Prevalence of cocaine and derivatives in blood and urine samples of trauma patients and correlation with injury severity: a prospective observational study.

PURPOSE: The abuse of cocaine and its derivatives presents a likely risk factor for injury. Trauma incurred by cocaine and derivative abusers may be more severe than that incurred by non-users. OBJECTIVES: To ascertain the presence of cocaine and its derivatives in trauma patients and to correlate RTS (Revised Trauma Score) and ISS (Injury Severity Score) with the presence of cocaine and its derivatives in blood and urine samples. METHODS: All trauma victims treated in an emergency unit between November 11, 2012 and September 15, 2013 were included in the study. Blood and urine samples were collected on admission to hospital. RTS and ISS scores were then compared with the presence or absence of cocaine and its derivatives in the samples. The associations between RTS < 7.84 and ISS > 16 and the independent variables were evaluated by the gross odds ratio values, determined by univariate logistic regression. Multivariate analysis was performed using multivariate logistic regression. RESULTS: Of 453 patients (83.7% male) included in the study, 28.6% presented ISS > 16 and 33.6% presented RTS < 7.84. A total of 435 samples were collected, and 86 (19.8%) provided positive samples for cocaine, 48 (11%) for crack and 69 (15.9%) for cocaethylene. Compared to other patients, drug users showed a greater probability of RTS < 7.84 (2.18 times greater) and a greater probability of ISS > 16 (1.76 times greater). CONCLUSION: For the trauma patients included in our study, the use of cocaine and its derivatives was shown to be associated with more severe traumas, as demonstrated by their RTS and ISS scores.

Compartment syndrome after South American rattlesnake (Crotalus durissus terrificus) envenomation.

CONTEXT: In order to report the outcome of a patient who developed compartment syndrome after South American rattlesnake (Crotalus durissus terrificus) envenomation, confirmed by subfascial pressure measurement and magnetic resonance imaging (MRI). CASE DETAILS: A 63-year-old male was admitted 1 h after being bitten on the right elbow by a "large" snake, which was not brought for identification. Physical and laboratory features upon admission revealed two fang marks, local tense swelling, paresthesia, intense local pain, hypertension, coagulopathy, and CK = 1530 U/L (RV < 170 U/L). The case was initially treated with bothropic antivenom (80 mL, intravenously), with no improvement. Evolution within 13-14 h post-bite revealed generalized myalgia, muscle weakness, palpebral ptosis, and severe rhabdomyolysis (CK = 126,160 U/L) compatible with envenoming by C. d. terrificus. The patient was then treated with crotalic antivenom (200 mL, intravenously), fluid replacement, and urine alkalinization. Twenty-four-hour post-bite MRI showed marked muscular edema in the anterior compartment of the right forearm, with a high subfascial pressure (40 mmHg) being detected 1 h later. ELISA of a blood sample obtained upon admission, before antivenom infusion, revealed a high serum concentration of C. d. terrificus venom. No fasciotomy was performed and the patient was discharged seven days later without sequelae. CONCLUSION: Snakebite by C. d. terrificus with subfascial venom injection may lead to increased intracompartmental pressure.

Coagulopathy as the main systemic manifestation after envenoming by a juvenile South American rattlesnake (Crotalus durissus terrificus): case report.

