Clinical features of seven patients poisoned with a tolfenpyrad-based insecticide in Thailand.

INTRODUCTION: Tolfenpyrad, a novel insecticide originating from Japan and first approved in 2002, has been marketed in numerous countries. Data on tolfenpyrad exposure in humans are limited. This study aimed to characterize the clinical features and outcomes of acute poisoning from tolfenpyrad-based insecticides in Thailand. METHODS: This retrospective study analyzed cases of tolfenpyrad exposure reported to the Ramathibodi Poison Center from 2012 to 2022. RESULTS: A total of seven patients were identified, with the majority being male (n = 5). Deliberate tolfenpyrad exposure accounted for three cases. The median age was 33 (range 1-46) years. Severe systemic effects were evident at presentation in the four patients ingesting tolfenpyrad. These included altered mental status (n = 4), mydriasis (n = 2), cardiac arrest (n = 1), hypotension (n = 4), bradycardia (n = 2), and high anion gap metabolic acidosis (n = 4). The median time from exposure to hospital presentation was 30 (range 15-60) minutes. All four patients ingesting tolfenpyrad died, whereas the three patients exposed via inhalation and dermally developed only mild clinical effects, and all were discharged following supportive care. DISCUSSION: We observed many of the clinical features reported previously, including vomiting, mydriasis, altered mental status, metabolic acidosis, and hypotension. We also noted a combination of bradycardia and hypotension while not observing respiratory depression. CONCLUSIONS: Tolfenpyrad insecticide poisoning has been reported infrequently. Rapid systemic toxicity can follow ingestion, resulting in a high mortality. Larger-scale studies are essential to identify predictors of severity and determine the optimal treatment for tolfenpyrad-poisoned patients.

A 10-Year Retrospective Analysis of Medication Errors among Adult Patients: Characteristics and Outcomes.

Medication errors (MEs) are a global health problem. We conducted this study to clarify the clinical characteristics, outcomes, and factors associated with MEs that caused harm to adult patients (>15 years of age) who were managed in hospitals or healthcare facilities. We performed a 10-year retrospective study (2011-2020) by analyzing data from the Ramathibodi Poison Center (RPC) database (RPC Toxic Exposure Surveillance System). There were a total of 112 patients included in this study. Most were women (59.8%) and had underlying diseases (53.6%). The mean patient age was 50.5 years. Most MEs occurred during the afternoon shift (51.8%) and in the outpatient department (65.2%). The most common type of ME was a dose error (40.2%). Local anesthetic was the most common class of ME-related drug. Five patients died due to MEs. We analyzed the factors associated with MEs that caused patient harm, including death (categories E-I). The presence of underlying diseases was the single factor that was statistically significantly different between groups. Clinical characteristics showed no significant difference between patients aged 15-65 years and those aged >65 years. In conclusion, our findings emphasized that MEs can cause harm and even death in some adult patients. Local anesthetics were the most commonly involved in MEs. Having an underlying disease might contribute to severe consequences from MEs. Preventive measures and safety systems must be highlighted and applied to prevent or minimize the occurrence of MEs.

Comparing Ultrasonography and Surface Landmark-Guided Lumbar Puncture in Patients with Obesity and Difficult Anatomy; a Randomized Controlled Trial.

