Asia Pacific Journal of Medical Toxicology
Volume:9 Issue: 4, Autumn 2020

This research aims to evaluate heavy metals contamination of Alfalfa forage and soil in industrial and non-industrialregions of Tehran province. The soil and plant samples were collected from Alfalfa fields situated in industrial and non-industrialareas during two harvests of Alfalfa harvest. The Electrothermal atomizers spectroscopy technique was employed to measure the heavy metals (lead, arsenic, andcadmium) levels in the samples. A flame atomic absorption spectrometer equipped with acetylene-air flame was employed. The highest heavy metals concentrations were detected in the soil and Alfalfa samples from the industrial regions. Lead hadthe highest level in the soil followed by arsenic and cadmium; the same trend held for the Alfalfa as well. Moreover, the heavy metalcontent in Alfalfa declined from the first to second harvest, while it increased in the soil. The heavy metals content of Alfalfa wasbelow the maximum permitted concentration for feedstuffs and livestock. The highest soil-plant transfer factor of heavy metals wasdetected in the first harvesting. The highest arsenic transfer factor was recorded in the industrial areas. The findings of the current study can be helpful in the determination of healthy forage in various areas

Polypharmacy and inappropriate prescriptions are the most highlighted health issues among geriatric population, as they have multiple comorbidities. The objective of this study was to assess prescriptions using the World Health Organization (WHO) core indicators and Beers Criteria to discover polypharmacy and inappropriate prescriptions. This was a prospective, cross-sectional study of geriatric patients (65 years and above) who were attending the medicine outpatients clinic of a tertiary care teaching hospital hospital from May to December, 2016. World Health Organization (WHO) indicators and updated Beers Criteria were used to assess the drug utilization pattern and the prevalence of potentially inappropriatemedications (PIMs), respectively. The prescriptions of 250 geriatrics patients with a distribution of 57.6% male and 42.4% female were assessed for this study. The total numbers of drugs recorded from the prescriptions were 1635 drugs, with an average of 6.54 drugs per person. According tothe Beers Criteria, it was found that nearly 23.05% of the total prescribed drugs were potentially inappropriate. Polypharmacy and use of inappropriate medicines presents a health risk to the geriatric population. Causes could include healthcare practitioner shortage, lack of awareness of PIMs, not understanding drug interaction, and the need for multiple drugs. Prescriber training and retraining is needed.

Consumption of non-commercial alcoholic drinks is the main cause of methanol poisoning in the world. Non-standardized production methods or deliberate spiking of methanol in non-commercial and homemade alcoholic beverages have been reported, globally. The analysis of toxic alcohol contents in illegally produced alcohol beverages is necessary for prevention and early diagnosis of methanol poisoning especially during alcohol mass poisoning episodes. In this study, we analyzed methanol, ethanol and higher alcohols content in seized illegal alcoholic beverages during methanol mass poisoning outbreak in Bojnourd City (northeast of Iran) in 2018. During the methanol mass poisoning outbreak in Bojnourd city (northeast of Iran), happened in one –month period from September 22 to October 22, 2018, samples of all illegal alcoholic beverages either found consumed by poisoned patients who admitted  to the hospitals or seized by the law enforcement were analyzed. Qualitative and quantitative analysis of ethanol, methanol, 1-propanol, 2-propanol and acetone were performed using GC-FID method.   In the samples collected from a total of 116 seized illegally produced alcohol beverages; methanol was detected in 39.6% with mean concentration of 77.6 %v/v and the range from 12 to 97% v/v. Ethanol was detected in 77 (66.4%) samples with mean concentration of 32.3%v/v. Only 8 (6.9%) samples had a mixture of ethanol and methanol. 1-propanol, 2-propanol and acetone were not detected in any samples. Methanol is the main toxic chemical component in illegal alcoholic beverages with toxic level and could be considered as a cause of mass poisoning during the alcohol mass poisoning in Bojnourd City. This finding could be considered in planning and implementing of public health measures in Iran.

Indonesia is one of world’s largest producers of coal. Coal fly ash (CFA), a product of the coal combustion process, consists of various minerals and causes toxic effects by inhalation. This study aimed to analyze the toxic effects of CFA inhalation in mice models by examining oxidative stress and inflammation markers in the blood. A true experimental with post-test control group design was used in this study. Twenty-four mice were randomly divided into three groups including control (P1), CFA inhalation for 24 hours (P2), and CFA inhalation for 30 days (P3). Mice in the P2 and P3 groups were exposed to CFA measuring 0.075 mm with doses equal to 12.5 mg/m3 for 1 hour/day. Malondialdehyde (MDA) and the percentage of blood eosinophils were examined as parameters of toxic effects. One way analysis of variance (ANOVA) test was used to compare the toxic effects between groups. MDA were significantly increased in between groups (p <0.05). The percentage of blood eosinophils in P1 was significantly differenced to P2 and P3 (p=0.04 and p=0.14, respectively), however there was no different than P2 and P3 (p = 0.891). CFA inhalation induces toxic effects through increased oxidative stress and inflammation in mice models. This may indicates health hazards after CFA inhalation.

