دکتر غلامعلی دوروشی

Poisoning with Organophosphates (OP) and/or Pyrethroids (PYR) pesticides is common. We present a rare case of OP+PYR poisoned patient who suffered from Atrial Fibrillation (AF) at the beginning of treatment by a low dose of atropine and reviewed the literature. 

A 50-year-old man had ingested about 5-10 ml of a mixture of chlorpyrifos/cypermethrin.  Half an hour later, he went to the rural hospital and 2 hr later, after gastrointestinal decontamination, he was referred to the clinical toxicology department with normal vital signs except normal sinus tachycardia [Heart rate (HR)]=105. On admission, he had nausea, vomiting, diarrhea, mild sialorrhea, symmetric mid-size pupils, wet skin, and bilateral moist rales in his lungs. His cardiac rhythm changed to rapid AF (HR >140 beats/min) after treatment with 3 mg midazolam followed by 0.3 mg of atropine (0.1 mg every 1-3 min). Atropine administration was discontinued and he was treated with 0.5 mg of digoxin. 6 hr later, his arrhythmia disappeared and all cardiac and laboratory evaluations changed to normal except reduced serum cholinesterase activity.  

AF may be induced by Organophosphates (OP) and Pyrethroids (PYR) intoxication or during the treatment by atropine. We could not find any known risk factor (cardiac or medical issues) for AF in the current case. It may be suggested that poisoning with OP, PYR (alone or mixed) or atropine (in general or in low dose), or combination is the trigger of AF. However, AF is not life threating and can easily cure by antiarrhythmic therapy.

There is a high prevalence of intentional paraquat poisoning especially for suicide reported from many part of the world, with its negative effects on the lungs, kidneys, heart, and digestive system. This study was planned, aimed at investigating the efficacy of sucralfate in the treatment of oral paraquat poisoning with respect to its clinical outcomes.

A randomized double-blind clinical trial was conducted on 70 patients, suffering from oral paraquat poisoning. These patients were divided into two groups of 35 each. Subsequently, gastric lavage was performed for each patient in the control and treatment groups with 5g sucralfate mixed in tap water in the treatment group, but with tap water alone in the controls. The patients’ hemodynamic and laboratory parameters were evaluated and recorded, on admission and the hospital discharge dates. In addition, the patients’ final clinical outcome, including survival or death was also recorded.

The results of the present study revealed that the patients’ hemodynamic parameters, coagulation factors, renal and liver laboratory findings did not differ significantly between the two groups (P>0.05). Moreover, 45.7% and 31.4% of the patients died in the control and treatment groups, respectively (P>0.05).

The sucralfate administration did not have a significant effect on the patients’ hemodynamic and laboratory parameters. The survival of patients in the treatment group was slightly higher than those in the control group. Also the patients in the treatment group had less pulmonary and renal complications in the long-term than those in the control group.

Paraquat (PQ) poisoning is a serious public health concern, especially in developing countries, due to its easy access and lack of awareness of potential harms. No effective treatment has been reported yet. Conventional hemodialysis (HD) is still used in many centers for excreting PQ or reducing acute kidney injury, but there is no consensus on its efficacy. Therefore, we aimed to review the HD efficacy in PQ poisoning mortality.

We searched Web of Science, PubMed, Excerpta Medical Database, Google Scholar, Scopus, Cochrane, Web of Knowledge, Pro?Quest, ScienceDirect, Springer, Clinical Key,  cientific Information Database, Magiran, and Iran?doc, in publications before January 1, 2020. We compared patients who underwent HD (Group 1) with those who did not (Group 2). The outcome was considered mortality/survival. The data were analyzed by Comprehensive Meta?analysis Software.

This systematic review and meta?analysis included five studies with a combined total of 203 patients. The patients in the Group 1 had higher mortality than Group 2 (odds ratio, 2.84; 95% confidence interval: 1.22–6.64; P = 0.02). There was no evidence of publication bias (P value for Egger’s test = 0.833).

Although HD did not affect the survival of patients, other variables such as the amount of ingested PQ, poisoning severity, the time between PQ ingestion and the start of HD, duration, and times of HD sessions may influence the results regarding mortality.

Aluminum phosphide (ALP) (rice-tablet) is a common cause of adult poisoning in Iran, including Isfahan. So far, no effective treatment has been identified for this poisoning. We aimed to investigate the outcome of ALP poisoned patients admitted to the clinical toxicology ward of Khorshid Hospital in Isfahan from 2017 to 2019.

