Robin B. McFee

Intravenous mercury injection and ingestion: clinical manifestations and management.

Background: Mercury is a complex toxin with clinical manifestations determined by the chemical form, route, dose, and acuity of the exposure. Parenteral injection of elemental mercury remains uncommon. Case Report: A 40-year-old male injected 3 mL of elemental mercury intravenously and ingested 3 mL as a suicide attempt. Within 24 hours, he became dyspneic, febrile, tachycardic, and voiced mild gastrointestinal complaints. Chest X-ray revealed scattered pulmonary infiltrates and embolized mercury bilaterally. A ventilation/perfusion scan demonstrated ventilation/perfusion deficits. Additionally, his renal function declined, as manifest by minor elevations in blood urea nitrogen and creatinine and decreased urine output. Pulmonary therapy, intravenous hydration, and chelation using 2,3-dimercaptoscuccinic acid (DMSA/Succimer) were started. Over the next 36 hours, the patients pulmonary and renal functions improved. Temperature and heart rate subsequently normalized, and symptoms at discharge were mild exertional dyspnea. Discussion: Liquid mercury injected intravenously embolizes to the pulmonary vasculature and perhaps vessels in other organs such as heart and kidney. In-situ oxidation to inorganic mercury, which is directly toxic to a variety of tissues, may help explain the multisystem involvement. Conclusion: Significant pulmonary dysfunction accompanied by radiographically demonstrated mercury emboli and temporary abnormalities in several organs improved shortly after initiation of chelation. The impact of chelation on long-term outcome of parenteral mercury exposure remains uncharacterized.

Nosocomial or Hospital-acquired Infections: An Overview

osocomial or hospital-acquired infections (HAI) are a leading cause of orbidity and mortality in the USA. Several studies have been onducted over the years to characterize and quantify this ever-growing ublic health problem. In a 2002 study published in 2007, the estimated umber of HAI in US hospitals, adjusted to include federal facilities, was .7 million, with almost 99,000 deaths directly resulting from the nfection. The highest infection rates per 1000 patient-days occurred in ntensive care units (ICU), followed by high-risk nurseries. urgical site infections accounted for a significant number of infecions. The most common sites of infection in this study included rinary tract infections, which accounted for 36% of HAI, surgical site nfections (20%), pneumonia (11%), and bloodstream infection (11%). In 995, the Centers for Disease Control and Prevention estimated 1.9 million AI. Among the deaths associated were the following 35,967 neumonia, 30,665 bloodstream infections, 13,088 urinary tract infecions, 8205 surgical site infections, and 11,062 other infections. Other ational estimates are closely aligned with these data. Within the context of HAI are selected pathogens that are or have merged as significant public health threats—methicillin-resistant staphlococcus aureus (MRSA), Enterococcus-resistant vancomycin, and lostridium difficile (C diff). The latter is especially problematic as t is highly difficult to eradicate from the health care environment and is ncreasing in incidence and certain strains are emerging with increased irulence. C diff will be discussed in the next article. oreover, antibiotic use is a preceding catalyst as are other commonly mployed medical interventions, especially among the very young and ld. Given the well-recognized reality that hand hygiene rates re abysmal among health care workers, another risk factor for C diff, it s likely continued unnecessary deaths from C diff specifically and HAI

A Primer for Nuclear Terrorism

Mass exposure to radiologic substances presents a unique challenge to the entire response effort, which includes health care professionals, law enforcement personnel, and other first responders. Recognition of signs and symptoms of exposure, and focus on removal and decontamination are priorities of management. Radiation injuries require specialized equipment and access to experts. Patients can have complex patterns of injury, ranging from trauma and the immediate results of an explosion or exposure, to progressive damage associated with radiation sickness. Both conventional injury and radiation illness may require critical care management. Remembering the essentials of first response, that is, treat the patient, not the poison, by addressing the ABCs of airway, breathing, and circulation, is critical to appropriate treatment of radiation exposure. Understanding the basic science of radiologic agents will aid the provider in managing affected patients and preventing further casualties.