CONTEXT: Rattlesnake bites in Brazil are generally caused by adult individuals, with most of the envenomed patients showing systemic manifestations that include varying degrees of neurotoxicity (acute myasthenia), rhabdomyolysis and coagulopathy, with only mild or no local manifestations. We report a case of envenoming by a juvenile South American rattlesnake (Crotalus durissus terrificus) that involved coagulopathy as the main systemic manifestation. CASE DETAILS: A 19-year-old male was admitted to our Emergency Department with coagulopathy (incoagulable PT, APTT and INR), no remarkable local manifestations and no signs/symptoms of myasthenia or rhabdomyolysis (serum CK, LDH, ALT and AST within reference levels) 5 days after being bitten by a small snake that was described as a rattlesnake but was not brought for identification at admission. The patient had already been treated in another Emergency Department with i.v. bothropic antivenom (AV) 1 h and 4 days post-bite. Based on the possibility of an unusual rattlesnake bite, crotalic AV was administered i.v., which improved the coagulation (9 h post-CroAV, INR = 2.11; 36 h post-CroAV, INR = 1.42). During hospitalization, relatives brought the snake that caused the bite, which was identified as a 38-cm long C. d. terrificus. DISCUSSION: Little is known about the clinical manifestations after bites by juvenile C. d. terrificus. This case shows that systemic envenoming by juvenile C. d. terrificus may result in coagulopathy as the main systemic manifestation, without neuromyotoxic features normally associated with bites by adult specimens. Despite the delayed administration, crotalic AV was effective in improving the blood coagulation.

Bothrops snakebite on the head: case report and review of the literature.

A previously healthy, 21-year-old female was admitted 5 h after being bitten in the occipital region by a pitviper presumed to be Bothrops jararaca. Physical examination revealed marked cranial and facial oedema extending to the neck and dorsum, bilateral eyelid ecchymosis, and local conjunctival and gingival bleeding. The patient was alert and complained of mild, local pain and nausea. There were no signs of neurological involvement. The main laboratory findings on admission included incoagulable blood, a platelet count of 4000/microl, and an ELISA-estimated serum venom concentration of 62.6 ng/ml. Sequential serum creatinine, urea nitrogen, sodium and potassium concentrations were normal. The case was classified as severe and, after the intravenous administration of ranitidine, chlorpheniramine and hydrocortisone, the intravenous infusion of 12 vials of undiluted bothropic equine antivenom [F(ab)(2); 10 ml/vial] was initiated. The antivenom infusion was halted after 10 vials because the patient developed a severe early reaction, although this was successfully treated with subcutaneous adrenaline and intravenous hydrocortisone. Platelet replacement (seven units) was performed and 24 h after the antivenom infusion, normal results in blood-coagulation tests and an increase in the platelet count (to 100,000/microl) were observed. No circulating venom was detected in blood samples collected 6, 12, 24 or 48 h post-admission. The patient was discharged after 4 days, with clinical improvement and no signs of local infection, and subsequent follow-up revealed no sequelae.

Chagasic megaesophagus and megacolon diagnosed in childhood and probably caused by vertical transmission.

Reports on children presenting symptoms compatible with the chronic phase of Chagas disease are sporadic. We report a case of a 7-year-old boy who had megaesophagus and megacolon, both of them a consequence of the trypanosomiasis. The etiology was established by means of laboratory and histological features. Based on epidemiological data, the authors concluded that vertical transmission was the most probable route of acquisition. This diagnosis should be considered in children presenting similar complaints, even those living away from endemic areas.

Snakebites by Bothrops spp in children in Campinas, São Paulo, Brazil.

From January, 1984 to March, 1999, 73 children under 15 y old (ages 1-14 y, median 9 y) were admitted after being bitten by snakes of the genus Bothrops. Twenty-six percent of the children were classified as mild envenoming, 50.7% as moderate envenoming and 20.6% as severe envenoming. Two patients (2.7%) showed no signs of envenoming. Most of the patients presented local manifestations, mainly edema (94.5%), pain (94.5%) ecchymosis (73.9%) and blisters (11%). Local and/or systemic bleeding was observed in 28.8% of the patients. Before antivenom (AV) administration, blood coagulation disorders were observed in 60.7% (incoagulable blood in 39.3%) of the 56 children that received AV only in our hospital. AV early reactions, most of which were considered mild, were observed in 44.6% of these cases (in 15/30 patients not pretreated and in 10/26 patients pretreated with hydrocortisone and histamine H1 and H2 antagonists). The main clinical complications observed were local infection (15.1%), compartment syndrome (4.1%), gangrene (1.4%) and acute renal failure (1.4%). No deaths were recorded. There were no significant differences with regard to severity of envenoming versus the frequency of blood coagulation disorders among the three categories of envenoming (p = 0.75) or in the frequency of patients with AV early reactions between the groups that were and were not pretreated (p = 0.55). The frequency of local infection was significantly greater in severe cases (p < 0.001). Patients admitted more than 6 h after the bite had a higher risk of developing severe envenoming (p = 0.04).