Aluminum phosphide (ALP) is one of the most common causes of poisoning. Also, it is commonly used to attempt suicide. Extracorporeal Membrane Oxygenation (ECMO) is a therapeutic method that supports the function of the heart and lungs, giving body enough time for detoxification and organ function improvement; therefore, management of the problem using ECMO is critical in these patients and increases the survival chance. Moreover, the impact of COVID-19 on the treatment course during the COVID-19 pandemic and the patients' involvement and contact with the virus is a critical issue with unknown consequences.

The patient was an 18-year-old girl who was hospitalized due to the poisoning aluminum phosphate. The ECMO was connected to the patient during CPR. Then, the patient was transported to a specialized healthcare facility. At the time of arrival, the EF (Ejection Fraction) was less than 5%. During the course of poisoning, the patient developed ARDS, fulminant hepatitis, massive gastrointestinal and vaginal bleeding, and septicemia. The ECMO was weaned on day 5 when the EF was reported 55%. In the following, the general and pulmonary conditions of the patient exacerbated when she was suspected of having COVID-19. The necessary therapeutic measures were done and finally, the patient was discharged after 45 days.

ECMO is a useful therapeutic procedure in ALP poisoned patients. In case of careful management, it can be used in multiple organ involvement and prolonged PCR. Considering the COVID-19 pandemic, it is very important to notice the chance of COVID-19 infection in ICU during treatment.

Neuroparalytic snake bite is a serious life-threatening hazard all over the world, especially in tropical countries of South-East Asia. But it is one of the most neglected tropical diseases. Patients can present with envenomation signs without a history of snakebite or an identifiable bite mark. Apart from neuroparalysis, symptoms of autonomic dysfunction can also be seen with krait envenomation.

Case Report: 

11-year-old girl presented with early morning sudden onset altered sensorium. On examination found to have absent spontaneous respirations, severe hypertension, dilated pupils, and absent brainstem reflexes, so labeled as probable brain death. Later with control of hypertension, she was able to respond by blinking but had severe neuroparalysis. There was no evidence of snakebite but with a strong suspicion of krait envenomation, anti-snake venom was given empirically and continued ventilatory support, following which child had a complete recovery.

As the majority of krait bites occur during sleep and due to its painless nature, they often go unnoticed. Also, krait bite leaves very fine puncture marks and the local reaction is markedly absent, so fang marks couldn’t be easily identified. Autonomic dysfunction following krait envenomation can present as abdominal pain, vomiting, sweating, mydriasis, fluctuation of heart rate and blood pressure, and paralytic ileus. In severe krait envenomation, complete paralysis of all voluntary muscles leads to quadriplegia and anathria which resembles locked-in syndrome. Locked-in syndrome when associated with internal ophthalmoplegia can mimic brain death.

Snakebite should be considered in the differential diagnosis of unexplained neuroparalysis and hypertension. Envenomation should not be excluded by the absence of a history of snakebite or identifiable bite mark.

Phenytoin, a commonly prescribed antiepileptic drug, causes side effects like ataxia, tremor, hirsutism, gum hyperplasia, insomnia, confusion, headache and vertigo when used for longer duration. However, chorea is a rarely reported side effect of phenytoin and is completely reversible on stopping treatment. 

A twenty-one-year-old Indian male patient, who had generalized epilepsy and had been on sodium valproate for 2 years, presented with acute onset chorea four days after starting phenytoin sodium. He had normal serum phenytoin levels. A thorough evaluation was done, which suggested phenytoin as a possible cause of chorea. Phenytoin was withdrawn, resulting in a dramatic subsiding of chorea. A rechallenge with the drug resulted in reappearance of choreiform movements. These disappeared again after drug withdrawal, implicating phenytoin as the possible etiological agent for chorea.

Phenytoin rarely induces involuntary movements as an adverse effect. During phenytoin therapy, if a patient develops involuntary movements, phenytoin toxicity should be suspected even with normal drug levels. This is important as drug withdrawal leads to complete symptomatic improvement thereby avoiding extensive workup for other secondary causes.

Polysubstance use or abuse is defined as the ingestion or use of more than one drug of abuse within a defined time frame, aiming to enhance or modulate psychoactive effects, alleviate unwanted side effects of one substance and free access to different kinds of substances. Although deaths involving cocaine and other psychostimulants are increasing in many countries, it is not common in Iran due to the high price of cocaine due to a decrease in the supply chain to Iran.

We report the case of a death due to polysubstance use. Analytical toxicology results were positive for cocaine, cocaethylene, morphine (heroin metabolite), and methadone in combination with positive blood and vitreous humor alcohol contents. The most significant histopathologic features were vascular hypertrophy, chronic myocardial ischemia, moderate to severe atherosclerosis, acute myocardial infarction, hemorrhagic pulmonary edema, diffuse alveolar collapse, micro-vesicular steatosis, focal hepatocyte necrosis, chronic hepatitis, and steatohepatitis.

polysubstance users mix drugs to reduce the negative effects of each drug. However, mixing recreational drugs is very dangerous. Pharmacokinetic and pharmacodynamics interactions in polysubstance users can produce health consequences leading to death.  

Results of this forensic case study increased attention to overdose mortality due to polydrug use.