Third-degree burns following contact with Giant Hogweed
Giant Hogweed (Heracleum mantegassianum)shutterstock.com/jps 3.5 out of 5 stars Keeping pace with the media; Giant Hogweed burns — a case series and comprehensive review. Baker BG et al. Burns 2017;43:933-938 Abstract   Earlier this month, the Richmond Times-Dispatch reported that an incoming student preparing for his freshman year at Virginia Tech suffered third-degree burns to his face and arm after he came into contact with a Giant Hogweed plant (Heracleum mantegassianum). “The top layer of skin on the left side of his face was basically gone and appeared to be like a really bad burn that had already peel...
Source: The Poison Review - July 24, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical burn injury dermatitis dermatology Giant hogweed Heracleum mantegassianum phytophotodermatitis skin Source Type: news

Great new review of Novichok nerve agents
This article now brings together much that we do know, and is the best short publication in English on the topic. Some key points made in the paper: Unlike other nerve agents that primarily affect the central nervous system, the Novichok group is thought to also target peripheral nerves and can cause chronic neuropathy. Hydrolysis of Novichok agents produces hydrofluoric acid, hydrochloric acid, hydrogen cyanide, and various oximes that can prolong cholinergic effects. Since dry bleach powder can accelerate hydrolysis of Novichok agents into toxic byproducts, they should not be used. Must reading for anyone interested in...
Source: The Poison Review - July 5, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical Amesbury Britain nerve agent Novichok Salisbury Skripal United Kingdom Source Type: news

Acute cyanide poisoning: are skin findings and odors helpful in making the diagnosis?
2 out of 5 stars Challenges in the diagnosis of acute cyanide poisoning. Parker-Cote JL et al. Clin Toxicol 2018;56(7):609-617 Abstract The stated goal of this somewhat confusing and unfocused article was to “identify isolated acute cyanide poison cases and to identify reported signs, symptoms and laboratory findings.” The authors did a systematic literature review to retrieve cases reports and case series describing patients who were alive on presentation after acute exposure to a cyanide salt. Patients exposed to cyanide in association with smoke inhalation were excluded. They found 65 relevant studies (52 c...
Source: The Poison Review - June 19, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical bitter almond odor cherry red skin clinical characteristics cyanide poisoning ingestion Source Type: news

Novichok: a fourth-generation class of nerve agents
Salisbury, U.K. April 25, 2018. Decontamination efforts where Sergei and Yulia Skripal were found poisoned. [shutterstock.com]2.5 out of 5 stars Novichok: a murderous nerve agent attack in the UK. Vale JA et al. Clin Toxicol 2018 May 14 [Epub ahead of print] Reference In an article in yesterday’s New York Times, medical workers who treated Sergei and Yulia Skripal after they were found poisoned and unconscious on March 4 describe how they feared both patients would die and that many more patients might ultimately be affected. Initially it was thought that the Skripals were suffering from opioid overdose. But after ...
Source: The Poison Review - May 31, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical nerve agent Novichok organophosphate Skripal Source Type: news

Can cannabinoid hyperemesis syndrome be fatal?
shutterstock.com/Stanimir G. Stoev 2.5 out of 5 stars Cannabinoid Hyperemesis Syndrome: Reports of Fatal Cases. Nourbakhsh M et al. J Forensic Sci 2018 May 15 [Epub ahead of print] Abstract This paper reports on 2 fatal cases that the authors argue were attributable to the effects of cannabinoid hyperemesis syndrome (CHS). CASE #1: A 27-year-old woman is brought to hospital by ambulance after friend found her unresponsive with agonal respirations. On arrival she was apneic with bradycardia and decorticate posturing. Pupils were fixed and dilated. Serum glucose was 34 mg/dL. After presentation she deteriorated and could ...
Source: The Poison Review - May 30, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical cannabinoid hyperemesis syndrome cannabis cyclic vomiting fatality marijuana Source Type: news

A case of life-threatening loperamide toxicity
3 out of 5 stars Severe loperamide toxicity associated with the use of cimetidine to potentiate the “high.” Hughes A et al. AM J Emerg Med 2018 May 15 [Epub ahead of print] Reference The potential adverse effects of loperamide (Imodium) are often underestimated since, even though it is an opioid, it is available over-the-counter and has been since 1988. Loperamide is used to treat diarrhea. It acts on the mu-opioid receptors in the gut, decreasing gastric motility. It is rather effective at this. However at therapeutic doses (2-16 mg per day) it does not cause central opioid effects such as euphoria or relief ...
Source: The Poison Review - May 24, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical imodium loperamide overdose toxicity Source Type: news

Finally! The “New England Journal of Medicine” discovers medical toxicology
4 out of 5 stars Case 12-2018: A 30-Year-Old Woman with Cardiac Arrest. Goldstein JN, Dudzinski DM, Erickson TB et al. N Engl J Med 2018 Apr 19;378:1538-1549. Reference In the past, we’ve complained that the New England Journal of Medicine never seemed to include a toxicologist or emergency physician as a discussant in relevant cases in their series “Case Records of the Massachusetts General Hospital.” This resulted in some embarrassingly lame reviews, especially for a journal of such prestige. Well, it looks like the editors may finally have seen the light. In a recent issue, our friend Dr. Tim Eric...
Source: The Poison Review - May 22, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical case records of the massachusetts general hospital doxepin new england journal of medicine tricyclic overdose Source Type: news

Must-read article: America ’s Misguided War on Childhood Lead Exposures
This article is essential reading for all pediatricians, emergency practitioners, and toxicologists. (Source: The Poison Review)
Source: The Poison Review - March 23, 2018 Category: Toxicology Authors: Leon Gussow Tags: Best of TPR Medical blood level lead toxicity Source Type: news

