Pyrethrin, Pyrethroid Poisoning

 SUBSTANCE

-          Pyrethrin 除蟲菊精

-          Artificial: pyrethroid [1]

Common name or Trade name 

-          蚊香, 速必落, 滅飛, 拜貢, 克蟑[1]

 

Involving SYSTEM

-          delaying the closure of voltage-sensitive sodium channels. [1, 2]

-          Nearly 1% absorbed via skin [1]

-          GI discomfort [1, 2]

-          Airway irritative [1]

-          Bronchospasm [3]

-          Neurotoxic [2].

-          Cardiotoxic effects: prolonged bradycardia [2]

 

Presentation

-          Type I: T, tremor [1]

-          Tyee II: contains cyano-group, CS, choreoathetosis with salivation. [1]

-          Eye pain, tearing, and photophobia.[1]

-          Glasgow Coma Scale (GCS) <15 (33.9%) [4]

-          respiratory failure requiring ventilator care (17.9%) [4]

-          hypotension (10.7%), acute kidney injury (10.7%) [4]

-          pneumonia (7.1%) [4]

-          seizure (3.6%) and death (3.6%). [4]

 

Antidote and Treatment 

-          No antidote, supportive care. [1]

-          Using Bronchodilator when bronchospasm. [1, 5]

-          Decontamination [1]

-          Atropine improve the symptoms of type II pyrethrin related hypersecretion. [1]

-          Steroids, antihistamines and epinephrine PRN [5]

-          ACLS.

 

Disposition

-          Fatal dose when 10—100 gm. [1]

 

REFERENCES

1.      急診醫學會. 急性中毒救命術. 三版p.77—83.

2.      Shilpakar O, Karki B. Cypermethrin poisoning manifesting with prolonged bradycardia: A case report. Toxicol Rep. 2020 Dec 10;8:10-12. doi: 10.1016/j.toxrep.2020.12.005. PMID: 33364178; PMCID: PMC7750177.

3.      Wax PM, Hoffman RS. Fatality associated with inhalation of a pyrethrin shampoo. J Toxicol Clin Toxicol. 1994;32(4):457-60. doi: 10.3109/15563659409011049. PMID: 8057406.

4.      Cha YS, Kim H, Cho NH, Jung WJ, Kim YW, Kim TH, Kim OH, Cha KC, Lee KH, Hwang SO, Nelson LS. Pyrethroid poisoning: features and predictors of atypical presentations. Emerg Med J. 2014 Nov;31(11):899-903. doi: 10.1136/emermed-2013-202908. Epub 2013 Aug 19. PMID: 23959805.

5.      van den Bersselaar LR, van der Hoeven JG, de Jong B. Suicide after inhaling a pyrethrins containing insecticide spray. BMJ Case Rep. 2019 Apr 16;12(4):e227936. doi: 10.1136/bcr-2018-227936. PMID: 30996064; PMCID: PMC6506137.

edited by Yu-Jang Su    Nov 9, 2021. 

Bee Venom Poisoning

 

SUBSTANCE

   -Melittin and phospholipase A2, hyaluronidase, apamin, [1, 2, 3]

-           peptide 401 [3].

 

Common name or Trade name 

- Bees/wasps sting venom poisoning.

 

Involving SYSTEM

- Skin. 

-   Kidney:  Acute kidney injury: related to melittin attacking renal tubular epithelial cells (RTECs) [4, 5, 6, 7]

- acute respiratory failure, acute liver failure, rhabdomyolysis.

- 24.1% of hospitalized patients: Rhabdomyolysis [8]

-19.2% of hospitalized patients: hemolysis [8]

- liver injury in 30.1% of hospitalized patients [8].

- coagulopathy in 22.5% of hospitalized patients. [6, 8]

Presentation

-          Skin itching, painful. Systemic symptoms and signs when > 20 stings. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0083164]

-          Anaphylaxis. [9]

-          Skin necrosis. [10]

-          Angioedema [2]

-          Bronchospasm [2]

-          Shock [2]

-          wheezing

-          Gastrointestinal bleeding. [11]

-          DIC [2]

-          Coma [11]

 

Antidote and Treatment 

-          no antidote.

-Epinephrine 0.3 mg SC when anaphylactic shock. Bosmin 1 amp in N/S IV pump keep 30 c.c./hr.

