gholamali dorooshi

Aluminum phosphate (ALP) poisoning has a high mortality rate (MR) secondary to cardiogenic shock. Recently, extracorporeal membrane oxygenation (ECMO) showed a successful result in this issue. We conducted a systematic review and meta?analysis to compare the MR of patients with ALP poisoning who underwent ECMO versus those with conventional treatment.

Two parallel databases’ reviews were done to find the ECMO treatment?applied studies or conventional treatment?applied studies according to the PRISMA protocol. All studies in any languages and English conference abstracts wereincluded for ECMO treatment?applied studies. Only English?language human  observational studies, which reported MR, were included in conventional treatment?applied studies. All ETAS case reports were summarized and used as a newly generated cross?sectional study (NGCSS) for inclusion in the meta?analysis.

Out of 167 and 1043 records, 17 case reports (24 cases), 3 cross?sectionalstudies, and 9 conventional treatment?applied studies were selected. In meta- analysis NGCSS applied as the fourth cross?sectional ECMO treatment?applied studies. The overall MR of ECMO?treated cases (23% [95% confidence interval (CI): 7%– 39%]) was significantly less than conventionally treated cases (60% [95% CI: 39%–63%]; P < 0.001). In ECMO?treated cases, the weighted mean difference (WMD) for age, blood pH, ALP dose, hospitalization, ECMO lag time, and ECMO duration were not statistically significant between survived and nonsurvived cases. However, WMD of cardiac ejection fraction (4.6%; 95% CI: 2.76%–6.39%; P < 0.0001), exposure to hospitalization lag time (?2.05; 95% CI: ?4.05–0.14 h; P = 0.06), and length of hospital stay (16; 95% CI: 12.0–20.5 days; P < 0.0001) between survived and  nonsurvived ETC were significant.

ECMO reduced the MR of ALP?poisoned patients; however, it is a highly invasive and complicated procedure.

Considering the high prevalence of paraquat poisoning with the intention of suicide and its extremely deadly effects on the major organs of the body, choosing the best treatment can play a significant role in reducing the mortality rate of these patients. For this purpose, this study was conducted to evaluate the therapeutic outcomes of paraquat-poisoned patients treated with a new treatment protocol.

The current retrospective study was conducted on 39 paraquat-poisoned patients treated with a new protocol. In the new protocol, in addition to the standard protocol, treatment with curcuma, pirfenidone, selenium plus, and silymarin is prescribed by gavage. By referring to the archive, basic and clinical information of these patients was extracted and recorded.

In this study, 18 (46.2%) recovered and 21 (53.8%) died. The prevalence of mortality was significantly related to the frequency distribution of gender and age of patients. Hence, the percentage of mortality was higher in men and in those over 35 years of age. In addition, in the new treatment protocol, it was found that although the administration of selenium, curcumin, and silymarin increased the chances of patients' recovery to an insignificant extent (P > 0.05), the administration of pirfenidone can significantly increase the recovery of patients (OR = 3.14 and P = 0.028).

According to the results of the present study, the administration of pirfenidone and other antioxidants can increase the recovery rate. Although the administration of silymarin, selenium, and curcumin did not show a significant relationship in terms of reducing mortality or increasing recovery, it seems that the treatment regimen based on these drugs results in a higher recovery rate.

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.

Poisoning is one of the most common methods of suicide in developing countries. We assessed the frequency of impaired hematological indices in patients with acute poisoning. The present study was a cross-sectional retrospective. Using the census sampling method, all patients who had attempted suicide by poisoning and were admitted from 2013 to 2023 were included in this study. Different variables, including age, gender, hematological index on admission, hospital stay, and outcome (mortality), were recorded in a data-gathering form. ANOVA and chi-square or Fisher’s exact tests were used for analysis. This study was conducted on 48186 patients, 53.4% of whom were male. The average age of the patients was 34.92 (±13.23). Of all patients, 6% had anemia, 15.1% leukocytosis, 15% higher than average hemoglobin, and 9.1% lower than average platelet count. White blood cell (WBC) count was higher (mean difference=3741.85, SD=151.35, 95% CI=3445.21–4038.5) in deceased patients, while platelet count was significantly lower in deceased patients (mean difference=17.19, SD=2.57, 95% CI=12.14–22.24) (P<0.001). Anemia correlated with more extended hospital stayby an average of 1.61 days (SD=0.27, 95% CI=0.98–2.24) compared to patients with normal hemoglobin. Thrombocytopenia also correlated with more extended hospital stays by an average of 1.38 days (SD=0.21, 95% CI=0.88–1.89). The frequency of abnormal hematological indices was not high in patients with acute poisoning. Deceased patients had higher WBC and lower platelet counts compared to surviving patients. Patients with anemia and thrombocytopenia had more extended hospital stays

Dry bite in snakebite is when progressive local symptoms, systemic manifestations, and laboratory disorders are not seen, generally there is no need for antivenom. The purpose of this research was to investigate the pattern of dry bites and their treatment outcome in the referral center.

