Acute cholestatic liver injury caused by polyhexamethyleneguanidine hydrochloride admixed to ethyl alcohol.

INTRODUCTION: Polyhexamethyleneguanidine hydrochloride (PHMG) is an antimicrobial biocide of the guanidine family. In the period from August 2006 to May 2007, more than 12500 patients were admitted to hospital with a history of drinking illegal cheap "vodka" in 44 different regions in Russia, of whom 9.4% died. In reality, the "vodka" was an antiseptic liquid composed of ethanol (≈93%), diethyl phthalate, and 0.1-0.14% PHMG (brand name "Extrasept-1"). MATERIAL AND METHODS: We performed an analysis of the clinical features and outcome in four poisoning treatment centers in the cities of Perm, Ekaterinburg, Irkutsk, and Khabarovsk. A total of 579 patients (215 females and 364 males) with similar symptoms were included. RESULTS: The main symptoms on admission included jaundice (99.7%), skin itch (78.4%), weakness (96%), anorexia (65.8%), dizziness (65.3%), nausea (54.8%), vomiting (22.6%), stomach ache (52.7%), diarrhea (32%), and fever (50%). Mild symptoms were found in 2.5% of cases, moderate in 63%, and severe in 34.5%. Laboratory results were (mean ± SD): total bilirubin 249 ± 158 µmol/L, direct bilirubin 166 ± 97 µmol/L, cholesterol 14 ± 8 mmol/L, alanine aminotransferase 207 ± 174 IU/L, aspartate aminotransferase 174 ± 230 IU/L, alkaline phosphatase 742 ± 751 IU/L, and gamma-glutamyltranspeptidase 1199 ± 1095 IU/L. Patients generally recovered over a period of 1-5 months, although high levels of alkaline phosphatase and gamma-glutamyltranspeptidase were still found in all patients examined after 6 months. Sixty-one patients (10.5%) died between 23 and 150 days after poisoning. Local cholestasis, inflammatory infiltration, and fibrosis developing into cirrhosis were found by liver biopsy. CONCLUSION: Acute liver injury caused by PHMG-hydrochloride or PHMG in combination with either ethanol or diethyl phthalate can be characterized as cholestatic hepatitis with a severe inflammatory component causing high mortality.

Clinical and institutional aspects of antidote therapy in Russia.

The problem of antidote application for treatment of acute poisoning is related to epidemiology and characterization of poisoning cases, and possibilities for supplying antidotes to health care institutions. To investigate the situation in Russia we have analyzed reports by poisoning treatment centers for 1997-1999, comparison of medical aid standards for poisoning treatment in Russia with WHO recommendations. Acute poisoning pattern varies in different regions. Particularly, poisoning pattern in large cities in European Russia and the Urals is dominated by pharmaceuticals (up to 63.1%). Pesticide and insecticide poisoning cases do not exceed 1 to 2%, metal compounds and methemoglobin forming poisons (below 1% in each group). Antidotes are used in Russia in line with the recommendations adopted in international toxicological practice. The most actual are antagonists of opiates and benzodiazepines, physostigmine, atropine, pyridoxine, antagonists of beta-adrenergic blockers, activated charcoal. Such antidotes as DMPS (Unithiol), N-acetylcysteine, methylene blue, amyl nitrite (or sodium nitrite), complex formers of EDTA group are also included in the list of specific agents. The main problem is that some important antidotes are currently not produced in Russia. The Ministry of Health of the Russian Federation is taking efforts to launch production of some previously known and also newly developed important antidotes.

Epidemiology and medical aid at acute poisoning in Russia.

The present study is based on the selected data obtained from medical reports by some Russian poisoning treatment centers, recent publications, statistical materials, and the review of the existing system of medical aid at acute poisoning. The number of acute poisoning cases in Moscow and large Russian cities has increased almost twofold in the last fifteen years. The main groups of toxic agents causing poisoning are pharmaceuticals (up to 63.1%), alcohol and surrogates (up to 49.3%), corrosives (up to 21.8%), although the figures vary in various Russian regions. Acute poisoning mortality in Russia tends to increase with about 56,000 in the recent years. The main causes of poisoning were alcohol (62.2%), carbon monoxide (15.4%), acetic acid (6.3%), pharmaceuticals (4%) (data by the Moscow Forensic Bureau). Specialized medical aid is represented by poisoning treatment centers organized in 37 cities, 1 toxicology information and advisory center of federal level. Physicians can advance their skills at post-diploma courses organized at 4 chairs of clinical toxicology. Scientific research in the field is carried out by Moscow city poisoning treatment center, the abovementioned chairs and other interested institutions. To obtain the maximum complete data on the number, pattern and causes of acute poisoning a unified system for toxicological monitoring was introduced in Russia in 2000.

Information technologies for clinical toxicology in Russia.

OBJECTIVE: To describe Poison Information in Russia. RESULTS: The Moscow Toxicology Information and Advisory Center was created in 1993 as an institution of the Russian Federation Ministry of Health and Medical Industry. The Toxicology Information and Advisory Center is the first in a network of over 20 toxicology information centers to be created in different regions of Russia by 1998. At present the Toxicology Information and Advisory Center serves over 20 million people in the Moscow region with episodic inquiries from other areas. A prototype national bank of clinical and toxicological data on acute chemical poisoning and an information retrieval system POISON have been created. Work is underway to create computerized systems for data analysis of telephone inquiries on diagnosis and treatment protocols of acute poisoning.