharged on day 6 and follow-up revealed no sequelae. Conclusion. To our knowledge, this is the first report of SS after sibutramine overdose in a child, with sequential monitoring of the plasma levels of the drug and its two active metabolites. The growing consumption of weight reducing pills may increase the risk of unintentional acute toxic exposures in children.

Coagulopathy as the main systemic manifestation after envenoming by a juvenile South American rattlesnake (Crotalus durissus terrificus): Case report

Abstract Context. Rattlesnake bites in Brazil are generally caused by adult individuals, with most of the envenomed patients showing systemic manifestations that include varying degrees of neurotoxicity (acute myasthenia), rhabdomyolysis and coagulopathy, with only mild or no local manifestations. We report a case of envenoming by a juvenile South American rattlesnake (Crotalus durissus terrificus) that involved coagulopathy as the main systemic manifestation. Case details. A 19-year-old male was admitted to our Emergency Department with coagulopathy (incoagulable PT, APTT and INR), no remarkable local manifestations and no signs/symptoms of myasthenia or rhabdomyolysis (serum CK, LDH, ALT and AST within reference levels) 5 days after being bitten by a small snake that was described as a rattlesnake but was not brought for identification at admission. The patient had already been treated in another Emergency Department with i.v. bothropic antivenom (AV) 1 h and 4 days post-bite. Based on the possibility of an unusual rattlesnake bite, crotalic AV was administered i.v., which improved the coagulation (9 h post-CroAV, INR = 2.11; 36 h post-CroAV, INR = 1.42). During hospitalization, relatives brought the snake that caused the bite, which was identified as a 38-cm long C. d. terrificus. Discussion. Little is known about the clinical manifestations after bites by juvenile C. d. terrificus. This case shows that systemic envenoming by juvenile C. d. terrificus may result in coagulopathy as the main systemic manifestation, without neuromyotoxic features normally associated with bites by adult specimens. Despite the delayed administration, crotalic AV was effective in improving the blood coagulation.

Antidote availability in the municipality of Campinas, São Paulo, Brazil

CONTEXT AND OBJECTIVE: The lack of availability of antidotes in emergency services is a worldwide concern. The aim of the present study was to evaluate the availability of antidotes used for treating poisoning in Campinas (SP). DESIGN AND SETTING: This was a cross-sectional study of emergency services in Campinas, conducted in 2010-2012. METHODS: The availability, amount in stock, place of storage and access time for 26 antidotal treatments was investigated. In the hospitals, the availability of at least one complete treatment for a 70 kg adult over the first 24 hours of admission was evaluated based on stock and access recommendations contained in two international guidelines. RESULTS: 14 out of 17 functioning emergency services participated in the study, comprising pre-hospital services such as the public emergency ambulance service (SAMU; n = 1) and public emergency rooms for admissions lasting ≤ 24 hours (UPAs; n = 3), and 10 hospitals with emergency services. Six antidotes (atropine, sodium bicarbonate, diazepam, Phytomenadione, flumazenil and calcium gluconate) were stocked in all the services, followed by 13 units that also stocked activated charcoal, naloxone and diphenhydramine or biperiden. No service stocked all of the recommended antidotes; only the regional Poison Control Center had stocks close to recommended (22/26 antidotal treatments). The 10 hospitals had almost half of the antidotes for starting treatments, but only one quarter of the antidotes was present with stocks sufficient for providing treatment for 24 hours. CONCLUSION: The stock of antidotes for attending poisoning emergencies in the municipality of Campinas is incomplete and needs to be improved.CONTEXT AND OBJECTIVE: The lack of availability of antidotes in emergency services is a worldwide concern. The aim of the present study was to evaluate the availability of antidotes used for treating poisoning in Campinas (SP). DESIGN AND SETTING: This was a cross-sectional study of emergency services in Campinas, conducted in 2010-2012. METHODS: The availability, amount in stock, place of storage and access time for 26 antidotal treatments was investigated. In the hospitals, the availability of at least one complete treatment for a 70 kg adult over the first 24 hours of admission was evaluated based on stock and access recommendations contained in two international guidelines. RESULTS: 14 out of 17 functioning emergency services participated in the study, comprising pre-hospital services such as the public emergency ambulance service (SAMU; n = 1) and public emergency rooms for admissions lasting ≤ 24 hours (UPAs; n = 3), and 10 hospitals with emergency services. Six antidotes (atropine, sodium bicarbonate, diazepam, Phytomenadione, flumazenil and calcium gluconate) were stocked in all the services, followed by 13 units that also stocked activated charcoal, naloxone and diphenhydramine or biperiden. No service stocked all of the recommended antidotes; only the regional Poison Control Center had stocks close to recommended (22/26 antidotal treatments). The 10 hospitals had almost half of the antidotes for starting treatments, but only one quarter of the antidotes was present with stocks sufficient for providing treatment for 24 hours. CONCLUSION: The stock of antidotes for attending poisoning emergencies in the municipality of Campinas is incomplete and needs to be improved.

