Case Report: Serial Seizures Due to the Pesticide Poison Strychnine, Refractory to High Doses of Benzodiazepines

Drugs and poisons are the most common causes of new cases of seizure at emergency wards, a fact that can be easily missed unless physicians consider its likelihood in mind. In this report, we describe a case of recurrent seizures due to intentional ingestion of a pesticide poison (strychnine) that was refractory to very high doses of benzodiazepines and other anticonvulsants. Our patient suffered from 12 times tonic seizures and generalized muscular spasms, until he underwent anesthesia to control the seizures. Finally, he was discharged without any serious complications

Lead Poisoning Can Be Misdiagnosed as Guillain-Barre Syndrome; A Case Report

Background: Toxic neuropathy is a global health problem affecting many people over the world, annually. Lead poisoning (LP) represents neurological complaints and neurobehavioral disorders. Therefore, its significances, especially its neurological consequences, can be misdiagnosed as other neuropathies like syndromes.Case Presentation: In this case report, we aim at describing a 45-year-old woman with Guillain-Barre-like syndrome (GBS), who was admitted to the hospital with peripheral neuropathy and complaints of paresthesia in the lower and upper limbs. Suffering from GBS-like syndrome, she incidentally showed opium consumption during the hospitalization and taking her history. Serum lead levels were precisely elevated (88.6 µg/dL). To assess the neurologic effects, the brain CT, MRI, EMG, and NCV were performed, indicating severe sensory-motor demyelinating polyradiculopathy. The patient was admitted to the hospital again after 2 years with severe radicular pain in the lower and upper limbs and with positive myoclonus and tremor. While treated with plasma exchange and pregabalin at the first stage of admission, signs were normal and again recurred after 2 years, suggesting the reversibility of the histological findings and misdiagnosis. At the second stage, intravenous immunoglobulin (IVIG) was prescribed. The patient recovered and was discharged with chelation therapy of CaNa2EDTA for LP. The most frequent neurological complication induced by LP is severe sensory-motor demyelinating polyradiculopathy and axonal polyneuropathy. But, the clinical examination and the electrophysiological findings may also suggest a GBS-like syndrome.Conclusions: Any discrepancies in this regard should be reconsidered to confirm LP diagnosis

The Efficacy of Aminophylline on Raising Consciousness in Benzodiazepines-Intoxicated Patients

Background: Loss of consciousness and respiratory failure are the most important medical problems in acute benzodiazepines (BZDs) toxicity. The possibility of respiratory apnea increases in intentional cases and also in the presence of underlying cardiopulmonary diseases. The inhibitory effect of aminophylline on adenosine receptor may be the cause of recovery of consciousness in patients intoxicated by BZDs. The effect of aminophylline as an agonist of cAMP (cyclic adenosine monophosphate), on reversal of inhibitory effects of BZDs (benzodiazepines) on the brain and increasing the level of consciousness is the main question. Method: we reviewed literature sources on topic of aminophylline and consciousness. 29 articles were compiled from prestigious scientific databases such as PubMed, Scopus and Elsevier, from 1983 to 2017. Results: This review showed that intravenous aminophylline can lead to clinical improvement of both consciousness and respiration via antagonizing sedation that induced by BZDs. Although administration of flumazenil is still the first choice for apnea related to BZDs overdose and it is also more potent than aminophylline on reversing sedation, aminophylline can be substituted when flumazenil is not available or when it has contraindication such as in epileptic patients and in overdoses with drugs capable of causing convulsion. Also, aminophylline is useful in those BZD-intoxicated patients with coincident underlying COPD and asthma. Conclusion: intravenous aminophylline could decrease the sedative effects of BZDs and also speed up the recovery of consciousness in patients under sedative effects of BZDs

