Relating calls to US poison centers for potential exposures to medications to Centers for Disease Control and Prevention reporting of influenza-like illness.

CONTEXT: The Centers for Disease Control (CDC) monitors influenza like illness (ILI) and the National Poison Data System (NPDS) warehouses call data uploaded by US poison centers regarding reported exposures to medication. OBJECTIVE: We examined the relationship between calls to poison centers regarding reported exposures to medications commonly used to treat ILI and weekly reports of ILI. MATERIALS AND METHODS: The CDC reports ILI, by age group, for each of 10 Health and Human Services (HHS) regions. We examined NPDS summary data from calls reported to poison centers regarding reported exposures to acetaminophen, cough/cold medications, and promethazine, for the same weeks, age groups, and HHS regions for influenza seasons 2000-2013. ILI and NPDS exposures were examined using graphical plots, descriptive statistics, stepwise regression analysis, and Geographic Information Systems (GIS). RESULTS: About 5,101,841 influenza-like illness cases were reported to the CDC, and 2,122,940 calls regarding reported exposures to medications commonly used to treat ILI, were reported by poison centers to the NPDS over the 13 flu seasons. Analysis of stepwise models of the linear untransformed data involving 24 NPDS data groups and for 60 ILI measures, over the 13 influenza seasons, demonstrated that reported exposures to medications used to treat ILI correlated with reported cases of ILI with a median R(2 )=( )0.489 (min R(2 )=( )0.248, max R(2 )=( )0.717), with mean ± SD of R(2 )=( )0.494 ± 0.121. Median number of parameters used (degrees of freedom - 1) was 7. CONCLUSIONS: NPDS data regarding poison center calls for selected ILI medication exposures were highly correlated with CDC ILI data. Since NPDS data are available in real time, it provides complimentary ILI monitoring. This approach may provide public health value in predicting other illnesses which are not currently as thoroughly monitored.

Acute Methylenedioxypyrovalerone Toxicity.

The objective of this study was to characterize the acute clinical effects, laboratory findings, complications, and disposition of patients presenting to the hospital after abusing synthetic cathinone. We conducted a retrospective multicenter case series of patients with synthetic cathinone abuse by searching for the terms bath salts, MDPV, methylenedioxypyrovalerone, mephedrone, methcathinone, methylone, methedrone, and cathinone within the "agent" field of a national clinical toxicology database (ToxIC). The medical records of these patients were obtained and abstracted by investigators at each study site. Patients with confirmatory testing that identified a synthetic cathinone in either blood or urine were included in the series. Patients who had either an undetectable synthetic cathinone test or no confirmatory testing were excluded. A data abstraction sheet was used to obtain information on each patient. We entered data into an Excel spreadsheet and calculated descriptive statistics. We identified 23 patients with confirmed synthetic cathinone exposure--all were positive for methylenedioxyprovalerone (MDPV). Eighty-three percent were male and 74 % had recreational intent. The most common reported clinical effects were tachycardia (74 %), agitation (65 %), and sympathomimetic syndrome (65 %). Acidosis was the most common laboratory abnormality (43 %). Seventy-eight percent of patients were treated with benzodiazepines and 30 % were intubated. Ninety-six percent of patients were hospitalized and 87 % were admitted to the ICU. The majority (61 %) of patients was discharged home but 30 % required inpatient psychiatric care. There was one death in our series. The majority of patients presenting to the hospital after abusing MDPV have severe sympathomimetic findings requiring hospitalization. A number of these patients require inpatient psychiatric care after their acute presentation.

Acute lung injury following refrigeration coil deicing.

We report a case of a worker who developed ALI requiring mechanical ventilatory support after attempting to melt ice condensate by applying the flame of an oxy-acetylene torch to refrigeration coils charged with a halocarbon refrigerant in a closed environment. A discussion of possible etiologies are discussed, including phosgene, carbonyl fluoride, and nitrogen oxides. Primary prevention with adequate respiratory protection is recommended whenever deicing is performed in a closed space environment.

Is maternal opioid use hazardous to breast-fed infants?

Over the last few decades, the rate of breastfeeding has increased steadily in the developed countries of the world. During this time, opioid use in the general population has steadily increased as well. Despite this, clinicians remain unclear whether opioid use is safe during breastfeeding. While the vast majority of medications used during breastfeeding occur without incident, case reports and studies have reported possible opioid toxicity in breast-fed infants. Multiple enzymes are involved in the metabolism of opioids. CYP2D6 catabolizes O-demethylation of codeine, tramadol, oxycodone, and hydrocodone to more potent metabolites. CYP3A4 inactivates methadone, meperidine, and buprenorphine. Glucoronide conjugation by the UGT enzyme family inactivates morphine and hydromorphone. Genetic polymorphisms and interfering medications affect the maternal metabolism, which in turn determines the exposure and risk to the breast-fed neonate. We review the production of breast milk, the transfer of xenobiotics from blood to milk, the characteristics that alter xenobiotic breast-milk concentrations, and we review the evidence of specific common opioids and infant toxicity. The short-term maternal use of prescription opioids is usually safe and infrequently presents a hazard to the newborn.

