Adult Lead Poisoning Caused by Contaminated Opium: A Two-Year Longitudinal Follow-Up Study.

Background: A major episode of lead poisoning caused by lead-adulterated opium occurred in Iran in 2016. Patients were removed from exposure and treated with chelating agents. A subset of those patients was evaluated in this follow-up study to evaluate treatment efficacy in relation to patient outcome. Methods: Between March 2016 and December 2017, thirty-five male cases of lead poisoning due to ingestion of lead-adulterated opium were followed for two years. There are three patient groups: 1) those who abstained from opium use; 2) those who continued to use potentially contaminated opium; and 3) those who abstained from opium and were placed on maintenance therapy. Maintenance therapy included: methadone and opium tincture, offered by the Opioid Maintenance Therapy (OMT) clinics. Amongst the three patient groups Blood Lead Levels (BLL), complete blood count, and kidney and liver function tests were compared. Findings: The results of BLL, hemoglobin, hematocrit, and aspartate aminotransferase were significantly different between the admission time and follow-up. Of the three patient groups, no difference was detected in these measures. Conclusions: Treatment of lead poisoning combined with OMT proved an effective method to prevent recurrent lead poisoning.

Blood Lead Levels in Opium-Poisoned Children: One Cross-Sectional Study in Iran.

BACKGROUND: Lead poisoning is now more common due to accidental or intentional exposure to opium impregnated with lead. We aimed to determine the relationship between the blood lead levels (BLLs) and basic characteristics in opium-poisoned children. METHODS: In this cross-sectional study, 32 children younger than 13 years old who had been admitted to Loghman Hakim Poison Center, Tehran, Iran, due to opium poisoning, were evaluated for BLLs. Patients' demographics, symptoms, signs, and lab tests were evaluated as well as the BLLs. FINDINGS: The median and range of age in children with opium poisoning were 14 and 141 months with minimum and maximum age of 3 and 144 months, respectively, and 62.5% were boys. Their mean BLL was 9.78 ± 3.44 µg/dl and in 70% of opium-poisoned children, BLL was ≥ 5 µg/dl. There was a significant difference between mean BLLs in girls and boys (17.07 ± 6.57 µg/dl in girls and 6.61 ± 3.22 µg/dl in boys, P = 0.02). We found a significant correlation between BLL and hemoglobin (Hb) level. In very low Hb level (< 8 g/dl), the BLL was higher but with increasing Hb level, BLL increased as well; in Hb levels > 14 g/dl, BLL decreased again (P = 0.01). CONCLUSION: Although none of the children needed chelation therapy, strategies should be developed to prevent children from being exposed to opium and other materials impregnated with lead regarding its effects on all organs of children.

Vitamin D toxicity in a pediatric toxicological referral center; a cross-sectional study from Iran.

BACKGROUND: Vitamin D is an essential element for body health with its supplements generally administered to prevent vitamin D deficiency. Since these supplements are available in domestic settings, vitamin D toxicity may happen in children. METHODS: All children younger than 12 years who presented to the pediatric emergency department of Loghman Hakim Hospital, Tehran, Iran with history of ingestion of more than 1500 IU/day of vitamin D supplements were enrolled. Patients' demographic data, on-presentation signs and symptoms, laboratory findings, treatments given, and outcome were evaluated. RESULT: Fifteen patients presented during the study period. Their mean age was 46.53 ± 10.14 months and 12 (80%) were girls. All of them had unintentionally ingested vitamin D. Mean ingested dose was 406700.7 ± 227400.1 IU. In eight patients (53.3%), 25 hydroxy vitamin D level was more than 100 ng/mL. One patient experienced hypercalcemia while all of them were asymptomatic and discharged without complications. There was no significant difference between patients with and without high levels of 25 OH vitamin D regarding lab tests, toxicity course, and outcome. CONCLUSIONS: It seems that acute vitamin D toxicity is a benign condition in our pediatric population which may be due to high prevalence of vitamin D deficiency in Iran.

Encephalopathy following ingestion of Lead-contaminated opium; magnetic resonance imaging findings.

