Vinegaroon exposures reported to a Poison center.

BACKGROUND: Vinegaroons (Mastigoproctus giganteus), also known as whip scorpions, are arachnids commonly found in the southwestern United States, parts of Mexico, and southern Florida. They do not bite, but have special teeth on the inside of the trochanters of the front appendages, used to crush prey. They are best known for having pygidial gland secretions containing 83% acetic acid, which are sprayed upon potential predators. There are no published descriptions of injury to human related to vinegaroon exposures. Our primary aim was to characterize types of exposures and clinical effects reported to a poison center that serves an area indigenous to this animal. METHODS: The database from a regional poison center was searched for all cases from 1998 to 2022 regarding human exposures to the vinegaroon. Data captured included age, sex, exposure route, type and duration of symptoms, and part of the body affected. RESULTS: There were 50 exposures reported, with age range from 5 months to 54 years. Females represented 32 cases, males 17, and one unknown. Bites were more commonly described (36 cases), with 13 cases reported skin exposure to secretions, 3 ocular exposures, and 2 ingestions. Location of injury was upper extremities in 16 cases, lower in 11 cases, and torso in 3 cases. Symptoms were present in 88% and included pain, skin erythema, numbness or tingling, itching, and swelling. Ocular exposure were associated with pain in all 3 cases, with blurred vision in one case; effects lasted 1 h, 17 h, and more than 5 days. Four non-ocular exposures were followed to outcome, with duration of effects ranging from less than 1 h to more than 2 days. DISCUSSION/CONCLUSION: In a large series of vinegaroon exposures, females predominated, with most exposures occurring from skin contact with secretions. The most common symptoms were pain, erythema, numbness, itching, and swelling, which resolved in less than two days. Ocular exposures were associated with more symptoms and longer duration of effects.

Comparison of F(ab')2 and Fab antivenoms in rattlesnake envenomation: First year's post-marketing experience with F(ab')2 in New Mexico.

Two antivenoms are available for rattlesnake envenomations in the U.S., Fab (CroFab®, BTG, UK), and F(ab')2 (Anavip®, Bioclon, Mexico) antivenom (AV) with F(ab')2AV released in October 2018. The F(ab')2AV Phase 3 comparative clinical trial demonstrated similar efficacy in treating venom-caused hematologic toxicity, similar rates of Types I and III hypersensitivity reactions, and a lower rate of recurrent hematological effects than FabAV. We hypothesized that a post-marketing, comparative study of effectiveness and rates of hypersensitivity reactions in treating rattlesnake envenomations in New Mexico would demonstrate similar outcomes. Patients eligible for the study presented to a New Mexico healthcare facility between May and October 2019 and were known/suspected to have a rattlesnake bite. Exclusion criteria for antivenom comparison were those with a dry bite, lost to follow-up, or late presentation. All cases were included for patient/bite demographics, initial local control, hematological control, number of maintenance/control doses, development of persistent, recurrent or late-, new-onset hematologic effects, and hypersensitivity reactions. We used Fisher's exact tests for analysis and 0.05 cutoff to determine significance. There were 54 rattlesnake-bitten patients in New Mexico with 17 excluded for comparison of antivenom because of dry bites, loss to follow-up, and one case of late presentation. Thirty-seven patients remained for comparative analysis between F(ab')2AV (n = 11) and FabAV (n = 26). There were no significant demographic differences between F(ab')2 and Fab-treated patients. No patient had a Type I hypersensitivity reaction. No rescue doses were given. The rate of recurrent, persistent or late-, new-onset of hematologic effects was 0% with F(ab')2AV and 29% with FabAV. No patient was readmitted. No patient had bleeding complications. Type III hypersensitivity reactions were similar between F(ab')2AV (36%) and FabAV (25%). The results of our study are consistent with the Phase 3 clinical comparative trial and indicate no significant differences in safety or effectiveness between FabAV and F(ab')2AV. F(ab')2AV offers the advantages of not requiring maintenance doses and may have a lower rate of late hematologic effects in treating rattlesnake envenomations.

Unpredicted late-, new-onset thrombocytopenia and hypofibrinogenemia in Fab antivenom-treated rattlesnake envenomation.

The use of Fab antivenom (Crotalidae Polyvalent Immune Fab (Ovine) (CroFab); Boston Scientific) against North American Crotalidae envenomation is associated with the development of late- (≥4 days post-envenomation), new-onset of hematological abnormalities. Although attempts have been made to identify predictive indicators during the acute phase of an envenomation, of patients who are not at-risk of late-, new-onset of hematological abnormalities, there has been at least one prior report of a patient who developed thrombocytopenia that was unpredicted by current indicators. We add three cases of unpredicted, late-, new-onset of hematological abnormalities in patients with Fab-treated rattlesnake bite.

