Organophosphate poisoning-induced acute renal failure.

BACKGROUND: Acute kidney injury as a direct complication of organophosphate poisoning has rarely been described and its etiology is unclear. CASE: A 17-year-old adolescent girl was admitted to the pediatric intensive care unit after a suicidal attempt with chlorpyrifos, an organophosphate insecticide compound. The patient developed acute kidney injury followed by renal failure, necessitating renal replacement therapy. She was treated with continuous venovenous hemofiltration with full resolution of her renal function. CONCLUSIONS: Organophosphate poisoning can lead to renal failure, which, with proper treatment, may be reversible but, if left unattended, might aggravate the clinical course of the disease. Physicians should be aware of this rare complication.

Lethal brain edema, shock, and coagulopathy after scorpion envenomation.

We report the case of a 2-year-old Bedouin boy in whom developed severe and unusual complications after being stung, most probably, by the yellow scorpion Leiurus quinquestriatus hebraeus. Five hours after arrival to the emergency department, the boy had multisystem organ failure involving the central nervous system (seizure activity followed by coma with dilated, nonreactive pupils, and severe brain edema), shock (noncardiogenic), disseminated intravascular coagulation, renal failure, hepatic failure, and watery diarrhea, causing his death. In view of the relevant literature, we discuss the pathophysiologic events ultimately leading to his death.

[Severe and uncommon complications of anticholinesterase intoxication in children].

BACKGROUND: The Northern region of the Negev desert is an endemic area of organophosphate and carbamate intoxications in Bedouin children. Most victims are intoxicated by drinking the poisonous material kept by the parents in soft drink bottles. Signs and symptoms of intoxication are commonly known and generally include various effects on the central nervous system, usually a decreased level of consciousness in children, cholinergic muscarinic (sweating, rhinorrhea, miosis, vomiting) and nicotinic (weakness) effects. Specific therapy includes Atropine Sulphate and Oximes. PURPOSE AND RESULTS: To describe the course of disease of four (out of 47) children admitted to the Division of Pediatrics with organophosphate or carbamate poisoning during a two-year period. The four children 3-17 years of age ingested the poisonous material: organophosphate chlorpyrifos (2 children); carbamate methomyl (one child) and an unidentified compound in another child. Three of the four patients ingested the poison in a suicide attempt. All 4 children suffered from severe and uncommon complications, including severe respiratory failure from different etiologies. In addition, two of the four suffered from a neurological deficit causing prolonged disability. Three had renal failure necessitating hemofiltration in one case. One child had severe hemodynamic failure and arrhythmias necessitating, among other therapy, the insertion of a temporary pace maker. Two children had (laboratory) pancreatitis. One of the children with severe respiratory failure died after 38 days of extracorporeal membrane oxygenation. CONCLUSIONS: Intoxications by anticholinesterase compounds are not uncommon among Bedouin children in the Negev. This public health threat should be prevented and completely eradicated by the health authorities. Severe intoxication, especially in cases arising after suicide attempts, wherein the amount of the poisonous material is large, may be complicated by life threatening, multi-organ failure during and after the initial phase of poisoning and may progress into prolonged disability and death.

Contact dermatitis with severe scalp swelling and upper airway compromise due to black henna hair dye.

Temporary tattooing with black henna is known to cause contact dermatitis; however, this adverse effect is not considered to be life threatening. We report a female adolescent who used black henna as a hair dye and developed severe contact dermatitis with scalp, facial, and neck swelling causing hoarseness and stridor. A flexible bronchoscopy showed a normal epiglottis, and the patient was intubated, ventilated, and eventually recovered. We conclude that the use of black henna hair dye in sensitized patients can be life threatening.

[Soroka University Medical Center marks its 50th anniversary--a celebration for Israel's health services].