- Tetanus toxoid [2].

- Ice packing, steroid ointment [2]

-Antihistamine [2]

- Steroid [2]

-Antibiotics when secondary infection. [2]

 

Disposition

 -76.9% of the hospitalized cases attacked 10 or > 10 stings with a mortality of 5.1%. [8]

-          4.4 % of hospitalized cases died of multi-organ injury [8]

-          1% of hospitalized cases died who were attacked less than 10 stings. [8]

-          Poor outcome when high creatinine level, shock, oliguria, and anemia [8].

REFERENCES

1.      Pillur Tamilarasu K, Shankar T, Kabi A. Unusual case of recurrent hypoglycaemia in multiple bee sting envenomation. BMJ Case Rep. 2021 Jul 26;14(7):e242440. doi: 10.1136/bcr-2021-242440. PMID: 34312127; PMCID: PMC8314743.

2.      急診醫學會. 急性中毒救命術.三版 p.191—197

3.      Silva GBD Junior, Vasconcelos AG Junior, Rocha AMT, Vasconcelos VR, Barros J Neto, Fujishima JS, Ferreira NB, Barros EJG, Daher EF. Acute kidney injury complicating bee stings - a review. Rev Inst Med Trop Sao Paulo. 2017 Jun 1;59:e25. doi: 10.1590/S1678-9946201759025. PMID: 28591253; PMCID: PMC5459532.

4.      Kim H, Hong JY, Jeon WJ, Baek SH, Ha IH. Bee Venom Melittin Protects against Cisplatin-Induced Acute Kidney Injury in Mice via the Regulation of M2 Macrophage Activation. Toxins (Basel). 2020 Sep 6;12(9):574. doi: 10.3390/toxins12090574. PMID: 32899913; PMCID: PMC7551791.

5.      Shu Y, Yang Y, Zhao Y, Ma L, Fu P, Wei T, Zhang L. Melittin Inducing the Apoptosis of Renal Tubule Epithelial Cells through Upregulation of Bax/Bcl-2 Expression and Activation of TNF-α Signaling Pathway. Biomed Res Int. 2019 May 29;2019:9450368. doi: 10.1155/2019/9450368. PMID: 31772938; PMCID: PMC6854966.

6.      Chen TH, Liao WT, Chen CS, Lin PC, Wu MY. An Envenoming Syndrome from Massive Vespa Stings Induces Multiple Organ Failure. Insects. 2020 Apr 2;11(4):219. doi: 10.3390/insects11040219. PMID: 32252275; PMCID: PMC7240471.

7.      Grisotto LS, Mendes GE, Castro I, Baptista MA, Alves VA, Yu L, Burdmann EA. Mechanisms of bee venom-induced acute renal failure. Toxicon. 2006 Jul;48(1):44-54. doi: 10.1016/j.toxicon.2006.04.016. Epub 2006 May 6. PMID: 16774771.

8.      Xie C, Xu S, Ding F, Xie M, Lv J, Yao J, Pan D, Sun Q, Liu C, Chen T, Li S, Wang W. Clinical features of severe wasp sting patients with dominantly toxic reaction: analysis of 1091 cases. PLoS One. 2013 Dec 31;8(12):e83164. doi: 10.1371/journal.pone.0083164. PMID: 24391743; PMCID: PMC3877022.

9.      Hughes RL. A Fatal Case of Acute Renal Failure From Envenoming Syndrome After Massive Bee Attack: A Case Report and Literature Review. Am J Forensic Med Pathol. 2019 Mar;40(1):52-57. doi: 10.1097/PAF.0000000000000451. PMID: 30531211.

10.  Toledo LFM, Moore DCBC, Caixeta DMDL, Salú MDS, Farias CVB, Azevedo ZMA. Multiple bee stings, multiple organs involved: a case report. Rev Soc Bras Med Trop. 2018 Jul-Aug;51(4):560-562.

11.  Iliev YT, Tufkova SG, Prancheva MG. A rare case of severe intoxication from multiple bee stings with a favorable outcome. Folia Med (Plovdiv). 2010 Jul-Sep;52(3):74-7. doi: 10.2478/v10153-010-0010-5. PMID: 21053677.

edited by Yu-Jang Su    Oct 30th, 2021. 