Envenomations during pregnancy reported to the national poison data system, 2009-2018.

Envenomations during pregnancy have consequences affecting both maternal and fetal outcomes. U.S. poison center data on envenomations offers a comparative view of envenomations in pregnant and non-pregnant women. The National Poison Data System of the American Association of Poison Control Centers was searched for cases of envenomation during pregnancy between January 1, 2009 and December 31, 2018 and compared with exposures to non-pregnant females of childbearing age. Odds ratios and descriptive statistics were used where appropriate. There were a total of 3,555 venomous animal exposures in pregnant women during this 10-year period, most commonly with scorpion stings. These were compared with 87,553 envenomations in non-pregnant women of childbearing age during that time period. Overall, drug treatment was administered in 350 (9.9%) cases of envenomation in pregnant women compared with 21,381 (24.4%) of non-pregnant patients. Antihistamines were less likely to be used in pregnant patients with scorpion (1.8% v. 9.2%), hymenoptera (bee, wasp, or hornet) (12.4% v. 37.1%), black widow spider (2.8% v. 8.1%), and caterpillar (10.4% v. 37.7%) exposures. There was an increased likelihood of antivenom use during pregnancy with rattlesnake envenomations (85.0% v. 58.9%) and black widow spider bites (4.8% v. 2.2%). There were no maternal deaths, and most maternal outcomes were coded as having no (1.0%) or minor (87.6%) effects. Three fetal deaths occurred, all following snakebites and all before 20 weeks gestation. Two were attributed as related, and one as of uncertain relationship to the exposure, by the managing poison centers. Most envenomations caused no or minor effects to pregnant women.

Superwarfarin poisoning in children: a prospective study.

This prospective study was undertaken to determine the incidence, severity, time of onset, and duration of coagulopathy in children following accidental ingestion of long-acting anticoagulant rodenticides, often called "superwarfarins." Of 110 children, who ingested superwarfarins and in whom one or more prothrombin time values were obtained, 8 had a prothrombin time ratio (patient to control) of greater than or equal to 1.2, indicative of anticoagulation. Prothrombin time values obtained 48 hours after ingestion were more likely to be prolonged (6/34, 17.6%) than values obtained 24 hours after ingestion (2/104, 1.9%) (P less than .005). The occurrence of an abnormal prothrombin time could not be predicted based on the history of amount ingested or on the presence of the characteristic green-blue product dye in or around the child's mouth. Acute toxicity was evidenced by transient abdominal pain, vomiting, and heme positive stools in 2 patients. The duration of prothrombin time prolongation could not be determined because of the few values obtained after 48 hours. To detect all possible abnormal prothrombin time values, 24- and 48-hour determinations are recommended after a child has ingested a superwarfarin.

Toxic effects of nonsteroidal anti-inflammatory drugs in overdose. An overview of recent evidence on clinical effects and dose-response relationships.

Nonsalicylate, nonsteroidal anti-inflammatory drugs (NSAIDs) can be divided into 4 chemical classes: acetic acids, fenamic acids, oxicams and propionic acids. Most NSAID overdoses result in a benign outcome. Of 50,614 exposures reported to poison centres in the United States in a 2-year period, 131 (0.26%) had a major outcome, with 10 deaths. Despite the generally mild effects reported in large patient series, isolated case reports have documented serious toxicity, such as seizures, hypotension, apnoea, coma and renal failure. The majority of these consequences occur after ingestion of substantial quantities by adults attempting suicide. Rarely, with ibuprofen and piroxicam, children who ingest small amounts in accidental exposure develop serious toxicity. Typical signs and symptoms of NSAID overdose include nausea, vomiting, headache, drowsiness, blurred vision and dizziness. Seizures are rarely documented across all NSAID classes, with the exception of mefenamic acid (where seizures occur in over one-third of cases), or following massive ingestion of other agents. Drugs in the propionic acid group have produced metabolic acidosis, respiratory depression and coma in severe cases. Ibuprofen is the agent with the most published data on overdose, probably because it is available without a prescription in many countries. Symptoms are unlikely after ingestion of 100 mg/kg or less, and are usually not life-threatening unless more than 400 mg/kg is ingested. There is some relationship between plasma concentrations and the potential for development of symptoms, but plasma concentrations have no impact on treatment decisions. Treatment of NSAID overdose is entirely supportive. Recent trends in emergency department procedures regarding gastric decontamination are evolving towards the recommended administration of activated charcoal without gastric emptying in patients presenting more than 1 hour after ingestion, although gastric lavage, followed by administration of activated charcoal, may be advisable in patients who present earlier. Home administration of syrup of ipecac is still recommended if treatment is given shortly after ingestion, with a few exceptions: for example, ipecac is contraindicated after ingestion of mefenamic acid or ibuprofen in amounts greater than 400 mg/kg. Urine alkalinisation and diuresis have been recommended to enhance the elimination of NSAIDs, based on a pKa in the range of 3 to 5. However, because the drugs are universally highly protein bound, with little unchanged renal excretion, this technique is not likely to be beneficial. Haemodialysis is also unlikely to enhance elimination, but may be required if oliguric renal failure develops. Multiple dose activated charcoal may be useful in enhancing elimination of NSAIDs with long half-lives, such as piroxicam and sulindac.