This chart-review study was performed on the population of ALP poisoned patients admitted to the clinical toxicology ward of Khorshid University Hospital from 2017 to 2019 treated with the hospital’s new treatment protocol, using the complete enumeration approach. The outcomes were determined by reviewing and abstracting medical charts of ALP poisoned patients from the hospital archive.

The most common complaints at admission were depressed consciousness (41.9%) and vomiting (32.2%). There was no significant change in blood sugar, pH, base excess (BE), and venous blood bicarbonate throughout their hospitalization (P > 0.05). Treatment outcomes had a significant relationship with blood pH 2 h and 6 h after admission and the BE 6 h after admission (P < 0.05). There was also a significant relationship between the outcome and the length of stay, initial ejection fraction (EF), and EF in predischarge echocardiography (P < 0.05). Out of 31 patients, 24 (77.4%) died within 72 h, 5 (16.1%) recovered without any complication, and 2 (6.5%) recovered with some complications.

The mortality rate of ALP poisoned patients was reasonably high and can be attributed to the poor efficacy of the new treatment protocol or the long time it takes for patients to reach the hospital and start receiving treatments.

Ethanol is a chemical that is easily absorbed in all parts of the gastrointestinal tract. This feature increases the risk of poisoning by ingesting this chemical at any amount; the signs and symptoms depend on the poisoned individual. Common symptoms of ethanol poisoning include sedation, poor coordination, vomiting, slurred speech, ataxia, respiratory depression, coma, and death. A rare manifestation of alcohol consumption is the raccoon eye. This article presents a 5-year-old girl who gradually showed a unilateral raccoon eye following ethanol consumption.

Lead poisoning was on the rise in recent years. There exists a lack of easy access to some of the main chelator drugs in developing countries. Thus, this study aimed to explore the comparative effects of Succimer and D-Penicillamine on acute lead poisoning patients from 2013 to 2018.

This descriptive study was conducted in the Clinical Toxicology Department of Khorshid Hospital in Isfahan City, Iran. Adult patients with acute lead poisoning were included in the study. Patients in the 3 treatment groups of D-Penicillamine, D-Penicillamine with succimer, and succimer were compared concerning demographic characteristics as well as clinical and laboratory findings at admission time and two weeks later.

In total, 163 patients were evaluated in this research. There was no significant difference between the treatment groups respecting improvement in clinical symptoms. The mean blood lead levels during hospitalization and two weeks after the treatment did not significantly differ between the three groups; however, there was a significant reduction in all study groups after two weeks of treatment (P<0.05). The mean white blood cell count was significantly lower only in the D-Penicillamine group two weeks after hospitalization (P<0.05). In the D-Penicillamine group, the mean platelet, hematocrit, and hemoglobin levels were significantly lower two weeks after hospitalization, although within the healthy range.

D-Penicillamine may be an acceptable chelator drug for treating patients with acute lead poisoning, especially in communities without access to drugs, like succimer.

Alcohol consumption leads to a significant number of deaths, mostly in men, worldwide. Considering the effect of ethanol toxicity on the heart, we studied various Electrocardiographic (ECG) changes in patients with acute ethanol poisoning.

A cross-sectional study was performed on patients admitted to Khorshid Hospital (affiliated to Isfahan University of Medical Sciences) due to ethanol poisoning. All 15- to 50-year-old patients with acute ethanol intoxication were included in the study (N=250). The patients’ information, including the demographic characteristics, clinical manifestations, and ECG changes were recorded and analyzed. Different variables were compared between the patients with or without ECG changes.

Most of the research patients (n=208) were men (83.82%). The Mean±SD age of the study patients was 26.8±8.87 years. About 54.8% of the patients presented abnormal ECG. The changes in ECG were not significantly different based on the demographic characteristic and clinical manifestations. The time interval between ethanol consumption and admission was significantly higher in patients with abnormal ECG, compared to those with normal ECG (Mean±SD: 7.09±10.67 vs. 4.77± 4.54 hours, respectively) (P=0.03).

ECG changes are common in patients with ethanol poisoning. The time interval between ethanol consumption to hospital admission may be an important factor in the occurrence of ECG changes.

Digoxin is extensively prescribed for cardiac diseases, so its chronic or acute toxicity commonly occur. Although digoxin specific antibodies (anti-digoxin Fab) are recommended to be used in patients with cardiac symptoms of digoxin toxicity, there is ongoing controversy about the effectiveness and dose of anti-digoxin Fab. Because our department lacks access to anti-digoxin Fab and the high cost of the antidote, we evaluated 10 years of experience in treating patients with digoxin toxicity without using digoxin Fab antibodies considering outcomes.