False-Positive Urine Drug Screen

  

UDS (urine drug screen)	Causing False Positive Substance	Possible Treatment-Related	References
Amphetamine and 3,4-methylenedioxymethamphetamine (MDMA)	Amantadine Aripiprazole Bupropion chlorpromazine  Esmolol Ephedrine Labetalol Dimethylamylamine (DMAA) Methylphenidate promethazine Selegiline Phentermine Pseudoephedrine Ranitidine Selegiline  Trazadone	trazodone	[1] [2] [3] [4] [5]
Benzodiazepine	50% of Efavirenz user Oxaprozin Sertraline		[3] [4] [5]
Cannabinoid	Efavirenz 600mg lumacaftor/ivacaftor Ibuprofen Naproxen		[3] [4] [5] [6]
Ketamine	Quetiapine (Seroquel)		[7]
Methadone	quetiapine		[3]
Opiate, Opioid	Quetiapine 69.2% Levofloxacin, ofloxacin and pefloxacin users Poppy seeds Verapamil	Buprenorphine Naloxone	[3] [4] [5] [7]
Phencyclidine (Angel Dust)	Tramadol Venlafaxine Medicon (Dextromethorphan) Diphenhydramine Ketamine		[3] [4] [5]
Tricyclic Antidepressants	Carbamazepine Cyclobenzaprine Diphenhydramine Phenothiazines		[5]

 

1.      Caricasole V, Spagnolo G, Di Bernardo I, Cirnigliaro G, Piccoli E, Dell'Osso B. Aripiprazole causing false positive urine amphetamine drug screen in an adult patient with bipolar disorder. Compr Psychiatry. 2019 Oct;94:152126. doi: 10.1016/j.comppsych.2019.152126. Epub 2019 Sep 5. PMID: 31518847.

2.      Adashek JJ, Khadilkar A, Enciso J, Rane R, Wu R. A Case of Esmolol-Induced False-Positive Amphetamine Urine Drug Test. Cureus. 2021 Jan 2;13(1):e12429. doi: 10.7759/cureus.12429. PMID: 33542876; PMCID: PMC7849827.

3.      Saitman A, Park HD, Fitzgerald RL. False-positive interferences of common urine drug screen immunoassays: a review. J Anal Toxicol. 2014 Sep;38(7):387-96. doi: 10.1093/jat/bku075. Epub 2014 Jul 1. PMID: 24986836.

4.      Shafiq Q, Mutgi A. Urine opiate screening: false-positive result with levofloxacin. CMAJ. 2010 Oct 19;182(15):1644-5. doi: 10.1503/cmaj.091508. Epub 2010 Sep 27. PMID: 20876267; PMCID: PMC2952012.

5.      Algren DA, Christian MR. Buyer Beware: Pitfalls in Toxicology Laboratory Testing. Mo Med. 2015 May-Jun;112(3):206-10. PMID: 26168592; PMCID: PMC6170116.

6.      Kissner D, LeFlore Y, Narayan SB, Marigowda G, Simard C, Le Camus C. False-positive cannabinoid screens in adult cystic fibrosis patients treated with lumacaftor/ivacaftor. J Cyst Fibros. 2018 Nov;17(6):e51-e53. doi: 10.1016/j.jcf.2018.08.006. Epub 2018 Sep 12. PMID: 30217546.

7.      Liu CH, Wang HY, Shen SH, Chiu YW. False positive ketamine urine immunoassay screen result induced by quetiapine: A case report. J Formos Med Assoc. 2017 Sep;116(9):720-722. doi: 10.1016/j.jfma.2017.04.008. Epub 2017 May 8. PMID: 28495417.

edited by Yu-Jang Su   Sep 12, 2021.

NOACs, novel oral anticoagulants

 