Introduction: Previous studies have shown higher lumbar puncture (LP) success rates when using ultrasound guidance. This study aimed to compare the first-attempt success rate of ultrasound-guided LP with blind technique of needle insertion using the palpable spinal surface landmark in patients with obesity or a difficult anatomy. Methods: This prospective randomized controlled study was performed at the emergency department of Ramathibodi Hospital, an academic tertiary university hospital, from August 2015 to July 2016. Results: 40 patients were enrolled (20 surface landmark-guided and 20 ultrasound-guided LPs). 52.5% of the patients were male with the mean age of 60.33 ± 4.24 years. The first-attempt success rate in the ultrasound-guided LP group was significantly higher than the landmark-guided LP group (80% vs. 35%, respectively), with risk difference (RD) of 45.00% (95% confidence interval (CI): 17.72%, 72.28%). This indicated absolute risk reduction and number needed to treat of 45.00% and 2.22, respectively. The median procedural duration required to achieve successful LP in the ultrasound-guided LP group was significantly shorter than the surface landmark-guided LP group (5 [IQR: 3-18] minutes vs. 13.5 [IQR: 5-30] minutes, respectively). Traumatic puncture as a complication occurred less frequently in the ultrasound-guided LP group than the surface landmark-guided LP group with risk ratio (RR) = 0.33 (95% CI: 0.08, 1.46) and RD = -20.00% (95% CI: -44.00%, 4.00%). This indicated absolute risk reduction and number needed to harm of 20.00% and 5.00, respectively. However, the difference was not significant. Conclusion: Using ultrasound to help localize the insertion point before LP increased the first-attempt success rate and improved other LP outcomes in Thai patients with obesity or a difficult anatomy. It also shortened the procedural duration and reduced the incidence of traumatic tap.

A Retrospective Cohort Study of Cobra Envenomation: Clinical Characteristics, Treatments, and Outcomes.

This study investigated the clinical characteristics, treatments, and outcomes of envenomation involving cobra species in Thailand (Naja kaouthia, Naja siamensis, and Naja sumatrana). Data of patients who had been bitten by a cobra or inoculated via the eyes/skin in 2018-2021 were obtained from the Ramathibodi Poison Center. There were 1045 patients admitted during the 4-year study period (bite, n = 539; ocular/dermal inoculation, n = 506). Almost all patients with ocular/dermal inoculation had eye involvement and ocular injuries, but none had neurological effects. Most of the patients bitten by a cobra had local effects (69.0%) and neurological signs and symptoms (55.7%). The median interval between the bite and the onset of neurological symptoms was 1 h (range, 10 min to 24 h). Accordingly, patients should be observed closely in hospitals for at least 24 h after a bite. Intubation with ventilator support was required in 45.5% of patients and for a median duration of 1.1 days. Antivenom was administered in 63.5% of cases. There were nine deaths, most of which resulted from severe infection. Neurological effects and intubation were significantly more common after a monocled cobra bite than after a spitting cobra bite. The administration of antivenom with good supportive care, including the appropriate management of complications, especially wound infection, might decrease fatality.

Poisoning from Ingestion of Fungus-Infected Cicada Nymphs: Characteristics and Clinical Outcomes of Patients in Thailand.

The current data regarding poisoning associated with ingestion of fungus-infected cicada nymphs are limited. We performed a retrospective cohort study of patients who ingested fungus-infected cicada nymphs and were referred to the Ramathibodi Poison Center for consultation from June 2010 to June 2022. Thirty-nine patients were included for analysis. Most were men (53.8%). Mean age was 40.2 ± 15.0 years. All nymphs were ingested as a health/food supplement. Thirty-one patients (79.5%) reported gastrointestinal symptoms. Median time from ingestion to symptom onset was 5 h. Twenty-nine patients (74.4%) reported neurological symptoms, including tremor, myoclonus, muscle rigidity, nystagmus/ocular clonus, drowsiness, dysarthria, seizure, and confusion. Some complained of dizziness, urinary retention, and jaw stiffness. Most patients (94.9%) were admitted to the hospital. Median hospital stay was 3 days. Ibotenic acid was detected in the blood and urine samples of one patient. All received supportive care. Four patients developed infectious complications. No deaths occurred. Consuming fungus-infected cicada nymphs may cause poisoning in humans. Gastrointestinal and neurological symptoms were common. Ibotenic acid might be the underlying cause. The main treatment is supportive care and appropriate management of complications. Education of the general public is advocated to prevent the incidence of this type of poisoning.

Clinical characteristics, treatment and outcomes of acute propanil poisoning in a 7-year retrospective cohort study.