BACKGROUND: Encephalopathy is an uncommon but serious presentation of lead toxicity. OBJECTIVE: We aimed to determine and follow-up the brain magnetic resonance imaging (MRI) abnormalities in the patients with lead encephalopathy due to ingestion of lead contaminated opium. METHODS: In a cross-sectional study during lead-contaminated opium outbreak, all lead-poisoned patients with any signs/symptoms of encephalopathy were included. RESULTS: Of 19 patients with lead encephalopathy, five died early and other five could not be sent to MRI during their hospitalization period. Mean age was 51 ± 11 years and males were dominant (89%). Median [IQR] blood lead level (BLL) was 101 [81, 108] µg/dL (range; 50 to 200 µg/dL). There was no correlation between MRI findings and signs/symptoms. MRI was normal in six and abnormal in three. Bilateral symmetric involvement of parieto-occipital lobes was observed. Gray matter, gray-white matter junction, and subcortical white matter were also affected. Follow-up MRI was performed in two with abnormal MRI which showed complete and near complete resolution of the abnormalities after cessation of opium use and treatment. CONCLUSION: There was no correlation between MRI findings and BLL. Complete recovery of brain MRI lesions was detected after cessation of opium use.

The effects of opium on the cardiovascular system: a review of side effects, uses, and potential mechanisms.

BACKGROUND: In Iran, as in many other Asian and Middle Eastern countries, some believe that opium has beneficial effects on cardiovascular system. Dependent patients suppose that opium has positive effects on cardiovascular function and can prevent or improve cardiovascular diseases; however, only few comprehensive studies evaluating such effects have been performed. OBJECTIVES: In this study, we sought to clarify the effect of opium on cardiovascular problems by incorporating the previous findings and the current information on the issue and to explain the possible mechanisms of this effect. METHODS: The available human studies published up to October 30, 2019, were searched in different databases. Case-control, cohort, and cross-sectional studies were retrieved. Papers published in English or those with an English abstract were included. The risk of bias for each included study was assessed based on the Newcastle-Ottawa Scale (NOS). We then categorized the effects of opium on cardiovascular problems along with its probable underlying mechanisms of action. RESULTS: In this study, most of the published articles suggested the adverse effects of opium on the cardiovascular system, including atherosclerosis, myocardial infarction, arrhythmia, low ejection fraction, and cardiovascular mortality; however, some articles reported the beneficial or impartial effects of opium on the cardiovascular system. In this article, we have categorized all the effects of opium on cardiovascular system; also, the proposed mechanisms of action of opium in each of the above-mentioned disorders are summarized. CONCLUSION: Although the available evidences were incoherent, it was mostly suggested that opium use does not protect against or improve cardiovascular problems.

Broken thermometer in foot: a source of mercury poisoning.

A 17-year-old boy was referred after jumping from a ladder onto the ground, crushing a medical thermometer with his right foot. Some days later, he complained of loss of appetite and weakness. A radiograph of the affected foot demonstrated radiopaque densities. Blood and 24-h urine assays for mercury demonstrated toxic levels. Chelation therapy cured the patient dramatically.

Lead poisoning due to ingestion of lead-contaminated opium: A diagnostic study on patients' imaging findings.

OBJECTIVES: Our study attempts to determine if for patients following ingestion of lead-contaminated opium, radiographs [plain X-ray (KUB)] or unenhanced computed tomography (CT scan) of the abdomen may be predictive of lead poisoning. METHODS: Our study is concerned with patients of >21 years with elevated lead concentrations, who had undergone KUB or CT. Patients with other toxicities who had undergone similar imaging profiles but who had low blood lead level (BLL) were enrolled as controls. RESULTS: We evaluated a total of 79 cases and 79 controls with median [IQR] BLLs of 126 [97.4, 160] µg/dL and 8.7 [5.5, 15] µg/dL. All cases and eleven controls (13.9%) were addicted to oral opium, and of these cases, anemia (94.9%) and abdominal pain (92.4%) were the two most common clinical manifestations. Two radiologists reviewed the X-ray and non-contrast CTs. Fifty (63.3%) and 53 (67.1%) cases and controls underwent CT scanning with 34 (68%) vs. 6 (11.3%) positive CTs (P < 0.001) while 43 (54.4%) and 39 (43.3%) underwent X-rays with 21 (48.8%) vs. 4 (11.8%) positive X-rays, respectively (P < 0.001). Positive CT is associated with BLL between 10 and 45 µg/dL with a specificity of 96.9%, 88.7% and positive predictive value of 97.5% and 85% respectively. CONCLUSIONS: In suspected cases of lead exposure due to ingested opium, and if BLL is not readily available, a positive imaging result may guide radiologists and physicians to consider lead poisoning.

