Poisoning-Induced Acute Kidney Injury: A Review.

Acute kidney injury (AKI) is a debilitating, multi-etiological disease that is commonly seen in clinical practice and in the emergency department. In this review, we introduce the definition, symptoms, and causes of poisoning-related AKI; we also discuss its mechanisms, risk factors, and epidemiology, as well as elaborate on the relevant laboratory tests. Subsequently, we discuss the treatment strategies for toxin- and substance-related AKI caused by Glafenin, antimicrobial agents, lithium, contrast media, snake venom, herbicides, ethylene glycol, synthetic cannabinoids, cocaine, heroin, and amphetamines. Finally, for a comprehensive overview of poisoning-related AKI, we review the management, prevention, and outcomes of this condition.

A Faster, Novel Technique to Detect COVID-19 Neutralizing Antibodies.

BACKGROUND The COVID-19 pandemic has spread globally in a short period of time. It is known that antibody (nAb) level can effectively predict vaccine efficacy, which leads to the exploration of vaccine trials for efficacy assessment. Thus, the current study aimed to develop a platform to quantify nAb levels faster, at lower cost, and with better efficiency. MATERIAL AND METHODS A total of 69 sera samples were collected for the research, 28 of which were from unvaccinated participants. The other 27 samples and the remaining 14 samples were from the participants who had received the first and second dose, respectively, of AZ vaccine 1 month before. With cPass assays (Genscript cPass nAb ELISA assay) used as a criterion standard and lateral flow immunoassay kit (Healgen Scientific - LFIA test kit) coupled with a spectrometer (LFIA+S) for checking each specimen, we aimed to detect the presence of neutralizing antibodies in sera and to confirm the relationship between the inhibition rate from cPass assays and the nAb index from the LFIA+S. RESULTS Data analysis of the research were taken from the certified ELISA and LFIA+S, which indicated a high consistency (Pearson's r =0.864; ICC=0.90138) between the 2 methods. CONCLUSIONS The dataset demonstrated that LFIA+S was affordable, had a strong correlation with results of the cPass nAbs detection kit, and has potential clinical applications, with an exclusive feature that allows non-experts to use it with ease. It is believed that the proposed platform can be promoted in the near future.

Gender differences in clinical characteristics of emergency department patients involving illicit drugs use with analytical confirmation.

BACKGROUND: To compare gender differences in socio-demographics, clinical manifestations, and laboratory test results of individuals who visited emergency departments (EDs) involving drug use. METHODS: We retrospectively collected the data from 10 hospitals in Taiwan on drug-related ED visits from May 2017 to December 2020. We then examined the gender differences in their socio-demographics, clinical manifestations, urine toxicological results, and other laboratory tests results using chi-square or multivariable logistic regression. RESULTS: Among individuals with drug-related ED visits, there were 546 (73.7%) men and 195 (26.3%) women. The most commonly used drugs were meth/amphetamine, followed by synthetic cathinones, and ketamine and its analogs. Compared to men, women were younger (32.03 ± 10.86 vs. 36.51 ± 10.84 years, p < 0.001) and more likely to use new psychoactive substances (NPS) (p = 0.011). Men were more likely to have human immunodeficiency virus infection (p < 0.001), whereas women were more likely to report psychiatric comorbidities (p = 0.003). Women were less likely to have aggressive behaviors (odds ratio (OR): 0.59, 95% CI: 0.39-0.88). After adjusting for socio-demographics and drug types, women were still less likely to have aggressive behaviors than men (adjusted OR: 0.59, 95% CI: 0.38-0.93). The likelihood of rhabdomyolysis and intensive care unit admission was higher in men (p < 0.001). CONCLUSION: We found considerable gender differences in clinical characteristics among ED-visiting drug users, which could offer valuable information for the future development of more tailored gender-specific drug prevention and treatment strategies.

Thyrotoxic periodic paralysis with ventricular tachycardia.