The present study was a 7-year retrospective cohort study (2012-2018) of patients treated for acute propanil poisoning by ingestion, using data from Ramathibodi Poison Center, Thailand. The aim of this study was to describe the clinical characteristics, treatment, outcomes and factors associated with moderate to severe outcomes and death following acute exposure to propanil. The effect of administering multiple-dose activated charcoal (MDAC) on clinical outcomes was also evaluated. A total of 275 cases were included. The results show that two thirds of patients were male and mean age was 40 years. Patients ingested either propanil or a mixture of propanil and other herbicides. The majority (98%) of exposures was intentional. Most patients (65.5%) presented with gastrointestinal symptoms. Methemoglobinemia and hemolysis were observed in 108 patients (39.3%) and 25 patients (9.1%), respectively. Median time to onset of methemoglobinemia and hemolysis after propanil ingestion was 5.5 and 48 h, respectively. One hundred and forty-one patients (51.3%) were treated with MDAC, and some patients received methylene blue (21.5%), intubation (18.5%), or blood transfusions (8%). All patients were admitted to hospitals. The median length of hospital stay of patients who survived was 3 days. Multivariate analysis indicated that neurological symptoms at presentation, methemoglobinemia and acute kidney injury during admission, were associated with moderate to severe outcomes. Factors associated with mortality were older age, larger amount of ingestion, neurological symptoms at presentation and hypotension during admission. The overall mortality rate was 6.2%. The mortality rate was 3.6% in patients that received MDAC and 9% in patients that did not, although the difference was not statistically significant. Subgroup analysis of patients who developed methemoglobinemia or both methemoglobinemia and hemolysis found a statistically significant lower mortality rate in patients that received MDAC. In conclusion, methemoglobinemia and hemolysis contribute to poor outcomes in acute propanil poisoning. Age, amount of ingestion, neurological symptoms at presentation and hypotension during admission could prognosticate deaths, and patients with these factors should be closely observed and aggressively managed.

Early Adverse Reactions to Snake Antivenom: Poison Center Data Analysis.

Antivenom is an essential treatment for snake envenomation; however, early adverse reactions (EARs) are major limitations to its use. We performed a retrospective cross-sectional study using Ramathibodi Poison Center data (January 2016 to December 2017) to clarify the incidence and severity of EARs following different F(ab')2 antivenoms. Among 1006 envenomed patients, 684 (68%) received antivenom therapy with a total of 1157 doses, mostly green pit viper antivenom. The overall EAR incidence and rate were 22. 5% (154/684) and 15% (173/1157), respectively. The EAR rate following each type of antivenom was >10%, except for Russell's viper antivenom (2.9%); the severe reaction rate was 2.6% (30/1157). Malayan pit viper bites caused a high incidence of EARs (37.8%) and the highest EAR rate (22.3%). Fifty-two cases developed anaphylaxis. All EARs occurred within 2 h after treatment initiation. No deaths were attributed to EARs. The duration of administration was significantly different between doses of antivenom that induced EARs and those that did not. In conclusion, all types and every dose of antivenom should be infused for 30−60 min. Preparation of resuscitation equipment and continuous clinical observation are crucial for at least 2 h after administration, and prompt treatment should be provided when EARs occur.

The Impact of the Coronavirus Disease 2019 (Covid-19) Pandemic on the Use of Emergency Medical Services System in Bangkok, Thailand.

Background: Coronavirus disease 2019 (COVID-19) has widely affected the global public health system, especially the emergency medical service (EMS), which has been the first responders since 2020. However, this pandemic persists with still limited studies on its impact on EMS. This study aimed to compare the number of EMS patients and the operation periods of Bangkok EMS in Thailand between 2020 (severe COVID-19 pandemic) and 2019 (prepandemic). Patients and Methods: We retrospectively analyzed data of patients with severe COVID-19 were collected from the emergency medical information system of Bangkok EMS center. Data were compared between the two periods. The COVID-19 pandemic period (study period) spanned from January 01, 2020 to December 31, 2020, whereas the control period referred to the same period in the previous year (January 01, 2019 to December 31, 2019). Results: A total of 178,594 patients were serviced by EMS, with 93,288 during the study period and 85,306 during the control period. The study period had more EMS patients overall by 9.36% (95% confidence interval [CI]: 9.16-9.55) and significantly more EMS patients per day, with a mean difference of 21.19 (254.90 ± 25.55 vs 233.71 ± 23.49; 95% CI: 17.63-24.76, p < 0.001), than the control period. Furthermore, all EMS operation periods studied were significantly longer during the study period. Conclusion: During COVID-19 pandemic period, a significantly increased number of EMS patients compared to one during non-COVID-19 pandemic period for both traumatic and non-traumatic patients, as well as remarkably increased every EMS operation period of both groups during COVID-19 pandemic period were found in the present study. From this knowledge, provision of necessary EMS resources and preparation of emergency staff to be ready for management of future pandemics should be obtained to reduce EMS operation period in the future pandemics.

