A case report of stomach perforation during automatic mechanical chest compression following pulseless electrical activity due to cibenzoline intoxication.

BACKGROUND: The current report describes a case of stomach perforation, a rare but serious complication, that occurred during cardiopulmonary resuscitation following severe cibenzoline intoxication. CASE PRESENTATION: A woman aged in her 30s was brought into our hospital while receiving cardiopulmonary resuscitation for pulseless electrical activity. After starting extracorporeal membrane oxygenation (ECMO), her abdominal X-ray examination revealed free air in her abdomen. She was diagnosed with internal gastric perforation. An emergency operation was carried out while the circulation was maintained using ECMO. As the patient's blood cibenzoline concentration on admission was 3,868 ng/mL, she was diagnosed with cibenzoline intoxication caused by the self-intake of twice the prescribed dose. She was successfully weaned off ECMO and discharged alive with full recovery. CONCLUSION: We successfully treated a case of gastric perforation after pulseless electrical activity requiring ECMO support due to cibenzoline intoxication. Abdominal surgery can be carried out even if ECMO support is needed.

Course of matrix metalloproteinase-1 and pulmonary oxygenation in acute respiratory distress syndrome caused by oral ingestion of large doses of oxadiazon/butachlor emulsion: a case report.

BACKGROUND: We treated a patient who developed acute respiratory distress syndrome following ingestion of oxadiazon/butachlor emulsion. In this case, we continuously measured matrix metalloproteinase-1 level, an enzyme that reduces the extracellular matrix in the lungs, and tissue inhibitors of metalloproteinase-1. CASE PRESENTATION: A 50-year-old woman attempted suicide by ingesting approximately 300 mL of oxadiazon/butachlor emulsion. Respiratory disorders were observed upon admission, therefore tracheal intubation was performed, followed by artificial respiratory management (ventilator support). After that, her condition became complicated by acute respiratory distress syndrome, but it improved with intensive care management. Matrix metalloproteinase-1 level showed a course opposite to the partial pressure of arterial oxygen/percentage of inspired oxygen ratio, whereas the matrix metalloproteinase-1/tissue inhibitors of metalloproteinase-1 ratio changed in parallel with the partial pressure of arterial oxygen/percentage of inspired oxygen ratio. CONCLUSION: The relationship between matrix metalloproteinase-1 and tissue inhibitors of metalloproteinase-1 was presumed to be important for the development of acute respiratory distress syndrome.

Toxicokinetics of the Synthetic Cathinone α-Pyrrolidinohexanophenone.

Synthetic cathinones inhibit monoamine transporters, such as serotonin, norepinephrine, and dopamine transporters, and act on the central nervous system via increasing synaptic concentrations of monoamines. These compounds, which are highly addictive and potentially poisonous, are new psychoactive substances. In this study, we investigated the toxicokinetics of the synthetic cathinone, α-pyrrolidinohexanophenone (α-PHP), and assessed the relationship between the toxicokinetics and the long-term clinical symptoms induced by α-PHP in a male patient. The patient (39 years old) suddenly started uttering inarticulate words and demonstrating incomprehensible behavior in his house, and was brought to the emergency department of Iwate Medical University hospital. He presented with psychotic symptoms, such as hallucinations and delusion; however, his vital signs were normal. The hallucinations and delusion improved by the third day of hospitalization. Toxicological analysis was performed using liquid chromatography-tandem mass spectrometry with QuEChERS extraction. α-PHP was detected in his serum at a concentration of 175 ng/mL on his arrival at the hospital. His serum concentrations of α-PHP were serially determined and their natural logarithms were plotted against time after arrival. Although serum concentrations at early time points were lacking, the obtained curve was consistent with a two-compartment model and indicated a serum elimination half-life of 37 h. The long-lasting psychotic symptoms induced by synthetic cathinones appear to be correlated with their toxicokinetic characteristics, such as their long half-lives. Finally, interpreting the toxicokinetics of synthetic cathinones may provide useful information for the toxicological assessment of new psychoactive substances for forensic and clinical purposes.

Utility of the Measurement of Carboxyhemoglobin Level at the Site of Acute Carbon Monoxide Poisoning in Rural Areas.

