Asia Pacific Journal of Medical Toxicology
Volume:5 Issue: 1, Winter 2016

In December 2015, the World Health Organization (WHO) published the first ever report on the estimates of the global burden of foodborne diseases, which included diseases related to chemical exposures in foods such as peanut allergy. In the report, the burden of disease related to peanut allergies was measured for the European, American and West Pacific Regions. The report showed that unlike other food-related chemical exposures, peanut allergies are far more common in the European and American Regions than in the West Pacific Region. In this commentary we tried to inform physicians and public health workers, and to raise awareness about peanut allergies to facilitate future discussions. Although the WHO report on the estimates of the global burden of foodborne diseases indicates a possible geographical difference in global peanut allergy prevalence, further studies need to compare the relative risk of peanut allergies among individuals of different racial backgrounds in one defined population.

The pattern of poisoning in Russia may be different from other countries. The study objective was to describe the pattern of poisoning with cardiovascular drugs in a major industrial city in Russia, Yekaterinburg.
This study was part of a larger prospective multi-center study including all acute poisonings in patients older than 15 years of age in the city of Yekaterinburg, during March 2009 to March 2010. Patients with main diagnosis of acute poisoning by cardiovascular drugs and two other commonly used drugs affecting cardiac system were included.
Cardiovascular drugs were the main poisoning agent in 269 cases of 3,112 acute poisonings (8.6%) during the study period. Median age of the patients was 36 (range: 16-88) years and 108 patients (40%) were men. Over 85% of patients required hospital admission and ICU care was needed for 45.7% of patients. Men significantly outnumbered women in veratrine poisoning (P The most common drugs causing hypotension and cardiac arrhythmias were clonidine, CCBs, drotaverine and the veterinary drug “veratrine”. Drotaverine, clonidine and CCBs were the most common drugs causing death. Poisonings with these agents are rare in other countries. Measures to reduce the availability of drotaverine and veratrine should be taken in Russia.

Acute poisoning has been reported to be the most common reason for hospitalization in Iran. This study was designed to delineate the toxic agents responsible for acute poisonings in Iran by reviewing poisoning cases treated at four major referral hospitals for treatment of poisoning across the country.
This was a descriptive retrospective study on poisoned patients treated at four tertiary hospitals referral for poisoning in Iran, including Loghman Hakim Hospital (LHH) in Tehran, Imam Reza Hospital (IRH) in Mashhad, Noor and Ali Asghar Hospital (NAH) in Isfahan, and Ghaemshahr Razi Hospital (GRH) in Ghaemshahr, as reported to the National Drug and Poison Information Center during the years 2012 and 2013.
During the two-year study period, 61,187 poisoned patients (i.e. 32,107 patients in 2012 and 29,080 patients in 2013) were treated at the four hospitals. In these two years, 22,185 patients (36.3%) were treated at LHH, 22,160 patients (36.2%) at IRH, 10,897 patients (17.8%) at NAH and 5,945 patients (9.7%) at GRH. Cumulatively in all hospitals, the highest rate of admissions was due to drug poisoning (42,017, 68.7%), recreational substances overdose (7,302, 11.9%) and pesticide poisoning (5,217, 8.5%).
Pharmaceutical products, substances of abuse and pesticides are the most common causes of poisoning-related admissions to referral Iranian poison treatment centers. Effective measures to reduce poisoning with these substances should be done.

