Perioperative Occupational Exposure to Coxiella burnetii-Infected Thoracic Endovascular Aneurysm Stent Graft.

We conducted this study to determine the risk of transmission of Q fever to health care workers (HCWs) during perioperative exposure to Coxiella burnetii-infected thoracic endovascular aneurysm stent graft. Pre-operative and 6-week post-operative phase I and II IgG Q fever antibody titers were determined in 14 staff members of an operation room. The room had a negative pressure and all the members of the surgical team wore either a fitted N-95 mask or a powered purified air respirator. Phase I and II IgG antibody titers were <1:16 for 11 of the 14 studied HCWs; 2 HCWs did not follow up at 6 weeks and 1 had a pre-exposure phase II IgG titer of 1:128 with no change 6 weeks later. We concluded that risk of transmission of C. burnetii in the operating room from infected patient to HCWs who wore appropriate personal protective equipment is low.

Cluster of Acute Toxicity from Ingestion of Synthetic Cannabinoid-Laced Brownies.

INTRODUCTION: Synthetic cannabinoid receptor agonists (SCRAs) are emerging designer drugs of abuse. Most reports on the health effects of these drugs are case reports. Unlike SCRAs, marijuana has classically been used via many routes of exposure including oral, such as in brownies. We report on 11 symptomatic patients who unknowingly ingested brownies laced with analytically confirmed SCRA and presented with mostly neuropsychiatric and cardiovascular symptoms. CASE SERIES: All 11 patients were taken to the ED within 1 h of exposure with the onset of various symptoms. There were five males and six females, age range 20-57 years. Neuropsychiatric and cardiovascular symptoms predominated: memory impairment (91 %, 10/11) and inappropriate giggling (36 %, 4/11). All the patients had light-headedness, perioral and facial numbness and tingling sensation, dry mouth, difficulty focusing/blurring of vision, and sluggishness. No patient had depressed consciousness. Two patients had heart rates >100, and 4 of 11 (36 %) had BP >140/80. One patient had chest pain. All the symptoms were completely resolved 4 h following their onset except two patients who had ongoing weakness and fatigue. All patients had negative urine drugs of abuse immunoassays and ethanol, acetaminophen, and salicylate concentrations, as well as normal electrocardiograms (ECGS) and metabolic panels. The SCRA was confirmed to be AM-2201. All the patients were discharged from the ED in stable condition within 10 h of the exposure. CONCLUSION: Oral exposure of 11 patients to brownies laced with analytically confirmed SCRA resulted in neuropsychiatric and cardiovascular symptoms. This series reflects that like marijuana, oral exposures to SCRAs can lead to symptoms.

Successful management of olanzapine-induced anticholinergic agitation and delirium with a continuous intravenous infusion of physostigmine in a pediatric patient.

