A Case of Salicylate Intoxication Complicated by Coagulopathy, Pulmonary Edema, and Pancreatitis.

The large availability of salicylic acid products makes them an often encountered source of poisoning in the emergency department. Even though in most cases the prognosis is good, with a low incidence of long-term morbidity and mortality, complications do occur, and some of those can be life threatening. We present an unusual case of salicylate intoxication in an adolescent in which several uncommon complications (severe coagulopathy, pulmonary edema, and pancreatitis) conjoined together. We review the literature and discuss the complications pathogenesis and differential diagnosis. We suggest that these potentially life-threatening complications be acknowledged, investigated, and rapidly treated.

Death due to acute salicylate intoxication despite dialysis.

BACKGROUND: Salicylate poisoning is a common problem with appreciable morbidity and mortality. We present a case of a patient with a large aspirin ingestion who expired despite aggressive hemodialysis (HD). CASE REPORT: A 35-year-old man arrived at the Emergency Department 7.5 h after ingesting 400 tablets of 325-mg aspirin. He was afebrile, the respiratory rate (RR) was 30 breaths/min, heart rate (HR) 120 beats/min, blood pressure (BP) 125/76 mm Hg, and oxygen saturation 99% on room air. His salicylate concentration was 89.6 mg/dL. His initial arterial blood gas: pH 7.48, pCO(2) 21 mm Hg, PaO(2) 97 mm Hg, and bicarbonate 15.8 mmol/L. His initial serum chemistry panel was normal. He received activated charcoal and intravenous hydration with sodium bicarbonate. Two hours after arrival, salicylate concentration was 91.6 mg/dL. The patient became agitated and HD was initiated; 22 h after presentation, repeat salicylate concentration was 88.4 mg/dL and his creatinine was 3.9 mg/dL. A second run of HD was performed. After this, his temperature had risen to 39.06°C (102.3°F), BP 122/64 mm Hg, HR 168 beats/min, RR 43 breaths/min, and oxygen saturation 95% (2 L nasal cannula). His confusion increased, and he died 40 h after his ingestion. CONCLUSION: HD is widely advocated in managing severe salicylate intoxications, however, no consensus exists for the duration and best mode of therapy. Patients with severe salicylate poisonings may require extended durations of HD to effectively mitigate toxicity. Additional study is warranted to determine optimal therapy in severe salicylate intoxications.

Salicylic acid ingestion leading to esophageal stricture.

Accidental ingestion of caustic substances (acid and alkali) occurs more frequently in children than in adults. The subsequent injury varies from minimal to severe, with perforation and even death as potential complications. Several factors have been shown to mediate the severity of injury, including the pH, concentration and physical state of the ingested substance, tissue contact time, and quantity (volume) of the ingested material. Liquids with a pH of less than 2 (acidic) or a pH of greater than 12 (alkali) are considered to be extremely corrosive and hold the greatest risk for injury. Esophageal injury after caustic ingestion is endoscopically graded with a score of 0 for no injury to IIIb for significant circumferential injury with ulcers and necrosis. Ingestion of either a strong alkali or acid has been documented to result in esophageal necrosis and ulcers (grade IIIb). Alkali ingestions occur more frequently because of their presence in daily life (detergents, degreasers) and therefore have more reports of injury. Despite more than 8200 documented cases of topical salicylic acid ingestions annually in US children younger than 19 years, there are no reported cases of salicylic acid resulting in gastrointestinal pathology. We report 2 cases of salicylic acid ingestion resulting in esophageal strictures. Both patients had more significant injury than anticipated given their initial clinical presentations. Given our recent experience, we recommend close follow-up and evaluation for strictures in patients with exposure to salicylic acid.

In vitro studies on the application of colloidal emulsion aphrons to drug overdose treatment.