Akutni respiratorni distres sindrom uzrokovan sirupom metadona

Acute respiratory distress syndrome (ARDS) due to methadone (MTD) toxicity is a known but rather uncommon phenomenon. In most of the previously reported cases of MTD-related ARDS, MTD was ingested orally in the form of tablets in high or unknown amounts. Despite the findings from the available literature, this case report is aimed at demonstrating that even small amounts of MTD syrup can cause ARDS earlier than it is usually expected. We present a non-addicted MTD-overdosed patient who developed ARDS after ingesting a very small amount of MTD syrup. We suggest close monitoring of MTD-overdosed patients from at least 48 h to 72 h for possible respiratory complications such as pulmonary oedema.Akutni respiratorni distres sindrom (ARDS) uzrokovan toksičnošću metadona (MTD) poznat je ali rijedak fenomen. U većini dosadašnjih slučajeva ARDS-a uzrokovanog MTD-om, MTD je konzumiran u obliku tableta te u velikoj ili nepoznatoj količini. Unatoč nalazima dostupne literature, ovaj prikaz slučaja dokazuje kako čak i mala količina sirupa MTD-a može uzrokovati ARDS, i to ranije nego što bi se očekivalo. Obrađen je slučaj pacijentice koja nije bila ovisnica, a oboljela je od ARDS-a nakon konzumacije tek male količine sirupa MTD-a. Predlažemo pomnije praćenje pacijenata predoziranih MTD-om od najmanje 48 sati do 72 sata usmjereno na detekciju respiratornih komplikacija poput plućnih edema

Gender Identification Based on the Parameters of the Sternum Bone in the Cadavers

Background: Identifying identity in the absence of large bones becomes more difficult and complicated; accordingly, it is highly beneficial to use the features of the sternum. The present study aimed to evaluate the dimensions of the sternum and its relation with gender in the Iranian population.Methods: This cross-sectional study was conducted on 200 cadavers (100 men and 100 women). By performing an autopsy, the sternum bone was first cut in the midline using a vibrating saw, and the different dimensions were measured using a caliper.Results: Among different dimensions related to the sternum, the mean length of manubrium, mesosternum, the largest width of manubrium, and the shortest width of manubrium were significantly higher in men compared to women. Regarding the value of each sternal diameter in discriminating male and female gender, the highest discriminative value was specified to the shortest width of manubrium (cutoff: 26.75, sensitivity: 100%, specificity: 84.0%), followed by the length of sternebrae 1 (cutoff: 8.45, sensitivity: 76.0%, specificity: 21.0%).Conclusion: Measuring various indices of sternum bone, particularly the shortest width of the manubrium and the length of sternebrae 1, leads to gender identity accurately

Efficacy of Hi-Lo Evac Endotracheal Tube in Prevention of Ventilator-Associated Pneumonia in Mechanically Ventilated Poisoned Patients

Background. Ventilator-associated pneumonia (VAP) is the most common health care-associated infection. To prevent this complication, aspiration of subglottic secretions using Hi-Lo Evac endotracheal tube (Evac ETT) is a recommended intervention. However, there are some reports on Evac ETT dysfunction. We aimed to compare the incidence of VAP (per ventilated patients) in severely ill poisoned patients who were intubated using Evac ETT versus conventional endotracheal tubes (C-ETT) in our toxicology ICU. Materials and Methods. In this clinical randomized trial, 91 eligible patients with an expected duration of mechanical ventilation of more than 48 hours were recruited and randomly assigned into two groups: (1) subglottic secretion drainage (SSD) group who were intubated by Evac ETT (n = 43) and (2) control group who were intubated by C-ETT (n = 48). Results. Of the 91 eligible patients, 56 (61.5) were male. VAP was detected in 24 of 43 (55.8) patients in the case group and 23 of 48 (47.9) patients in the control group (P = 0.45). The most frequently isolated microorganisms were S. aureus (54.10) and Acinetobacter spp. (19.68). The incidence of VAP and ICU length of stay were not significantly different between the two groups, but duration of intubation was statistically different and was longer in the SSD group. Mortality rate was less in SSD group but without a significant difference (P = 0.68). Conclusion. The SSD procedure was performed intermittently with one-hour intervals using 10 mL syringe. Subglottic secretion drainage does not significantly reduce the incidence of VAP in patients receiving MV. This strategy appears to be ineffective in preventing VAP among ICU patients. © 2016 Ahmad Ghoochani Khorasani et al

