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.

Endovascular Treatment of Medial Tentorial Dural Arteriovenous Fistula Through the Dural Branch of the Pial Artery.

Background: Tentorial dural arteriovenous fistula is a rare subtype of intracranial dural arteriovenous fistula (DAVF) with a deteriorating natural course, which may be attributed to its pial angioarchitecture. TDAVF often harbors feeders arising from pial arteries (FPAs). Reports have revealed that, if these feeders are not obliterated early, the restricted venous outflow during the embolization process may cause upstream congestion in the fragile pial network, which increases the risk of hemorrhagic complications. Because most reported cases of TDAVF were embolized through feeders from non-pial arteries (FNPAs), little is known of the feasibility of direct embolization through FPAs. Methods: We present three patients with medial TDAVFs that were embolized through the dural branches of the posterior cerebral and superior cerebellar arteries. Findings from brain magnetic resonance imaging, computed tomography, angiography, and clinical outcomes are described. Furthermore, we performed a review of the literature on TDAVFs with FPAs. Results: The fistulas were completely obliterated in two patients; both recovered well with no procedure-related complications. The fistula was nearly obliterated in one patient, who developed left superior cerebellum and midbrain infarct due to the reflux of the embolizer into the left superior cerebellar artery. Including our cases, eight cases of TDAVFs with direct embolization through the FPAs have been reported, and ischemic complications occurred in three (37.5%). Conclusions: Advancing microcatheter tips as close to the fistula point as possible and remaining highly aware of potential embolizer flow back into the pial artery are key factors in achieving successful embolization. Balloon-assisted embolization may be an option for treating TDAVFs with FPAs in the future.

Spontaneous small bowel perforation secondary to Vibrio parahaemolyticus infection: A case report.

BACKGROUND: Vibrio pararhaemolyticus (V. parahaemolyticus), a pathogen that commonly causes gastroenteritis, could potentially lead to a pandemic in Asia. Its pathogenesis and molecular mechanisms vary, and the severity of illness can be diverse, ranging from mild gastroenteritis, requiring only supportive care, to sepsis. CASE SUMMARY: We outline a case of a 71-year-old female who experienced an acute onset of severe abdominal tenderness after two days of vomiting and diarrhea prior to her emergency department visit. A small bowel perforation was diagnosed using computed tomography. The ascites cultured revealed infection due to V. parahaemolyticus. CONCLUSION: Our case is the first reported case of V. parahaemolyticus-induced gastroenteritis resulting in small bowel perforation.

Rapid-onset acute respiratory distress syndrome after mastectomy in a breast cancer patient: A case report and review of literature.

RATIONALE: Postoperative acute respiratory distress syndrome (ARDS) often results in severe morbidity and mortality in surgical patients. The etiology of this condition is complex, especially in cancer patients. PATIENT CONCERNS: We encountered a 53-year-old woman with left breast cancer, cT1cN2M0, stage IIIA with left axillary lymph node metastasis. She had received chemotherapy with 4 cycles of doxorubicin plus cyclophosphamide, and 4 cycles of trastuzumab plus docetaxel within a span of 6 months. Subsequently, she underwent left simple mastectomy and axillary lymph node dissection, shortly after which she developed respiratory distress with progressive desaturation and hemoptysis. DIAGNOSIS: ARDS was diagnosed using the Berlin criteria. Her arterial blood gas analysis revealed profound hypoxemia and her chest imaging was suggestive of pulmonary edema. She developed diffuse alveolar hemorrhage (DAH) that was confirmed with bronchoscopy and hemorrhagic samples on bronchoalveolar lavage. INTERVENTIONS: She was mechanically ventilated with lung protective measures for management of ARDS. In addition to antibiotic cover with amoxicillin sodium-potassium clavulanate for occult infections during her stay in the intensive care unit, we administered epinephrine inhalations, intravenous treatment with tranexamic acid, and methylprednisolone for DAH. OUTCOMES: Her clinical course improved; she was extubated successfully on day 7 and discharged home on day 11. LESSONS SUBSECTIONS: Chemotherapeutic agents may cause pulmonary toxicity through a direct cytotoxic effect or immune-mediated reactions and result in an increased risk of development of ARDS. Furthermore, surgery may trigger a systemic inflammatory response syndrome that can also induce ARDS. In our patient, the development of ARDS was attributed to the combined effects of surgery and chemotherapeutic agents (trastuzumab or docetaxel). When patients undergo major surgery after receiving chemotherapeutic agents, careful consideration is necessary to prevent the development of ARDS.

Derivation and Validation of a Scoring System for Intravenous Tissue Plasminogen Activator Use in Asian Patients.

BACKGROUND AND PURPOSE: As Chinese Asian populations have an increased risk of intracerebral hemorrhage (ICH) after intravenous tissue plasminogen activator (IV tPA), we aimed to design a rapid, clinically applicable risk scoring system to predict ICH and functional outcomes after IV tPA treatment in Asian ischemic stroke patients. METHODS: From January 2009 to December 2012, consecutive acute ischemic stroke patients treated with IV tPA recruited from the Stroke Registry in Chang Gung Healthcare System (SRICHS) in Taiwan and the National University Hospital of Singapore (NUHS) acute stroke database were used to create and validate a scoring system. Nomogram was created for ICH and 3-month mortality. RESULTS: In total, 932 patients were included in the study: 386 from SRICHS for the derivation of scoring system and 546 from NUHS to validate it. We used nomograms to assign weightage to the scoring system. The presence of atrial fibrillation, glucose level, and the National Institutes of Health Stroke Scale (NIHSS) score were significantly associated with the risk of ICH. Age, NIHSS score, hyperlipidemia, and the presence of post-tPA ICH were significantly associated with mortality. The areas under the curve of derivation and validation cohorts were .663 and .662 for ICH, and .808 and .790 for mortality, respectively. CONCLUSIONS: The scoring system using nomograms can provide a fast, practical, and user-friendly tool that allows physicians to predict the risk of ICH and functional outcomes with IV tPA treatment in a clinical setting.

Vibsane diterpenoids from the leaves and flowers of Viburnum odoratissimum.

In addition to the five known compounds 5-epi-vibsanin H, vibsanins C, H, and G, and aldovibsanin B, four new diterpenes, 5-epi-vibsanin G (1), 18-O-methylvibsanin G (2), vibsanin M (3), and aldovibsanin C (4), were isolated from an acetone extract of the leaves and flowers of Viburnum odoratissimum by bioassay-directed fractionation. In addition, two acetyl derivatives 5 and 6 were obtained from the naturally occurring diterpenes. The structures of the new compounds were established on the basis of NMR spectral analysis, including COSY, HMQC, HMBC, and NOESY correlations. The compounds were evaluated for cytotoxicity against human nasopharyngeal carcinoma (HONE-1) tumor cells and human gastric cancer (NUGC-3) cells.

New cadinene sesquiterpenoids from the Formosan soft coral Xenia puerto-galerae.

Six new cadinene sesquiterpenoids, xenitorins A-F (1-6), were isolated from the methylene chloride solubles of the Formosan soft coral Xenia puerto-galerae. The structures were elucidated by 1D and 2D NMR spectral analysis, and their cytotoxicity against selected cancer cells was measured in vitro.