A diagnosis you can ’t afford to miss
4 out of 5 stars Antibody-Mediated Encephalitis. Dalmau J, Graus F. N Engl J Med 2018 Mar 1;378:840-851. Reference TPR has posted before about anti-NMDA receptor encephalitis, a must-know, can’t-miss, humbling diagnosis that is distressingly easy to overlook. Although it is not a toxicologic condition, all toxicologists and emergency physicians should be thoroughly familiar with its presentation and clinical course. Let me explain why. NMDAR encephalitis often begins with behavioral changes, mood swings, and memory deficits in relatively young patients. According to this somewhat technical but excellent review, the ...
Source: The Poison Review - March 2, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical anbitody-mediated encephalitis anti-NMDA receptor encephalitis brain on fire diagnosis Source Type: news

Flubromazolam: a potent designer benzodiazepine
Flubromazolam 3 out of 5 stars Flubromazolam — A new life-threatening designer benzodiazepine. Lukasik-Glebocka M et al. Clin Toxicol 2016;54:66-68. Abstract Last month, the Peoria (IL) Journal-Star reported that local police had seized samples of two rarely seen designer sedatives: flubromazolam (alleged street name “liquid Xanax“) and etizolam. This paper from Poland presents a case report of flubromazolam exposure. A 27-year-old male known to use psychotropic drugs was brought to hospital after being found unconscious at home. On arrival he was comatose with a Glasgow Coma Scale of 3. On exam, he was br...
Source: The Poison Review - February 28, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical benzodiazepine analog designer drug etizolam flubromazolam liquid xanax sedative-hypnotic Source Type: news

Can we improve prognostic indications in acetaminophen-induced hepatic failure?
The objective was to compare the markers of hypoglycemia (glucose < 50 mg/dL,) coagulopathy, and lactic acidosis (lactate above hospital’s “normal” range) in predicting a composite endpoint of death or liver transplantation. The authors identified 334 unique cases. 19 of these were listed for transplant, and 13 actually received liver transplant. (2 transplanted patients subsequently died.) Although 96 patients (29%) met the King’s College Criteria, it is not clear how many of these who were not transplanted died. There were 40 deaths in all. After some statistical manipulation  which was not at...
Source: The Poison Review - February 9, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical acetaminophen poisoning hepatic failure king's college criteria liver transplantation Source Type: news

Can smoking marijuana cause meningitis?
Cryptococcus neoformans (wikipedia.org) 2.5 out of 5 stars Cryptococcal meningitis in a daily cannabis smoker without evidence of immunodeficiency. Shapiro BB et al. BMJ Case Rep 2018 Jan 26 [Epub ahead of print] Abstract Can smoking marijuana cause meningitis? The question is not unreasonable. A wide range of pathogenic fungi — including Aspergillus and various Cryptococcus species — have been isolated from dispensary-grade medical marijuana samples. Concern that these pathogens could cause pneumonia or central nervous system infections has focussed on those with immunodeficiency, such as HIV and organ transplant...
Source: The Poison Review - February 2, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical cannabis cryptococcus fungal infection marijuana meningitis Source Type: news

Anterograde amnesia and hippocampal lesions: is fentanyl the culprit?
Hippocampus (wikipedia.org) 3 out of 5 stars An Unusual Amnesic Syndrome Associated With Combined Fentanyl and Cocaine Use. Duru LB et al. Ann Intern Med 30 Jan 2018 [Epub ahead of print] Reference Last year we reviewed an MMWR report describing 14 cases of anterograde amnesia associated with substance abuse and bilateral ischemia of the hippocampi, as well as an additional paper giving somewhat more detailed clinical information on the initial four cases. This letter describes an additional case that occurred in West Virginia. A 30-year-old man with a history of heroin use was found at home to be difficult to arouse. Wh...
Source: The Poison Review - January 31, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical cocaine fentanyl hippocampus hippocampus ischemia norfentanyl opiate opioid Source Type: news

Comprehensive up-to-date review of toxic alcohol poisoning
3.5 out of 5 stars Toxic Alcohols. Kraut JA, Mullins ME. N Engl J Med 2018 Jan 18;378:270-280. Reference This is a good general review and update of clinical issues regarding the major toxic alcohols: methanol, ethylene glycol, isopropanol, diethylene glycol, and propylene glycol. The article is chockablock with information, and would I think be somewhat difficult to follow if one was not already familiar with these agents. For those wishing to learn the subject de novo, a good introductory book chapter in a toxicology or emergency medicine text would be better. But this is a very good refresher for those already comfort...
Source: The Poison Review - January 30, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical diethylene glycol isopropanol methanol propylene glycol Review toxic alcohol Source Type: news

Tox Tunes #114: Mr. Pharmacist (The Fall)
Although The Fall had been making music since the late 1970s and is considered one of the most durable and long-lasting groups to emerge from the British post-punk scene, they had really never been on my radar. When the group’s vocalist and founder Mark E. Smith died this week, his obituary in the New York Times noted: At various points in the band’s four-decade career, the Fall might sound like punk, hard rock, psychedelia, funk, blues-rock, jazz-rock, electropop or sheer noise. “If it’s me and your granny on bongos, it’s the Fall,” Mr. Smith once declared. The BBC disc jockey John Peel, an early and ste...
Source: The Poison Review - January 29, 2018 Category: Toxicology Authors: Leon Gussow Tags: Medical Mark E. Smith Mr. Pharmacist the fall tox tunes Source Type: news