Chronic amitriptyline overdose in a child.

Amitriptyline, a tricyclic antidepressant, has a well-described toxicity profile, and acute ingestions are common in the pediatric toxicology world. However, little can be found in the literature regarding chronic overdose. We describe a case of a 6-year-old girl who was prescribed amitriptyline 30 mg nightly for sleep problems, but was mistakenly given 300 mg (15 mg/kg) nightly for over a month. She was noted to have mental status changes and difficulty reading several days after starting the medication. She presented to the local children's hospital in status epilepticus with significant cardiac conduction abnormalities on ECG. Her total amitriptyline/nortriptyline level was found to be 1676 ng/mL (normal therapeutic level 50-300 ng/mL). She was treated for several days with sodium bicarbonate. Within 24 h, her neurologic status improved and had returned to baseline within several days. Her ECG normalized, and she was discharged home, without apparent sequelae. A brief discussion of possible protective mechanisms (including pharmacogenomic) is presented.

Systemic loxoscelism confirmation by bite-site skin surface: ELISA.

We report here a case of systemic loxoscelism, confirmed by bite-site skin surface swab. Features of systemic loxoscelism present in this case included debilitating symptoms, a classic local bite-site reaction, hemolysis causing loss of approximately 15% of the blood volume within 72 hours, and a symptomatic exanthem. A skin surface ELISA test was used to confirm the presence of venom. This test enables confirmation of cases of loxoscelism for which no spider is found.

Toxicity and use of over-the-counter cough and cold medication in the pediatric population.

Discussions of the efficacy and toxicity of over-the-counter cough and cold medication have been circulating in the pediatric literature for years. Adverse effects of these medications and the lack of evidence of their efficacy in children make their use a serious matter. An additional consideration for physicians is the recreational use of over-the-counter medications, including adolescent abuse of dextromethorphan. The recent increase in media attention to these issues warrants further review.

24-hour provoked urine excretion test for heavy metals in children with autism and typically developing controls, a pilot study.

INTRODUCTION: The complementary and alternative medicine practice of prescribing chelators to children with autism is based on the premise that the chronic symptoms of autism can be ameliorated by reducing heavy metal body burden. However, there has not been definitive evidence, published to date, to support the assertion that children with autism are at increased risk of an excess chelatable body burden of heavy metals. The oral chelator meso-2,3-dimercaptosuccinic acid (DMSA) can be used diagnostically to mobilize heavy metals from extravascular pools, enhancing the identification of individuals who have a chelatable body burden. METHODS: Seventeen children with autism and five typically developing children were enrolled in a pilot study to test for chelatable body burden of Arsenic (As), Cadmium (Cd), Lead (Pb), and Mercury (Hg). Evaluation included a questionnaire regarding potential exposure to heavy metals, diet restrictions, a baseline 24-hour urine collection, and a DMSA-provoked urine collection. Urine collections were sent for As, Cd, Pb, and Hg quantification by Inductively Coupled Plasma-Mass Spectrometry. Unprovoked reference ranges were used in the interpretation of all collections. RESULTS: Fifteen autistic children and four typically developing children completed the study. Three autistic subjects excreted one metal in greater quantity during the provoked excretion than baseline. Two of these were very close to the limit of detection. In the third case, the provoked excretion of mercury was between the upper limit of normal and lower limit of the potentially toxic reference range. Fish was removed from this child's diet for greater than one month, and the provoked excretion test repeated. The repeat excretion of mercury was within the normal range. CONCLUSION: In the absence a proven novel mode of heavy metal toxicity, the proportion of autistic participants in this study whose DMSA provoked excretion results demonstrate an excess chelatable body burden of As, Cd, Pb, or Hg is zero. The confidence interval for this proportion is 0-22%.

Cytokines and toxicity in acetaminophen overdose.

Several cytokines have been reported to have hepatoprotective properties in animal models of acetaminophen toxicity. To investigate the relationships of cytokines and toxicity in acetaminophen overdose, blood samples were collected from patients following acute ingestions of acetaminophen. Samples for cytokine analysis were collected at the time of routine clinical monitoring in 111 patients (90 females; mean age 13.6 years). Plasma concentrations of interleukin 6, interleukin 8, interleukin 10, and monocyte chemoattractant protein 1 were analyzed by enzyme-linked immunosorbent assay. Patients were stratified by toxicity severity, defined by the maximal values of hepatic transaminase elevation. Levels of interleukin 6, interleukin 8, and monocyte chemoattractant protein 1 were higher in patients with serum alanine aminotransferase > 1000 IU/L, and monocyte chemoattractant protein 1 had the strongest association with toxicity. Monocyte chemoattractant protein 1 values were higher in patients with greater delays in N-acetylcysteine treatment and in patients with higher values of prothrombin time. Monocyte chemoattractant protein 1 elevation in acetaminophen overdose may represent an innate, immunomodulary response of the liver to earlier events in the toxicity. An understanding of the role of cytokine responses in acetaminophen overdose may be relevant to the future development of new therapies for acetaminophen toxicity.