In December 2009, the Soroka University Medical Center celebrated its 50th anniversary. Following a difficult struggle, Soroka was established in 1959 as a small community hospital. Today, it is difficult to imagine the health services in Israel without a major hospital in the Negev. Soroka is presently providing quality primary, secondary and tertiary medical care to a diverse population of one million people from Kiryat Gat to Eilat. Soroka is the second largest hospital in Israel with over 200,000 emergency visits, 90,000 admissions, 32,000 surgeries and a birth rate of over 13,000 annually. in 1974, the Ben-Gurion University Medical School was opened adjacent to the hospital, with the vision and mission of training humane and skilled physicians and pursuing advanced medical education and research. Within the faculty's framework and the infrastructure of Soroka, the largest Department of Family Physicians in Israel was developed in the Negev. Graduates serve in most of the Negev clinics and have had a tremendous impact on health in the Negev. Many of the graduates are currently serving in key positions in Israel's health services. A third of the School's graduates are annually accepted for training at Soroka. This special edition includes 11 articles representing the clinical research carried out in the hospital's various divisions. They all expose clinical implications of general medical science and some are related to special health problems in the Negev with its diverse population--old native and new immigrants, Jews and Arab Bedouin.We salute Soroka on its outstanding achievements.

Antivenom serotherapy and volume resuscitation partially improve peripheral organ ischemia in dogs injected with scorpion venom.

We tested the hypothesis that fluid resuscitation combined with antivenom serotherapy given after injection of scorpion venom may increase cardiac output (CO) and blood pressure (BP) and prevent the decline in bicarbonate, pH and gastric perfusion. Seventeen anesthetized, mechanically ventilated dogs were given 0.1 mg/kg i.v. venom of the scorpion Leiurus quinquestriatus. The dogs were randomized into three groups: six dogs were given venom alone; three dogs were given 6 ml of antivenom 1 minute before venom injection; eight dogs were given 6 ml of antivenom and 20 ml/kg of synthetic colloid solution, 20 min after venom injection. Parameters reflecting respiratory and circulatory functions were determined at baseline and 120 min after venom injection. Scorpion venom caused a decrease in CO, BP, pH and HCO3-. Gastric mucosal perfusion was severely affected as assessed by mucosal pH (pHi) and the gradient between mucosal and arterial pCO2 (delta pCO2). Antivenom given before venom injection prevented all the effects induced by the venom. Antivenom and fluid given 20 min after venom injection caused a marked increase in CO and BP, but had no effect on pH and HCO3- decline (compared with venom alone). Gastric perfusion slightly improved as the increase in delta pCO2 was attenuated. The combination therapy of antivenom and fluid in this dog model is superior to the therapy of each of them alone. The marked and long-standing improvement of CO is promising and may suggest improvement in HCO3- and pH with time.

Effect of venom from the scorpion Leiurus quinquestriatus on rat vascular aortic rings.

The present study was designed to examine the effects of venom from the scorpion Leiurus quinquestriatus hebraeus (Lqh) on the contractility of rat aortic rings. We first examined the effect of Lqh venom on the contractile tension of isolated rat vascular aortic rings and then whether long-term exposure to the venom reduces the contractility of vascular smooth muscle by increasing the production of nitric oxide. Following the administration of 33 microg/mL of crude Lqh venom, contractile tension increased by 18.9 +/- 11.4 percent. The administration of 2.4 x 10(-7) M noradrenaline (NA) led to a 31.6 +/- 8.2 percent increase in tension (p < 0.01). The effects induced by NA and Lqh venom were similar and additive (p < 0.01). Pretreatment with the alpha-adrenergic blocker phenoxybenzamine (0.2 microM) eliminated the effect of the venom, whereas the calcium-channel blocker verapil (8.3 microM) merely attenuated the effect. Incubation of the rings with Lqh venom for 16 to 18 h, followed by NA stimulation, led to a 15 to 20 percent decrease in tension (p < 0.001). Treatment with N-omega-nitro-L-arginine methyl ester (110 microM), a constitutional nitric oxide inhibitor, restored the tension to control values. Treatment with S-methyl-isothiourea (0.1 microM), an inducible nitric oxide synthesis inhibitor, had no effect on contractile tension. The results of the present study suggest that the effect of Lqh venom on isolated aortic rings is induced via sympathetic nerve terminals. Calcium had little effect on the smooth muscle contractility of aortic rings incubated with the venom. No evidence was found to support nitric oxide synthesis after the long-term exposure of the rings to Lqh venom.

