Caffeine poisoning and lactate rise: an overlooked toxic effect?

Severe caffeine poisoning is rare but associated with a high mortality. The symptoms are mainly attributable to hyperadrenergic stimulation, are relatively well known and described in the literature. Transient rises in plasma lactate levels may occur but are, however, less well described. We present a case of serious caffeine poisoning with a concomitant rise in lactate treated with a non-selective beta-blocker and discuss briefly the symptomatology, the management of caffeine poisoning and the association between lactate and metabolic acidosis.

Hydrofluoric acid-induced burns and life-threatening systemic poisoning--favorable outcome after hemodialysis.

BACKGROUND: Skin contact with hydrofluoric acid (HF) may cause serious burns and life-threatening systemic poisoning. The use of hemodialysis in fluoride intoxication after severe dermal exposure to HF has been recommended but not reported. CASE REPORT: A 46-year-old previously healthy man had 7% of his body surface exposed to 71% HE Despite prompt management, with subsequent normalization of the serum electrolytes, recurrent ventricular fibrillation occurred. On clinical suspicion of fluoride-induced cardiotoxicity, acute hemodialysis was performed. The circulatory status stabilized and the patient fully recovered. High fluoride levels in the urine and serum were confirmed by the laboratory. DISCUSSION: There is no ultimate proof that the favorable outcome in this case was significantly attributable to the dialysis. However, most reported exposures of this magnitude have resulted in fatal poisoning. As our patient had normal serum electrolytes and no hypoxia or acidosis at the time of his arrhythmias, it was decided that all efforts should be focused on removing fluoride from his blood. The rationale for performing hemodialysis for this purpose is clear, even though such intervention is more obviously indicated in patients with renal failure. CONCLUSION: Hemodialysis may be an effective and potentially lifesaving additional treatment for severe exposure to HF when standard management has proven insufficient.

Presence of phenylethylamine in hallucinogenic Psilocybe mushroom: possible role in adverse reactions.

The use of mushrooms containing the hallucinogenic substance psilocybin for intentional intoxication is relatively common. Occasionally, this results in adverse reactions with typical tachycardia that is not evidently caused by psilocybin. This study demonstrates the presence of phenylethylamine in the species Psilocybe semilanceata using gas chromatography-mass spectrometry and shows that the amount of this substance may vary much more than that of psilocybin. The highest amount of phenylethylamine (146 microg/g wet weight) was observed in mushrooms from a case of three young men hospitalized because of adverse reactions. Comparison of the symptoms observed in clinical cases of magic mushroom intoxication with those after intake of pure psilocybin or phenylethylamine suggests that phenylethylamine might have a role in the development of adverse reactions to Psilocybe mushroom intake.

First clinical experiences with specific sheep Fab fragments in snake bite. Report of a multicentre study of Vipera berus envenoming.

OBJECTIVES: To evaluate the efficacy and safety of specific, ovine Fab fragments in the treatment of envenoming by the common adder, Vipera berus. DESIGN: Open study with historical controls. SETTING: Multicentre study involving patients (n = 30) with V. berus envenoming, treated in 18 Swedish hospitals during 1991-94. MAIN OUTCOME MEASURES: Initial symptoms, clinical course after treatment, duration of hospital stay and adverse effects of the antivenom were evaluated. Two earlier studied patient groups, given either equine F(ab)2 antivenom (n = 30) or no antivenom (n = 16), were used as controls. RESULTS: Specific ovine Fab fragments influenced favourably the acute symptomatology as well as the long term clinical course. Acute symptoms such as hypotension, shock, vomiting, diarrhoea and CNS-depression resolved quickly. The incidence of extensive swelling involving the trunk and the length of hospital stay were both reduced significantly compared to nontreated patients (23 vs. 88% and 3.5 vs. 6 days). Also the incidence of anaemia was reduced (23 vs. 44%). These results were consistent with those obtained with equine F(ab')2 antivenom, but with ovine Fab there were no immediate anaphylactic reactions or serum sickness. CONCLUSION: Specific Fab fragments produced from sheep immunized with V. berus venom were safe and effective in counteracting the effects of V. berus bite in humans. These results justify further studies of this new treatment for snake envenoming.

Nitrogen dioxide pneumonitis in ice hockey players.

