FATAL ACUTE ALIMINIUM PHOSPHIDE POISONING - CASE REPORT AND LITERATURE REVIEW WITH REFERENCE TO CURRENT TREATMENT PROTOCOLS AND OUTCOME.

Aluminum phosphide (AlP) has been known for more than 80 years as an effective pesticide for grain protection, but also as a suicidal agent used for human self-poisoning. Phosphine gas released in contact with stomach acid after oral ingestion of AlP is responsible for its toxicity. The poison affects all systems, so the mortality rate is quite high, especially after deliberate ingestions. We report the first case of severe AlP poisoning seen in our institution with a fatal outcome and furthermore, we present literature review on existing and newer treatment options. A 35-year-old woman with a history of epilepsy was admitted to the University Clinic for Toxicology in Skopje two hours after deliberate ingestion of one tablet of phostoxin (AlP). The first signs of poisoning were vomiting and abdominal pain, leukocytosis, prolonged PT, as well as inverted T waves in D3, AVF and left precordial leads on ECG. After developing respiratory failure and hypotension she was transferred to the intensive care unit (ICU). Her blood pressure was 80/40 mmHg, pulse rate 120/min. Laboratory findings showed signs of hepatic lesion, rhabdomyolysis and renal failure (AST 2267.42 U/L, ALT 2102.26 U/L, CPK 1334.81U/L, blood urea nitrogen 23.03 mmol/L, creatinine 211.9 µmol/L). Arterial blood gas analyses showed metabolic acidosis (pO2 9.6 kPa, pCO2 4.14 kPa, pH 7.15, bicarbonate 11 mmol/L, BE -15). The patient was placed on mechanical ventilation. Despite fluid supplementation, intensive therapy and inotropic support, hemodynamic instability worsened and cardiopulmonary resuscitation was performed three times. Unfortunately, the patient had a fatal outcome on the fourth day of intoxication. Solid formulations of AlP are very toxic. One tablet of phostoxin containing 3 grams of AlP is sufficient for the progression of life-threatening symptoms and fatal outcome. In the absence of antidote and elucidated mechanisms of toxicity, the key to treatment is rapid decontamination and initiation of resuscitation measures.

Clinical importance of insulin resistance after renal transplantation in patients on triple immunosuppressive therapy with cyclosporine, corticosteroids and mycophenolate mofetil.

INTRODUCTION: Post-transplant diabetes mellitus and impaired glucose tolerance are confirmed complications after solid organ transplantation associated with the use of glucocorticoids and calcinuerin inhibitors in maintenance immunosuppression. Insulin resistance (IR) is also an independent factor for cardiovascular morbidity and mortality among renal allograft patients. The aim of our work was to investigate the clinical importance of elevated IR in renal transplant recipients on standard triple-drug immunosuppression in correlation with immunosuppressive therapy and certain independent factors such as body mass index (BMI), time after transplantation, lipid disorders, etc. METHODS: 36 allograft pts with different periods after transplantation without previous glucose disorders were included in the study. An oral glucose tolerance test (OGTT) was made to distinguish pts with or without glucose disorders. The basal values of glucose (G) and insulin (I) were used to calculate indexes of IR and beta-cell function according to the homeostasis equations. Impaired fasting glucose (IFG), impairred glucose tolerance (IGT), impaired post prandial hyperglycemia (IPPH) and diabetes mellitus (DM) were also analysed. RESULTS: The mean value of the IR index was 2.57 +/- 1.20. It was elevated in 31 pts (86%) The IR showed a positive correlation with: I0 (p < 0.01), I2 (p < 0.05), beta cell function (p < 0.05) and CsA (p < 0.01). The fasting I, G, and BMI were shown as independent risk factors for IR (p < 0.01, p < 0.01, and p < 0.05 respectively). There were 12 pts with different glucose disorders (IFG, IGT, DM) and 24 pts without. The pts with glucose disorders showed an elevated IR index (91%) more frequently compared with (41.67%) decreased beta-cell function. CONCLUSION: IR is frequent among renal recipients with and without glucose disorders. IR is an independent risk factor for atherogenesis. Higher CsA trough levels are assotiated with higher Insulin values and indexes of IR. The defect in insulin action is more a prominent mechanism in post-transplant glucose disorders than the impaired insulin secretion.