A clinico-epidemiological study of bites by spiders of the genus Phoneutria.

From January, 1984 to December, 1996, 422 patients (ages 9 m-99 y, median 29 y) were admitted after being bitten by spiders which were brought and identified as Phoneutria spp. Most of the bites occurred at March and April months (29.2%), in the houses (54.5%), during the day (76.5%), and in the limbs (feet 40.9%, hands 34.3%). Upon hospital admission, most patients presented only local complaints, mainly pain (92.1%) and edema (33.1%) and were classified as presenting mild (89.8%), moderate (8.5%) and severe (0.5%) envenomation. Few patients (1.2%) did not present signs of envenomation. Severe accidents were only confirmed in two children (9 m, 3 y). Both developed acute pulmonary edema, and the older died 9 h after the accident. Patients more than 70 year-old had a significantly greater (p<0.05) frequency of moderate envenomations compared to the 10-70-year-old individuals. Proceedings to relief local pain were frequently performed (local anesthesia alone 32.0%, local anesthesia plus analgesics 20.6% and oral analgesics alone 25. 1%). Only 2.3% of the patients (two cases classified as severe and eight as moderate, eight of them in children) were treated with i.v. antiarachnid antivenom. No antivenom early reaction was observed. In conclusion, accidents involving the genus Phoneutria are common in the region of Campinas, with the highest risk groups being children under 10 years of age and adults over 70 years of age. Cases of serious envenomation are rare (0.5%).

[Acute dapsone exposure and methemoglobinemia in children: treatment with multiple doses of activated charcoal with or without the administration of methylene blue] / Exposição aguda à dapsona e metemoglobinemia em crianças: tratamento com doses múltiplas de carvão ativado.

OBJECTIVE: To study the changes in methemoglobinemia of 17 children admitted with acute exposure to dapsone complicated by a methemoglobin concentration greater than 20% of the total hemoglobin. The children were treated with multiple doses of activated charcoal with or without the administration of methylene blue.PATIENTS AND METHODS: Seventeen patients (ages 1-13 y, median 3 y), were admitted 1-72 h after the ingestion of 100-1200 mg (median 350 mg, 10 patients) or an unknown amount of dapsone (7 patients). The methemoglobin blood concentrations upon admission ranged from 23.5%-49.7% (median 37.8%), and the main clinical features were cyanosis (17), tachycardia (17), vomiting (11) and tachypnea (8). All of the children received multiple doses of activated charcoal orally or via nasogastric tube (1g/kg, 10% solution, 4-6 times/day, 3-16 doses with a median of 8 doses). Twelve of the 14 patients with methemoglobin levels greater than 30% were also treated with a single dose of methylene blue (1-2% solution, 1-2 mg/kg) infused IV over 5 min.RESULTS: There was a progressive decrease in the methemoglobin levels after the beginning of both treatments (multiple doses of activated charcoal alone or associated with methylene blue), and only one dose of methylene blue was necessary. There were no significant statistical differences between the results of the two treatments according to the time-course decrease in methemoglobinemia (p=0.49 Wilcoxon test).CONCLUSIONS: Multiple doses of activated charcoal given when methemoglobin levels were greater than 20% can be considered as a possible treatment for pediatric patients, with or without the administration of methylene blue, after acute dapsone exposure.

Serum levels of cytokines in patients envenomed by Tityus serrulatus scorpion sting.

