Asia Pacific Journal of Medical Toxicology
Volume:9 Issue: 3, Summer 2020

Background:

 In Pakistan, most of the data on poisoning comes from scattered case series with data on poisoning mortality, and especially relating to people of lower socioeconomic status, lacking. We aim to shed some insight on the factors relating to poisoning mortality in Pakistan in an effort to appreciate the potential measures required to reduce it Methods A total of 204 cases of poisoning fatalities, occurring between May 29, 2013, and September 10, 2019, were reviewed retrospectively from the National Poison Control Centre at Karachi, Pakistan. Cases of poisoning by accident, suicide, and homicide were included and animal bites and food poisoning were excluded. Patients less than 13 years of age were excluded. 

Results:

 From our deceased patient medical records, 67.2% were males and 32.8% were females. The mean age of the patients was 29.20 ± 13.04 years. Most of the deaths from poisoning were attributed to organophosphate consumption, mainly through the ingestion of rat killer (30.9%), dichlorvos based pesticide (23.5%), and insecticides (10.3%). A noteworthy number of the deceased patients were housewives (12.7%) and students (11%) and a significant association was seen between occupation and poison consumed (p=0.048). Treatment for most of the cases was non-specific.  

Poisoning is a serious threat to all demographics and mortality can be attributed to substances that can be easily obtained and are widely used. This indicates a gap in safety measures and calls for tighter regulation standards.

  Scorpion envenomation is a common public health problem worldwide and children are at greater risk of developing severe cardiac, respiratory and neurological complications. Scorpion envenomation is a preventable life-threatening medical accident. This study aims at identifying the demographic parameters, clinical features, complications, outcome and response to prazosin in scorpion envenomation of children admitted at tertiary care hospital. It was a retrospective cross sectionalstudy conducted on 52 pediatrics cases admitted in department of Paediatrics, Uttar Pradesh University of Medical Science (UPUMS), Saifai from Jan 2016 to Dec 2019 with history of scorpion sting. The clinical details, investigations, treatment and prognosis of all children were evaluated based on the scorpion envenomation. Parameters were expressed as percentage. Majority of children were in the age group of 1 to 6 years 34 (65.38%) with 32 (61.53%) male and belonging to rural area 44 (84.62 %) with sting at lower limb 27 (51.92%) and gap b/w sting and hospitalization was < 6 hours 28 (53.85%). Most common clinical presentation was pain 46 (88.46%) and pulmonary edema 10 (19.23%) was common complications. Majority of children had received prazosin 49 (94.23%) within 6 hours 26 (51.02 %) with 3-6 doses 24 (48.98 %). 51 (98.0%) were successfully discharged and one patient was expired. Scorpion envenomation in children is a significant environmental health hazard especially in rural areas. Scorpion envenomation is an acute lifethreatening emergency, and recovery from scorpion sting is hastened by administration of prazosin therapy with excellent prognosis without use of scorpion antivenom

Drug abuse is a global problem in most countries and poisoning caused by them has involved the emergency department (ED).  This paper aims to investigate the changes in the epidemiological pattern of poisoned cases due to drugs in Hamadan province of Iran. In this five year cross - sectional study, we assessed the epidemiologic pattern of poisoned cases due to drugs hospitalized in Farshchian - Sina Hospital of Hamadan, west Iran from March 2015 to March 2019. During this period, 7199 poisoned patients referred to hospital and 1773 of them  hospitalized due to any kind of drugs.81% were male and 19% were female (p <0.001). The mean age in male cases was 40.85 ± 16.85 and in female cases was 42.37 ± 18.36. 86.4% of the cases lived in urban areas and 13.6% of them lived in rural areas. The most common drugs were opium (33%), methadone (22.7%) and methamphetamine (20.9%). In 35.1% male cases and in 45.8% female cases the most common drugs were opium and methamphetamine, respectively (p <0.001). In 79.2% of cases, overdose and in 20.5% of them, suicide attempt was the most common causes of use. Most cases were alive and only 1.7% were deceased. Although, poisoning by traditional drugs was still the most common cause of poisoning at the time of the study in this province, poisoning by synthetic drugs are on the rise.

Iron is an important element for normal cell metabolism, but in excess amounts is quite cytotoxic, and even deadly. Iron poisoning is a calamity repeated many times in the world. The clinical signs of the patients include gastrointestinal symptoms, a short period of relative stability, Cardiogenic shock, liver failure, and scarring of the gastrointestinal tract. Iron tablets are specifically tempting to children because they are similar to candy. Iron overdose in adults is usually to attempt suicide. The present study is a descriptive-analytic study based on hospital information, that was conducted among the patients affected with iron poisoning admitted to Razi hospital (a referral medical setting for poisoning treatment in southwest Iran) during 2014-2017. Patient information has been extracted and inserted in the inquiry form and data were analyzed by SPSS software. In this study, 52 patients (94.2% female) were studied. 5 (9.6%) of women were pregnant.  The majority of them (69.2%) were between 15-25 years of age. Nausea and vomiting (50%) are two of the most common side effects. 5 patients (9.6%) received deferoxamine. All Patients who received deferoxamine, symptoms had less than 6 hours of onset. Most patients were hospitalized between 6-24 hours. 25% of patients took vitamins simultaneously with iron. The Serum level of iron in 3 patients (5.8%) was above 300 µg/dL. Based on this research, mortality was reported in one patient. In this study, the prevalence of iron poisoning was examined based on demographic and clinical characteristics. Considering the most prevalent iron poisoning in the young age group (96.2% suicides), more research in the psychological and social problems is critical for preventative behaviors.