TOXIC EXPOSURES IN CHILDREN INVOLVING LEGALLY AND ILLEGALLY COMMERCIALIZED HOUSEHOLD SANITIZERS

ABSTRACT Objectives: To analyze and to compare clinical repercussions of accidents involving legally and illegally commercialized household sanitizers in children under 7 years of age. Methods: A descriptive cross-sectional design was used to collect data from electronic database of a regional Poison Control Center during one year. Data were analyzed by means of descriptive non-parametric statistics and association tests. Results: The sample had 737 reported cases. Most of the accidents occurred with children under 3 years of age (median: 1 year of age; interquartile interval: 1-3 years of age), at home (92.9%), by ingestion (97.2%). Products involved were cleaning products with low toxicity and no caustic effects (38.9%); caustics (24.1%); hydrocarbons (19.3%); pesticides/rodenticides (16.6%), and other products (1.1%). Seventy accidents were due to exposures to illegal products, mainly caustics (n=47) and rodenticides (n=15). Among the 337 children presenting post-exposure clinical manifestations, the most frequent were vomiting (n=125), oral burns (n=74), cough (n=35), drooling (n=26), and abdominal pain (n=25). Clinical manifestations were significantly more frequent after illegal products exposure (55/70 versus 282/667, p<0.01). Nineteen children had to be hospitalized (caustics, n=17; illegal products, n=12; median time of hospitalization: 2 days), 22 were submitted to esophagogastroduodenoscopy (sodium hydroxide, n=14; illegal products, n=14); and 12 cases had endoscopic alterations (severe in 2). No deaths occurred. Conclusion: Toxic exposures owing to illegal household sanitizer products are associated with greater morbidity when compared with legal ones.

Serotonin Syndrome Following Sibutramine Poisoning In A Child, With Sequential Quantification Of Sibutramine And Its Primary And Secondary Amine Metabolites In Plasma.

Objective. To report a case of serotonin syndrome (SS) after sibutramine overdose in a child. Case report. A 4-year-old girl was admitted 25 h after accidentally ingesting approximately 27 pills of sibutramine (15 mg, ∼23 mg/kg). The child developed clinical features suggestive of SS, including diaphoresis, tachycardia, hypertension, agitation, insomnia, incoordination, hypertonia (lower limbs ≫ upper limbs), and hallucinations. Serum creatine phosphokinase levels reached a peak on day 3 (2,577 U/L, reference value <145), suggesting mild rhabdomyolysis. No relevant changes were detected in other laboratory examinations or in the electrocardiogram throughout the period of hospitalization. The quantification of sibutramine and the active metabolites, M1 (mono-desmethyl sibutramine) and M2 (di‐desmethyl sibutramine), by liquid chromatography/electrospray ionization tandem mass spectrometry in six sequential samples collected from 25 to 147 h post-ingestion revealed a nonlinear decrease in the log-scale plasma concentrations. Treatment was only supportive and involved prolonged sedation to control the agitation, sleeplessness, and hypertension; no cyproheptadine was used. The patient was discharged on day 6 and follow-up revealed no sequelae. Conclusion. To our knowledge, this is the first report of SS after sibutramine overdose in a child, with sequential monitoring of the plasma levels of the drug and its two active metabolites. The growing consumption of weight reducing pills may increase the risk of unintentional acute toxic exposures in children.