Physostigmine effectively reverses anticholinergic delirium. However, continuous IV infusion of physostigmine is rarely used due to concern for cardiotoxicity and signs of cholinergic excess such as seizures, nausea, and vomiting. We report the successful use of continuous IV physostigmine in a 6-year-old boy with anticholinergic delirium. A 6-year-old, 30-kg boy with attention deficit hyperactivity disorder (ADHD) ingested 15-20 olanzapine (5 mg) tablets. He was agitated and was treated with lorazepam at a local hospital. His heart rate was 148 beats per min; respiratory rate, 32 breaths per minute; blood pressure, 111/70 mmHg; temperature, 96.8°F, and O2 saturation of 98% on room air. His pupils were 5-6 mm, and his skin was warm and initially flushed. Blood chemistry results were normal. A 12-lead ECG showed sinus tachycardia with normal QRS and QT intervals. The agitation worsened and did not respond to benzodiazepines. The patient was then given a dose of 0.6 mg physostigmine (0.02 mg/kg) intravenously with reversal of the agitation. But the effect only lasted 45 min requiring administration of a second bolus of 0.6 mg (0.02 mg/kg). A physostigmine intravenous infusion was administered at a rate of 0.5 mg/h (0.0167 mg/kg/h). Overnight, the patient became more agitated. The physostigmine was discontinued, and IV dexmedetomidine (0.2 µg/kg/h) was started at 21:00. The patient became over-sedated with pinpoint pupils resulting in discontinuation of the dexmedetomidine at 04:00. The patient again became agitated and developed visual hallucinations. Three 1-mg (0.03 mg/kg) boluses of physostigmine were administered over 45 min, and the physostigmine infusion was restarted at a rate of 1 mg/h (0.03 mg/kg/h) for 16.5 h. He received 19.5 mg of physostigmine with no return of anticholinergic symptoms and no signs of cholinergic excess except for a tremor that resolved when the infusion was stopped. He was discharged home without further sequelae. There are few publications describing a continuous infusion of physostigmine to reverse anticholinergic delirium. Our patient received a total dose of 25.5 mg with complete resolution of symptoms. We report the successful use of continuous infusion of physostigmine to reverse anticholinergic delirium in a pediatric patient who unintentionally ingested olanzapine.

Cardiotoxicity associated with the synthetic cannabinoid, K9, with laboratory confirmation.

Synthetic cannabinoids have been popular recreational drugs of abuse for their psychoactive properties. Five of the many synthetic cannabinoids have been recently banned in the United States because of their unknown and potentially harmful adverse effects. Little is known about these substances. They are thought to have natural cannabinoid-like effects but have different chemical structures. Adverse effects related to synthetic cannabinoids are not well known. We provide clinical effects and patient outcome following K9 use. In addition, we briefly review synthetic cannabinoids. We present a 17-year-old adolescent boy with chest pain, tachycardia, and then bradycardia associated with smoking K9. Two synthetic cannabinoids, JWH-018 and JWH-073, were confirmed on laboratory analysis. In addition to the limited current data, we demonstrate harmful adverse effects related to toxicity of 2 synthetic cannabinoids. Further studies are needed.

Myocardial infarction associated with use of the synthetic cannabinoid K2.

Designer drugs have been problematic over the years. Products such as K2 and Spice, which contain synthetic cannabinoids, are marketed as incense and are widely available on the Internet and at various specialty shops. The effects are reported as cannabis-like after smoking them. In addition, use of these synthetic cannabinoids will not appear on a routine urine toxicology screen. Recently, K2 became a popular alternative to marijuana among youths. Health implications of these designer drugs are not completely understood. Little has been reported about the harmful effects of K2. We report here the first (to our knowledge) cases of myocardial infarction (MI) after smoking K2. Three patients presented separately to the emergency department complaining of chest pain within days after the use of K2. Acute MI was diagnosed in each case on the basis of electrocardiogram changes and elevated troponin levels. Coronary angiography was performed, and the results were normal for the first 2 patients. The incidence of ST-elevation MI is low among teenagers, and association with drug use should be suspected. Public education and awareness need to be heightened about the possible health implications of K2.

Leukocytosis and hypercalcemia: a rare combination of paraneoplastic features in squamous cell penile cancer.

Penile cancer is very rare in North America and Europe, as compared with the rest of the world. Squamous cell carcinoma (SCC) accounts for more than 95% of the cancer type. Paraneoplastic syndrome (PNS), a clinical syndrome of nonmetastatic systemic effects that occurs in patients with malignant disease, is often associated with SCC. However, the association of penile SCC with leukocytosis and hypercalcemia is very rare. We report a case of penile SCC involving a change in the patient's mental status along with hypercalcemia and leukocytosis; all three conditions resolved after the tumor was excised. We also discuss the possible factors contributing to hypercalcemia, leukocytosis and change in mental status in SCC. These three conditions and other features of PNS can significantly influence a patient's overall prognosis and, if recognized early, can play an important role in the care plan.