Synthetic cannabinoids (SCs) are highly abused of New Psychoactive Substances (NPS). SCs has known under street names such as “Spice”, “herbal incense” and “K2”, act as endocannabinoids (CB) receptor full agonists and have unpredictable toxicity and abuse potential. This narrative review was conducted to update the present evidence about the clinical and forensic toxicological aspects of SCs.

PubMed, Scopus and Google Scholar  databases from 2015 to 2020 (up to 1st May) were searched using the terms “synthetic cannabinoids”, “synthetic cannabimimetics”, “ K2”,  “Spice”, “clinical toxicology”, “forensic toxicology”, “poisoning”, “toxicity”, “abuse” , “addiction “analysis” and “determination” to identify the relevant articles. In addition, a manual search of reference lists of the retrieved articles was conducted.

ADB-FUBINACA , XRL-11, 5F-ADB, 5F-PB-22, MDMB-CHMICA and MMB-2201 are the commonly reported SCs analogues among acute toxicities and fatalities cases. Adverse reactions and toxic effects of SCs includes psychoneurological, cardiovascular, renal and gastrointestinal involvements. Deaths related to SCs have been reported due to stroke and cardiac dysrhythmia. Analysis of SCs in biological samples in the clinical and postmortem setting needs sophisticated analytical instruments. Liquid gas chromatography tandem mass spectrometry (LC-MS/MS) has a crucial role for detection of SCs and their metabolites in biological samples.

Unlike natural cannabinoids, the SCs abuse/poisoning has serious and life-threatening effects in abuser. Also, analysis of SCs is not included in the routine forensic urine drug testing. Therefore, suitable measures of informing the public and health care professionals for prevention of SCs abuse are recommended.

Venlafaxine is a serotonin and norepinephrine reuptake inhibitor (SNRI) used to treat major depressive episodes and anxiety. The risk of hypoglycemia is mentioned in the Summary of Product Characteristics (SmPC) of venlafaxine in the “warnings and precautions” section in diabetic patients. This effect appears neither in the “adverse reactions” nor in the “overdose” section. We herein report a case of severe hypoglycemia with coma in relation to venlafaxine poisoning.  

Case Report:

 A 35-year-old non-diabetic obese woman (BMI, 29 kg/m2) was found unconscious a few hours after ingesting venlafaxine and bromazepam in a suicide attempt. Vital signs on day 1 were as follows: Glasgow Coma score of 7, blood pressure of 99/66 mmHg and heart rate of 100/min. Electrocardiogram showed no abnormality. She was admitted to the intensive care unit. Due to sustained hypoglycemia [0.5 g/L (day1); 0.41 g/L (day2); 0.8 to 1.20 (day3)], she received continuous intravenous 10% glucose infusion for 3 days to normalize blood glucose. Plasma venlafaxine concentration was 11.7 times the upper the limit of therapeutic dose range (UTDR) on day 2 and reached the therapeutic dose range (TDR) on day 6. Plasma bromazepam concentration was 6.7 times UTDR on day 3 and reached TDR on day 8. Alternative etiologies of hypoglycemia were excluded, i.e. hypoglycemic sulfonamide, insulin poisoning, insulinoma, and disease of the adrenal gland, liver and thyroid. She was transferred to a psychiatric unit after one week.

Impairment of blood glucose homeostasis is rarely described with venlafaxine. In our patient, hypoglycemia appeared to be correlated with plasma venlafaxine concentrations and may be explained by increased insulin sensitivity, considering her obesity.

Healthcare professionals should be aware of hypoglycemia induced by venlafaxine or other SNRIs in non-diabetic patients.

 We present a case of Cerbera fruit ingestion which highlight the knowledge gap in unusual glycoside poisoning. Despite the patient’s asymptomatic presentation, life threatening clinical features such as hyperkalaemia, hypotension and arrhythmia occurred later. Treatments instituted were activated charcoal (AC), atropine, hyperkalaemia management, Digoxin Fab and intravenous lipid emulsion (ILE). Advanced Cardiac Life Support (ACLS) was instituted with automated chest compression device. The patient died despite prolonged of resuscitation effort. Cerbera glycoside toxicity warrants serious consideration in view of rare presentation and unpredictable nature of toxicology. 

 We highlight the prevalence of Cerbera species in Asia-Pacific and present the similarities of cardiac glycosides pharmacology. Early recognition of ingestion and cardiac monitoring are particularly important. In this case, we highlight the diagnostic and prognostic challenge as patient deteriorated despite normal serum digoxin level. As the evidence of Cerbera glycoside poisoning treatment options is lacking, we take this opportunity to examine treatment options assuming similar pharmacology among cardiac glycoside family. We argue for a case for use of Digoxin Fab which is the prevailing treatment for glycoside poisoning. Multi-dose-activated charcoal (MDAC) and ILE are postulated to have physiological basis given current evidence. Electrical and pharmacology treatment for arrhythmia were explored as there is limited evidence. We propose ECMO should always be considered for cardiac toxicity in anticipation of treatment failure as the novel therapy has shown great promise. 

 Cerbera glycoside poisoning should be treated with utmost caution as the fruit is easily accessible and highly toxic. Close cardiac monitoring is a must due to high mortality risk. Digoxin Fab should be instituted as guided by toxicologist. Patients should be transferred to ECMO centre for observation in all cases due to the unpredictable nature of toxin. Further investigation of treatment is awaited.