A 47-year-old man presented to our emergency department (ED) with limbs weakness for 2 h. His heart rate was 127 beats per minute and blood pressure was 95/49 mm Hg. He found weakness of limbs after 4-h sleep. Physical examinations revealed that the muscle strength of upper limbs is 3/5, and lower limbs are 2/5. Electrocardiogram (ECG) revealed wide QRS complex, monomorphic ventricular tachycardia (VT) with ST-segment depression and long QT interval. Serum potassium level was extremely low as 1.0 mEq/L. This led to periodic hypokalemic paralysis. Due to severe hypokalemia with possible atrioventricular block, the patient was admitted to the intensive care unit. During hospitalization, his potassium level returned to 5.1 mEq/L on the first day. He had a low level of thyroid stimulating hormone (TSH) of <0.03 micro-IU/mL (normal range: 0.25-4.00) and a high free thyroxine (T4) level of 2.43 ng/dL (normal range: 0.89-1.79 ng/dL). Therefore, hyperthyroidism was diagnosed, and 5 mg of methimazole was administered twice a day. The patient was discharged on the seventh day after admission. The final diagnosis is thyrotoxic periodic paralysis (TPP), also as known as nocturnal paralysis or night palsy.

Unusual cervical spine epidural abscess.

A 48-year-old man presented to the emergency department with complain of severe neck pain and anterior chest pain. Intermittent fever in the recent 2 days was also noted. There is a track maker over his left side of neck. The laboratory examination showed leukocytosis and high C-reactive protein level. Urine drug screen was positive for opiate. Empirical antibiotic administration was given. Blood culture grew gram-positive cocci in chain, and there was no vegetation found by heart echocardiogram. However, progressive weakness of four limbs was noted, and patient even cannot stand up and walk. The patient also complained of numbness sensation over bilateral hands and legs, and lower abdomen. Acute urine retention occurred. We arranged magnetic resonance imaging survey, which showed evidence of inflammatory process involving the retropharyngeal spaces and epidural spaces from the skull base to the bony level of T5. Epidural inflammatory process resulted in compression of the spinal cord and bilateral neural foramen narrowing. Neurosurgeon was consulted. Operation with laminectomy and posterior fusion with bone graft and internal fixation was done. Culture of epidural abscess and 2 sets of blood culture all yielded methicillin-sensitive Staphylococcus aureus. For epidural abscess, the most common involved spine is lumbar followed by thoracic and cervical spine. Diagnosis and treatment in the drug abusers are still challenging because they lack typical presentation, drug compliance, and adequate follow-up and because it is hard to stop drug abuser habit. Significant improvement of neurological deficit can be expected in most spinal abscess in drug abusers after treatment.

The first time devastating food poisoning happened in Taiwan - Bongkrekic acid poisoning.

Bongkrekic acid (BKA), a rarely happened foodborne toxin by Burkholderia gladioli pathovar cocovenenans (Burkholderia cocovenenans) might leads to devastating life-threatening condition after eating meal contaminated BKA. Unbelievable event from March 19, 2024, to March 24, 2024, there was an outbreak of BAP in a luxury shopping area of eastern Taipei, Taiwan. Most of the victims are young to middle-aged people who made a tour over there and ate the cooked wet rice noodles. Of them, 13 males and 20 females, aged 40.9 ± 14.7 years old visited or were sent by ambulances to the emergency department presenting with watery diarrhea, and vomiting. Some progressed to severe hepatic and renal failure, altered mental status, disseminated intravascular coagulation, and fatalities within several hours within 2 days. The primary health workers especially emergency physicians need to keep in mind of BKA poisoning is quite different in presentations from other infectious colitis commonly seen before. Knowing the toxic-kinetic and toxic-dynamic mechanisms is important to farseeing the presentation of these BAP patients. Throughout this outbreak, we gathered abundant experiences in mitigating and managing these debilitated patients. Aggressively supportive care and early liver transplantation if there is no concurrent inflammatory process and the patient's condition is tolerable to surgical intervention saves lives. For food safety education, it is crucial to enhance our understanding of inhibiting BKA production and promote proper food preservation methods and a suitable environment to ensure food safety.

Red stripe on left forearm after stung by fish gill: A case report.