Characteristics and Consequences of Medication Errors in Pediatric Patients Reported to Ramathibodi Poison Center: A 10-Year Retrospective Study.

Purpose: This study was performed to evaluate the clinical characteristics of, consequences of, and factors associated with medication errors (MEs) that cause harm to pediatric patients (<15 years of age) treated in the hospital setting. Patients and Methods: We performed a 10-year retrospective study (January 2011-December 2020) by analyzing data from the Ramathibodi Poison Center. MEs were classified into categories A to I according to the severity of the outcome. Results: In total, 121 patients were included in the study. Most (51.24%) patients were male. Their median age was 1 year (range, 1 hour-14 years). Infants, newborns, and toddlers were the three most common age groups in which MEs were reported. Most MEs occurred during the afternoon shift [n = 60 (49.59%)] and in the inpatient department (66.12%). The most common type of MEs was a dose error (64.46%). Antibiotics, sedative agents, and bronchodilators were the three most common classes of ME drugs. Four patients died. Three deaths occurred because of a dose error. One patient was a 1-year-old girl who received an iatrogenic intravenous phenytoin overdose of 10 times the normal dose, resulting in a phenytoin level of 72.4 mcg/mL. She died 22 hours after the ME occurred. The work shift was the only factor that significantly differed between patients with category C and D MEs and those with category E to I MEs. Conclusion: Small children were at highest risk for MEs. MEs induced harm and deaths in some patients. A preventive and safety system, including appropriate shift work administration, should be emphasized and implemented to prevent and/or decrease the occurrence of MEs.

Situation of snakebite, antivenom market and access to antivenoms in ASEAN countries.

INTRODUCTION: Snakebite envenoming is a neglected tropical disease posing public health challenges globally. The Association of Southeast Asian Nations (ASEAN) countries are among the tropical regions with disproportionately high incidence of snakebite. Hence, this study aimed to review the situation of snakebite, antivenom market and access to antivenoms in ASEAN. METHODS: This mixed-methods study included comprehensive literature review and in-depth interviews with key informants to assess the situation of management system of snakebite, antivenom market and access to antivenoms in seven ASEAN countries, including Malaysia, Thailand, Indonesia, Philippines, Vietnam, Lao PDR and Myanmar. Data were analysed by a framework method. RESULTS: ASEAN have developed various strategies to improve outcomes of snakebite victims. Five domestic antivenom manufacturers in the region produce up to 288 375 vials of antivenoms annually with the value of US$13 058 053 million which could treat 42 213 snakebite victims. However, there remain challenges to be addressed especially the lack of snakebite-related informatics system, inadequate antivenoms at the healthcare facilities and when the majority of snakebite victims seek traditional healers instead of conventional treatment. CONCLUSION: Improving the situation of snakebite and antivenom is not only about the availability of antivenom, but the whole landscape of surrounding management and supporting system. The assessment of the situation of snakebite and antivenom is crucial for countries or regions where snakebites are prevalent to recognise their current standpoint to inform the development of strategies to achieve the goal set by the WHO of halving the global burden of snakebite by 2030.

Malayan Pit Viper Envenomation and Treatment in Thailand.