A retrospective study was performed in Khorshid Hospital, affiliated with Isfahan University of Medical Sciences, from October 2008 to September 2018. Patients with acute or chronic digoxin toxicity were included in the study. The patients’ data were gathered and analyzed according to their medical documents.

Out of 150 cases with digoxin toxicity, 38% (n=57) were acute and 62% (n=93) were chronic. About 64.7% (n=97) were female. The most common non-cardiac manifestations of toxicity were gastrointestinal (67.3%, n=101) and neurological symptoms (52.7%, n=79). Bradyarrhythmia (80.5%, n=33) was the most cardiac manifestation in patients with acute (15.8% n=9) and chronic (25.8%, n=24) toxicity. A total of 144 (96%) cases fully recovered with supportive care, and 6 patients (4%) died. None of the cases received anti-digoxin Fab.

The majority of presentations with acute or chronic toxicity recovered with supportive measures without using anti-digoxin Fab

Serotonin toxicity is a common but often unrecognized toxicological condition. In most cases, a combination of two or more serotonergic drugs can cause serotonin syndrome. We describe a case of serotonin toxicity in a 17-year-old woman, secondary to suicidal ingestion of 1000 mg lamotrigine and 400 mg citalopram, which has been rarely reported. Our patient had a medical history of depression and was treated with lamotrigine and citalopram. She was brought to the emergency room with nausea, diaphoresis, agitation, shivering, tremor, vertigo, ataxia, mydriasis, nystagmus, hyperreflexia, myoclonus, tachycardia, tachypnea, and mild fever. The symptoms and signs were resolved within 3 days following hydration, sedation, and cyproheptadine. Minor cardiovascular symptoms are probably due to the less toxic dose of citalopram. Lamotrigine, especially in combination with other serotonergic drugs, should be considered a cause of serotonin toxicity.

Myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) is syndrome with clinical evidence of acute MI (AMI) with normal coronary arteries. This study reports the case of a 23‑year‑old single woman referring to the hospital with clinical manifestations of MI, with electrocardiography findings of slow ventricular tachycardia or accelerated idioventricular rhythm and atrioventricular dissociation, and high troponin levels, which was admitted with the diagnosis of MINOCA due to mental stress (grief) and was discharged after 4 days of monitoring and following stabilization of conditions and absence of symptoms. Other causes of MINOCA ruled out through imaging studies. Mental stress can lead to MINOCA.

Paraquat has been recognized as a highly toxic agent for pest removal and is used worldwide.In adults, paraquat poisoning for suicidal attempts is much more common than accidental exposure poisoning. Approximately 20% of patients with paraquat poisoning develop pneumomediastonium as a complication with a mortality rate of approximately 100%. A 19‑year‑old man patient was admitted to the poisoning emergency department of Khorshid hospital, who had ingested paraquat. He had nausea and vomiting and had normal vital signs and examination in admission. Initial treatment for the patient was done. The patient signs got worsened on the 21st day of hospitalization and had severe emphysema of the superficial and deep spaces of the neck, followed by bilateral pneumothorax, and severe pneumomediastinum. Unfortunately, the patient died on the 27th day of hospitalization. Purpose of the current study is to raise awareness of rare paraquat toxicity complications, treatment, and especially its lethal complications, including pneumomomediastonium.

A case is presented on a 40-year-old male with chronic lead poisoning with loss of consciousness, rhabdomyolysis, and acute renal failure after occupational exposure. Physical examination revealed generalized atrophy, tenderness, and swelling in the right limb and a decreased proximal muscle strength in the lower limb. A severe acute polyradiculoneuropathy in lower limbs documented by electromyography. All paraclinical tests were normal except increased blood lead level (75 μg/dl) and blue line in gum of the teeth. The patient was treated with penicillamine (500 mg q8 h) and pyridoxine (50 mg daily) for 8 months, only accessible drug in Iran. Force of patient's muscles in the proximal part of the lower limb was improved, and also the blood lead level reached to normal range. This is the first patient with rhabdomyolysis and muscle necrosis induced by lead poisoning.

Minoxidil is an antihypertensive direct vasodilator that can cause severe toxicity when sufficiently ingested. We report a case of accidental ingestion of 5 ml topical minoxidil solution 5% presented with chest pain and new‑onset ST depressions. After giving IV saline and performing echocardiography/angiography, the patient fully recovered without any pharmacotherapy such as vasopressors and discharged 4 days after admission. The clinical toxicology, treatment, and previous case reports of minoxidil poisoning have been reviewed.