Lead poisoning outbreak among opium users in the Islamic Republic of Iran, 2016-2017.

OBJECTIVE: To describe an outbreak of lead poisoning among opium users in the Islamic Republic of Iran and estimate the number of affected people in the country. METHODS: We used data from the country's largest poison treatment centre to illustrate the epidemiology of an outbreak of lead poisoning in oral opium users. We describe the government's referral and treatment guidelines in response to the outbreak. Based on the number of individuals treated and previous studies on the prevalence of oral opium use we estimated the total number of people at risk of lead-contaminated opium nationwide. FINDINGS: In February 2016, we noticed a steep increase in the numbers of oral opium users referred to our poison treatment centre with abdominal pain, anaemia and constipation. Numbers peaked in June 2016 but the outbreak was ongoing in August 2017. The mean blood lead level in a sample of 80 patients was 140.3 µg/dL (standard deviation: 122.6). Analysis of an illegal opium sample showed 3.55 mg lead in 1 g opium. Treatment was exposure reduction with opioid substitutes and laxatives, or chelation therapy if indicated. Over 7 months, 4294 poison cases were seen at main referral hospitals in Tehran out of an estimated 31 914 oral opium users in the city. We estimate more than 260 000 out of 773 800 users nationwide remain untreated and at risk of poisoning. CONCLUSION: Lead-contaminated opium and heroin that has transited through the Iranian markets is a global risk and highlights a need for better monitoring of illegal drug supplies.

A Fatal Case of Amlodipine Toxicity Following Iatrogenic Hypercalcemia.

Using calcium salts in management of amlodipine overdose is challenging. A 25-year-old male with known history of adult polycystic kidney disease presented with hypotension, tachycardia, and intact neurological status after ingestion of 450 mg of amlodipine. Immediately, normal saline infusion and norepinephrine were initiated. Two grams of calcium gluconate was injected, followed by intravenous infusion of 1.16 mg/kg/h. The patient was put on insulin-glucose protocol to maintain euglycemia and hyperinsulinemia. Electrocardiography demonstrated junctional rhythm. Serum creatinine was 2.5 mg/dL with metabolic acidosis. By the end of 24 h post-admission, his consciousness, blood pressure, and urine output were normal. Almost 32 h post-admission, he became disoriented and his oxygen saturation decreased and therefore was mechanically ventilated. Second chest X-ray showed pulmonary edema. Serum calcium level increased to 26.1 mg/dL. Calcium was discontinued, and furosemide infusion and calcitonin were intravenously administrated. Urine output increased and hemodialysis improved pulmonary edema and serum calcium level with no change in consciousness. Three days after admission, the patient became anuric and developed multi-organ failure and died 5 days post-admission. To avoid the consequences of excessive infusion of calcium in renal failure patients, the minimum calcium dose with close monitoring is recommended.

Lead Toxicity due to Ingestion of Lead-Contaminated Opium in a Patient Presenting with Motor Neuropathy and Upper Limb Paresis: A case report.