The importance of early bedside echocardiography in children with scorpion envenomation.

Scorpion sting may cause myocardial injury and heart failure (HF). Clinical signs of failure may develop several hours or even days after the sting, while electrocardiography (ECG) and blood examination soon after the sting may be normal. We sought to examine whether normal echocardiographic (echo) examination performed shortly after hospital arrival would exclude subsequent HF. We also sought to check if blood troponin and natriuretic peptide values measured shortly after arrival may predict or exclude subsequent HF. Natriuretic peptide activities have not been measured in scorpion sting victims. We also wanted to check if HF occurs in envenomated young infants. In a 3-year prospective study we looked at the demographic, clinical, laboratory, ECG, and echo data of all patients with general envenomation who arrived at the emergency department (ED) after scorpion sting. Clinical, laboratory, ECG, and echo results on arrival and 24 h after arrival were checked and compared between groups of patients with normal and abnormal echo on arrival. We then looked for differences in clinical course, therapy, and outcome between groups. The study included 98 children aged 80 days to 19 years (median 53.1 months), 25 were below the age of 2 years. Envenomation by the "yellow scorpion"Leiurus quinquestriatus was suspected in 74 cases. Median time between sting and ED arrival was 80 min. Echo was performed on arrival in 93 of the 98 patients, (in 5 occasions it was not performed or not recorded) 74 were normal and 19 were abnormal. Abnormal echo included hypokinesia and low fractional shortening and ejection fraction of the left ventricle. Clinical signs, abnormal ECG, and laboratory results were not discriminative between groups on arrival. Mean troponin T was higher in patients with abnormal echo, but within normal range in 13 of the 19 patients with abnormal echo and above normal in 2 of the 74 patients with normal echo-missing sensitivity and specificity. Mean N-terminal pro B-type natriuretic peptide was above normal in both groups but within normal range in 5 patients with abnormal echo and above normal range in 24 patients with normal echo-missing sensitivity and specificity. None of the patients with normal echo had subsequent HF and none of the children younger than 2 years of age had HF. All patients survived the intoxication and were discharged home without sequel. We conclude that early echo examination is an important procedure. In our study, normal examination excluded subsequent HF. Abnormal examination accelerated cardiac therapy which might have contributed to our favorable outcome. HF did not occur in infants younger than two years of age.

Non invasive positive pressure ventilation in infants with respiratory failure.

OBJECTIVE: To determine whether non-invasive positive pressure ventilation (NIPPV) delivered via nasal prongs can alleviate the need for tracheal intubation and invasive ventilation in infants admitted to the pediatric intensive care unit (PICU) with impending respiratory failure, and to find predictive factors for success or failure with this mode. DESIGN: A single center retrospective cohort study. SETTING: PICU in a university affiliated hospital. PATIENTS: During the 14 months of the study period we recovered 22 NIPPV episodes in 19 infants (median age 65 days) with impending respiratory failure. The patient's respiratory failure etiologies were bronchiolitis (n = 13), pertussis (n = 3), and other respiratory conditions (n = 6). MEASUREMENTS AND RESULTS: In 64% of the cases, intubation was prevented and the patients were weaned off to spontaneous breathing (Responders group). 36% failed NIPPV and had to be intubated and invasively ventilated (Non-responders group). Apneic episodes were the indication for ventilation in 11 patients (50%) with a 73% success rate in preventing invasive ventilation. Hypoxemic respiratory failure was present in nine patients (41%) and the rate of success was 44%. Two patients with post extubation respiratory distress, improved with NIPPV. Responders and non-responders did not differ with regard to demographics or disease severity prior to initiation of NIPPV. After initiating NIPPV respiratory rate and the need for sedation were lower in the NIPPV responders. CONCLUSIONS: In a set group of patient population such as infants with apnea secondary to bronchiolitis NIPPV may be successful to reduce the need for invasive ventilation. Our study failed to detect any physiological or clinical markers which could distinguish between so called "responders" and "non-responders" before initiating NIPPV.

