Shiraz Emedical Journal
Volume:3 Issue: 2, Apr 2002

A 26 y/o man soldier came in with chief complaints of abdominal pain and diarrhea and bloody vomiting after ingesting some mushrooms. He also developed raised liver enzymes and alkaline phosphatase and was managed as a case of hepatic failure.

Arsenic, a heavy metal, has been used for many years in agriculture, industry, and medicine.In some countries (e. g., Iran) arsenic compounds is used as an alternative for mechanical hair trimming. However, it acts as a poison in the settings of acute overdosage and chronic (usually occupational) exposure. They have been used as suicidal and homicidal poisons since the middle Ages. It also induces caustic injury because of its alkaline contents. Acute arsenic poisoning leads to usually pronounced gastrointestinal symptoms due to dilatation of splanchnic vessels resulting in submucosal vesicle formation. The patient develops nausea, vomiting, diarrhea (which may be bloody), and abdominal pain. A garlicky breath odor may be detectable. Delayed cardiomyopathy, acute tubular necrosis and hemolysis may develop; fatal rhabdomyolysis is reported after acute arsenic ingestion. Arsine gas causes severe hemolysis within 3 to 4 hours and can lead to acute tubular necrosis and renal failure. In chronic arsenic poisoning, the onset of symptoms comes at 2 to 8 weeks, typical findings are skin and nail changes, such as hyperkeratosis, hyperpigmentation, exfoliative dermatitis, and mee''s lines (transverse white striaes of fingernailbeds which become evident after 2-3 weeks of exposure), sensory and motor polyneuritis manifesting as numbness and tingling in a "stocking-glove" distribution, distal weakness, and quadriplegia, and inflammation of the respiratory mucosa. When acute arsenic poisoning is suspected, an x-ray film of the abdomen may reveal ingested arsenic. Serum (or blood) levels are detectable only during the first 2 to 4 hours after ingestion, after which arsenic (in any form) is not readily detectable in blood or serum. Urinary arsenic levels should be measured in 24-h specimens collected after 48 hours of abstinence from seafood ingestion. Treatment of acute arsenic poisoning is consisted of vomiting induction, gastric lavage, hydration with control of electrolyte balance, administration of Dimercaprol (BAL), and finally hemodialysis. For chronic intoxication, avoiding further exposure is only approved treatment.

Systemic sclerosis (SS) was first identified over two centuries ago. It is characterized by its skin manifestations. However, cardiac signs were described in 1943 that were results of the underlying vascular involvement or sclerotic involvement of the kidney or lung. Cardiac involvement is a poor prognostic factor, but diagnosis may be late or missing because of the frequent discrepancy between clinical manifestation and cardiac involvement, for this reason, resort to all available diagnostic procedures is recommended to achieve an early diagnosis. Cardiac signs include myocardial fibrosis, myocardial necrosis (ischemia), Conduction abnormalities such as left anterior hemiblock, systolic and diastolic dysfunction, pericarditis and pericardial effusion/tamponade (which is usually secondary to renal involvement). These abnormalities usually present with biventicular congestive heart failure, atrial and ventricular arrhythmias, ischemic heart disease and sudden cardiac death. Antimyosin scintigraphy is a valuable non-invasive method for early detection of clinically silent cardiac involvement in patients with systemic sclerosis, even in the absence of left ventricular dysfunction. In patients with positive antimyosin study, intense pharmacologic treatment with vasodilators may be warranted. Cardiac score is a semiquantitative measure of cardiac involvement that improves prediction of prognosis in systemic sclerosis. Using this method, cardiac involvement assessed yearly by a semi quantitative cardiac scoring technique (the sum of 2 variables, scored 0 or 1 for left axis deviation and 0 or 2 for moderate-large pericardial effusion) and outcome at 10 years were evaluated in 90 systemic sclerosis patients enrolled in a 3 years prospective drug trial. Higher cardiac score was more significantly related to survival than any other individual cardiopulmonary variable. Predicted 6 year survival was 79% in patients with a cardiac score of 0, 51% in those with a score of 1, 15% in those with a score of 2 and 0% in those with a score of

A 38 years old pregnant lady is referred due to headache, weakness, facial pulsy and convulsion. Finally, cerebral venous thrombosis was diagnosed. Causes of persistent headache in pregnancy are reviewed briefly in this article.