Seventeen patients stung by Tityus serrulatus scorpion were classified as mild (pain at the site of the sting, n = 6), moderate (local pain and one of the following manifestations: vomiting, psychomotor agitation, prostration, sweating, tachypnea, tachycardia and mild arterial hypertension, n = 10) and severe cases (equal moderate cases plus cardiac failure, pulmonary edema and shock, n = 1). Venous blood was sampled for biochemical and hematological analysis and for IL-1alpha, IL-6, IL-10, TNF-alpha, IFN-gamma and GM-CSF ELISAs at the time of hospital admission, 6 h (moderate and severe cases), and 12, 18, 36 and 72 h (severe case) later. Ten age-matched healthy volunteers were used as control. Increased serum levels of IL-1alpha was noticed in all patients, high levels of IL-6, IFN-gamma and GM-CSF were observed only in a patient with severe envenomation. Our data suggest that a systemic inflammatory response-like syndrome is triggered during severe envenomation caused by T. serrulatus sting and that release of cytokines may be involved in this response.

Effect of toxin-g from Tityus serrulatus scorpion venom on gastric emptying in rats.

The effect of toxin-gamma from Tityus serrulatus scorpion venom on the gastric emptying of liquids was studied in 176 young adult male Wistar rats (2-3 months of age) divided into subgroups of 8 animals each. Toxin-gamma was injected i.v. at doses of 25, 37.5, 50 or 100 micrograms/kg and the effect on gastric emptying was assessed 30 min and 8 h later. A time-course study was also performed by injecting 50 micrograms of toxin-gamma/kg and measuring the effect on gastric emptying at times 0.25, 0.5, 1, 2, 4, 8, 24 and 48 h post-venom. Each envenomed animal was paired with its saline control and all received a saline test meal solution containing phenol red (60 micrograms/ml) as a marker. Ten minutes after administering the test meal by gavage the animals were sacrificed and gastric retention was determined by measuring the residual marker concentration of the test meal. A significant delay in gastric emptying, at 30 min and 8 h post-venom, was observed only after 50 and 100 micrograms of toxin-gamma/kg compared to control values. The responses to these two doses were significantly different after 8 h post-venom. Toxin-gamma (50 micrograms/kg) significantly delayed the gastric emptying of liquids at all times studied, with a peak response at 4 h after toxin administration compared to control values. These results indicate that the i.v. injection of toxin-gamma may induce a rapid, intense and sustained inhibition of gastric emptying 0.25 to 48 h after envenomation.

Effect of toxin-g from Tityus serrulatus scorpion venom on gastric emptying in rats

The effect of toxin-g from Tityus serrulatus scorpion venom on the gastric emptying of liquids was studied in 176 young adult male Wistar rats (2-3months of age) divided into subgroups of 8 animals each. Toxin-g was injected iv at doses of 25, 37.5, 50 or 100 µg/kg and the effect on gastric emptying was assessed 30 min and 8 h later. A time-course study was also performed by injecting 50 µg of toxin-g /kg and measuring the effect on gastric emptying at times 0.25, 0.5, 1, 2, 4, 8, 24 and 48 h post-venom. Each envenomed animal was paired with its saline control and all received a saline test meal solution containing phenol red (60 µg/ml) as a marker. Ten minutes after administering the test meal by gavage the animals were sacrificed and gastric retention was determined by measuring the residual marker concentration of the test meal. A significant delay in gastric emptying, at 30 min and 8 h post-venom, was observed only after 50 and 100 µg of toxin-g /kg compared to control values. The responses to these two doses were significantly different after 8 h post-venom. Toxin-g (50 µg/kg) significantly delayed the gastric emptying of liquids at all times studied, with a peak response at 4 h after toxin administration compared to control values. These results indicate that the iv injection of toxin-g may induce a rapid, intense and sustained inhibition of gastric emptying 0.25 to 48 h after envenomation.

[Pseudo-tumoral schistosomiasis: case report]. / Esquistossomose pseudo-tumoral: relato de um caso.