Suicide with cyanides is relatively rare but highly lethal. The lethal oral dose of cyanide salts is 200 mg, and concentrations >3 mg/L may be potentially lethal. The symptoms of poisoning are predominating in the central nervous system and cardiovascular system. We report the case of a 43-year-old goldsmith man who presented with self-poisoning by cyanide salt ingestion. Patient's symptoms included confusion, cardiac arrhythmias, hyperkalemia, leukocytosis, metabolic acidosis with high anion gap, hypotension, and then hypertension. The cause of the patients poisoning was not initially diagnosed. Intensive supportive treatment was performed. The patient died on the 3rd day of admission following cardiac arrest. At autopsy, hemorrhagic gastritis and cherry-red discoloration of the chest muscles were observed. Forensic toxicology showed cyanide in the blood and tissues. Cyanide poisoning could appear in different forms, and like our case, the symptoms can last for several days with nonspecific symptoms.

Poisoning with any of the colchicine or chloroquine drugs is rare. These drugs exert therapeutic and toxic effects on tissues by different mechanisms. Colchicine is used to treat a number of rheumatologic diseases and heart problems. In addition, chloroquine is used to treat malaria and some inflammatory diseases. There is a small gap between the therapeutic and toxic doses of these drugs. Gastrointestinal symptoms are the initial causes of poisoning with these drugs and then widespread organ failure in later stages can lead to sudden cardiac death. We introduce a case of concurrent poisoning with both drugs, in which the patient presented with a headache, nausea, and vomiting several hours after suicide. On the 1st day, the patient's status was stable, but on the 2nd day, the patient suddenly becomes ill and died even though the patient received supportive therapy. Concurrent poisoning with chloroquine and colchicine is extremely lethal, and early aggressive management is recommended even in an apparently stable patient.

One of the most frequent causes of death is poisoning worldwide. Investigating the causes of mortality due to poisoning profoundly affects making decisions and improving standards for preventing adverse events. Therefore, to better understand this problem and evaluate the causes, this study aimed to determine the risk of suicide using the SAD PERSONS Scale (SPS) criteria and its relationship with the birth month in poisoned patients.

This cross-sectional descriptive-analytic study was conducted on poisoned patients admitted to Khorshid Hospital in Isfahan City, Iran, in 2018. First, the patients’ age, gender, and birth month were recorded. Then, their suicide risk was assessed by SPS.

From 2735 referred patients with poisoning, 1839 (67.2%) attempted suicide, and 896(32.8%) cases were poisoned. The Mean±SD SPS score in patients with suicidal attempts was 4.89±1.94, and in the poisoned patients was equal to 2.74±1.46 (P<0.001). There was no significant relationship between suicide and birth month; however, gender (male), age, depression, previous suicidal attempts, ethanol abuse, rational thinking loss, social support lacking, and being unmarried significantly increased the risk of suicide (P<0.01). In addition, the SPS scores ≥5 with a sensitivity of 43.77%, and specificity of 98.44% had an acceptable diagnostic value in identifying the risk of suicide (P<0.0001).

As SPS criteria have an appropriate diagnostic value for suicide prediction, it is recommended that these criteria be assessed among individuals with susceptible suicide characteristics (e.g. males, elders, depression, the lack of social support, etc.), to prevent future suicide attempts and appropriate medical-psychological measures.

Tramadol is an analgesic drug being abused today a lot. Excessive ingestion will lead to hazardous complications such as convulsion and occasionally respiratory apnea. The aim of this study based on frequency respiratory apnea in patients with acute tramadol poisoning hospitalized in Farshchian Hospital of Hamadan, Iran from Jan 2014 to Dec 2015.
All patients with tramadol poisoning who hospitalized and treated at poisoning ward were enrolled into the study. Their demographic data including age, gender, drug ingestion dose, and respiratory apnea leading to taking naloxone or intubation collected and analyzed statistically by SPSS software.
Overall, 350 patients aged between 14 to 68 yr old were investigated. About 75% of them were male and among them, 81.14% had deliberate self-poisoning. 4.86% developed apnea whose average tramadol consumption was 4158.83 mg. In patients who had not apnea, the average tramadol consumption was 122.38 mg, that was statistically significant difference (P Although apnea development frequency in patients with excessive tramadol ingestion is rare, it is significant as a potentially life-threatening risk, occasionally ignored.