Recreational phenethylamine poisonings reported to a French poison control center.

OBJECTIVES: Over the last decade, use of phenethylamines has become increasingly prevalent. This study aimed to describe typical aspects of phenethylamine poisoning in order to better inform patient care. METHODS: Phenethylamine poisoning cases reported to the Poison Control Center of Angers, France, from January, 2007 to December, 2013 were examined. Clinical findings were examined in 105 patients, including phenethylamine used, symptoms and final outcome. Patients were predominantly male (80%), with mean age 26±8 years. RESULTS: MDMA (38%), amphetamine (18%) and methamphetamine (14%) were the most commonly reported. Synthetic cathinones (10%) and the 2C series (7%) were also found. Substances most commonly associated with phenethylamine poisoning were cannabis (27%), ethanol (20%) and cocaine (9%). The most frequently reported symptoms included anxiety and hallucinations (49%), mydriasis and headache (41%), tachycardia (40%) and hypertension (15%). Complications such as seizures (7%), cardiac arrest (5%), toxic myocarditis (1%) and hemorrhagic stroke (1%) were also observed. Of the cases, the Poison Severity Score was: null or low, 66%, moderate, 21%, severe or fatal, 13%. Of the patients, 77% received hospital care and 12.4% were admitted to an intensive care unit. Analytical confirmations were obtained for all severe cases. While 93% of patients recovered, there were 5 deaths and 2 patients presented with neurological sequelae. CONCLUSIONS: Phenethylamine poisonings may be severe in young and healthy individuals. Physicians, toxicologists and analysts should be aware of new phenethylamine consumption trends in order to inform management of patient care and to contribute to a more responsive drug policy.

European viper envenomings: Assessment of Viperfav™ and other symptomatic treatments.

UNLABELLED: The treatment of European viper envenomings is based on IV antivenom infusions. Viperfav™ contains purified F(ab')(2) fragments of equine antibodies, and a 4 ml vial can neutralize 500-1000 mouse LD50 of Vipera aspis, V. ammodytes and V. berus venoms and is known to be safe and efficient. Assessments of Viperfav™ (dosage and timing of infusions) and of symptomatic treatments such as low-molecular-weight heparin (LWHM), corticosteroids and the routine use of antibiotic therapy have not as yet been reported. OBJECTIVES: The objective was to compare the efficacy and safety of Viperfav™ as a function of the time to infusion and to assess other symptomatic treatments given for European viper bites such as antibiotics, corticosteroids and LWMH. METHODS: A prospective case review study of viper envenomings treated with Viperfav™ was compiled by the Angers Poisons Centre. The endpoints chosen were as follows: duration of hospital stay, complications (haematoma, infection) and persistent functional discomfort on day 15. Statistical studies were based on multivariate data analysis (MVA). RESULTS: 268 moderate or severe envenomings (Grades II and III) recorded in adults and children between 1999 and 2009 were included in the study. A time to the Viperfav™ infusion < 10 h after the bite (179 patients vs. 72) significantly reduced the incidence of haematomas (OR 2.3; p < 0.006), functional discomfort (OR 3.7; p < 10 - 4) and length of hospital stay (OR 2.1; p < 0.03). Multiple doses of Viperfav™ (2 or 3 vials in 22 patients vs. 246 treated with 1 vial) did not improve the selected endpoints. Routine antibiotic therapy was prescribed in 102 patients (vs. 166 patients without) and no significant difference was seen with respect to the endpoints. Moreover, no local or systemic infections were recorded in the non-antibiotic group. Corticosteroids were prescribed in 36 patients (vs. 232 without) but they did not significantly improve the endpoints or oedema. LMWH in 32 patients (vs. 236 without) increased the length of hospital stay (OR 3.2; p < 0.009 and the level of significantly persistent functional discomfort at day 15 (OR 3.7; p < 0.003). CONCLUSIONS: A single infusion of Viperfav™ (one vial) was effective whatever the grade of envenomation, and multiple doses did not improve the outcome. Viperfav™ was most effective when given soon (< 10 h) after envenoming. The routine use of antibiotic therapy was not necessary. Corticosteroids did not improve the endpoints selected, and we do not recommend the use of LMWH as this increased persistent functional discomfort and the length of hospital stay.

Metam sodium intoxication: the specific role of degradation products--methyl isothiocyanate and carbon disulphide--as a function of exposure.