INTRODUCTION: The Malayan pit viper (MPV; Calloselasma rhodostoma) is a hematotoxic snake found in all regions of Thailand and many countries in Southeast Asia. Treatment of MPV envenomation varies among facilities due to their capabilities. MATERIALS AND METHODS: This study was a retrospective review of patients with MPV envenomation who were reported to the Ramathibodi Poison Center from 1 July 2016 to 30 June 2018. RESULTS: Of the 167 patients (median age, 40.5 years; range, 1.3-87.0 years) bitten by an MPV, the most common bite site was the foot (29.3%). Most patients reached the hospital within 1 hour of being bitten. One-hundred fifty-six patients (93.4%) had local effects from envenomation; 17 patients (10.2%) had severe local complications including necrotizing fasciitis (3.0%) and compartment syndrome (7.2%). Systemic effects such as hemorrhage and abnormal hemostasis occurred in 147 patients (88.0%). Additional effects included abnormal venous clotting time in 123 patients (73.7%), unclotted 20-minute whole blood clotting time in 57 patients (34.1%), low platelet counts (<50,000/µL) in 29 patients (17.4%), prolonged international normalized ratio (>1.2) in 51 patients (30.5%), and systemic bleeding in 14 patients (8.4%). The median onset of bleeding disorder was 6 hours. Monitoring for 24, 48, and 49 hours after bite enabled detection of systemic effects in 94.2%, 99.3%, and 100.0%, respectively. Three hundred fifteen courses of antivenin were administered to 144 patients (86.2%). All the patients who received antivenin recovered from bleeding disorder. Only 7.0% of antivenin doses were administered without Thai Red Cross indications. Allergic reactions from antivenin occurred in 34.7% of the 144 patients. One hundred thirty patients (77.8%) received antibiotics, and 32 patients (19.2%) required surgical management, including debridement and fasciotomy. CONCLUSION: MPV envenomation results in local and systemic effects. Most systemic effects were abnormal clotting test results. Most patients reported onset of bleeding disorder within 48 hours.

Poisoning of Butanol-Containing Products: Clinical Characteristics and Outcomes.

BACKGROUND: Butanol (butyl alcohol) is a chemical which occurs naturally in some foods and is used in the manufacture of other chemicals. Current data on butanol poisoning in humans are limited. OBJECTIVE: This study describes clinical characteristics and outcomes of patients exposed to products containing butanol. METHODS: We performed a 5-year retrospective cross-sectional study by analyzing data from the Ramathibodi Poison Center Toxic Exposure Surveillance System for 2013-2017. RESULTS: There were 163 patients included in the study. All products containing butanol reported were agricultural adjuvant products. Most (67.5%) patients were males and had ingested butanol accidentally (75.5%). The median age was 42 years. Almost all patients had oral exposure to butanol. At presentation, most of our patients had normal vital signs and were conscious. Clinical presentations mostly included gastrointestinal symptoms (65%) and local irritation (28.8%). Fifty-four patients (33.1%) had no obvious clinical effects at presentation. Most patients had normal laboratory tests at presentation, although eight developed systemic effects including high anion gap metabolic acidosis (n=8), acute kidney injury (AKI; n=5), depression of consciousness (n=5), and hypotension (n=3). Of these eight patients, two with intentional ingestion developed altered consciousness, hypotension, AKI, severe metabolic acidosis, and eventually died. One of these died within 1 day after ingestion, while the other died later through complications during admission. Therefore, the mortality rate was 1.23%. Sixty-six patients (40.5%) were admitted to hospitals, with a median length of stay of 1 day. Most patients received only supportive treatment and fully recovered. CONCLUSION: Agricultural adjuvant products containing butanol or butanol itself caused only mild effects in most patients, but systemic effects occurred in some. The mortality from this poisoning was very low, and both fatalities were from intentional ingestion. Supportive care and proper management of complications should be the main treatment for this form of poisoning.

Development of a Physiologically Based Pharmacokinetic Model of Mitragynine, Psychoactive Alkaloid in Kratom (Mitragyna Speciosa Korth.), In Rats and Humans.