Complete heart block and death following lamotrigine overdose.

CONTEXT. Lamotrigine is used for both seizure and psychiatric disorders. Overdoses typically follow a benign course. CASE DETAILS. A 19-year-old male with bipolar disorder ingested 4 g of lamotrigine. The patient suffered from multiple seizures, charcoal aspiration, respiratory arrest, prolongation of the QRS interval on electrocardiogram, complete heart block, multiorgan failure and ultimately death. DISCUSSION. We describe the emergency department (ED) and ICU course for this patient and briefly review the toxic effects of lamotrigine and the pharmacokinetics with and without hemodialysis.

Massive hymenoptera envenomation in a 3-year-old.

BACKGROUND: Envenomation by a large number of hymenopterans can cause significant morbidity and mortality due to venom load. We present the first case of massive Hymenoptera envenomation by native US Hymenoptera. CASE: A 3-year-old boy and his family were hiking in Oregon and were attacked by yellow jackets. On emergency department arrival, the child was uncomfortable and vomiting. Vital signs were normal; physical examination showed more than 90 punctate lesions on the head and neck, and 30 below the neck without urticaria. Initial laboratory values were normal except for a white blood cell count of 37,500/µL and mild hypokalemia, including a normal creatinine kinase. Intravenously administered fluids, ondansetron, midazolam, and morphine were given for symptom control.Generalized edema developed 12 hours later and was treated with intravenously administered dexamethasone and diphenhydramine. His creatinine kinase peaked at 2085 U/L after 32 hours. Forty-eight hours after the incident, the child began to take oral fluids with laboratory values returning to normal. DISCUSSION: Delayed toxic effects of mass envenomation are due to direct toxic effects from the large venom load, with several cases of death reported. All prior cases of mass Hymenoptera envenomation in the United States have involved Africanized "killer" honeybees. Guidelines recommend admitting all pediatric patients sustaining more than 50 stings for 24 hours for laboratory evaluations. CONCLUSIONS: Delayed toxic reaction may be caused by native US species of Hymenoptera. Physicians should be aware that endemic US species can cause this reaction and should have a low threshold to admit pediatric patients with more than 50 stings for 24 hours.

Survival after diphenhydramine ingestion with hemodialysis in a toddler.

A 13-month-old male who ingested 20 diphenhydramine (25 mg) tablets presented with seizures and ultimately progressed to status epilepticus and wide-complex tachycardia. Due to worsening clinical course, hemodialysis was performed with temporal resolution of his symptoms. Hemodialysis may be considered in critically ill diphenhydramine overdoses not responsive to conventional supportive care.

Catatonia associated with initiating paliperidone treatment.

We present a case of catatonia, which occurred shortly after starting a new antipsychotic, paliperidone, an active metabolite of risperidone. Catatonia may be caused by a variety of conditions, including metabolic, neurologic, psychiatric and toxic processes. Interestingly, risperidone, which has been thought to cause several cases of catatonia, has also been recommended as a potential treatment. We discuss potential mechanisms for causes of drug-induced catatonia as well as potential treatment options.

Muscle spasm associated with therapeutic use of Cang Er Zi Wan.

INTRODUCTION: Cang Er Zi Wan (CEZW) is a herbal medication derived from Xanthium sibiricum that is used to treat allergies and upper respiratory problems. Its toxicity has been described in grazing animals, in experimental studies, and in human overdoses. We describe a case of muscular spasm that was associated with the therapeutic use of CEZW. CASE REPORT: A 17-year-old female was prescribed CEZW for chronic allergies. Shortly after her second dose of 10 pills BID, she developed intermittent muscular spasms. She was seen in an Emergency Department and had normal vital signs and no significant laboratory abnormalities. Her physical exam was significant only for intermittent spasm of the muscles of the face, neck, and upper extremities. No tremor, fasciculation, dystonia, akisthisia, chorea, bradykinesia, or clonus was noted. She discontinued the CEZW and the symptoms slowly decreased over 4 days. Testing of the product did not detect any other medications or drugs. DISCUSSION: CEZW is a herbal medication that contains X. sibiricum. X. sibiricum is a widespread weed that has caused muscular spasm, seizures, and death in animals that graze on it as well as animals experimentally exposed to it. Eleven cases of accidental human ingestion of Xanthium leading to spasm, somnolence, hypoglycemia, renal, and liver toxicity have been described. We describe a unique case of isolated muscular spasms because of the therapeutic use of a CEZW product.

