Thallium-201 for cardiac stress tests: residual radioactivity worries patients and security.

BACKGROUND: A 47-year-old man presented to the Emergency Department (ED) in duress and stated he was "highly radioactive." There were no reports of nuclear disasters, spills, or mishaps in the local area. OBJECTIVES: This report discusses the potential for thallium-201 (Tl-201) patients to activate passive radiation alarms days to weeks after nuclear stress tests, even while shielded inside industrial vehicles away from sensors. Characteristics of Tl-201, as used for medical imaging, are described. CASE REPORT: This patient was twice detained by Homeland Security Agents and searched after he activated radiation detectors at a seaport security checkpoint. Security agents deemed him not to be a threat, but they expressed concern regarding his health and level of personal radioactivity. The patient was subsequently barred from his job and sent to the hospital. Tl-201 is a widely used radioisotope for medical imaging. The radioactive half-life of Tl-201 is 73.1h, however, reported periods of extended personal radiation have been seen as far out as 61 days post-administration. CONCLUSION: This case describes an anxious, but otherwise asymptomatic patient presenting to the ED with detection of low-level personal radiation. Documentation should be provided to and carried by individuals receiving radionuclides for a minimum of five to six half-lives of the longest-lasting isotope provided. Patients receiving Tl-201 should understand the potential for security issues; reducing probable tense moments, confusion, and anxiety to themselves, their employers, security officials, and ED staff.

Prevalence of sodium bicarbonate-induced alkalemia in cardiopulmonary arrest patients.

BACKGROUND: Intravenous sodium bicarbonate (SB) administration during cardiopulmonary arrest (CPA) is intended to counteract lactic acidosis due to hypoxia, poor perfusion, and anaerobic metabolism. Despite a lack of documented efficacy and a level III recommendation from the American Heart Association, SB is widely used during resuscitation events. SB has both theoretical and measurable adverse effects. Excess or poorly timed administration during a CPA may elevate a patient's pH, inducing alkalemia. Despite decades of controversy surrounding use of this drug, the prevalence of SB-induced alkalemia has not been previously documented. OBJECTIVE: To estimate the prevalence of SB-induced alkalemia in inpatients after CPA and to investigate the pattern of SB administration. METHODS: Medical records were retrospectively reviewed with attention to SB administration and arterial blood gas (ABG) data. After application of inclusion and exclusion criteria to 264 CPA patients, the study group comprised 88 patients. When measured, if PCO(2) and pH were above normal limits after SB administration, we concluded that SB contributed to the alkalemia. RESULTS: Twenty-seven (31%) patients received SB without any ABG data, and 70 (79%) patients received at least one empiric SB dose. Of the 61 patients with ABG data, alkalemia occurred in 10, a prevalence of 16%. Administration of SB increased pH in only 9 (15%) other CPA patients and had no effect in the 42 (69%) remaining patients. CONCLUSIONS: Administration of SB during CPA was causally linked with inducing alkalemia in 16% of patients. Early collection of ABG samples may assist in optimizing pH during CPA and thus reduce unwarranted empiric use of SB.

Mustard gas: imminent danger or eminent threat?

OBJECTIVE: To increase awareness of the widespread environmental prevalence of the chemical warfare agent mustard gas, examine the acute and chronic toxic effects to exposed humans, and discuss medical treatment guidelines for mustard gas exposures. DATA SOURCES: Literature retrieval of medical case reports and clinical studies was accomplished using PubMed and the Cochrane Database (1919-March 2007). Search terms included mustard, mustard gas, sulfur mustard, chemical warfare, blister agents, vesicants, and war gas. Historical information and current events were accessed through military field manuals and Internet searches. STUDY SELECTION AND DATA EXTRACTION: All articles in English identified from the data sources were evaluated. Adult and pediatric populations were included in the review. DATA SYNTHESIS: Mustard gas and other chemical weapons are feared for their use as weapons of terror; however, the major threat of mustard gas lies elsewhere. Tons of this chemical agent were produced for war, then subsequently buried in landfills, disposed of at sea, or left to decay in storage facilities. There are documented and anecdotal reports of chemical weapon burial sites and ocean dumps across the globe spanning from the Arctic Circle to Australia. Numerous accidental exposures have occurred over the past decade. Mustard gas is corrosive to the skin, eyes, and respiratory tract. Extensive exposures can also affect other organ systems. Its ability to cause harm to multiple organ systems at extremely low doses in virtually any environmental condition makes it an extremely dangerous agent. Immediate decontamination of people exposed to mustard gas liquids and vapors is paramount. Supportive care and long-term followup is necessary for exposed persons. Research is under way to find antidotes or treatment methods for mustard gas exposure, but currently there are no definitive treatment guidelines. CONCLUSIONS: Mustard gas is a weapon, but also a prevalent environmental threat. Recognizing the immense environmental presence of mustard gas disposal sites and the signs and symptoms of exposure will help speed treatment to those accidentally or purposefully exposed.