Cardiac manifestations following electrocution in children.

BACKGROUND: Electrical injury can result in a variety of cardiac abnormalities. We evaluate the cardiac effects in patients injured by electric shock and treated in our medical centre. METHODS: We reviewed retrospectively the findings in 52 children, aged from 7 months to 17 years, with a mean age of 10.1 +/- 5.1 years, all evaluated and treated for accidental electric shock from January, 1992, through July, 2004. Relevant data regarding clinical presentation, electrocardiogram recording and cardiac enzymes was compiled. We also evaluated the echocardiographic findings, clinical course, treatment, and outcome. RESULTS: Syncope had been the presenting symptom in 17 children (33%), asystole in 1 patient, and ventricular fibrillation or tachycardia in 2 patients. Characteristic changes of acute ischaemia of the anterior wall on the basis of changes in the ST segments were noted in 2 patients. Total creatine phosphokinase was measured in 33 children (63%), and was elevated in 20. Creatine phosphokinase-MB was measured in 11 patients, and was abnormal in six (54%). Troponin was measured in three children, and was significantly high in one (33%). Cardiopulmonary resuscitation and mechanical ventilation for a significant period was necessary in 5 patients, of whom 4 (80%) survived. None of the survivors was left with any cardiac disability following the acute event. CONCLUSIONS: Significant cardiac damage and complications are rare in children and young adults who survive incidental electrocution. Most of the cardiac events are observed during the acute phase and immediately subsequent to electrocution. No delayed complications are anticipated.

Hydrocarbon poisoning in children: a 5-year retrospective study.

OBJECTIVE: To investigate the demographics, incidence, and symptoms and signs of hydrocarbon poisoning in admitted children from the Negev Desert area of Israel. METHODS: The medical records of all children admitted for hydrocarbon poisoning from 1995 to 1999 were reviewed retrospectively. RESULTS: Of the 274 admitted children, 61% were boys and 39% were girls, with ages ranging from 6 months to 18 years (median, 1.58 years). Ninety-four percent of the patients were Moslem Arab Bedouins, and 6% were Jews. The largest group of patients (106) was admitted during the summer months (P < .003). Also, more patients were admitted in spring (63) and autumn (67) than in winter (38) (P < .013). Thirty-two percent of the cases were seen in the Pediatrics Ambulatory Unit and then discharged, while 68% were hospitalized. The most commonly observed symptoms were tachypnea (73.7%), fever (63.5%), vomiting (51.1%), and cough (38.0%). About one third of the patients showed signs of central nervous system (CNS) impairment, including drowsiness, restlessness, stupor, and convulsions. These symptoms were significantly correlated with pneumonia, hypoxemia, and fever (P < .001). Of 274 patients, 43% (118 children) had pneumonia--usually interstitial pneumonitis (90%). Vomiting was significantly correlated with pneumonia (P < .05). CONCLUSIONS: 1) There is a higher risk of hydrocarbon poisoning during the hot months of the year; 2) the respiratory system is the main target organ affected; 3) pneumonia is in most cases interstitial and bilateral; 4) vomiting after hydrocarbon ingestion is related to the rate of development of pneumonia; 5) symptoms of CNS impairment were correlated with hypoxemia, pneumonia, and fever; and 6) CNS toxicity may occur without hypoxemia, concurrent pulmonary pathology, or other pathology.