Multiple nails in the brain: An unusual suicidal attempt

We describe dangerous multiple self-inflicted brain-penetrating injuries caused by a nail gun device after a suicidal attempt for the first time in Iran. At the first forensic visit, we could not explain the manner of injuries. The authors reviewed the literature on the topics, and clinical presentation, radiographic findings, and forensic medical records are discussed. Copyright © 2012 Lippincott Williams & Wilkins

Prognostic Factors in Acute Methadone Toxicity: A 5-Year Study

Background. Delayed or recurrent profound respiratory depression, ventricular dysrhythmias, acute lung injury, and death are the major complications of MTD overdose. We aimed to clarify the prognostic factors in MTD toxicity. Materials and Methods. Retrospectively, medical files of all patients poisoned by MTD and older than 12 years of age who had presented to Loghman Hakim Poison Center between 2007 and 2012 were evaluated. The data was compared between survivors and nonsurvivors. Results. Twenty-eight out of 322 patients died (mortality rate = 8.7%). MTD-related death was higher in patients with acute on chronic toxicity who were on daily dose of MTD and had ingested higher doses (in comparison to those with acute toxicity due to firsttime exposure; 13% versus 6%). Renal failure was the most common medical complication related to deaths due to MTD toxicity. Conclusions. Based on previous researches, the most common cause of MTD overdose-related deaths is respiratory impairment; however, in our study, acute renal failure with or without rhabdomyolysis was the main delayed cause of deaths in MTD-poisoned patients. Antidotal therapy, early recognition, and treatment of hemodynamic compromise and rhabdomyolysis can be life-saving in these patients

The Outbreak of Lead Poisoning in Opium Users: Presentation and Chelation Therapy

Recently, there have been a few reports of an outbreak of lead poisoning due to opium contaminated with lead in Iran. This study aimed to evaluate the clinical features of lead toxicity in opium abusers, and response to oral chelation therapy based on the severity of poisoning. One hundred thirty-three chronic opium users with a diagnosis of lead poisoning were included. Based on blood lead level (BLL), the cases were divided into 2 mild (BLL;40-69 µg/dL) and moderate (BLL;70-100) groups. Both groups received D-penicillamine (D-P) as a Chelator. Changes in BLL compared between two groups. All cases were oral opium users. Abdominal pain (75%), anorexia (55.6%), and constipation (53.2%) were the most common symptoms of lead poisoning.  67.8% of cases experienced only one round of chelation therapy and "Rebound phenomenon" happened in 9% of these. Ninety percent of the patients had wellbeing sensation, and symptoms improved at the end of the first round of treatment. The mean BLL before and after chelation therapy were 66.87 and 45.7 µg/dL, respectively. Oral Chelator reduced BLL in both mild and moderate poisoning groups (35.61% vs. 35.90%, P: 0.057), respectively. The comparison of BLL before and after chelation therapy showed that the treatment was effective equally in both mild and moderate toxicity. However, in a few cases, the rebound phenomenon may occur

Acute respiratory distress syndrome caused by methadone syrup

Acute respiratory distress syndrome (ARDS) due to methadone (MTD) toxicity is a known but rather uncommon phenomenon. In most of the previously reported cases of MTD-related ARDS, MTD was ingested orally in the form of tablets in high or unknown amounts. Despite the fi ndings from the available literature, this case report is aimed at demonstrating that even small amounts of MTD syrup can cause ARDS earlier than it is usually expected. We present a non-addicted MTD-overdosed patient who developed ARDS after ingesting a very small amount of MTD syrup. We suggest close monitoring of MTD-overdosed patients from at least 48 h to 72 h for possible respiratory complications such as pulmonary oedema