Objective. This study examined the hypothesis that correlations exist between the carbon monoxide exposure time and the carboxyhemoglobin concentration at the site of carbon monoxide poisoning, using a pulse carbon monoxide oximeter in rural areas or the carboxyhemoglobin concentration measured at a given medical institution. Background. In previous studies, no definitive relationships between the arterial blood carboxyhemoglobin level and the severity of carbon monoxide poisoning have been observed. Method. The subjects included patients treated for acute carbon monoxide poisoning in whom a medical emergency team was able to measure the carboxyhemoglobin level at the site of poisoning. We examined the relationship between the carboxyhemoglobin level at the site of poisoning and carbon monoxide exposure time and the relationships between the arterial blood carboxyhemoglobin level and carbon monoxide exposure time. Results. A total of 10 patients met the above criteria. The carboxyhemoglobin levels at the site of poisoning were significantly and positively correlated with the exposure time (rs = 0.710, p = 0.021), but the arterial blood carboxyhemoglobin levels were not correlated with the exposure time. Conclusion. In rural areas, the carboxyhemoglobin level measured at the site of carbon monoxide poisoning correlated with the exposure time.

Acute pancreatitis-induced thrombotic thrombocytopenic purpura with recurrent acute pancreatitis.

Recent successive reports on acute pancreatitis-induced thrombotic thrombocytopenic purpura (TTP) have revealed that TTP-related microvascular damage is an aggravating factor of acute pancreatitis. Here, we report the case of a 26-year-old man diagnosed with acute pancreatitis due to high alcohol consumption. The patient was unconscious as he had taken an overdose of medication, and presented with fever and renal failure due to acute pancreatitis on admission. Although the pancreatitis subsequently improved, the symptoms were still observed; on the next day, he exhibited hemoglobinuria, anemia, and thrombocytopenia. Moreover, general blood examinations indicated the presence of schistocytes and reduced activity of ADAMTS13 (a disintegrin-like metalloproteinase with thrombospondin type 1 motif 13) to 47 %. Thus, the patient was diagnosed with TTP, and plasma exchange was performed. After the development of TTP, the acute pancreatitis recurred, but a severe pathogenesis was prevented by plasma exchange. Thus, ADAMTS13 activity may be useful for predicting a severe pathogenesis of acute pancreatitis. In ADAMTS13-deficient cases, plasma exchange may be an effective technique for preventing aggravation of acute pancreatitis.

Clinical and toxicological findings of acute intoxication with synthetic cannabinoids and cathinones.

Aim: Reporting of the analytical and clinical findings of synthetic cannabinoids and cathinones is essential in carrying out a complete clinical assessment of new psychoactive substances. Methods: From 2012 to 2014, we examined synthetic cathinone and cannabinoid poisoning in six patients aged 22-42 years old. Analyses of these compounds were carried out using liquid chromatography-tandem mass spectrometry. Results: The observed clinical symptoms were similar to those reported for intoxication with synthetic cathinones and cannabinoids. In cases of intoxication with synthetic cathinones, the psychiatric and neurological symptoms were long-lasting, and these compounds were detected in serum for 15-48 h after use. Although the clinical symptoms induced by the synthetic cannabinoids disappeared within several hours after use, the range of serum concentrations of these compounds was ≤5 ng/mL for 1-3 h after use. In one fatal case, in which high serum concentrations of synthetic cathinones and cannabinoids were detected, the most plausible cause of death was heart failure due to overdose with these drugs. The long-lasting symptoms induced by synthetic cathinones correlated with the long detection window in serum, whereas the early disappearance of symptoms induced by synthetic cannabinoids corresponded to the short detection window in serum. Conclusions: This study shows that the profiles of synthetic cathinones and cannabinoids in serum are closely related to the duration of the toxic symptoms and that concomitant use of two psychoactive drugs with different pharmacological actions may have the potential for fatal cardiotoxicity.

Prolonged hypotension induced by ingesting a topical minoxidil solution: analysis of minoxidil and its metabolites.

Case: A 47-year-old man ingested 60 mL of a topical solution (3,000 mg minoxidil) and presented with prolonged hypotension. Treatment with dopamine hydrochloride and noradrenaline provided blood pressure control. Serum unchanged minoxidil concentrations at 4 and 16 h after ingestion were 4,994 and 33.9 ng/mL, respectively. Urine concentrations of unchanged minoxidil, minoxidil-O-glucuronide, and minoxidil-N-O-sulfate at 16 h after ingestion were 360.4, 1,953, and 104.5 ng/mL, respectively. Outcome: The serum unchanged minoxidil concentration rapidly decreased over a short interval. However, the patient needed to receive vasopressor support for the first 4 days after being admitted to the hospital. The urine minoxidil-O-glucuronide concentration was higher than the concentrations of unchanged minoxidil and minoxidil-N-O-sulfate. Conclusion: Although the serum concentration of unchanged minoxidil rapidly decreased, ingesting large amounts of a topical minoxidil solution can have serious and prolonged cardiovascular effects. Analyzing the minoxidil-O-glucuronide concentration in urine is useful for diagnosing minoxidil poisoning.