Combined antipyretictherapy: Another potential source of chronicacetaminophen toxicity

The Journal has recently published 2 articles and an editorial that discussed mortality from chronic acetaminophen toxicity in children.[1] [3] The Poison Center has recently encountered an innovative way in which a pediatricianis instructions can produce confusion and potentially lead to acetaminophen or ibuprofen intoxication. Six calls to our center from May 1, 1997, through February 20, 1998, alerted us that parents had been instructed by their pediatricians to administer acetaminophen for fever, and if the temperature had not responded in 2 hours, to administer ibuprofen. The parents called because they were confused about the instructions and times of administration of these 2 medications. Although none of these cases resulted in toxicity, we are concerned about the concept and the potential for drug intoxication and interactions. Similar instructions have been written on medication order sheets of children in the hospital.

Gulf War Servicemen and Servicewomen: The Long Road Home and the Role of Health Care Professionals to Enhance the Troops' Health and Healing

he war on terror and Persian Gulf War (PGW) pose a wide array of hreats to our troops and new diagnostic challenges to clinicians. With dvances in body armor and battlefield medicine, catastrophic combat njuries that would have been unsurvivable in prior wars can be reated. However, the survivors of such injuries face significant sychological and physical challenges, lengthy rehabilitation and readustment to family, work, and social activities. Multiple amputations ose an enormous challenge for survivors and their families. Military edical resources for returning troops are strained and unable to keep ace with the demand. Traumatic brain injuries (TBI) and tympanic embrane injuries are on the rise given the ubiquitous nature of daily life mong insurgents using improvised explosive devices (IED). BI, especially mild and moderate cases, are often overlooked or isdiagnosed; such injuries can significantly impair memory and other ctivities of daily living. Moreover, they can be mistaken for psychologcal illnesses. Beyond the psychological trauma of war, chemicals and ome infectious diseases can be neurotoxic and damage the central ervous system, resulting in altered behavior and interpreted as psychoathology when in fact the patient is suffering from neurotoxicity. ur troops will be exposed to desert illnesses and pathogens endemic in he Middle East but relatively uncommon in the U.S. Some of these can ose a diagnostic challenge to clinicians unaccustomed to these illesses. In a world of emerging pathogens and infections endemic o one region but often unknown to North America, it is important to

Update - pathogens of concern.

TB is the second most common cause of infection-related death in the world, resulting in 3–4 million deaths annually. It is estimated that there are 8 million new cases a year. Of concern, TB organisms resistant to the wide array of anti-tuberculosis therapeutics are widespread and prevalent worldwide. Of note, TB drug-resistant strains can spread person to person much the same as TB sensitive to chemotherapeutics. It is also the most common opportunistic pathogen associated with HIV. TB is not just a global threat, but one that the US continues to face. While TB can be a challenge to treat, often requiring multiple antimicrobial agents, drug-resistant (DR), multi-drug-resistant (MDR), and extensively drug-resistant (XDR) TB continue to be significant public health concerns. MDR-TB is caused by mycobacterium that is resistant to the most effective anti-TB drugs, isoniazid and rifampin, for example, and can result from either infection with organisms which are already drug resistant or develop it in the course of treatment. This often occurs with inadequate initial treatment. XDR-TB is a growing global concern and is caused by organisms resistant to isoniazid, rifampin (MDR-TB), and any fluoroquinolone and any of the second-line anti-TB injectable medicines (amikacin, kanamycin, and capreomycin). Neither MDR-TB nor XDR-TB respond to the standard 6-month treatment with first-line anti-TB drugs and can take upwards of 2 years of treatment. The WHO estimated about 500,000 new MDR-TB cases in 2011, of which 60% of these occurred in Brazil, China, India, the Russian Federation, and South Africa; 50% were in China and India alone. In 2008, 440,000 people had MDR-TB, and the WHO estimates onethird died. In Africa, little data are available, and most cases of MDR and XDR-TB go undiagnosed. Worrisome is the fact that the drugs used to treat resistant TB (MDR and XDR) are less potent, more toxic, and expensive than first-line drugs. Of note, 48% of patients with MDR-TB enrolled for treatment in 2009 were reported to have been successfully treated. There is an increase in the detection of MDR-TB patients due to the availability of rapid diagnostics. The Xpert MTB/RIF assay has been deployed in 77 countries in 2012, allowing better treatment. Ideally patients who are initially diagnosed with TB will be adequately treated; this includes emphasizing the critical

Global infectious diseases—The new norm for the United States?

