Poisoning in Israel: annual report of the Israel Poison Information Center, 2007.

BACKGROUND: The Israel National Poison Information Center, Rambam Health Care Campus, provides telephone consultations on clinical toxicology as well as drug and teratogen information around the clock. The Center participates in research, teaching and regulatory activities and also provides laboratory services. OBJECTIVES: To analyze data on the epidemiology of poisonings and poison exposures in Israel. METHODS: We conducted computerized queries and a descriptive analysis of the medical records database of the IPIC during 2007. RESULTS: Overall, 26,738 poison exposure cases were recorded, a 118.5% increase compared to 1995. Children under 6 years old were involved in 45% of cases; 73% of the calls were made by the public and 25.5% by physicians; 74.4% of exposures were unintentional and 9.2% intentional. Chemicals were involved in 37.9% of cases, pharmaceuticals in 44.2%, bites and stings in 4.3% and poisonous plants in 1.2%. Substances most frequently involved were analgesics, cleaning products and antimicrobials. Clinical severity was moderate/major in 3.5%. Substances most frequently involved in moderate/major exposures were insecticides, drugs of abuse and corrosives. Eight fatalities were recorded - three unintentional exposures (all chemicals) and five intentional (chemicals, medications, drugs of abuse). CONCLUSIONS: The rates of poison exposures and poisonings in Israel have increased significantly, contributing substantially to morbidity and mortality. The IPIC database is a valuable national resource for collecting and monitoring cases of poison exposure and can be used as a real-time surveillance system. It is recommended that reporting to the IPIC become mandatory and that its activities be adequately supported by national resources.

Illicit cathinone ("Hagigat") poisoning.

INTRODUCTION: Khat leaves (mainly cathinone and cathine) have been chewed for centuries as stimulants. Hagigat (capsules of 200 mg cathinone) have been marketed in Israel as a natural stimulant and aphrodisiac. The consequences of illicit exposure to cathinone are reported. METHODS: Prospective observational study of calls to the Poison Center regarding exposure to Hagigat during the course of 10 months. Demographic and clinical data were abstracted from patients' records and telephone follow up was performed. RESULTS: Data of 34 consecutive patients aged 16-54 years were analyzed. The amount consumed was (1/2)-6 capsules (ingestion-32, sniffing-2). Main clinical manifestations were headache, vomiting, hypertension, nausea, tachycardia, dyspnea, chest pain, and myalgia. Main complications were myocardial ischemia (3), pulmonary edema (2), and intracerebral hemorrhage (1), all in young subjects. Treatment was supportive; one patient underwent neurosurgery. CONCLUSION: Exposure to illicitly synthesized cathinone is associated with serious cardiovascular and neurological toxicity, even in young subjects.

Intrathecal methotrexate neurotoxicity: clinical correlates and antidotal treatment.

The neurotoxicity of methotrexate (MTX) is more severe when administered intrathecally (IT) than by the oral and intravenous (IV) routes, and has been reported even with a single administration of therapeutic doses of 12 or 15mg. Prompt recognition and treatment are essential to improve the outcome after massive IT-MTX overdose. Treatment options include CSF drainage or CSF exchange, ventriculolumbar perfusion, IT corticosteroids to reduce CSF inflammation and IV leucovorin to reduce systemic toxicity. Toxicity resulting from IT injection of leucovorin is controversial. CSF drainage and exchange are particularly effective if performed soon after the overdose. In this paper we describe a protocol of treatment for severe cases of IT-MTX overdose in excess of 100mg. The mainstay of treatment is dilution and removal from CSF of excessive methotrexate alongside with specific antidotal therapy.

Toxicological features of deliberate self-poisonings.

BACKGROUND: Deliberate self-poisoning (DSP) is a major health problem with increasing incidence mainly among young people. OBJECTIVE: To examine the clinical and toxicological characteristics of DSP, it is compared to unintentional (non-DSP) exposures and those characteristics which might be associated with increased toxicological risk are identified. METHODS: Two-year retrospective poison centre chart review. STATISTICS: chi2 analysis. RESULTS: 3802 DSP cases were reported. Most calls (95%) were made by physicians compared to 51% in non-DSP exposures, P <0.0001. There were almost twice as many females as males, contrary to unintentional exposures (P <0.001). Peak frequency involvement was at the age of 15-20 years for females and older for males. Only 19.8% of DSP calls were made within the first hour of exposure compared to 46% of the non-DSP calls (P < 0.001). Younger patients tended to present earlier. The vast majority of exposures occurred by ingestion and at home. Pharmaceuticals and chemicals were involved in 86% and 12% of DSP cases, respectively (compared to 29% and 44% in non-DSP exposures, respectively, P < 0.001). Psychiatric drugs were more commonly used in older age groups and analgesics among the younger. Insecticides, sodium hypochlorite and rodenticides were the most frequently used chemicals. Neurological involvement was observed in 48.2% of DSP patients compared to 16.9% in non-DSP exposures. DSP was associated with greater severity than non-DSP exposures (21% and 10% had moderate to severe toxicity, respectively, P <0.001). Severity was greater among males, aged older than 45 years, with time from exposure to consultation 8 hours or longer and with exposure to chemicals, psychiatric drugs or combinations. CONCLUSIONS: Most DSP patients were females, aged 15-20 years, used pharmaceuticals and had neurological involvement. Males, aged over 45 years, with longer time to toxicology consult and the use of chemicals were associated with increased severity. These parameters should alert the treating physician to the possibility of a poor course and hence to a more aggressive therapeutic approach.