In this cross-sectional study, patients with viper bites who were admitted to the poisoning department of Khurshid Hospital in Isfahan from April 2013 to 2019 as dry bites; were studied. Demographic characteristics, local, systemic, and laboratory symptoms of these patients were collected and analyzed.

During this period, 47 patients (33.81% of all snakebites) had dry bites. Bites were more common in men and more in spring and summer, and the north of Isfahan province than in other regions. Snake bites were more frequent in the upper limbs, lower limbs and, trunk, respectively. The most common symptom of the patients was pain at the bite site (63.8%), which improved with anti-inflammatory drugs in 63.8% and without any specific treatment in 36.2% of cases. During hospitalization and follow-up, the patients did not have any complications.

Pain was the most common symptom in hospitalized patients with dry bites caused by viper bites; However, many snakebite patients did not require antivenom. This finding can indicate that pain at the bite site alone does not justify the requirement to receive antivenom.

Hypoxic encephalopathy in adults is associated with different causes including Cardiorespiratory arrest, shock, and some poisonings such as carbon monoxide poisoning.

In this case series study, all the poisoned patients who had hypoxic encephalopathy based on radiological findings and were admitted to the poisoning department of Taleghani and Imam Khomeini hospitals in Urmia between 2016 and 2016 were included. Demographic characteristics, type of poison, type of poisoning, imaging findings, mortality, and length of hospitalization were extracted from the available files.

A total of 14 patients, all of whom were men, with an average age of 41.21 years, were examined. 64.3% of patients had a history of addiction. 85.7% of poisoning cases were unintentional. The most common intoxicant was methadone (42.6%) and the most common cause of encephalopathy was cardiorespiratory arrest (50%). The most common CT scan finding was diffuse edema and loss of white and gray matter differentiation, and the most common laboratory finding was leukocytosis. The average length of hospitalization was 34.4 days. The mortality rate was 85.7%.

Drug-consuming patients are at risk of overdose and possible occurrence of hypoxic encephalopathy, increasing the length of stay in hospitals, and death.

Poisoning with super-warfarin, zinc phosphide (ZnP) and aluminum phosphide (ALP) are among the most common poisonings with rodenticides. The purpose of this study was to investigate the frequency of macroscopic and microscopic findings obtained from autopsy in the deceased due to poisoning with these rodenticide poisons.

This cross-sectional study was conducted in 2020 in Isfahan Forensic Medical Center and referral poisoning emergency center in Khorshid Hospital, Isfahan, Iran. The autopsy and pathological findings in the deceased cases due to phosphides and super warfarin poisoning from 21 March 2018 to 20 Feb 2021 were evaluated.

During the study period, 165 patients were hospitalized due to super warfarin and ZnP; and 105 patients with ALP poisoning. Death ‎due to super warfarin was not reported. One patient died due to ZnP poisoning who did not undergo autopsy. 37(35.2%) people died from ALP of which 33 cases underwent postmortem examination. 24 (72.7%) of the deceased were men. And the average age was 29.39 years. In the autopsy findings, pulmonary edema (69.6%) and pleural effusion (21.2%) were the most common findings in ALP poisoning. The pathological findings were liver degeneration, pulmonary edema, and pulmonary hemorrhage. There was a significant relationship between serum bicarbonate on admission and liver autopsy finding. Also time from ingestion to hospital admission was correlated with liver pathology finding.

Considering the prevalence of pulmonary edema and pleural effusion in deceased patients with ALP, guiding fluid therapy by controlling central venous pressure should be considered.

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.

Tricyclic antidepressants poisoning (TCA) is associated with cardiovascular complications, electrocardiographic abnormalities, and central nervous system toxicity. This study aimed to compare the clinical manifestations of poisoned patients with tricyclic antidepressants alone or with benzodiazepine (BZD) intoxication according to the dose of BZDs.

In this case–control study, 120 patients with TCA poisoning were divided into four groups: the first group of TCA poisoning alone, the second group of TCA and BZD poisoning of <7.75 mg, the third group of TCA and B poisoning of 7.75 to 80 mg, and the fourth group of more than 80 mg of TCA and BZD poisoning. Patients’ demographic, clinical, and cardiac information was extracted from their records at admission and 6 h after admission.

Cardiac complications 6 h after referral and total cardiac complications between TCA and TCA low-dose BZD groups were significantly reduced in the low‑dose BZD poisoning group. Comparison of TCA and TCA groups with a moderate dose of BZD showed a significant reduction in time six and total cardiac complications. However, due to the significant difference in TCA values between the two groups, the results are not significant. Comparing the two groups of TCA and TCA with a high dose of BZD, both 6-hour cardiac complications and total cardiac complications in the high-dose BZD group, it was significantly reduced. However, the loss of consciousness was also considerably greater in the high-dose BZD group than in the TCA group.

Concomitant BZDs with TCA can reduce cardiovascular complications from TCA poisoning. However, with high doses of BZDs, there is a greater loss of consciousness.