Colloidal emulsion aphrons (CEAs) are considered as the micron-sized water-in-oil (W/O) emulsion-cores encapsulated by a "soapy shell" consisting of multi-layer surfactant molecules. In this dispersion, the emulsion-core sizes are mainly in 10-100 microm and that of the inner phase droplets are in 1-5 microm. CEAs not only behave analogously to emulsion liquid membrane (ELM) in extraction with advantages of high concentration ratio, counter-concentration extraction and combination of extraction with backwash together, but also have the large interface areas, easy scatteration and quick extraction which colloidal liquid aphrons (CLAs) possess. CEA extraction overcomes the restriction of partition equilibrium between the water and the oil phase that CLAs have. They have greater extraction capacity than CLAs. In this study, the application of CEAs to drug overdose treatment was studied using salicylic acid as the model drug, paraffin oil as the membrane phase, PEG-30 dipolyhydroxystearate (P135) as the hydrophobic surfactant, nonylphenol ethoxylate-10 (NP10) as the hydrophilic surfactant and NaOH solution as the receptor phase. Also some factors affecting the stability of this dispersion and extraction ratio were investigated. In order to prepare CEAs successfully, the concentrations of NP10 and P135 should be in 1.5-3.0% (w/v) and 0.25-1.0% (w/v), respectively, together with the ratio of the volume of oil phase to the volume of inner aqueous phase of CEAs, R(oi)> or =1:1. For the extraction of salicylic acid, the pH value of the feed phase was supposed to be lower than 2.0 and the suitable NaOH concentration of the receptor phase was higher than 0.02 mol/L. Under this condition, more than 98.7% of salicylic acid was transported into receptor phase in half a minute.

[Suicidal salicylate intoxications and unintentional percutaneous poisoning with salicylic ointment]. / Samobójcze zatrucia salicylanami i przypadkowe przezskórne zatrucie mascia salicylowa.

Suicidal salicylate poisonings are presented in 49 patients, 33 women and 16 men, aged from 18 to 71 (mean 37) years. Mixed poisonings with multiple agents were four times more frequent, had more severe clinical course and demanded longer hospitalisation than acute intoxications with salicylates alone. Four patient were over 65 years old (8.2%). Difficult economic situation of geriatric population in Poland had no effect on frequency of suicidal attempts in the studied cohort. There were no fatalities in the studied group. There were two unintentional systemic poisonings due to topical administration of the 10% salicylic acid ointment for wide spread skin lesions (more than 80% of body surface) in two patients with exudative psoriasis.

Limitation of the Vitros dry-slide technique in measuring high concentrations of salicylate in plasma.

The linearity of the Vitros dry-slide method for plasma salicylate was assessed in two ways: serial concentrations of sodium salicylate were added to fresh lithium heparin plasma, and the salicylate was determined both neat and in dilution. Vitros salicylate results submitted to the Heathcontrol External Quality Assessment Scheme were compared to the spike value. Similar loss of linearity was observed in both cases. Serious salicylate overdosage requiring specific clinical treatment may have been underestimated.

[Acute salicylate intoxication after trancutaneous absorption]. / Intossicazione acuta da salicilato da assorbimento transcutaneo.

Topical salicylate preparations are primarily employed as keratolytic agents in the treatment of dermatologic disorders. A case of severe salicylate intoxication in a 70-year-old man with psoriasis, treated with a topical cream containing salicylic acid, is described. After five days the patient was admitted to ICU with encephalopathy and severe acid-base disturbances (respiratory alkalosis, metabolic acidosis, increased anion gap). A plasma salicylate concentration was elevated at 695 mg/Lt. Emergent hemodialysis was accompanied by a rapid lowering of plasma salicylate concentration and resolution of metabolic acidosis. Salicylate is well absorbed by normal and diseased skin. In this patient the lack of a normal epidermal barrier greatly enhances absorption of topical salicylate. It is therefore suggested that all topical salicylate treatments should be routinely monitored with salicylate blood concentration especially during the initial few days after onset or after any changes in treatment.

[Possibilities for toxicologic evidence in adipocere formation and postmortem interval of several years]. / Toxikologische Nachweismöglichkeiten bei Fettwachsumwandlung und mehrjähriger Liegezeit.

It is reported on a 31-year-old man, whose dead body was found together with numerous packets of poisons and medicaments in a forest after a post-mortem period of nearly 3 years. Despite advanced skeletization and complete transformation of the still existing residual soft tissues to adipocere, highly toxic concentrations of two heavy metals (cadmium: 0.30 mg/kg; thallium: 0.91 mg/kg) and minor levels of three organic substances (phenobarbitone: 0.32 mg/kg; nordazepam: 0.14 mg/kg; salicylic acid: 0.04 mg/kg) were detected in adipoceratous samples. Even if it is not possible to derive similar blood levels from post-mortem values, the cause and manner of death (suicidal intoxication) could be clarified with the necessary degree of certainty. Few comparable literature reports either deal with exhumations or non-toxic concentrations of substances in morphologically better preserved adipoceratous bodies. Our case demonstrates that toxicological analyses may contribute to the clarification of the cause of death even if advanced adipocere formation with a longer post-mortem interval is present.