Evaluation of antivenom therapy in Vipera palaestinae bites.

BACKGROUND: Vipera palaestinae antivenom has been successfully used to treat systemic and progressive local manifestations inflicted by this snake. The clinical course of several envenomations created the impression that the recommended fixed dose regimen of antivenom (50 ml) may not always be sufficient. OBJECTIVE: To evaluate the V. palaestinae antivenom fixed dose regimen and to assess the need for repeated antivenom administration as well as possible adverse effects. METHODS: Retrospective review of prospectively collected poison center data over a one-year period. RESULTS: One hundred and twelve patients were evaluated, 48% of whom were treated with antivenom. Antivenom treatment resulted in complete disappearance of systemic manifestations with no relapse. Three patients required additional doses of antivenom for marked progressive local signs--one initially received 50 ml of antivenom and two others only 30 ml. Anaphylaxis and serum sickness were each observed in 3.7% of the treated patients. CONCLUSION: The fixed dose regimen of 50 ml V. palaestinae antivenom is efficacious for the treatment of systemic and progressive local manifestations caused by this snake. There is insufficient data on whether smaller doses can be successfully used for systemic manifestations and whether initial larger doses are justified for marked progressive local signs (e.g. involvement of an entire limb). Randomized prospective controlled studies are needed to elucidate these issues.

Beneficial late administration of obidoxime in malathion poisoning.

Early treatment of organophosphate (OP) poisoning with oximes results in reactivation of acetylcholinesterase and patient recovery. Data on efficacy of late administration of oximes, particularly obidoxime, is limited. A 42-y old woman swallowed 60 ml of 50% malathion in a suicide attempt. Characteristic muscarinic, nicotinic and central manifestations of OP poisoning appeared: atropine and 250 mg obidoxime i.v., resulted in marked improvement. Several hours after the last dose, clinical manifestations recurred and ventilation was required. After 10 d cholinesterase was still low and liver enzymes were elevated. Obidoxime was reinstituted after the 9 d interruption and muscle strength improved with the first dose. The patient could be disconnected from the ventilator and within <24 h was extubated. Oxime therapy should be considered even late in the course of untreated or partially treated OP intoxications, especially when the etiologic agent is a lipid-soluble compound (ie malathion) that can cause a protracted course of poisoning. The clinical course of this patient did not support a cause-and-effect relationship between obidoxime and the abnormal liver function.

Rabbitfish ("aras"): an unusual source of ciguatera poisoning.

BACKGROUND: Ciguatera poisoning is the commonest fish-borne seafood intoxication. It is endemic to warm water tropical areas and is caused by consumption of bottom-dwelling shore reef fish, mostly during spring and summer. The causative agent, ciguatoxin, is a heat-stable ester complex that becomes concentrated in fish feeding on toxic dinoflagellates. The common clinical manifestations are a combination of gastrointestinal and neurologic symptoms. Severe poisoning may be associated with seizures and respiratory paralysis. OBJECTIVE: To describe a series of patients who sustained ciguatera poisoning in an uncommon region and from an unexpected source. PATIENTS: Two families complained of a sensation of "electrical currents," tremors, muscle cramps, nightmares, hallucinations, agitation, anxiety and nausea of varying severity several hours after consuming rabbitfish ("aras"). These symptoms lasted between 12 and 30 hours and resolved completely. The temporal relationship to a summer fish meal, the typical clinical manifestations along with the known feeding pattern of the rabbitfish suggested ciguatera poisoning. CONCLUSIONS: The Eastern Mediterranean basin is an unusual region and the rabbitfish an unusual source for ciguatera poisoning. There are no readily available and reliable means for detecting ciguatoxin in humans. A high index of suspicion is needed for diagnosis and a thorough differential diagnosis is essential to eliminate other poisonings, decompression sickness and encephalitis. Supportive therapy is the mainstay of treatment.