Septic shock associated with Shigella flexneri dysentery.

Septic shock is a very unusual presentation of Shigella infection. We describe a 3-y-old child who developed severe septic shock and severe encephalopathy during an episode of dysentery caused by Shigella flexneri.

Volume resuscitation does not alleviate peripheral organ ischemia in dogs injected with scorpion venom.

OBJECTIVES: To examine the effect of fluid resuscitation on the hemodynamic changes in dogs injected with scorpion venom and to explore the effects of the venom on the determinants of venous return (i.e., circulatory compliance, time constant, and resistance to venous return). DESIGN: A prospective, controlled animal study. SETTING: University animal research laboratory. SUBJECTS: Mixed-breed dogs. INTERVENTIONS: The effect of volume resuscitation (20 mL/kg of the synthetic colloid polygeline) 1 hr after venom injection (a time previously found to be related to severe decrease in cardiac output) was tested in two series of experiments. In the first series, 12 dogs were given venom and fluid, eight dogs were given venom alone, and four dogs served as the time-controlled group. In the second series, eight dogs were given venom and ten dogs served as controls. Scorpion venom (Leiurus quinquestriatus) at 0.1 mg/kg in the first series and 0.05 mg/kg in the second series was given intravenously. MEASUREMENTS AND MAIN RESULTS: In the first series of experiments, the venom decreased cardiac output from 5.0 +/- 1.1 to 2.9 +/- 0.7 L/min at 60 mins (p <.001). Arterial pH decreased from 7.39 +/- 0.05 to 7.16 +/- 0.1 (p <.001). Blood lactate increased from 0.9 +/- 0.8 to 3.2 +/- 1.9 mM (p <.05). Gastric pH decreased from 7.28 +/- 0.2 to 6.7 +/- 0.18 (p <.001). Arterial acidosis was secondary to gastrointestinal ischemia because the gradient between mucosal and arterial Pco2 increased from 17.5 +/- 7.7 to 98.6 +/- 75 (p <.01) 60 mins after venom injection. In the second series of experiments, circulatory compliance and time constant increased by 150% and 128%, respectively (p <.05), in dogs injected with venom compared with control dogs. Resistance to venous return increased after venom injection but did not change after fluid infusion. In both series of experiments, volume administration improved cardiac output but had no effect on oxygen delivery, arterial pH, HCO3-, lactate, and gastric mucosal pH. CONCLUSIONS: Metabolic acidosis and cardiovascular abnormalities seen after scorpion venom injection in dogs are closely related to gastrointestinal hypoperfusion. Fluid resuscitation increased cardiac output but had no effect on gastrointestinal perfusion and acidosis induced by the venom.

Successful treatment of infective endocarditis with recombinant tissue plasminogen activator.

OBJECTIVES: In a prospective study, we examined the effect of treatment with recombinant tissue plasminogen activator (r-TPA) on survival and morbidity in a series of high-risk children with infectious endocarditis (IE) after prolonged treatment with indwelling catheters. We hypothesized that r-TPA is an adjunctive therapy for dissolution of infected thrombi in drug-resistant IE. STUDY DESIGN: In the prospective 3-year study (1998-2001), we identified high-risk children with chronic illness and prolonged treatment with indwelling catheters who developed IE and overwhelming sepsis. Patients were allocated to receive r-TPA after persistent and enlarging intracardiac vegetations and failure to respond to conventional medical management. Complications associated with treatment, survival, and cardiac morbidity were observed. RESULTS: Seven infants were treated prospectively with r-TPA. All infants responded promptly to treatment, with resolution of the intracardiac vegetations within 3 to 4 days of commencement and without any adverse complications. All patients survived without long-term cardiac morbidity. CONCLUSION: Recombinant tissue plasminogen activator may offer a safe alternative to surgical intervention in the high-risk infant with IE.