A case of secondary aortoesophageal fistula inserted a covered self-expanding esophageal stent to control gastrointestinal bleeding.

A 73-year-old man presented with melena. After a thorough workup including esophageal endoscopy, computed tomography scans, and esophagography, the diagnosis of secondary aortoesophageal fistula was made. Two years previously, he had undergone endovascular stent-graft repair for the dissection of his descending thoracic aorta. Because of the generally poor condition of the patient and the high risk of any aggressive surgical intervention, we inserted a covered self-expanding esophageal stent on postadmission day 18. Esophagography after insertion did not show any evidence of a leak of contrast medium. Despite treatment with antibiotics, he developed sepsis and expired on day 52, but rebleeding did not occur in this period. We consider insertion of a covered self-expanding esophageal stent as a feasible option in the management of secondary aortoesophageal fistula in high-risk patients.

[Hypokalemic myopathy with severe constipation in a patient routinely administered sodium polystyrene sulfonate and the spherical carbon adsorbent].

66-year-old man was hospitalized because of severe abdominal pain. He had been treated for chronic renal failure. Sodium polystyrene sulfonate (SPS) and the spherical carbon adsorbent AST-120 were routinely administered to him. However, after several treatments, his pain did not resolve and his serum creatine kinase concentration was markedly elevated, so he was transferred to our hospital. Before admission to the previous hospital, muscular weakness was noted in his extremities and those symptoms persisted. His serum potassium concentration was 1.6 mEq/L, and he was administered potassium. A lower gastrointestinal endoscopy revealed normal mucosa and SPS powder-like brownish-yellow stool containing AST-120 granules in the colorectum. After massive stool discharge, the patient's pain improved and his serum potassium concentration gradually increased. The patient was diagnosed with hypokalemic myopathy thought to be mainly caused by accumulation of SPS in the colorectum.

Endotoxin adsorption therapy using polymyxin B-immobilized fiber as a treatment for septic shock-associated severe acute cholangitis.

The application of endotoxin adsorption therapy for severe acute cholangitis is controversial. We present a survival case of septic shock and multiple organ failure due to severe acute cholangitis. The patient was treated by endotoxin adsorption therapy using polymyxin B-immobilized fiber because he continued to remain in shock even after successful endoscopic nasobiliary drainage. The patient was an 84-year-old male diagnosed with acute cholangitis and acute pancreatitis who was transferred to our department because of shock and severe dyspnea. The patient had already developed acute respiratory failure, acute renal failure, and disseminated intravascular coagulation. We performed endoscopic nasobiliary drainage immediately, but the patient continued to remain in shock and plasma endotoxin level was markedly elevated at 133.6 pg/mL. Therefore, we performed direct hemoperfusion with polymyxin B-immobilized fiber. On starting the hemoperfusion, blood pressure and urine volume increased, and the plasma endotoxin level reduced considerably. On the basis of our experience in this case, we think that direct hemoperfusion with polymyxin B-immobilized fiber may be a useful modality in the management of severe acute cholangitis.

Tsunami lung.

We encountered three cases of lung disorders caused by drowning in the recent large tsunami that struck following the Great East Japan Earthquake. All three were females, and two of them were old elderly. All segments of both lungs were involved in all the three patients, necessitating ICU admission and endotracheal intubation and mechanical ventilation. All three died within 3 weeks. In at least two cases, misswallowing of oil was suspected from the features noted at the time of the detection. Sputum culture for bacteria yielded isolation of Stenotrophomonas maltophilia, Legionella pneumophila, Burkholderia cepacia, and Pseudomonas aeruginosa. The cause of tsunami lung may be a combination of chemical induced pneumonia and bacterial pneumonia.

[Detection of glimepiride and rosiglitazone from Chinese dietary supplements].

A 79-year-old man with diabetes mellitus developed prolonged hypoglycemia. The patient had ingested two Chinese dietary supplements in addition to his prescribed nateglinide (Fastic). Using liquid chromatography tandem mass spectrometry, glimepiride from sulfonylurea, as well as rosiglitazone from a thiazolidine derivative, were detected in the Chinese dietary supplements, which were then quantitatively analyzed using liquid chromatography with UV detector. Mean values (n=3) of glimepiride contents of the Chinese dietary supplements were 0.75 and 0.86 mg/capsule. Predicted intake of glimepiride in the patient was estimated to be 4.8-8.2 mg/day according to the glimepiride contents and directions of the Chinese dietary supplements. The daily intake of glimepiride in this patient was greater than daily maintenance doses (1-4 mg) of glimepiride for diabetic patients. Therefore, overdose of glimepiride by ingestion of the Chinese dietary supplements appears to be associated with the development of prolonged hypoglycemia.