Mitragynine is a major psychoactive alkaloid in leaves of kratom (Mitragyna speciosa Korth.). To understand its disposition in organs, this study aimed to develop a physiologically based pharmacokinetic (PBPK) model that predicts mitragynine concentrations in plasma and organ of interests in rats and humans. The PBPK model consisted of six organ compartments (i.e. lung, brain, liver, fat, slowly perfused tissues, and rapidly perfused tissue). From systematic searching, three pharmacokinetic studies of mitragynine (two studies in rats and 1 study in humans) were retrieved from the literature. Berkeley Madonna Software (version 8.3.18) was used for model development and model simulation. The developed PBPK model consisted of biologically relevant features following involvement of (i) breast cancer-resistant protein (BCRP) in brain, (ii) a hepatic cytochrome P450 3A4 (CYP3A4)-mediated metabolism in the liver, and (iii) a diffusion-limited transport in fat. The simulations adequately describe simulated and observed data in the two species with different dosing regimens. PBPK models of mitragynine in rats and humans were successfully developed. The models may be used to guide optimal mitragynine dosing regimens.

A comparative analysis of kratom exposure cases in Thailand and the United States from 2010-2017.

Background: Interest in the Southeast Asian natural remedy kratom has increased in Western countries recently, along with increasing concern over its potential toxic effects.Objective: To describe and compare demographics, common co-exposure substances, clinical effects, treatments, and medical outcomes of kratom "abuse" exposures in the United States (US) and Thailand.Methods: This is a retrospective analysis of kratom "abuse" exposures, defined as use when attempting to gain a psychotropic effect, reported to the National Poison Data System (NPDS) in the US and the Ramathibodi Poison Center (RPC) in Thailand from 2010 to 2017. Multivariate analysis identified risk factors for severe medical outcomes, defined as both ICU admissions and death.Results: Nine-hundred-twenty-eight cases were included (760 from NPDS and 168 from RPC). A greater proportion of cases involved co-exposures in Thailand (64.8% versus 37.4%; odds ratio [OR] = 3.10, 95% confidence interval [CI] = 2.15-4.47, p < .01). Both countries had a similar prevalence of opioid and benzodiazepine co-ingestions, but the US had more co-ingestions with other sedatives (4.6% versus 0%, OR = 0, 95% CI = 0-0.47, p < .01). Common clinical effects included tachycardia (30.4%), agitation/irritability (26.2%), and drowsiness/lethargy (21.1%). Six deaths occurred, including one single-substance exposure in the US, three multiple-substance exposures in the US, and two multiple-substance exposures in Thailand. Severe medical outcomes were reported more frequently in the US (OR = 18.82, 95% CI = 5.85-60.56, p < .01).Conclusions: Despite lower frequencies of co-ingestants overall, US kratom abuse exposures yielded greater clinical severity. This disparity may be attributable to differences in the products labeled "kratom," greater sedative co-exposures in the US, and/or differences in population genetics or use patterns.

A Surviving Child from Acute Liver Failure after an Ingestion of Cassia occidentalis Seeds.

Cassia occidentalis toxicity is thought to be uncommon; however, several cases have been described with acute hepatomyoencephalopathy with a high-mortality rate. We report a previously healthy, 2-year-old girl who developed acute liver failure after fresh seed ingestion. Without a specific antidote, we decided to implement supportive measures and medications including lactulose, sodium benzoate and N-acetylcysteine. The patient also experienced with cardiogenic shock and transient distal renal tubular acidosis, which were all spontaneously resolved. The liver chemistries returned to normal 3 months after the ingestion, without receiving liver assisted device or liver transplantation.

Poisoning of glutaraldehyde-containing products: clinical characteristics and outcomes.

