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

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

Clinical Study Effectiveness of Naltrexone in the Prevention of Delayed Respiratory Arrest in Opioid-Naive Methadone-Intoxicated Patients

Acute methadone toxicity is a major public health concern in Iran. Methadone-intoxicated patients are in a great risk of recurrent or delayed respiratory arrest despite the prescription of initial doses of naloxone. This study aimed to evaluate the effectiveness of oral naltrexone in the management of acute methadone overdose in opioid-naive patients and check if it could be a substitute of continuous infusion of naloxone in maintaining adequate ventilation. In a randomized, double-blind, placebo-controlled study, a total of 54 opioid-naive patients with acute methadone toxicity were enrolled. The patients received either oral naltrexone or placebo capsules after awakening by naloxone. All patients underwent close monitoring of respiration. Frequency of respiratory depression or arrest, need for another dose of naloxone, duration of hospital stay, and adverse outcomes compared between the two groups. The incidence of respiratory depression was significantly less in those who had received naltrexone. Our results show that single oral dose of naltrexone is quite efficient in the prevention of recurrent or delayed respiratory arrest in opioid-naive methadoneintoxicated patients. It can shorten the duration of hospitalization and, as a consequence, decreased the risk of complications. Further studies are warranted before the generalization of this approach to other patient populations

Severe Hypoglycemia Following Acute Aluminum Phosphide (Rice Tablet) Poisoning; A Case Report and Review of the Literature

Aluminum phosphide (AlP) as 3 g tablet is widely used in Iran to protect stored food grains from pests. Hyperglycemia following its ingestion has been already reported in the recent years but severe hypoglycemia is uncommon. Here, we report a 19 year old male who attempted suicide with one tablet of AlP and demonstrated severe hypoglycemia. Despite restoration of blood glucose concentration to normal, he failed to respond to supportive treatment and died. The possible mechanisms leading to severe hypoglycemia are discussed. Though severe hypoglycemia is rare following AlP poisoning, physicians managing such patients should be aware of it