Hydrogen peroxide ingestion associated with portal venous gas and treatment with hyperbaric oxygen: a case series and review of the literature.

INTRODUCTION: Ingestion of concentrated hydrogen peroxide (H(2)O(2)) has been associated with venous and arterial gas embolic events, hemorrhagic gastritis, gastrointestinal bleeding, shock, and death. Although H(2)O(2) is generally considered a benign ingestion in low concentrations, case reports have described serious toxicity following high concentration exposures. Hyperbaric oxygen (HBO) has been used with success in managing patients suffering from gas embolism with and without manifestations of ischemia. METHODS: Poison center records were searched from July 1999 to January 2010 for patients with H(2)O(2) exposure and HBO treatment. Cases were reviewed for the concentration of H(2)O(2), symptoms, CT scan findings of portal gas embolism, HBO treatment, and outcome. RESULTS; Eleven cases of portal gas embolism were found. Ages ranged from 4 to 89 years. All but one ingestion was accidental in nature. In 10 cases 35% H(2)O(2) was ingested and in 1 case 12% H(2)O(2) was ingested. All abdominal CT scans demonstrated portal venous gas embolism in all cases. Hyperbaric treatment was successful in completely resolving all portal venous gas bubbles in nine patients (80%) and nearly resolving them in two others. Ten patients were able to be discharged home within 1 day, and one patient had a 3.5-day length of stay. CONCLUSIONS: HBO was successful in resolving portal venous gas embolism from accidental concentrated H(2)O(2) ingestions.

Bactrian ("double hump") acetaminophen pharmacokinetics: a case series and review of the literature.

After acute ingestion, acetaminophen (APAP) is generally absorbed within 4 h and the APAP concentration ([APAP]) slowly decreases with a predictable half-life. Alterations in these pharmacokinetic principles have been rarely reported. We report here three cases of an unusual double hump, or Bactrian, pattern of [APAP]. We review the literature to describe the case characteristics of these rare cases. A 38-year-old woman ingested 2 g hydrocodone/65 g acetaminophen. Her [APAP] peaked at 289 mcg/mL (8 h), decreased to 167 mcg/mL (31 h), then increased to 240 mcg/mL (39 h). She developed liver injury (peak AST 1603 IU/L; INR1.6). A 25-year-old man ingested 2 g diphenhydramine/26 g APAP. His [APAP] peaked at 211 mcg/mL (15 h), decreased to 185 mcg/mL (20 h), and increased again to 313 mcg/mL (37 h). He developed liver injury (peak AST 1153; INR 2.1). A 16-year-old boy ingested 5 g diphenhydramine and 100 g APAP. His [APAP] peaked at 470 mcg/mL (25 h), decreased to 313 mcg/mL (36 h), then increased to 354 mcg/mL (42 h). He developed liver injury (peak AST 8,686 IU/L; peak INR 5.9). We report three cases of Bactrian ("double hump") pharmacokinetics after massive APAP overdoses. Cases with double hump pharmacokinetics may be associated with large ingestions (26-100 g APAP) and are often coingested with antimuscarinics or opioids. Several factors may contribute to these altered kinetics including the insolubility of acetaminophen, APAP-induced delays in gastric emptying, opioid or antimuscarinic effects, or enterohepatic circulation. Patients with double hump APAP concentrations may be at risk for liver injury, with AST elevations and peaks occurring later than what is typical for acute APAP overdoses.

Iatrogenic lipid emulsion overdose in a case of amlodipine poisoning.

INTRODUCTION: Intralipid therapy has been used successfully as "rescue therapy" in several cases of overdose. We present a case of iatrogenic lipid emulsion overdose because of a dosing error. CASE REPORT: A 71-year-old female overdosed on 27 tablets of 5 mg amlodipine. Although initially stable in the Emergency Department, she became hypotensive, oliguric, and respiratory failure developed despite medical therapy. The primary treating team felt that meaningful recovery was unlikely to occur without rapid improvement in clinical status, and 12.5 h after presentation, intralipid rescue therapy was initiated. A protocol for intralipid specifying a maximum infusion of 400 mL of 20% lipid emulsion was faxed, but the infusion was continued until 2 L of lipid emulsion was infused. There were no detectable adverse hemodynamic effects of the intralipid infusion. After this time, laboratory values were difficult to obtain. Three hours after the infusion, a metabolic panel was obtained from ultracentrifuged blood showing hyponatremia. A white blood cell (WBC) was obtained from a complete blood count (CBC) performed 22 h after the infusion, hemoglobin and hematocrit could not be obtained from this blood. A platelet count was obtained by smear estimate. Hematocrits were obtained from centrifuged blood and appeared elevated. No oxygenation could be obtained on blood gas. The patient's family chose to withdraw care on hospital day 2 and no further laboratory draws were obtained. Amlodipine was 1,500 ng/mL (ref. 3-11 ng/mL). DISCUSSION: Lipid emulsion overdose caused no detectable acute adverse hemodynamic effects. The following laboratory values were unobtainable immediately after infusion: white blood cell count, hemoglobin, hematocrit, platelet count, and a metabolic panel of serum electrolytes. Ultracentrifugation of blood allowed for detection of a metabolic panel 3 h after the infusion. Centrifuged hematocrits appeared to be higher than expected.