OBJECTIVE: This study describes the clinical characteristics, outcomes, and factors at presentation associated with death of cases poisoned by glutaraldehyde (GA)-containing products. METHODS: We performed a 5-year retrospective cohort study (July 2013-June 2018) using data from the Ramathibodi Poison Center. RESULTS: There were 244 cases included in this study. Most were men with a median age of 37 years. The GA-containing products were mainly used as farm disinfectants (99.2%), with a median concentration of 15%. Most products (76.2%) contained co-formulants such as cationic detergents and formaldehyde.Most circumstances were accidental (56.9%). The others were suicide attempts by ingestion, except one patient who intentionally injected GA subcutaneously. The most common route of exposure was ingestion (95.0%). Local symptoms in areas of exposure were common. Ingestion resulted in more severe local effects than other routes, and corrosive effects occurred in 23 cases (9.4%). Systemic signs and symptoms occurred in 149 patients (61.1%). Systemic effects included abnormal vital signs, desaturation, altered mental status, hypo/hypernatremia, hypokalemia, low bicarbonate/metabolic acidosis, acute kidney injury (AKI), hepatitis, and rhabdomyolysis. Systemic effects mostly resulted from ingestion. Most patients had mild severity, received only supportive treatment, and fully recovered. The median length of hospital stay was 2 days. The one case of subcutaneous injection developed both local and systemic effects but survived. The mortality rate was 3.7%. Multivariate analysis indicated that either neurological symptoms or AKI at presentation were associated with death. CONCLUSIONS: In our study, patients were exposed to GA-containing products that were mainly used as farm disinfectants and were generally co-formulated with other substances. Poisoning with these products commonly resulted in mild local irritative symptoms. However, some cases developed corrosive symptoms, systemic effects, or even died. As neurological symptoms or AKI could prognosticate deaths; physicians should look for these factors in patients with GA exposure at presentation for close monitoring and aggressive treatment.

Toad Poisoning: Clinical Characteristics and Outcomes.

OBJECTIVE: This study was performed to describe the clinical characteristics and outcomes of patients with toad poisoning in Thailand. METHODS: We carried out a retrospective study of patients with toad poisoning from the Ramathibodi Poison Center Toxic Exposure Surveillance System during a 5-year period (2012-2016). RESULTS: We studied 36 patients poisoned by toad toxin. The median age was 31 years. Most patients were male (66.7%) and had ingested toad meat (50%). The most common presentation was gastrointestinal (GI) symptoms with a median onset of 2 h after ingestion. Twelve patients presented with bradycardia; seven presented with shock and one with cardiac arrest. In the initial EKGs of all patients, the most common abnormality was sinus bradycardia.Two patients developed cardiac arrest early during management in the emergency room (within 15 minutes after ER arrival or within 4.5 h after ingestion). During admission, one patient developed sinus bradycardia, and two developed bradyarrhythmia; however, all three were stable. No tachyarrhythmias such as ventricular tachycardia were detected in any patient. Some patients (11.1%) presented with hyperkalemia. Serum digoxin was detected in five of seven patients tested, ranging from 0.43 to >8 ng/mL. Most patients (75%) were admitted to the hospital; the median duration of hospitalization was 2 d (range 0.5-5 d). The overall mortality rate was 8.3%, and all three patients that died ate toad meat and/or eggs and developed cardiac arrest. All patients received supportive with/without symptomatic care including GI decontamination, inotropic drugs, cardiac pacing, and management of hyperkalemia. One patient received intravenous calcium for hyperkalemia but did not develop dysrhythmia after calcium administration. One patient received digoxin-specific antibody fragments (DsFab), after which he clinically improved and was discharged. CONCLUSION: Toad poisoning commonly caused GI symptoms and bradycardia. However, in severe cases, death occurred. Tachyarrhythmia was not observed. Supportive, symptomatic care might be the main therapies for this poisoning, especially if DsFab is not available.

Acute Imidacloprid Poisoning in Thailand.

INTRODUCTION: Imidacloprid is the most commonly used neonicotinoid insecticide worldwide. Despite its reputation for safety, there is increasing evidence regarding its toxicity. This study characterized the clinical manifestations and outcomes of acute imidacloprid poisoning. METHODS: This was a retrospective study of patients with imidacloprid poisoning who were referred to the Ramathibodi Poison Center in Bangkok, Thailand between 2010 and 2018. RESULTS: A total of 163 patients with imidacloprid-only exposure were included. Most were exposed by ingestion (93.3%). The patients were predominantly male (55.8%), with a median age of 41.3 years. The common presenting features were gastrointestinal symptoms (63.8%) with no corrosive injuries and neurological effects (14.2%). The majority of medical outcomes was no (18.4%) to mild (76.1%) toxicity. One patient had symptoms mimicking cholinergic syndrome, three developed liver injury, and five died. Among the five deaths, two patients presented severe initial severity, and one presented moderate initial severity. Two of the patients who died initially presented only mild severity. The mortality rate was 3.1%. The estimated amount of ingestion, cardiovascular effects (especially tachycardia and cardiac arrest), central nervous system effects (especially coma), dyspnea, and diaphoresis were significantly associated with mortality. Patient management primarily included supportive and symptomatic care. CONCLUSION: Most patients with imidacloprid poisoning developed only mild toxicity. The mortality rate was low, but a few patients with mild initial severity died. Patients who ingest a large amount or show these warning signs including cardiovascular effects, central nervous system effects, dyspnea, and diaphoresis at the initial presentation should be considered for close observation and monitoring.

