Toxicity From Unintentional Pediatric Ingestion of a Performance-Enhancing Drug: A Case Report With Review of Clenbuterol Toxicity and Treatment.

BACKGROUND: Clenbuterol is a long-acting ß-adrenergic agonist that is not Food and Drug Administration-approved for use in the United States, but may be obtained without a prescription from various unregulated sellers. It has seen increasing use as a performance-enhancing drug for sports. Literature on pediatric toxicity and treatment is limited. CASE REPORT: We report a case of a 2-year-old female presenting after an exploratory ingestion of clenbuterol. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Use of performance-enhancing agents is increasing and physicians should be aware of the potential toxicity of intentional and unintentional ingestions of ß-adrenergic agonists. Patients may exhibit nausea, vomiting, tremor, tachycardia, and hypotension, along with laboratory abnormalities, including hyperglycemia, hypophosphatemia, hypokalemia, and hyperglycemia. Hypotension might not respond to adrenergic agents and may require administration of ß-adrenergic antagonists to maintain adequate perfusion.

First reported case of thrombocytopenia from a Heterodon nasicus envenomation.

CONTEXT: The vast majority of the 2.5 million annual worldwide venomous snakebites are attributed to Viperidae or Elapidae envenomations. Of the nearly 2000 Colubridae species described, only a handful are known to cause medically significant envenomations. Considered medically insignificant, Heterodon nasicus (Western Hognose Snake) is a North American rear-fanged colubrid common in the legal pet trading industry. Previously reported cases of envenomations describe local pain, swelling, edema, and blistering. However, there are no reported cases of systemic or hematologic toxicity. CASE DETAILS: A 20-year-old female sustained a bite while feeding a captive H. nasicus causing local symptoms and thrombocytopenia. On day three after envenomation, the patient was seen in the emergency department for persistent pain, swelling, and blistering. At that time, she was found to have a platelet count of 90 × 109/L. Previous routine platelet counts ranged from 315 to 373 × 109/L during the prior two years. Local symptoms peaked on day seven post envenomation. Her local symptoms and thrombocytopenia improved on evaluation four months after envenomation. DISCUSSION: We report the first Heterodon nasicus envenomation causing both local toxicity and thrombocytopenia. Potential mechanisms based on H. nasicus venom composition are discussed in detail. Treatment is largely supportive. Bites by H. nascius should be evaluated by a toxicologist familiar with Colubridae species. This represents the first reported case of hematologic toxicity from envenomation by a North American colubrid snake.

Skin perfusion and oxygenation changes in radiation fibrosis.

BACKGROUND: Ionizing radiation is known to have deleterious chronic effects on skin, including fibrosis and poor wound healing, hypothesized as mediated by ischemia and hypoxia. Past studies have been unable to simultaneously investigate changes in perfusion and oxygenation as separate parameters. Hyperspectral imaging has emerged as a tool with which to concurrently measure skin perfusion and oxygenation. The authors investigated the use of hyperspectral imaging in a novel murine model of chronic radiation injury. METHODS: Areas of flank skin (n = 20) on hairless mice were exposed to a 50-Gy dose of beta-radiation. Hyperspectral imaging acquisition was performed at select points through 8 weeks. Immunohistochemical staining and gene expression analysis were performed to evaluate cutaneous vascular density, epidermal cell hypoxia, and angiogenic factors. RESULTS: All irradiated areas developed a chronic-phase wound by day 28. Hyperspectral imaging demonstrated a 21 percent decline in perfusion on day 56 (p < 0.001), whereas oxygenation levels were unchanged. A 1.7-fold reduction in blood vessel density was measured in irradiated skin compared with control tissue (p < 0.001), but no difference in epidermal cell hypoxia was observed. Vascular endothelial growth factor and related receptor expression were significantly lower in irradiated tissue. CONCLUSIONS: The authors' analysis does not support the presence of hypoxia in chronic-phase irradiated skin but suggests that hypoperfusion may be a predominant characteristic. The concurrent states of hypoperfusion and normoxia may be explained by the lower metabolic demands of fibrosed tissue.

Human centromeric chromatin is a dynamic chromosomal domain that can spread over noncentromeric DNA.

Human centromeres are specialized chromatin domains containing the centromeric histone H3 variant CENP-A. CENP-A nucleosomes are interspersed with nucleosomes containing histone H3 dimethylated at lysine 4, distinguishing centromeric chromatin (CEN chromatin) from flanking heterochromatin that is defined by H3 lysine 9 methylation. To understand the relationship between chromatin organization and the genomic structure of human centromeres, we compared molecular profiles of three endogenous human centromeres, defined by uninterrupted higher-order alpha-satellite DNA, with human artificial chromosomes that contain discontinuous blocks of higher-order alpha-satellite DNA and noncentromeric DNA. The underlying sequence did not correlate with chromatin states, because both higher-order alpha-satellite DNA and noncentromeric DNA were enriched for modifications that define CEN chromatin, euchromatin, and heterochromatin. Human artificial chromosomes were also organized into distinct domains. CENP-A and heterochromatin were assembled over noncentromeric DNA, including the gene blasticidin, into nonoverlapping domains. Blasticidin transcripts were enriched at sites of CENP-A binding but not at H3 methylated at lysine 9, indicating that formation of CEN chromatin within a repetitive DNA environment does not preclude gene expression. Finally, we tested the role of centric heterochromatin as a centromeric boundary by increasing CENP-A dosage to expand the CEN domain. In response, H3 lysine 9 dimethylation, but not trimethylation, was markedly decreased at all centromeres examined. We propose that human centromere regions normally exist in a dynamic state in which a regional boundary, defined by H3 lysine 9 dimethylation, separates CEN chromatin from constitutive heterochromatin.