Review of parenteral sulfite reactions.

Sulfiting agents are commonly used in parenteral emergency drugs, including epinephrine, dexamethasone, dobutamine, dopamine, norepinephrine, phenylephrine, procainamide, and physostigmine. Published anaphylactic or asthmatic reactions have been associated with sulfited local anesthetics, gentamicin, metoclopramide, doxycycline, and vitamin B complex. The reactions differ from those caused by foods, in that they have a rapid onset, have no predilection for steroid-dependent asthmatics, and do not always coincide with a positive oral challenge. The mechanism is unknown, but may involve a dose-related reaction with disulfide bonds on sympathetic and parasympathetic receptor membranes. Patients with a history of positive oral challenge to 5-10 mg of sulfite may be at increased risk of developing a reaction to parenteral sulfites. Despite documentation of sensitivity, sulfites should not be withheld from patients experiencing a life-threatening emergency. Non-sulfited alternatives are often available, and should be used preferentially.

Dietary supplement-drug interactions.

Recent surveys show that 18% of adults in the United States use prescription drugs concurrently with herbal or vitamin products, placing an estimated 15 million patients at risk of potential drug-supplement interactions. Despite this widespread concurrent use of conventional and alternative medicines, documented drug-herb interactions are sparse. This review focuses on possible interactions between drugs and herbal medicines used for phytoestrogen-hormone and antiplatelet-oral anticoagulant therapy. Interactions with phytoestrogens are purely speculative, based on competitive estrogen-receptor binding or antiestrogenic effects. In contrast, several case reports document bleeding complications with Ginkgo biloba, with or without concomitant drug therapy. Case reports are also suggestive of interaction between warfarin and dong quai or Panax ginseng. Recommendations for counseling patients at highest risk of adverse interactions are given.

Imprint coding on solid medication forms: problems in interpretation.

Currently, the FDA is planning to mandate imprinting on all solid medication forms. Regardless of the system it employs, identifying the manufacturer accurately and quickly is critical. Our data demonstrate that the current use of "logotypes" falls far short of minimally acceptable accuracy. We urge use of clear identifiers and that the proposed system be tested in the field prior to its implementation.

A case of MAO inhibitor/MDMA interaction: agony after ecstasy.

After ingesting 3,4-methylene-dioxy-methamphetamine (MDMA) and the monoamine oxidase (MAO) inhibitor phenelzine, a 50 year old male developed marked hypertension, diaphoresis, altered mental status, and hypertonicity lasting 5-6 hours. This clinical course is typical of interaction between MAO inhibitors and some sympathomimetics including amphetamines. Such interaction has not previously been described involving MDMA. Sympathomimetic-MAO inhibitor interactions can cause excessive release of endogenous bioactive amines (e.g. norepinephrine, serotonin). Hypertensive crisis, intracranial hemorrhage, hypertonicity, and severe hyperthermia have occurred due to sympathomimetic-MAO inhibitor interactions. MDMA shares structural and pharmacologic features with other agents capable of causing this interaction, and this case suggests that MDMA can cause significant toxicity in patients taking MAO inhibitors.

Ibuprofen overdose--a prospective study.

Of 61 cases of ibuprofen overdosage reported consecutively to the Rocky Mountain Poison and Drug Center from September 1985 through April 1986, 16 were excluded because of incomplete follow-up or concurrent medication ingestion. A toxic reaction developed in 7 (16%) of the remaining 45 patients. Nausea, vomiting, abdominal cramps, mild central nervous system depression, coma, tachycardia, apnea, metabolic acidosis with or without respiratory alkalosis, hematemesis, and oliguric renal failure were noted. Two of six adults had a toxic reaction, and one died. Among pediatric patients, 5/39 (13%) had a toxic reaction. Of patients whose ibuprofen ingestion was less than 104 mg per kg, none became ill. All patients in whom the time of ingestion was known (six of seven) and who had a toxic reaction did so within four hours of ingestion. An ibuprofen overdose, although usually benign, can occasionally produce serious toxicity.