Introduction. The objective was to evaluate the toxicity of poisoning by metam sodium, a dithiocarbamate fumigant, the breakdown products of which are methyl isothiocyanate (MITC), carbon disulphide (CS2), and dihydrogen sulphide (H2S). Methods. This is a retrospective, observational case series of metam sodium exposure cases reported to the Angers Poison and Toxicovigilance Centre from 1992 through 2009. Results. A total of 106 cases of metam sodium exposure were recorded and 102 cases were included in this study. All cases of exposure were unintentional. Occupational poisoning occurred in eight cases. The most common route of exposure was inhalation (n = 96). In 79 cases, the patients were people living near fields where metam sodium had recently been applied. Most of the reported symptoms involved irritation of the eyes (n = 76), throat and nose (n = 65), attributable to MITC. Cough and dyspnoea occurred in four cases but no persistent, irritant-induced asthma or persistent exacerbation of asthma was observed. Sixteen patients at two different sites of pollution were exposed to emanations from the drainage system in their homes following the illicit discharge of metam sodium into the sewers. Most presented with nausea and headaches, but only four experienced eye or throat irritation. A breakdown product other than MITC was involved: air analysis at one site revealed the presence of CS2 (337 mg/m(3)) and no H2S. Two of these patients, who had consumed some alcohol, experienced dysgeusia but no disulfiram-like reaction. The only lethal case recorded was a truck driver who was found dead of acute lung injury after falling into a tank that had previously contained metam sodium. Two patients who ingested a dilute solution, presented with mild epigastric pain. Four skin exposures caused erythema (n = 2), moderate burns (n = 1), and urticaria (n = 1). According to the poisoning severity score, their symptoms were minor in 99% of cases. Conclusion. Acute metam sodium exposure usually causes minor symptoms. They vary as a function of the circumstances of exposure, which determine the degradation product that forms. On contact with moist soil, metam sodium decomposes into MITC and causes irritant symptoms. Under specific conditions, such as a spillage in the drainage system, metam sodium can degrade into CS2 and cause neurological signs.

[Creation and organization of an antivenomous serum bank in France]. / Création et organisation d'une banque des sérums antivenimeux en France.

For several years exotic snakes have been bred in France. In view of the increased risk of envenomation from some of these species, the Poison Centre in Angers has joined forces with several private licensed snake breeders to create an Anti-venom Serum Bank. The main objective of the new organization is to provide an effective means of dealing with bites and subsequent envenomation by exotic snakes by managing a stock of anti-venom serums in a hospital pharmacy, so that cases can be treated as quickly as possible. The hospital pharmacy has the authority to purchase and supply the anti-venom serums. The selection and purchase of the serums is done in conjunction with the French Ministry of Ecology, the French Drug Agency and specialist doctors. At the time of writing, the Antivenom Serum Bank has the capacity to treat about thirty different kinds of envenomation, compared to the 135 exotic venomous snake species officially registered. In the long term the Anti-venom Serum Bank will help eradicate the use of serums from unauthorized sources, evaluate the safety and efficacy of new serums and reduce transport times.

Can morels (Morchella sp.) induce a toxic neurological syndrome?

INTRODUCTION: Several cases of morel poisoning associated with neurological symptoms have been reported. The objective of this study was to describe this new mushroom poisoning syndrome. MATERIAL AND METHODS: Retrospective study of morel poisonings collected in the French Poison Control Centers from 1976 to 2006. Cases were classified as neurological syndrome (NS; tremor or dizziness/inebriation or unsteadiness/ataxia +/- associated with gastrointestinal symptoms) or isolated gastrointestinal syndrome. RESULTS: 146 patients presented gastrointestinal syndrome (median time to onset: 5 h) and 129 presented NS (12 h) after morel consumption. Gastrointestinal (67%) and other neurological symptoms were also present (mainly ocular/vision disorders: 26%, paresthesia: 7%, drowsiness/confusion: 6%, and muscle disorders: 6%). These patients more frequently ingested a large quantity of morels. Confusion with Gyromitra was ruled out. DISCUSSION: The NS is very different from the common gastrointestinal syndrome occurring after ingestion of poorly cooked morels and is not limited to a cerebellar syndrome.

Cardiogenic shock and status epilepticus after massive bupropion overdose.

BACKGROUND: To describe a profound cardiac dysfunction and a status epilepticus after a massive bupropion overdose. CASE REPORT: A 35-year-old man was admitted in coma following the deliberate ingestion of 12 g of bupropion. The course was marked by the rapid onset of severe and prolonged status epilepticus and cardiogenic shock. Plasma bupropion level determined four hours after the estimated time of ingestion was 1.4 mg/L. All clinical features resolved completely in response to symptomatic treatment. CONCLUSION: Several cases of bupropion overdose, with sinus tachycardia and seizures rapidly corrected by symptomatic treatment, have been reported in the literature. To our knowledge, this case of overdose with bupropion alone, at very high doses, is the first to describe clinical features comprising severe and prolonged status epilepticus and direct cardiotoxicity with the development of cardiogenic shock documented by echocardiogram.