Knowing the pattern of carbon monoxide (CO) poisoning in each region is vital for enhanced health planning. This study was designed to evaluate the epidemiologic pattern of unintentional acute CO poisoning in major cities of Fars province, southwest of Iran.
This one-year cross-sectional study was carried out on unintentional CO poisoning incidents in Fars province, Iran, during the year 2011. The target population was people living in 7 major cities under supervision of Shiraz University of Medical Sciences including Shiraz, Eghlid, Neyriz, Khorambid, Marvdasht, Darab and Bavanat.
During 2011, 111 CO poisoning events occurred in the catchment area. These events involved 420 individuals (50.2% men) who were present during the poisoning event, of which 281 individuals with mean age of 27.8 ± 14.8 years were poisoned (46.5% men). The majority of CO poisoning events (77.3%) occurred in colder months of the year. Most events happened in urban areas (61.3%). The most common source of CO was water heater (27.5%) closely followed by gas stove (24.8%). The majority of poisoned patients were asleep during the event (150/281: 53.3%). The main causes of CO generation were inbound gas return (62.2%) and inappropriate ventilation (28.8%). The fatality rate of CO poisoning was significantly higher in men compared to women both in involved individuals and poisoned patients (P = 0.035, Generally, the incidence and fatality rate of CO poisoning in the current study were comparable to those of the world statistics, but higher than in developed counties. Attention and emphasis on the safety of gas heaters, stoves, and other gas-powered appliances in residential places should be enforced.

Acute poisoning is a common medical emergency. This study was designed to investigate the pattern of drug utilization, poisoning agents, and outcome in patients with acute poisoning treated at a tertiary care teaching hospital in Vadodara, west of India.
This prospective cross sectional drug utilization study was carried out on patients with diagnosis of acute poisoning admitted to emergency department of Sir Shree Sayajirao General Hospital during October, 2013 to March, 2014.
During 6 months, 340 acute poisoning cases were enrolled, out of which 216 cases (63.5%) were men. Mean age of the patients was 31.9 ± 12.7 years. Commonest mode of poisoning was intentional (suicidal), which was observed in 62.1% of cases. Pesticides were the most common cause of poisoning (40%), followed by venomous animal exposures (25.9%). Fifty-six patients (16.5%) died. A significantly higher number of deaths was seen in intentional poisonings compared to accidental poisonings (24.2% vs. 3.9%; P Use of antimicrobial medicines for poisoned patients was too high and irrational. Due to high incidence of snakebites, hospital stockpiles should be regularly checked for availability of antivenom. Educational programs with emphasis on preventive measures for toxic exposures are necessary to create awareness among the general public.

Direct thrombin inhibitors and factor Xa inhibitors are gaining popularity as alternatives to warfarin for patients requiring anticoagulation. Toxicity due to these medications is difficult to manage because overdose experience is very limited and there is no clear guidance on when or whether to use antidote in this setting.
A 50-year-old man with normal renal function ingested 10 to 25 tablets of dabigatran 150 mg. He denied any specific symptoms and had an unremarkable physical exam. No bleeding or bruising was noted and stool was guaiac negative on initial workup. Per recommendations from the Regional Poison Center, a single 100 g dose of activated charcoal was administered approximately three hours post-ingestion and the patient was admitted for monitoring. Baseline coagulation parameters of the patient (including aPTT) revealed coagulopathy. However, no sign of systemic or local hemorrhage was detected. Having received only supportive treatments during admission, aPTT restored to normal limits by hospital day 2. A dabigatran level revealed the drug to be almost completely eliminated by 34 hours after ingestion.
Specific reversal agents for direct thrombin inhibitors are under final phases of development. The question of whether or not to use these antidotes is expected to come up in situations of accidental or intentional overdose with direct thrombin inhibitors. Similar to our observation, some scientists showed that dabigatran overdose can be managed conservatively with supportive treatments.
This case adds to the limited pool of literature regarding dabigatran overdose and outcomes, and suggests that a patient with an overdose of this magnitude may be safely managed without acute intervention. Literature review suggests that aPTT might be an appropriate method for monitoring anticoagulant effects related to this drug in the clinical setting.