Methamphetamine body stuffers: an observational case series.

STUDY OBJECTIVE: We describe the demographics, characteristics, treatment, and clinical course of methamphetamine body stuffers. We also determine the clinical characteristics of methamphetamine body stuffers who have severe outcomes. METHODS: A 6.5-year descriptive nonconcurrent observational case series evaluated methamphetamine body stuffers about whom the Oregon Poison Center was consulted by their primary physicians. Poison center charts were supplemented by completed hospital charts (for 95% of patients). RESULTS: Six hundred forty-eight patients with methamphetamine exposure were identified and reviewed, and 55 charts met the criteria for "methamphetamine body stuffer." We found the following characteristics of methamphetamine body stuffers: mean age 29 years (range 16 to 57 years), men in 44 of 55 cases (80%), mean time to arrival 2.7 hours after ingestion, with a median of 1 hour after ingestion. Ninety-seven percent (53/55) stuffed methamphetamine orally (2/55 rectally). Methamphetamine was most frequently swallowed in baggies, but 25% were unpackaged. The median dose ingested was 3.5 g of methamphetamine in 1 package. Outcome-based analysis revealed 29% (16/55) of patients had severe outcomes, as defined by end-organ toxicity, with agitation requiring intubation the most common severe outcome. There was 1 death reported. Toxicity did not appear to be related to the amount of methamphetamine or number of packets. Patients with severe outcomes had higher mean initial pulse rates and temperatures. Eighty-eight percent (14/16) of patients with severe outcomes had a presenting pulse rate greater than 120 beats/min or a temperature greater than 38 degrees C versus 18% (7/39) patients with a benign outcome. Twenty-four radiographic studies were obtained; none detected packets. CONCLUSION: Methamphetamine body stuffers have similar demographics to those of body stuffers of other stimulants, but tended to ingest fewer baggies with larger masses, and had a higher percentage of severe outcomes (29%) than previously reported with other stimulants. Increases in presenting pulse rate and temperature (pulse rate >120 beats/min or >38.0 degrees C) are common in patients who will develop end-organ damage.

Acute arsenic trioxide ant bait ingestion by toddlers.

INTRODUCTION: Arsenic trioxide is available for home use in ant baits. Potential arsenic toxicity from unintentional pediatric ingestion is not well studied. The goal of this study is to describe the clinical course and urinary arsenic concentrations of children who ingested ant bait containing arsenic trioxide (0.46%). METHODS: This is a case series of pre-school children who unintentionally ingested arsenic trioxide ant bait gel bars in the home reported to two U.S. poison control centers from January 2003 to July 2007. RESULTS: Six children (age range, 8 months to 4 years) ingested varying portions of ant bait gel bars containing arsenic trioxide (0.46%). All vomited shortly after exposure. The initial, pre-chelation urine total arsenic concentrations ranged from 1,858 to 13,981 mcg/L. All children had resolution of symptoms and received chelation with succimer. Follow-up urine arsenic concentrations were in the normal range 14-35 days after chelation and no further clinical toxicity was noted. CONCLUSIONS: Children who ingest all or part of a household ant bait gel bar that contains relatively low concentration of arsenic trioxide can develop markedly elevated urine arsenic concentrations with minor initial symptoms. Prompt chelation with succimer is recommended for children with these exposures and continued until urine arsenic concentrations are normal.

Hyperthyroidism.

The clinical spectrum of hyperthyroidism varies from asymptomatic,subclinical hyperthyroidism to the life-threatening "thyroid storm". Hyperthyroidism is a common form of thyroid disease that mimics many of the common complaints in the emergency department. The diagnosis of hyperthyroidism is often challenging due to the multitude of physical and even psychiatric complaints. Recognition and treatment by emergency physicians of severe hyperthyroidism is critical and can be life saving.