Opium users may present with central or peripheral nervous system-related symptoms, gastrointestinal complications and anaemia; in such cases, lead poisoning should be suspected and chelation therapy initiated as soon as possible. We report a 64-year-old male patient with a 20-year history of opium addiction who was referred to the Imam Reza Hospital, Birjand, Iran, in 2017 with severe motor neuropathy and paresis in both upper limbs. His primary symptoms were generalised weakness, abdominal and bone pain, constipation and lower limb paraesthesia that had started several months prior. In addition, he reported severe progressive bilateral paresis of the upper limbs of one month's duration. A diagnosis of lead poisoning was confirmed by a blood lead level of 140 µg/dL. The patient underwent chelation therapy after which he improved significantly. At a one-year follow-up visit, he was neurologically intact and symptom-free.

Prophylaxis of neutropenic fever with ciprofloxacin in patients with acute myeloid leukemia treated with intensive chemotherapy.

AIMS: Neutropenic fever is one of the most serious complications after induction chemotherapy in acute myeloid leukemia (AML). Prophylaxis with antibiotics for prevention of neutropenic fever in AML is controversial and there are few studies on this issue from developing countries. METHODS: In this retrospective study, we analyzed the clinical data and outcome of patients with AML who did or did not receive prophylactic ciprofloxacin 500 mg BD for neutropenic fever. RESULTS: A total of 69 AML patients were treated by "3 + 7" protocol for their first induction chemotherapy. Prophylaxis was given to 25 of them. Incidence of neutropenic fever was the same in both groups (80% vs 82%). Duration of fever and the mortality rate were also similar in both groups. CONCLUSION: It seems that in developing countries, using prophylactic ciprofloxacin has no significant effect on the incidence of neutropenic fever and the outcome of the AML patients.

Acute adult and adolescent poisoning in Tehran, Iran; the epidemiologic trend between 2006 and 2011.

BACKGROUND: The aim of this study was to determine the frequency of each poisoning and its related death in our center as a sample of Tehran in six consecutive years (2006 to 2011). METHODS: All poisoned children and adults referring to Loghman-Hakim hospital poison center and hospitalized in the study period were enrolled and evaluated. RESULTS: In 108,265 patients, the most common causes of poisoning were anti-epileptics and sedative-hypnotics (22.3%). The most common causes of death were pesticides (24.84%) and narcotics (24.75%). In drugs of abuse, opium was more prevalent in the early period of the study but was replaced by methadone later. CONCLUSION: It seems that national policies for drug control and prevention of suicide have not been efficient enough. We expect to see Iran in the first 50 countries with regard to suicide and to maintain the first place in narcotic abuse if enough attention is not provided.

Hallmarks of opium poisoning in infants and toddlers.

Accidental opium intoxication in children is an extremely dangerous poisoning if it remains undiagnosed and untreated. The classic triad of miosis, decreased level of consciousness and bradypnea, which are the hallmarks of opiate intoxication, are used for the diagnosis of opium poisoning in adults and children. Little attention has been paid to the signs of opium intoxication in children and no published study has explored the frequency of hallmarks of this type of poisoning in the paediatric population. We conducted a study in order to evaluate the prevalence of major signs of opium poisoning in infants and toddlers. In this study, a total of 228 infants and 82 toddlers who had been admitted to Loghman Hakim Hospital as a result of opium poisoning between 2001 and 2009 were evaluated, retrospectively. The most usual sign of opium poisoning was miosis (90%) followed by a decreased level of consciousness (88.4%), bradypnea (28.4%) and seizure (10.3%). The prevalence of the triad of miosis, bradypnea and a decreased level of consciousness was 25.2%. Miosis in association with decreased level of consciousness was detected in 82.6% of our patients. Bradypnea was present in 74 infants and 14 toddlers, which shows a statistically significant difference (P = 0.01). The mean age and weight of the patients with bradypnea were significantly less than those without bradypnea (P = 0.008 and P = 0.0001, respectively). Bradypnea and seizure were significantly more common in females (36.7% versus 26%; P = 0.05 and 15.2% versus 6.5%; P = 0.01, respectively). Miosis in association with a decreased level of consciousness is the most useful indicator of opium poisoning in infants and toddlers. Furthermore, seizure is a more common feature of this type of poisoning in infants, especially in those who are less than 1 month old.