New onset diabetes associated with bovine growth hormone and testosterone abuse in a young body builder.

CASE: A 33-year-old male presented to the emergency department with complaints of polydipsia, polyuria, nausea, headaches, blurry vision and malaise. Lab work revealed a serum glucose level of 1166 mg/dl (64.8 mmol/L). The patient admitted to completing a cycle of androgenic anabolic steroids (AASs) for bodybuilding. His regimen consisted of supraphysiologic intramuscular injections of a bovine growth hormone, trenbolone acetate and testosterone. The patient received intravenous fluids and insulin to restore metabolic balance. Previously healthy with a non-contributory family history, he was diagnosed with new onset diabetes. DISCUSSION: It has been demonstrated that AAS use, specifically growth hormone, can affect glucose homeostasis through increasing cellular insulin resistance and reducing glucose uptake. Excess growth hormone has been shown to cause symptoms of acromegaly which predisposes up to 40% of patients to diabetes. As trenbolone acetate is not indicated for human use and athletes are known to use supraphysiologic doses of this underground, performance enhancing drug, the correlation of the timing of events and the use of this veterinary growth hormone likely exacerbated an underlying condition or caused this new onset diabetes. CONCLUSION: We report a case of a young bodybuilder with no significant past medical history who was diagnosed with new onset diabetes associated with supraphysiologic self-injections of the bovine growth hormone, trenbolone acetate, combined with testosterone. AAS have the potential to induce or exacerbate diabetic conditions due to decreased glucose tolerance and increased insulin resistance.

Phencyclidine false positive induced by lamotrigine (Lamictal®) on a rapid urine toxicology screen.

BACKGROUND: This report describes two cases with unexplained positive results for phencyclidine (PCP). AIMS: This case will correlate lamotrigine (Lamictal®) use with false-positive results for PCP on a rapid urine toxicology screen. METHODS: Case 1: A 62-year-old male arrived to the emergency department in extreme psychosis. All positive results on the urine drug screen could be accounted for except PCP. A comprehensive drug screen was performed to confirm PCP use, but returned negative. PCP was ruled out as the causative agent. The reason for the PCP false positive remained unknown. Case 2: A 49-year-old female presented to the ED with a history of seizures and depression. Despite positive PCP results on a rapid urine drug screen, PCP use was ruled out due to patient presentation and comprehensive history. RESULTS: The differential diagnosis in case 1 included PCP abuse until PCP was ruled out by a comprehensive drug screen. A literature search failed to explain a reason for false-positive results. The patient in case 2 was not psychotic, but returned a positive urinalysis result for PCP. Case 2's presentation combined with a comprehensive history at the facility ruled out PCP use. Both patients were taking the anti-seizure medication lamotrigine with nothing else in common. CONCLUSION: Lamotrigine has the potential to cause false-positive results for PCP on the Bio-Rad TOX/See urine toxicology screen.

Antipsychotic-induced priapism in an HIV patient: a cytochrome P450-mediated drug interaction.

BACKGROUND: With upwards of 48% of human immunodeficiency virus (HIV)-infected persons having a probable psychiatric disorder, the possibility of cross-class drug interactions causing adverse effects or fatalities exists. AIMS: This report discusses an emergent case of low-flow priapism caused by an interaction between a previously prescribed combination protease inhibitor (PI) and newly added antipsychotic medications. METHODS: A 50-year-old HIV-positive man on highly active antiretroviral therapy (HAART), including the combination PI, lopinavir/ritonavir (Kaletra((R))), experienced an episode of priapism hours after beginning two new antipsychotic medications. Quetiapine (Seroquel((R))) and perphenazine (Trilafon((R))) were added to treat a diagnosed schizoaffective disorder. RESULTS: The patient presented to the emergency department complaining of a constant, painful erection lasting approximately 42 h. Treatment with intracavernous ephedrine, irrigation, and aspiration helped achieve detumescence. CONCLUSION: This case displays the immediate and detrimental effects due to the addition of antipsychotic medications to previously altered cytochrome P450 (CYP450) enzyme levels. The inhibition of CYP450 enzymes 3A4 and 2D6 by the combination PI, lopinavir/ritonavir, was likely the major culprit in causing greater than expected free levels of perphenazine and quetiapine resulting in priapism.