CT evaluation of congenital choanal atresia: our experience and review of the literature.

Congenital choanal atresia (CCA) is the developmental failure of the nasal cavity to communicate with the nasopharynx. The aim of this study was to investigate and analyse the CT findings in such cases. Seven patients with CCA were included in our study over a 3-year period (2001-2004). All had a CT scan of the nasal cavity and nasopharynx to establish the diagnosis and to define the extent and type of atresia. The choanal atresia was found to be more commonly bilateral and more of the mixed (membranous-osseous) type. Bilateral CCA in the neonate is a medical emergency that should be treated as early as possible. Computed tomography is a valuable and easily accessible diagnostic tool.

Prooxidative/antioxidative homeostasis in heroin addiction and detoxification.

BACKGROUND: Long-term heroin abuse is related to pathological changes in many organs mediated by oxidative stress (OS). OBJECTIVES: Estimation of systemic OS and antioxidant capacity in heroin addiction and detoxification provides information about prooxidant/antioxidant homeostasis in heroin misuse and need for antioxidant supplementation. METHODS: OS was evaluated by the measurement of plasma reactive oxygen metabolites using spectrophotometric method and plasma lipid peroxidation by its end product--malondyaldehyd using Tiobarbituric Acid Reactions Substances method. The extracellular antioxidant capacity was estimated using OXY-adsorbent test. RESULTS: This cross-sectional study includes 68 patients: 46 heroin addicts (20 patients on chronic heroin abuse, 19 patients on conventional method of detoxification and 7 patients on opioid antagonist--naltrexone (and 22 patients as a control) group. Increased OS was found in the heroin group (d-ROMs 349.3 +/- 102.2 UCarr, MDA 4.0 +/- 0.4 micromol/L) compared to the group on detoxification (d-ROMs 230.2 +/- 96.4 UCarr; MDA 3.6 +/- 0.3 micromol/L) and control group (d-ROMs 264.1 +/- 30.9 UCarr; MDA 3.7 +/- 0.2 micromol/L). TAC was decreased in the heroin group (324.5 +/- 75.0 micromol HClO/ml) and restored during conventional detoxification (371.8 +/- 25.1 micromol HClO/ml), but not completely in the group with naltrexone treatment (335.6 +/- 16.9 micromol HClO/ml) compared with controls (395.4 +/- 35.6 micromol HClO/ml). CONCLUSION: Long-term heroin abuse stimulates a progressive systemic oxidative stress which increases the extracellular antioxidants consumption and develops conditions for chronic heroin toxicity (Fig. 1, Tab. 4, Ref. 35). Full Text (Free, PDF) www.bmj.sk.

Cherubism: review of four affected members in a Kuwaiti family.

Cherubism is a rare autosomal dominant fibro-osseous disorder of childhood, mostly limited to the maxilla and mandible. Extra-cranial skeletal involvement is rare. Post-pubertal involution of the process and jaw remodeling occurs in adulthood. The aim of this case report is to present four cherubs, a father and his three daughters, in whom the diagnosis was made based on history, physical examination, laboratory tests and typical radiological features. The imaging characteristics are discussed and the published literature is reviewed.

Spectrophotometric and electrochemical study of protolytic equilibria of some oximes-acetylcholinesterase reactivators.

Newly synthesized oximes, mono and bis imidazole derivatives, which promise to be more effective acetylcholinesterase reactivators than standard antidotes used, were investigated by spectrophotometric and electrochemical methods. The electrochemical investigations confirmed the existence of overlapping equilibria, obtained by spectrophotometric methods. Dissociation constants of those oximes were also obtained by numerical treatment of overlapping equilibria, using the Lavendberg Marquardt least square method, and when compared with the same for some similar compounds, were found to be very effective acetylcholinesterase reactivators. The distribution of ionic forms of the investigated oximes, as a dependence of pH values, was calculated from the obtained values of dissociation constants. The results indicated that many oxime anions will be available at physiological pH 7.4 and a relative increased ability to reactivate inhibited acetylcholinesterase could be expected.