RATIONALE: Acute infectious lymphangitis represents a common complication of cellulitis, typically attributed to streptococcal infections after damaged skin integrity. PATIENT CONCERN: This is a 51-year-old woman with a medical history of relapsing polychondritis, managed with steroid and methotrexate therapy in the outpatient department. She presented with a progressive redness and swelling of the left hand, accompanied by purulent discharge, persisting for 5 days. The patient had sustained a small cutting wound from the gill of a narrow-barred Spanish mackerel (Scomberomorus commerson) while cooking previously. DIAGNOSIS: Lymphangitis and cellulitis of the left forearm were diagnosed. A distinctive red streak was identified on the skin covering the palmaris longus muscle, consistent with the anatomical course of the median forearm lymphatic channel. INTERVENTIONS: The patient received empirical intravenous ciprofloxacin (400 mg every 12 hours) and was subsequently admitted to the infectious disease ward. During hospitalization, the antibiotic regimen was adjusted to ceftazidime on the fourth day (2 g every 8 hours). The redness and swelling in the hand and arm gradually improved, and her blood culture showed no bacteria growth. OUTCOMES: She was recovered and discharged on the seventh day with a prescription for oral clindamycin (150 mg every 6 hours). LESSONS: A red stripe along the lymphatic route indicates acute lymphangitis and requires hospitalization for parenteral antibiotics.

Fatal Zargar grade 3b corrosive injury after hydrochloric acid ingestion: A case report.

RATIONALE: Caustic substance ingestion is an emergency and life-threatening condition as it leads to tissue damage, acidosis, and multiorgan failure. This study presents a case report of hydrochloric acid ingestion and notably dark-red urine output due to acute tubular necrosis. PATIENT CONCERNS: A 59-year-old male presented with attempted suicide by ingesting 500 mL of hydrochloric acid (37%), and complained of severe abdominal pain and shortness of breath. Upon arrival, his vital signs showed a temperature of 34.3°C, blood pressure of 104/77 mm Hg, a pulse rate of 135 beats per minute, and the Glasgow Coma Scale E4V2M6. Following Foley catheter insertion, dark, bloody urine resulting from acute tubular necrosis was observed. His creatinine level was 1.1 mg/dL, and urinalysis showed 38 red blood cells per high-power field. Arterial blood gas analysis revealed metabolic acidosis. DIAGNOSES: The patient's condition rapidly deteriorated in the emergency room, revealing diffuse circumferential ulceration with necrosis in the esophagus (Zargar score grade 3b). An exploratory laparotomy was performed for acidosis with intractable shock, revealing up to 1500 mL of bloody ascites, and ischemic changes with loss of peristalsis throughout the small bowel to the cecum. INTERVENTIONS: Esophagostomy with T-tube insertion was performed. Notably, stomach necrosis with perforation was identified, prompting a surgical consultation for primary perforation closure. OUTCOMES: During the operation, the patient experienced hemodynamic instability. The family confirmed the "Do Not Resuscitate" status, and he died in a critical state. LESSONS: For corrosive injuries, early endoscopy was crucial in assessing the extent of the damage and guiding treatment in this patient. It is essential to perform an early endoscopic examination in cases of acute nephrotoxic tubular necrosis following hydrochloric acid ingestion. Surgical intervention is warranted if necrosis is detected in the corrosive tissue.

NT-proBNP point-of-care testing for predicting mortality in end-stage renal disease: A survival analysis.

This study examines the predictive value of elevated N-terminal-pro brain natriuretic peptide (NT-pro BNP) levels for mortality among patients with end-stage renal disease (ESRD). Data from 768 ESRD patients, excluding those with cancer or lost follow-up, were analyzed using Kaplan-Meier curves and Cox proportional hazards models over three years. Results indicated that patients with very high NT-pro BNP levels had shorter average survival times and a significantly higher risk of mortality (hazard ratio 1.43). Advanced age, ICU admission, and comorbidities like cerebrovascular diseases and chronic obstructive pulmonary disease also contributed to increased mortality risks. Thus, elevated NT-pro BNP is an independent risk factor for mortality in ESRD patients.

Differences of chronological seasonality in drug overdose.