Ibuprofen overdose in adults.

A prospective study of 63 ibuprofen overdose cases in adults (14 years or older) reported to the Rocky Mountain Poison and Drug Center between March 1987 and February 1988 was done to determine the incidence of renal injury and utility of timed plasma levels. No serious toxicity was noted. No CNS or other significant toxicity was seen with ingestion of less than 3 g. Two patients with normal serum creatinines had minor elevations of the blood urea nitrogen after ingesting 4 and 4.8 g. Timed plasma levels (125 total) from patients without coingestants from this study (48) and previously published reports (77) were compared with a previously described nomogram. The resulting nomogram revision may be useful in determining which initially asymptomatic patients are likely to remain so. Renal function tests are not routinely required for patients ingesting less than 6 g. Four h of observation is sufficient for asymptomatic patients not requiring psychiatric admission. Plasma ibuprofen levels are not required for proper patient management.

Consultations with attorneys as a funding source for drug information centers.

The provision of legal consultations to attorneys as a method of generating income for a drug information center is described. The center established a formal, fee-based consultation service for lawyers after receiving several calls a month on a regular basis. During a six-month trial period, approximately 60% of the calls from lawyers were simple requests for information, such as the identification of a drug, drug dosage, or product availability. The remainder of the calls required formal written consultations, which had to be individualized to meet the attorneys' needs. The average length of these consultations was 2-3 pages including patient data, the request, response, conclusions, and 10-15 citations from the medical/pharmaceutical literature. No fees were charged for the requests that could be handled on the phone. For the preparation of a written consultation with references, the lawyers were billed +100/hr. Conferences with attorneys before preparing a request were also billed at +100/hr. If a deposition was required after the consultation services in the state's law journals and various legal publications. The majority of the attorneys who used the service indicated that they would probably use it again. The center found the provision of legal consultations to attorneys to be an effective mechanism for generating additional revenue.

Cigarette and nicotine chewing gum toxicity in children.

A prospective review of 51 cases of tobacco ingestion and 5 cases of nicotine resin chewing gum exposure was conducted to evaluate the incidence and degree of toxicity caused by these products in children. A dose-response relationship was observed for cigarette exposures. Nine of 10 children ingesting more than one cigarette or three cigarette butts developed signs or symptoms, while 12 of 24 ingesting lesser amounts became symptomatic (P less than 0.01). Severe symptoms (e.g. limb jerking and unresponsiveness) were only seen with the larger amounts. Nicotine resin gum produced toxicity in 4 of 5 children who chewed 1/2 to 4 pieces. Agitation, lethargy, tachycardia, hypotension, abdominal pain, and vomiting were seen within 30 min of exposure to the gum.

Ibuprofen overdose: 126 cases.

In this study of ibuprofen overdose, symptoms developed in 19% of patients (24 of 126)--in 7% of children (6 of 88) and in 47% of adults (18 of 38). Central nervous system depression, seizures, gastrointestinal disturbances, bradycardia, hypotension, apnea, abnormal renal functions, hematuria, nystagmus, and blurred vision were observed. No patients became symptomatic more than four hours after ingestion. There was no significant difference (P greater than .05) between symptomatic and asymptomatic adult groups in either total milligrams or milligram-per-kilogram amounts ingested by history. Pediatric patients who became symptomatic had a mean ingestion by history of 440 mg/kg; those who remained asymptomatic had a mean ingestion by history of 114 mg/kg (P less than .001). No patients ingesting less than 99 mg/kg by history developed any symptoms. Two children had seizures or apnea and one died. Ibuprofen occasionally may cause serious toxicity in overdose.

Clinical effects of accidental levothyroxine ingestion in children.

Forty-one children, aged 1 to 5 years, who accidentally ingested levothyroxine sodium were studied. Symptoms possibly associated with the ingestion occurred in 11 patients (27%). These symptoms (tachycardia, hyperactive behavior, fever, vomiting, diarrhea, diaphoresis, and flushing) were categorized as minor and all resolved without treatment. Because observed effects were generally mild and often unrelated to either estimated amounts of hormone consumed or serum thyroxine levels, a conservative approach to patient treatment is recommended in cases of levothyroxine ingestion in children.