The aim of this study was to investigate the frequency of poisoning mortality in the 5‑year period of 2014–2019 in Isfahan Khorshid Hospital, Iran.

This study is a cross‑sectional descriptive analytical study, which was performed in 2020. The demographic and clinical data about the patients were extracted from the patients’ files and were then analyzed.

The number of deaths due to poisoning in the study period was 264, and the mean age of the deceased was 42.33 ± 20.097. One hundred and ninety‑three (73.1%) patients were male. The frequency of deaths in the poisoning ward was 0.84%. The causes of death were accidental overdose (73, 26.9%), suicide (155, 63.2%), accidental use (18, 7.3%), and homicide in one patient. The mean age, time between exposure of toxin until death and history of addiction, substance use, and suicide in men patients was significantly higher than women (P < 0.05), however, such significant results were observed in married when compared with single patients. The differences between the two genders based on the type of toxic substance were statistically significant (P < 0.001). The most common causes of death were pesticides poisoning (n = 121), especially paraquat (n = 48) and Aluminum phosphide (n = 45), and multidrug poisoning (n = 48).

In this study, we showed that the death rate due to poisoning in our center was lower than other centers. The highest number of poisoning was in men as well as married patients. It is also recommended that more serious educational and preventive strategies should be used in this regard.

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.

Poisoning by opium and stimulants brings many patients to the poison emergency departments every year. This study planned to determine the risk factors for Opioid and Stimulant poisoning among patients admitted to the Khorshid Hospital.

The present cross-sectional study was performed on 243 patients poisoned with opioids or stimulants in Khorshid Hospital of Isfahan during December 2018 to the December 2019. The data about demographic variables including: (sex, age, marital status, occupation), type of intoxication (opium, heroin), and or stimulants(hashish, cannabis, marijuana, amphetamine) and intoxication with other substances, cause of intoxication, type of intoxication (accidental, intentional), method of intoxication (oral, inhalation, intravenous injection, intramuscular or subcutaneous injection, etc.), poisoning with other drugs, vital signs at entering the ward, length of stay in the poisoned ward, treatment outcome (recovery or death), and cause of death were extracted from the patients' files. The data were analyzed using the ANOVA and the Chi-square tests.

The results of this study showed that the most substance poisoning in individual of Iranian nationality was heroin and in non-Iranian was opium. In addition, substance poisoning was more common in men, especially in the age group of 31-35 years, and among the unemployed or self-employed, as well as among those with a diploma or lower.

According to the results of the present study, among opioid, heroin poisoning was the most and among stimulants, amphetamine was the most. Also, most of the poisoned people were under 40 years old and had low education.

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.

Emergency Medical Service (EMS) has an important role in the management of patients with opioid poisoning. Proper administration of naloxone is life-saving in these patients. We performed a study to compare the correlation between naloxone prescribed by the EMS and poisoning emergency physician in hospital for patients with opioid poisoning.

Patients with opioid poisoning referred by EMS to the poisoning emergency room of Khorshid Hospital affiliated to Isfahan University of Medical Sciences, Iran, from April 2016 to March 2017 were evaluated for toxico-epidemiological factors and outcome.

Out of 340 patients studied, 80% were men. Poisoning with methadone (33.3%) and opium (23.2%) were the most opioid poisoning. 47.9% of patients were drowsy after administration of naloxone by EMS, 35.9% were fully conscious, and 3.5% were restless. There was a significant difference in blood oxygen saturation between the two groups receiving and not receiving naloxone by EMS (P = 0.02). The mean age of patients receiving naloxone by EMS and hospital emergency service was higher than patients not receiving naloxone. There was a strong correlation between naloxone administration by EMS and in the hospital (r = 0.77; P < 0.001). Kind of opioid (opium) and patient’s age (more than 40 years) predicted the naloxone administration by EMS and in the hospital. All patients recovered completely.

There was a strong correlation in naloxone administration between EMS and emergency service in hospital. Due to the high average age of patients receiving naloxone, more attention to prevent possible side effects of naloxone is recommended.

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.

An 81-year-old female presented with a loss of consciousness and a history of fever, dry cough, dyspnea, and conjunctivitis during 5 days ago. On initial physical examination, the laboratory examination revealed high levels of lactate dehydrogenase and creatinine concomitant severe thrombocytopenia. Moreover, the peripheral blood smear showed schistocytes 3%, suggesting thrombotic thrombocytopenic purpura (TTP). A ground-glass pattern was reported in the high-resolution computed tomography of the lung. A positive polymerase chain reaction was reported for coronavirus disease 2019 (COVID-19). After initiating treatment for COVID-19, the patient received fresh frozen plasma and 24-h electrocardiogram monitoring in the emergency department. As the patient was being prepared for transfer to another hospital for plasmapheresis treatment, cardiac arrest occurred again, and the patient passed away. This study highlights the atypical behavior of this virus over the course of the disease including TTP with conjunctivitis, which could vary from case to case.

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.