Myotoxic Mushroom Poisoning in Thailand: Clinical Characteristics and Outcomes.

PURPOSE: To describe the clinical characteristics and outcomes of myotoxic mushroom poisoning in Thailand. PATIENTS AND METHODS: We performed a retrospective cohort study of cases of myotoxic mushroom poisoning from the Ramathibodi Poison Center Toxic Exposure Surveillance System during a 5-year period (2012-2016). RESULTS: Forty-one cases were included. Most (53.7%) were male with the average age of 49 years. In three cases, the mushrooms were identified as Russula species by an experienced mycologist. Common presenting symptoms were gastrointestinal (GI) symptoms and myalgia. The median onset of GI symptoms and symptoms suggesting rhabdomyolysis after consuming mushrooms was 2 hours (0.17-24 hours) and 24-48 hours (2-120 hours), respectively. Eight patients who ate the mushrooms together with other patients with rhabdomyolysis had GI symptoms but did not develop rhabdomyolysis. For patients with rhabdomyolysis, acute kidney injury (AKI) and hyperkalaemia occurred in 51.5% and 33.3% of cases, respectively. Median initial and maximum creatine phosphokinase (CPK) levels in patients with rhabdomyolysis were 31,145 and 47,861 U/L, respectively. Fifteen of 17 patients who were investigated for troponin levels had elevated troponin. Three patients had a low ejection fraction. Most patients (95.1%) were admitted to hospital, with a median stay of 5 days. The mortality rate was 26.8%. Treatments included intravenous fluid, urine alkalinization, haemodialysis and peritoneal dialysis. Among patients with rhabdomyolysis, AKI, hyperkalaemia during hospitalisation, maximum CPK level, maximum creatinine level and initial and maximum potassium levels were the factors found to be significantly different between patients who died and those who survived. CONCLUSION: Myotoxic mushroom poisoning had a high mortality rate. Most patients had early or delayed onset of clinical symptoms after mushroom ingestion. Some patients developed severe cardiovascular effects. Early detection, close monitoring (especially serum potassium, creatinine, CPK and cardiac effect) and good supportive care were the main treatment modalities.

Clinical Characteristics of Acalypha indica Poisoning.

BACKGROUND: Acalypha indica is a tropical plant used as a herbal medicine in various parts of the world, including Thailand. In glucose-6-phosphate dehydrogenase (G6PD)-deficient patients, acute hemolysis has been reported following the ingestion of this plant. Methemoglobinemia was reported in the present study. PATIENTS AND METHODS: Descriptive data of patients who suffered from Acalypha indica toxicity reported from different hospitals to the Ramathibodi Poison Center were retrieved from 2011 to 2019. RESULTS: Eight patients were included, mostly male with a median age of 61.5 years. The plant was ground for fresh juice or boiled before consuming as herbal medicine. All patients presented with dark urine. Most had jaundice and fever, and all reported hemolysis. Seven out of eight patients were diagnosed as methemoglobinemia. Methemoglobin level was confirmed in five patients with the highest level of 23.9%. Early symptoms occurred within 24 hours of the last ingested dose. DISCUSSION: In previous case reports of Acalypha indica ingestion, acute hemolysis was mostly observed in G6PD-deficient patients, consistent with the current findings. However, our patients also demonstrated methemoglobinemia, with some constituents in this plant (quinine, 2-methyl anthraquinone and tectoquinone) implicated as the cause in previous studies. Further studies are crucial to validate these findings. CONCLUSION: We report a case series in which acute hemolysis and methemoglobinemia after Acalypha indica ingestion were observed. This study presents methemoglobinemia as the other toxicity caused by this plant.