OBJECTIVE: To investigate the association between seasonality and intentional drug overdose (IDO), a commonly seen method of self-harm in daily emergency medicine practice. METHODS: Cases of IDO were retrospectively selected using the International Classification of Diseases (ICD)-10 coding system (codes T36-T50), in patients who attended the Emergency Department of MacKay Memorial Hospital between January 2018 and August 2019. Data regarding age, sex, arrival time, marital status, vital signs, comorbidities, psychiatric history, social conflicts, substance of overdose, and length of hospital stay by season, were analysed using Student's t-test and χ2-test. RESULTS: Of all included cases (n = 196), IDO occurred most frequently in spring (32.1%), particularly in male patients (28/49 male cases). First-time IDO occurred most frequently in spring (51/133 first-time cases) and most spring cases were first-time IDO (51/63 spring cases). Repeat IDO occurred most frequently in autumn (20/63 repeat cases). Female conflict with father and/or boyfriend, and personality disorder in patients who overdosed, showed seasonality with a spring peak. Hospital admission rate was highest in winter (10/45 winter cases [22.2%]). CONCLUSION: Episodes of IDO exhibited seasonality, with a spring peak, particularly for male patients, female patients in conflict with father and/or boyfriend, and those with personality disorder. Clinicians should pay close attention to the abovementioned patient groups.

Clinical characteristics in new psychoactive substance users: A single center study.

New psychoactive substances (NPS) are emerging illegal substances or synthetic drugs that pose public health threats worldwide. This study was aimed at reporting the clinical characteristics of NPS and classical illicit substances used by patients who presented to the emergency room. We conducted a retrospective cohort study on patients with suspected illicit substance use who visited the emergency department (ED) with the suspicion of illicit substance use. We divided the patients into 4 groups based on the NPS testing results: NPS positive, NPS negative, NPS combined with classical illicit drugs (INPS), and subjects with negative testing results. The majority of patients in all groups were male. The NPS users were significantly younger than those with negative results on toxic testing (26.4 vs 37.5, P = .005 < 0.05). The heart rate of NPS users was significantly faster than that of the group with negative results of toxic testing (111.1 vs 93.5 beats per minute, P = .046). The heartbeats of INPS group were also significantly faster than those with a negative result in toxicology screen (119.6 vs 93.5 beats per minute, P = .024). Those who used classical illicit drugs combined with NPS had significantly higher palpitation than those with negative results of toxic testing (27.3% vs 3.1%, P = .017). Patients who were highly suspicious of NPS use were younger, had tachycardia, felt palpitations, and had fair oxygen saturation compared to patients who were negative for urine toxicity screening.

Clinical characteristics of new psychoactive substances: A multicenter study.

BACKGROUND: New psychoactive substances (NPS) are synthetic alternatives to illicit drug abuse that are not under international control but may pose a public health threat. Moreover, the symptoms and signs of NPS users may be quite variable. This study aimed to figure out the clinical characteristics of NPS users presented to the emergency department (ED). METHODS: A total of 1385 cases were tested via urine toxicity screening from March 25, 2019, to January 28, 2020, in six medical centers, and ten hospitals, in Taiwan. A total of 123 non-NPS cases and 77 NPS-use cases were enrolled in this study. We compared the patient data-vital signs, presentation, co-morbidities, behaviors, symptoms, electrocardiograms, laboratory data, length of stays-and outcomes of NPS users and non-NPS drug users. RESULTS: NPS users were 5.7 years younger than the non-NPS drug users (37 vs. 42.7 years, p = 0.022). Presently, NPS users had a 2.6-fold (27.2%) higher rate of suicide and a 2.9-fold (11.7%) greater possibility of violence than non-NPS drug users. Moreover, in NPS users, eye-opening was affected at a scale of 3.1 versus 3.4 (p = 0.048) in non-NPS drug users in the evaluation of consciousness and they experienced a 4.3-fold greater feeling of palpitation (p = 0.024) and had 8.1-fold higher chance of presenting facial flush (p = 0.032) than non-NPS drug users. CONCLUSION: NPS users are relatively younger, are more likely to experience facial flush and palpitation and engage in more self-harm, violence, and suicide than non-NPS drug users. Physicians need to pay attention to people who have altered, bizarre mental statuses with the clinical characteristics described above.

Report of a Patient With Anti-Jo-1 Syndrome With Loss of Consciousness.