Mostly seen toxicities following vancomycin are ototoxicity and nephrotoxicity. We here report a very low birth weight preterm neonate who developed severe episodes of apnea after accidental iatrogenic vancomycin overdose, responsive to treatment with double volume exchange transfusion.
Case report: A preterm neonate weighing 1380 grams received two doses of 10-fold of the normal dose of vancomycin per kg in this age group. She developed sudden onset of frequent and severe episodes of apnea, which required noninvasive ventilation. Using fluorescence polarization immunoassay, serum vancomycin level was found to be 84 μg/mL 10 hours after the last dose. The patient underwent exchange transfusion. Apnea episodes terminated 12 hours after exchange transfusion. The blood level of vancomycin decreased from 84 μg/mL before exchange to 67 μg/mL immediately post-exchange and eventually to less than 1 μg/mL in 36th hour after exchange.
Target peak concentration of vancomycin in neonates is between 20 and 40 μg/mL and trough concentration ranges from 5 to 10 μg/mL. Peak serum concentration of our patient can be back extrapolated to be about 336 μg/mL which was higher than the target level. This high plasma levels of vancomycin might be the cause of apnea in our patient as evidenced in similar reports.
Apnea is a potential sign of vancomycin overdose in neonates and infants treated with this antibiotic. Exchange transfusion is a potential effective treatment to rapidly resolve this unwanted complication.

Amphetamine abusers are shown to have significant cognitive impairments as well as delusional disorders. We present a 17-year-old man who was admitted to the toxicology emergency department with amphetamine overdose. Along with the classic signs and symptoms of overdose including mydriasis, tachycardia, hypertension, sweating and severe agitation, his urine toxicology screen test was found to be positive for 3,4-methylenedioxy-methamphetamine. In physical examination, widespread round-to-oval cutaneous lesions were observed all over his limbs and chest, notably the most easily reached sites of skin to be scratched. After regaining consciousness, the patient complained of pruritus and sensing the movement of insects under his skin. Further medical history showed that he had abused amphetamines for more than two years along with persistent pruritus, for which he had visited different physicians who mainly had made the diagnosis of allergy or dermatitis for him. He had been treated with antihistamines (hydroxyzine) for a long period. He also had been diagnosed with scabies and treated with topical permethrin and lindane lotion. Despite receiving these treatments, he continued to have pruritus particularly on his forearms and hands. He was finally diagnosed with “Ekbom’s syndrome” and referred to psychological rehabilitation and psychosomatic outpatient clinic.

Dear editor,
We read the recent article of Rahmani et al entitled "Medical Management and Outcome of Paraquat Poisoning in Ahvaz, Iran: A Hospital-Based Study" in your journal (1). In their study they performed upper gastrointestinal (GI) endoscopy as a routine for all paraquat poisoned patients, because they considered paraquat a caustic agent and that it may cause severe mucosal injuries in esophagus. This approach seems rather excessive, as Yen et al established that paraquat is a mild caustic agent and produces only grades 1, 2a, and 2b esophageal injury that can be managed with supportive measures (2). In addition, Chen et al ascertained the same implication showing in their study that paraquat is only a weak caustic agent (3). In our experience (4), low rate of GI injury occurs in paraquat poisoning, and moreover, GI tract complications alone do not have any impact on patients’ survival (4).
Taking these facts together, because paraquat poisoning is common in some regions and upper GI endoscopy is an anecdotal routine in some hospitals for this type of poisoning, in our opinion the following comments are better to be considered in day to day practice and for future studies: 1- The relationship between clinical signs and symptoms of mucosal injury (vomiting, odynophagia, dysphagia, retrosternal pain, etc.) with the degree of injury in GI endoscopy in paraquat poisoning has not been determined yet.
2- The association of paraquat serum level with the level of mucosal injury (determined by endoscopy) has not been established in paraquat poisoned patients.
3- As paraquat poisoning may cause severe liver dysfunction and coagulopathy, for performing endoscopy, the optimal time should be considered. In this case, invasive measures may just worsen the patient's condition by exposing them at the risk of uncontrollable bleeding.
4- Comparing the specificity and sensitivity of chest esophageal CT scan (as a possible substitute for GI endoscopy) and GI endoscopy (as a gold standard method) for evaluation of esophageal injury seems to be beneficial.
5- Finally, in order to determine the severity of paraquat poisoning and better define prognosis, severity index of paraquat poisoning (SIPP) is a widely used tool (5). Performing GI endoscopy for patients with SIPP scores less than 10, which are indicative of better prognosis, can be taken into account for follow up purpose (5).