Indoxacarb poisoning causing methemoglobinemia treated with parenteral vitamin C: a case report.

INTRODUCTION: This case study reports on a suicide attempt involving indoxacarb and vitamin C. Indoxacarb is a neurotoxic insecticide used in agriculture and as a flea controller in pets. Cotton, vegetables, and fruits are treated with indoxacarb, an insecticide that can be applied both indoors and outdoors. It causes skin allergies, methemoglobinemia, and hemolytic anemia. It is also attributed to allergic reactions through ingestion, inhalation, physical contact, and translaminar action. This case report highlights use of vitamin C in methemoglobinemia caused by indoxacarb poisoning. Indoxacarb poisoning has the potential to be extremely serious and even lethal. In this instance, the patient initially had no symptoms after ingesting a substance containing indoxacarb in an attempt at suicide. However, further tests revealed methemoglobinemia and low oxygen levels. CASE PRESENTATION: A 28-year-old south-east Asian female patient ingested an insecticide containing 5.25% novaluron, 4.5% indoxacarb, and 25% thiamethoxam, and reported that she noticed muddy brown urine but presented with no active signs or symptoms of poisoning. Upon examination, the patient was fully conscious, alert, and hemodynamically stable, but had an oxygen saturation of 84%. Gastric lavage was performed, and blood investigations revealed a muddy-brown-colored blood sample and methemoglobin levels of 12%. The patient was treated with high-dose vitamin C and showed significant improvement, with a drop in methemoglobin levels to 1.2% and an increase in oxygen saturation to 97%. DISCUSSION: Indoxacarb poisoning can cause severe methemoglobinemia. Vitamin C may be a useful treatment option for methemoglobinemia caused by indoxacarb, particularly in cases in which traditional treatment with methylene blue is contraindicated or not tolerated. Hence high doses of ascorbic acid, that is, vitamin C, were administered to the patient, which lowered their methemoglobin levels and improved oxygen levels without much safety concerns. CONCLUSION: This example emphasizes the significance of early indoxacarb poisoning detection and treatment as well as the possible advantages of utilizing ascorbic acid in the management of methemoglobinemia, and highlights the use of vitamin C in the treatment of methemoglobinemia caused by indoxacarb poisoning. Therefore, it is important for healthcare professionals to be aware of the potential for indoxacarb to cause methemoglobinemia and to consider vitamin C as a treatment option.

Azathioprine hypersensitivity: A Sweet-like syndrome.

INTRODUCTION: Azathioprine hypersensitivity can occasionally present as Sweet-like syndrome, a dose-independent side effect characterized by the unanticipated onset of macules, papules, and pustules. CASE PRESENTATION: A 35-year-old woman with systemic lupus erythematosus presented with complaints of generalized maculopapular rash, facial swelling, and bilateral lower extremity edema with a duration of 4 days and a 2-day history of constitutional symptoms within 2 weeks of the beginning of azathioprine therapy to treat existing lupus nephritis (class 2/3). DISCUSSION: Patients who experience azathioprine hypersensitivity syndrome can present with erythema nodosum, small-vessel vasculitis, acute generalized exanthematous pustulosis, Sweet syndrome, and nonspecific dermatosis. The following signs and symptoms are used as criteria to diagnose drug-induced Sweet syndrome: (a) abrupt onset of painful erythematous plaques, (b) histopathological evidence of dense neutrophilic infiltrate without evidence of leukocytoclastic vasculitis, (c) temperature higher than 39.7°C, (d) temporal relationship between drug ingestion and clinical presentation, and (e) temporal resolution of lesions after drug withdrawal. Our patient met three out of five criteria and was diagnosed with Sweet-like syndrome. CONCLUSION: Our case highlights the uncommonly presented azathioprine-induced Sweet-like syndrome that occurs abruptly after the commencement of the offending drug. This diagnosis can be established through basic laboratory workup and skin biopsy findings.

Brugada syndrome unmasked by dengue fever.

Key Clinical Message: Understanding the circumstances, leading to unmasking of hidden Brugada syndrome is essential for the practicing clinician and the patients so that they are informed adequately to seek prompt medical attention. Abstract: Brugada syndrome is a genetic arrhythmia syndrome characterized by a coved type of ST-segment elevation in the ECG. The patients are usually asymptomatic, with unmasking of the disease under certain conditions. We are reporting the case of a patient diagnosed with Brugada syndrome, which was unmasked during an attack of dengue fever.

A rare extrapulmonary manifestation of tuberculosis in a chronic kidney disease patient.

Key Clinical Message: Chronic kidney disease (CKD) and tuberculoma are two distinct medical conditions. Nonetheless, they can be related in very rare cases. The purpose of this case report is to consider screening tests such as IGRA (interferon gamma release assay) and TST (tuberculin skin test), for tuberculosis in CKD patients with a risk of infection, thereby increasing the awareness of tuberculoma in CKD and ensuring early treatment which would eventually decrease the morbidity and mortality rates in such patients. Abstract: Chronic kidney disease (CKD) associated with tuberculoma represents one of the rarest conditions occurring worldwide. Among tuberculous patients, only 1% show central nervous system involvement. We present a case of a 45-year-old male with CKD who presented with a seizure and was diagnosed to have tuberculoma.

Toxic fasciculations-An unusual presentation of organophosphate poisoning.

The nicotinic symptom in Organo-Phosphate (OP) poisoning is an unusual presentation in an adult, as in our case of a 38-year-old man who also experienced decreased motor power of all limbs and diffuses fasciculation of the tongue and lower limbs.

Stars from the bones-An uncommon presentation of fat embolism syndrome.

Trauma or surgery to the lower limbs can cause fat from the marrow within the leg bones to enter the bloodstream and form an embolus. However, if there is cerebral involvement without any pulmonary or dermatological manifestations at diagnosis, it could delay identifying cerebral fat embolism (CFE).

Takayasu arteritis in peripartum period-A clinical paradox.

Takayasu arteritis is a primary systemic vasculitides occurring among women in the childbearing age group. This interaction between TA and pregnancy is an area of interest that has to be addressed. Preconception and antepartum management of arterial hypertension and TAK disease activity is important to improve maternal and fetal outcomes.

A rare case of extensive cutaneous spider angioma in Zieve's syndrome: A case report and review of literature.

Chronic alcoholism is a global public health problem showing increasing trends throughout the world. Alcoholic liver disease is one of the most important causes of mortality worldwide. Cutaneous features are one of the most frequent manifestations of liver disease and can often be a presenting feature. Spider angioma is one of the cutaneous manifestations in liver diseases. More than six spider nevi are considered abnormal. Here we present a case of a gentleman with a history of chronic alcohol intake and diagnosed with Zieve's syndrome, who presented with extensive cutaneous spider angioma.