From 1900 to the end of the 20th century, and into the present, there has been a significant shift in the top ten causes of death in the United States (Tables 1 and 2). Where once infectious diseases were leading health care concerns, these have been largely replaced by cardiovascular disease and cancer. Unfortunately for a large proportion of the planet, infectious diseases remain the leading causes of death, disability, in some cases preventable blindness, and other serious sequelae. Because of our location, significant public health and medical infrastructure, and widespread immunizations against a wide array of pathogens, the US has been fortunately isolated from many infectious diseases, with the notable exception of tuberculosis (TB), HIV/AIDS, Lyme, West Nile, pneumonia, and influenza-related illness, as well as hospital-acquired infections. Of note, West Nile virus infections in the United States resulted in more than 140 deaths in 2006. Unfortunately most of the world still bears an enormous burden related to infections. Instead of recognizing that billions of people worldwide are exposed to important and emerging infectious diseases, our training has relegated this topic mostly to “tropical medicine” or public health or labeled the threat as a “zebra” item. While most of us remember from our early medical training the old adage “If you hear hoof beats, think horses, not zebras,” the US, and our attention, including medical training, can no longer afford to follow this adage or relegate these so-called “zebras” to the dismissed column, as many of them are important global health concerns. The world has come to our country as much as we have traveled to the world. And by extension—the worlds diseases have come to our clinics, emergency departments, and health care facilities. Globalization, population shifts, and the changing ecology, including encroachment of previously unexplored regions, have altered the longstanding epidemiology of infectious diseases, causing spread where once continents and oceans contained the pathogen. New pathogens are occurring—some through unknown means and others through natural adaptation. It has long been recognized that influenza viruses exchange genetic material, either emerging as a new strain, as we continue to see with H5N1, H1N1, and now the latest H7N9. But this likely holds true for other viruses, as recently demonstrated with a novel coronavirus, most recently referred to as Middle East respiratory syndrome (MERS CoV). Social determinants of health—poverty, overcrowding, lack of infrastructure in many developing nations and in our own cities, which leads to poor sanitation, inadequate clean water, under-immunization and lack of health care access, environmental changes resulting in

Viral hemorrhagic fever viruses

Dengue, a viral hemorrhagic fever (VHF) virus, is the most common mosquito-borne illness (Figs. 1 and 2), and one of the fastest spreading infections worldwide. It is a significant global health concern given there are estimated 3 billion people who live in areas where dengue virus can be transmitted. Some suggest nearly half of the entire global population is at risk, including parts of the United States. Viral hemorrhagic fevers (VHFs) refer to a group of infectious illnesses that are caused by several distinct families of viruses, not surprisingly called the viral hemorrhagic fever viruses that include Ebola, Lassa, dengue, and others. VHFs are distributed worldwide. VHFs are a taxonomically diverse group of viruses capable of causing high morbidity and mortality. In addition to endemic illness worldwide, VHFs remain of considerable interest as possible biological weapons. Regardless of the pathogen, VHF refers to a severe multisystem syndrome that results primarily in fevers and bleeding risks. Some form of hematological event secondary to microvascular damage and changes in vascular permeability can occur, along with other symptoms. Inherent with VHFs, the overall vascular system is affected, resulting at times in severe dysregulation of coagulation; depending upon the underlying viral illness, a variety in severity of bleeding can occur from petechiae to circulatory collapse. Some VHF viruses cause primarily relatively mild illnesses, others cause a broad range (dengue), and yet others result in life-threatening disease (Ebola). Most VHFs are considered biosafety level 4 (BSL-4) pathogens—the highest level of security and threat, usually associated with pathogens for which there is no treatment and/or preventive measure. Exceptions to BSL-4 are dengue and yellow fever. VHF viruses belong to four distinct families (Table 1): arenaviruses, filoviruses, bunyaviruses, and flaviviruses that share the following common features:

Selected mosquito-borne illnesses—Chikungunya

ed from CDC and http://www.denguevirusnet.com/compare-dengue-zika-and-chikungunya.html. NB—These are for general guidance. Some overlap with these and other pathologies is possible. Moreover severity of these signs and symptoms can be influenced by multiple factors—host immunity, comorbidities, strain of virus, etc.

Selected mosquito borne illnesses – Zika

Department of Emergency/Family Medicine, Debusk College of Osteopathic Medicine, Lincoln Memorial University, USA Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA University of Miami-Miller School of Medicine, Palm Beach County, FL, USA Department of Pathology and Laboratory Medicine, Wellington Regional Medical Center, Blue Health, LLC, Palm Beach County, FL, USA