Exposure to the toxic gases carbon monoxide and nitrogen dioxide (NO2) in indoor ice arenas occasionally occurs and may result in severe symptoms. The gases are produced by ice resurfacing machines operating on hydrocarbons, and in certain conditions toxic levels accumulate. The damage to lung tissues caused by NO2 may not be evident until after a latency time of 1/2-2 days. The role of corticosteroids in the treatment is controversial, but there are clinical experiences as well as experimental data supporting their use. We report two cases of toxic pneumonitis, with delayed onset, due to NO2 exposure during an ice hockey game in an indoor arena. Signs and symptoms were cough, dyspnoea, haemoptysis, hypoxaemia and reduced peak expiratory flow. Chest radiographs showed parenchymatous infiltrative lesions and alveolar consolidation. Both patients were treated with high doses of corticosteroids by inhalation and orally or intravenously. Their condition rapidly improved and pulmonary function was restored.

Development and clinical application of immunoassays for European adder (Vipera berus berus) venom and antivenom.

An ovine affinity purified Fab antivenom was used in a clinical trial in Sweden to treat European adder (Vipera berus berus) envenoming. Immunoassays were developed to measure V. b. berus venom and antivenom concentrations in clinical samples to help assess the efficacy of treatment. A radioimmunoassay (RIA) was developed, optimized and validated to measure plasma levels of V. b. berus venom and compared with a conventional ELISA. Both showed a similar variation of zero binding in biological samples and the results obtained correlated closely. However, the ELISA was quicker and more sensitive (0.8 compared with 2 micrograms/litre). Before administration of antivenom, V. b. berus venom concentrations in plasma ranged from 10 to 53 micrograms/litre; 12 hr after the Fab infusion, no patient had measurable levels. However, two patients had low venom levels 24 hr after treatment. ELISA and RIA were also developed, optimized and used to measure concentrations of free Fab in plasma. There was a biexponential fall of Fab concentration with a fast distribution phase (t 1/2 = 0.9 hr) and a slower elimination phase (t 1/2 = 18 hr). The amount of Fab excreted in urine was low.

Antivenom treatment in Vipera berus envenoming--report of 30 cases.

OBJECTIVES: To assess efficacy and safety of two equine F(ab')2 antivenoms currently used to treat envenoming by European vipers. DESIGN: Retrospective case review study. SETTING: Case records collected by the Swedish Poison Information Centre concerning patients treated in Swedish hospitals for bites by the common European adder, Vipera berus. SUBJECTS: Patients presenting with V. berus envenoming treated with antivenom (n = 30) and two groups of patients not given antivenom (n = 16 and n = 38). MAIN OUTCOME MEASURES: Clinical course and time in hospital were retrospectively studied and compared in patients treated or not treated with antivenom. RESULTS: There was a significantly lower incidence of extensive oedema (23 vs. 88%) and anaemia (10 vs. 50%) in the antivenom-treated group, and the hospital stay was shorter (median: 3 vs. 6 days). Antivenom treatment also resulted in prompt clinical improvement in the acute phase. Adverse effects consisting of urticaria and serum sickness occurred in 10% of the patients given antivenom. CONCLUSIONS: Antivenom treatment was associated with a reduced morbidity in severe V. berus envenoming. However, the occurrence of allergic side-effects is not negligible with this type of antivenom.

Ethylene glycol poisoning: experiences from an epidemic in Sweden.

In 1987 two lethal adult cases of accidental ethylene glycol poisoning were given spectacular attention in the Swedish mass media. This resulted in an epidemic of intentional ethylene glycol poisonings. In addition to six cases related to alcohol abuse, another 30 severe suicidal poisonings were reported to the Swedish Poison Information Centre in five months. The clinical course and outcome in these 36 severe cases are reviewed. The primary clinical manifestations were metabolic acidosis, CNS disturbances and kidney damage with circulatory failure in the most severe cases. Mortality was 17%. Fragmentation of the normal striation in heart cells was found in two of the fatal cases and severe brain damage in all fatal poisonings. The degree of acidosis but not the serum ethylene glycol level correlated with both kidney damage and outcome. Treatment included ethanol, correction of the metabolic acidosis and dialysis. Four patients with serum ethylene glycol concentrations of 10-20 mmol/L (620-1240 mg/L) but with no or minimal metabolic acidosis were treated with ethanol alone; none of these patients developed renal damage.

[Ingestion of aliphatic hydrocarbons can cause life-threatening lung damage in infants]. / Aspiration av alifatiska kolväten kan ge livshotande lungpåverkan hos småbarn.

Ingestion of aliphatic hydrocarbons--even in small amounts--can cause severe respiratory distress in children. Such accidents are becoming increasingly common in Sweden. A case of severe hydrocarbon ingestion is reported, where a 16-month-old boy, initially treated with mechanical ventilation for respiratory distress, subsequently developed a reversible radiological complication, pneumatocele. Patients at risk of severe hydrocarbon intoxication can be identified by careful evaluation of their history and continuous clinical observation. Controlled ventilation should be instituted early in respiratory distress, and any radiological changes followed up in a few weeks.