A fatal case of acute hydrogen sulfide poisoning caused by hydrogen sulfide: hydroxocobalamin therapy for acute hydrogen sulfide poisoning.

A patient committed suicide with hydrogen sulfide (H(2)S) by combining two commercial products. The patient was given hydroxocobalamin as an antidote in addition to treatment with cardiopulmonary resuscitation, but died approximately 42 min after his arrival at the hospital. The patient's cause of death was attributed to acute hydrogen sulfide poisoning. Serum concentrations of sulfide before and after administration of hydroxocobalamin were 0.22 and 0.11 µg/mL, respectively; serum concentrations of thiosulfate before and after hydroxocobalamin administration were 0.34 and 0.04 µmol/mL, respectively. Hydroxocobalamin is believed to form a complex with H(2)S in detoxification pathways of H(2)S. Although H(2)S is rapidly metabolized and excreted, the decreased sulfide concentration may be also associated with this complex formation. The decreased sulfide concentration suggests that hydroxocobalamin therapy may be effective for acute H(2)S poisoning. The decreased thiosulfate concentration seems to be associated with formation of a thiosulfate/hydroxocobalamin complex, because hydroxocobalamin can form a complex with thiosulfate. The thiosulfate concentration decreased to a greater extent than did sulfide, suggesting that hydroxocobalamin has a higher affinity for thiosulfate than for H(2)S. Therefore, prompt administration of hydroxocobalamin after H(2)S exposure may be effective for H(2)S poisoning.

Balloon-occluded retrograde transvenous obliteration for gastric varices: the relationship between the clinical outcome and gastrorenal shunt occlusion.

BACKGROUND: The rupture of gastric varices is associated with high mortality rate. Balloon-occluded retrograde transvenous obliteration (B-RTO), a minimally invasive procedure that was introduced in the mid-1990s, has been widely accepted in Japan. Several reports have indicated that B-RTO yields satisfactory results; however, few reports have discussed the recurrence of gastric varices after this therapy. The purpose of this study is to retrospectively evaluate the technical aspects of B-RTO and the recurrence of gastric varices after treatment with this procedure. METHODS: B-RTO was performed in 47 patients with gastric varices, who were at a risk of variceal ruptures and who may or may not have had a history of variceal bleeding. We injected a sclerosing agent into the gastric varices for 30-60 minutes. To evaluate the therapeutic efficacy of the technique, we obtained contrast-enhanced computed tomography (CT) scans 5 days after B-RTO. As a general rule, if the gastric varices did not appear thrombosed, we repeated the procedure 7 days after the first procedure. RESULTS: B-RTO was a technical success in 37 patients. It was performed once in 26 patients, twice in 6 patients, thrice in 2 patients, and 4 times in 3 patients. Contrast-enhanced CT scans obtained after B-RTO showed thrombosed gastrorenal shunts in 29 patients and patent gastrorenal shunts in 8 patients. The gastric varices recurred in 2 patients who had patent gastrorenal shunts. The overall cumulative relapse-free rate of gastric varices was 90% at 5 years after B-RTO. CONCLUSIONS: B-RTO is an effective treatment modality for gastric varices. Moreover, obliteration of the gastrorenal shunt as well as the gastric varices appears to be important for the treatment of gastric varices.

[Case followed by delayed loss of consciousness after exposure to hydrogen sulfide that was treated with intermittent administration of sodium nitrite].

A 49-year-old man lost consciousness after being accidentally exposed to what was probably hydrogen sulfide gas while performing maintenance on a machine producing feather meal. He was immediately taken to the hospital. Upon admission, his consciousness level was 14 (E4V4M6) on the Glasgow Coma Scale (GCS), but it subsequently decreased, and the patient was intubated when his respirations became depressed as well. About 5 hours after the initial incident, he was transferred to our department. His consciousness level was GCS 9 (E2V2M5), his blood pressure was 95/78 mmHg, and his heart rate was 90 beats per min. There was no metabolic acidosis. Mechanical ventilation was begun and 10% sodium nitrite was intermittently administered intravenously, with the goal of lowering arterial blood methemoglobin saturation to 20%. Two days following admission, the patient regained full consciousness and sodium nitrite administration was stopped. The following day mechanical ventilation was also discontinued. This patient exhibited severe recurring neurologic symptoms without metabolic acidosis; thus, the manifestations of toxicity in this case might have been due to the direct neurologic toxicity of hydrogen sulfide, hypoxia, or delayed post-ischemic cerebral hypoperfusion syndrome. The patient made a full recovery without any sequelae; therefore we would like to hypothesize that repetitive intravenous administration of sodium nitrite is effective in cases of hydrogen sulfide exposure.