The schistosomiasis is an endemic disease in Brazil. The most frequent forms are: intestinal, hepatosplenic and hepatointestinal. Rare forms also manifest such as pseudo-tumoral form. The objective of this paper is to report a 8 years-old boy, from Minas Gerais State, with pseudo-tumoral schistosomiasis. He was submitted an exploratory laparotomy and a biopsy from abdominal mass was made. The histologic studies showed a chronic inflammatory process, with a large number of S. mansoni eggs. The treatment was a single-dose of oxaminiquine (20 mg/kg), with a positive evolution, with non-sequel observed after two years of follow-up.

[Brain abscess in childhren: A ten cases report] / Abscesso cerebral na infância: relato de 10 casos.

OBJECTIVES: Considering that the brain abscess is rare in infants, with a high mortality rate, the objective of this paper is to report the clinical evolution of ten children with the diagnosis of brain abscess in the Pediatric Nursery of the Hospital das Clínicas of the Medical School of the Campinas State University (UNICAMP).METHODS: The data of the patients with diagnosis of brain abscess recorded between January 1986 and July 1995 were reviewed. The following data were analyzed: age, sex, clinical manifestations, physical examination, radiological data, etiological agent, treatment, complications and clinical evolution of the patients.RESULTS: The age of the patients varied from 2 to 13 years (median 3 years); 6 of them were female. The neurological manifestations predominated, and 2 patients had history of prior otorhinolaryngological infection (chronic otitis media and sinusitis). Two patients had congenital cyanogenic cardiopathy (Fallot tetralogy and Pulmonary Stenosis with Interventricular Communication). The diagnosis and follow-up were made with computed tomography of the brain. In six cases there were one sole abscess located more frequently in the frontal lobe. The treatment in majority of the cases was broad-spectrum antibiotic association and surgical drainage. Five patients had neurological sequelae (seizure, hydrocephalus and paresis); one death occurred.CONCLUSIONS: Although rare, the brain abscess has to be remembered in patients that have neurological alterations associated to risk factors, as otorhinolaryngological infections and congenital cyanotic cardiopathy, being mandatory the realization of computed tomography of the brain to confirm the diagnosis.

Effect of Phoneutria nigriventer spider venom on gastric emptying in rats.

The effect of Phoneutria nigriventer spider venom (PNV) on the gastric emptying of liquids was studied in 240 young adult Wistar rats (2-3 months of age) divided into subgroups of 8 animals each. The study was performed in 3 stages. Initially, PNV was injected into rats at doses of 0.19, 0.38 or 0.76 mg/kg and the effect on gastric emptying was assessed 30 min later. In the second stage, a time-course study was performed by injecting 0.76 mg PNV/kg and measuring the effect on gastric emptying 15, 60 and 120 min post-venom. In the last stage, in order to investigate the possible mechanisms of PNV influence on gastric emptying, one group of rats underwent subdiaphragmatic vagotomy and then received 0.76 mg PNV/kg while three other groups were pretreated iv with either prazosin (0.4 mg/kg), domperidone (1.0 mg/kg) or propranolol (0.6 mg/kg) and then given 0.38 or 0.76 mg PNV/kg. In this last stage, gastric retention was measured 30 min post-venom. Each animal received a saline test meal solution containing phenol red as a marker (60 micrograms/ml). Ten min after administering the test meal by gavage, gastric retention was determined by measuring the residual test meal marker concentration and the animals were sacrified. PNV (0.76 mg/kg) provoked a significant delay in gastric emptying of liquids 15, 30 and 60 min after its administration. Propranolol partially interfered with gastric emptying in rats that had received 0.38 and 0.76 mg PNV/kg. Vagotomy and pretreatment of the rats with prazosin and domperidone had no effect. We conclude that the delay in the liquid gastric emptying observed in severely envenomed rats was probably due, at least in part, to a venom-stimulated release of catecholamines which inhibited gastric motility by activating smooth muscle beta-adrenergic receptors.