A 51-year-old febrile woman presented to the emergency department because of loss of consciousness while worshipping at a temple. She experienced muscle weakness and blurred vision before fainting. She also felt pain in her left shoulder and suffered from dry cough and shortness of breath during the previous week. The chest radiograph (CXR) showed bilateral reticular infiltration, indicating interstitial lung disease (ILD), and chest computed tomography revealed reticular, nodular, and reticulonodular patterns of infiltration that were compatible with ILD. Blood tests showed a creatinine kinase level of 3,307 IU/L and an Anti-Jo-1 autoantibody level of 586 AU/mL. It was found via right thigh biopsy results 8 days later that she had polymyositis with perivascular inflammation and degenerative muscle fiber change. Pulse therapy with methylprednisolone (1 gm/day for 3 days) was administered. After 4 days, she felt better and was discharged. Around 25.0%-34.1% of myositis patients have anti-Jo-1 autoantibodies, and ILD was noted in 65%-68% of anti-Jo-1-positive patients. A ground glass pattern may be observed in the CXRs of anti-Jo-1 ILD patients, and some articles described multiple pulmonary nodules mimicking lung metastasis or concomitant with pleural effusion. The conditions of approximately 42%-66% of ILD patients are controlled or are not worsened after treatment with corticosteroid and immunosuppressive drug treatment. However, some rapidly progressive cases are not sensitive to corticosteroid therapy alone.

A fatal case of chlorfenapyr poisoning and a review of the literature.

BACKGROUND: Chlorfenapyr is a widely used pesticide and is classified as moderately hazardous to human health. Ingestion usually leads to mortality in humans. However, chlorfenapyr toxicity has a variable course and mechanism of action.Case presentation: We report the case of a 79-year-old female who ingested chlorfenapyr with the intent to commit suicide. The liquid was ingested 2 hours before she was brought to our emergency department. Gastric lavage was immediately performed. On admission, laboratory examinations revealed mildly elevated liver enzyme and creatinine kinase levels. Acute fever occurred on day 7; on day 8, the patient died of progressive respiratory distress and conscious disturbance. Chlorfenapyr toxicity leads to high rates of mortality (75%) and causes damage to the liver and the nervous system. CONCLUSIONS: It is necessary to observe patients with chlorfenapyr toxicity for 3 weeks because no significant abnormalities occur in the early phase. The onset of fever and deterioration of consciousness is a warning sign of a sudden fatal outcome. We review the literature and discuss neurologic and cardiopulmonary impairment in the clinical course of chlorfenapyr poisoning.

Gangrenous cellulitis caused by coagulase­negative Staphylococcus infection: A case report.

A 40-year-old male with a history of alcohol and drug addiction presented with fever for 1 day in the emergency room. He reported the abuse of drugs via intravenous injection and consumed alcohol excessively. Upon arrival to the emergency room, his body temperature was 39.4˚C. Upon a physical examination, generalized skin gangrene over the trunk and four limbs were found. Laboratory tests revealed thrombocytopenia (platelets, 67,000/µl) and elevated C-reactive protein (30.4 mg/dl), creatine kinase (>20,000 IU/l), D-Dimer (>10,000 ng/ml) levels. The urinary drug screen test was positive for ketamine and benzodiazepine. The blood culture on day 4 of admission yielded coagulase-negative Staphylococcus (CoNS). The patient was diagnosed with CoNS induced by the venous injection of ketamine. He was admitted and received treatment with parenteral antibiotics with serial debridement due to the progressive necrosis of the skin gangrene. He was discharged 2 months later with clinical improvement. CoNS generally has a symbiotic association with the hosts in the cutaneous ecosystem, which frequently contaminates blood culture and occasionally causes diseases. CoNS should be thus considered opportunistic pathogens rather than contaminants. These organisms can cause occasional infection if the cutaneous organ system has been damaged by trauma, the direct implantation of foreign bodies or inoculation by needles. Predisposing factors for CoNS infections include an older age, immunosuppression and the implantation of medical devices, which may serve as a nidus for CoNS growth. Long-term alcoholism, drug addiction and malnutrition may have caused a decline in the immunity of the patient described herein. To date, at least to the best of our knowledge, there has been no report describing local skin necrosis induced by CoNS infection. In the case in the present study, treatment with parenteral antibiotics and serial debridement was successful. In summary, physicians need to be aware of the potential pathogenicity of CoNS in the skin and soft tissue infections.