Effect of Phoneutria nigriventer spider venom on gastric emptying in rats

The effect of Phoneutria nigriventer spider venom (PNV) on the gastric emptying of liquids was studied in 240 young adult Wistar rats (2-3 months of age) divided into subgroups of 8 animals each. The study was performed in 3 stages. Initially, PNV was injected into rats at doses of 0.19, 0.38 or 0.76 mg/kg and the effect on gastric emptying was assessed 30 min later. In the second stage, a time-course study was performed by injecting 0.76 mg PNV/kg and measuring the effect on gastric emptying 15, 60 and 120 min post-venom. In the last stage, in order to investigate the possible mechanisms of PNV influence on gastric emptying, one group of rats underwent subdiaphragmatic vagotomy and then received 0.76 mg PNV/kg while three other groups were pretreated iv with either prazosin (0.4 mg/kg), domperidone (1.0 mg/kg) or propranolol (0.6 mg/kg) and then given 0.38 or 0.76 mg PNV/kg. In this last stage, gastric retention was measured 30 min post-venom. Each animal received a saline test meal solution containing phenol red as a marker (60 microg/ml). Ten min after administering the test meal by gavage, gastric retention was determined by measuring the residual test meal marker concentration and the animals were sacrificed. PNV (0.76 mg/kg) provoked a significant delay in gastric emptying of liquids 15, 30 and 60 min after its administration. Propranolol partially interfered with gastric emptying in rats that had received 0.38 and 0.76 mg PNV/kg. Vagotomy and pretreatment of the rats with prazosin and domperidone had no effect. We conclude that the delay in the liquid gastric emptying observed in severely envenomed rats was probably due, at least in part, to a venom-stimulated release of catecholamines which inhibited gastric motility by activating smooth muscle beta-adrenergic receptors.

[Liver abscess in childhood: report of 8 cases]. / Abscesso hepático na infância: relato de oito casos.

The authors present eight cases of children with liver abscess diagnosed in the Pediatric Nursery of the "Hospital das Clínicas", State University of Campinas, SP, Brazil, during eight years. Five children were younger than five years. They were four boys and four girls. The symptomatology was inespecific. Staphylococcus aureus was the more frequent etiologic agent and in two cases it was seen Ascaris lumbricoides worm inside the abscess. The findings of ultrasound and computadorized tomography were similar. In most cases, were employed the association of broad spectrum antibiotics and percutaneous draining, and a good clinical outcome was observed in all patients.

A comparative study of severe scorpion envenomation in children caused by Tityus bahiensis and Tityus serrulatus.

From January 1984 to May 1994, 17 of 239 children under 15 years old stung by Tityus serrulatus (15.1%) or Tityus bahiensis (84.9%) presented severe envenoming. Of these 17 patients (1-11 years old; median = 2 yr) 14 were stung by T. serrulatus and three by T. bahiensis. All of them received scorpion antivenom i.v. at times ranging from 45 min. to 5 h after the accident (median = 2 h). On admission, the main clinical manifestations and laboratory and electrocardiographic changes were: vomiting (17), diaphoresis (15), tachycardia (14), prostration (10), tachypnea (8), arterial hypertension (7), arterial hypotension (5), tremors (5), hypothermia (4), hyperglycemia (17), leukocytosis (16/16), hypokalemia (13/17), increased CK-MB enzyme activity (> 6% of the total CK, 11/12), hyperamylasemia (11/14), sinusal tachycardia (16/17) and a myocardial infarction-like pattern (11/17). Six patients stung by T. serrulatus had depressed left ventricular systolic function assessed by means of echocardiography. Of these, five presented pulmonary edema and four had shock. A child aged two-years old presented severe respiratory failure and died 65 h after being stung by T. serrulatus. Severe envenomations caused by T. serrulatus were 26.2 times more frequent than those caused by T. bahiensis (p < 0.001).