NOAC	Trade name	Peak level	Action site (4)	Lower ICH rate than Warfarin (5)	antidote	Reversal by Hemodialysis	other
Dabigatran (2010)	Pradaxa 150 mg/cap BID, 75mg BID when CCr< 30 [1]	0.5—2 hrs.	Thrombin (IIa)	yes	Idarucizumab 2.5gm stat and BID. (6)  four factor prothrombin complex concentrate (4F-PCC)	Helpful (10)	Easily GI bleeding
Rivaroxaban	Xarelto 20mg/tab QD. 15mg QD when CCr<50 [1]	2—4 hrs	Xa	yes	andexanet alfa and four factor prothrombin complex concentrate (4F-PCC)(7*, 8)	will not be dialyzable [11]	Easily GI bleeding
Apixaban	Eliquis 5 mg/tab BID, 2.5 mg BID when > 2 risk factors. [Age ≥ 80; Weight ≤ 60; Serum Creatinine ≥ 1.5 mg/dL] [1]	2—4 hrs. (2)	Xa	yes	andexanet alfa and four factor prothrombin complex concentrate (4F-PCC)(7*, 8)	unclear whether dialysis would be useful [11].	Less significant bleeding, Hazard ratio=0.5 (12)
Edoxaban	Lixiana 60 mg/tab QD, 30mg QD when CCr<30 [1]	1—2hrs (3)	Xa	yes	four-factor prothrombin complex concentrate (4F-PCC) at 50 IU/kg (8, 9)	unclear whether edoxaban can be dialyzed [11].	Less significant bleeding, Hazard ratio=0.83 (12)

 

 * N=56, in setting of ICH, hemostatic efficacy occurred in 64.7% of patients receiving andexanet alfa and 54.8% of receiving 4F-PCC. Thirty-day all-cause mortality was 45.2% for 4F-PCC and 30% for andexanet alfa(7).

 GI = gastro-intestinal.

References

 

1.      Hu A, Niu J, Winkelmayer WC. Oral Anticoagulation in Patients With End-Stage Kidney Disease on Dialysis and Atrial Fibrillation. Semin Nephrol. 2018 Nov;38(6):618-628.

2.      https://www.mayocliniclabs.com/test-catalog/Clinical+and+Interpretive/65848

3.      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608015/

4.      Polzin A, Dannenberg L, Thienel M, Orban M, Wolff G, Hohlfeld T, Zeus T, Kelm M, Petzold T. Noncanonical Effects of Oral Thrombin and Factor Xa Inhibitors in Platelet Activation and Arterial Thrombosis. Thromb Haemost. 2021 Feb;121(2):122-130.

5.      Katsanos AH, Schellinger PD, Köhrmann M, Filippatou A, Gurol ME, Caso V, Paciaroni M, Perren F, Alexandrov AV, Tsivgoulis G. Fatal oral anticoagulant-related intracranial hemorrhage: a systematic review and meta-analysis. Eur J Neurol. 2018 Oct;25(10):1299-1302.

6.      Lindeman E. Målstyrd antidotterapi vid reversering av dabigatran [Goal-directed administration of antidote for reversal of dabigatran anticoagulation]. Lakartidningen. 2017 Dec 5;114:ESF3. Swedish.

7.      Vestal ML, Hodulik K, Mando-Vandrick J, James ML, Ortel TL, Fuller M, Notini M, Friedland M, Welsby IJ. Andexanet alfa and four-factor prothrombin complex concentrate for reversal of apixaban and rivaroxaban in patients diagnosed with intracranial hemorrhage. J Thromb Thrombolysis. 2021 Jun 8. doi: 10.1007/s11239-021-02495-3.

8.      Carpenter E, Singh D, Dietrich E, Gums J. Andexanet alfa for reversal of factor Xa inhibitor-associated anticoagulation. Ther Adv Drug Saf. 2019 Nov 26;10:2042098619888133.

9.      Galbiati G. Successful Cerebral Hemorrhage Control with Prothrombin Complex Concentrate in a Patient on Edoxaban Therapy: A Case Report. J Blood Med. 2020 Jan 30;11:35-38.

 

10.  Awad NI, Brunetti L, Juurlink DN. Enhanced elimination of dabigatran through extracorporeal methods. J Med Toxicol. 2015 Mar;11(1):85-95.

11.  Crowther M, Crowther MA. Antidotes for novel oral anticoagulants: current status and future potential. Arterioscler Thromb Vasc Biol. 2015 Aug;35(8):1736-45.

12.  https://jtp.taiwan-pharma.org.tw/139/013.html

 

 

edited by Yu-Jang Su  Aug, 17, 2021.

COVID-19 impacts on Poisoning

l  Decrease in the number of toxic effects by contacting with venomous animals and plants (ICD10: T63) in 2020, especially 2020 Q1-Q2 (-44.8%, -20.1%). The major cause is the staying home policy. 

l  Number of suicide overdose (ICD: T39, T42, T43, T50, T54, T58, and T60), increased during 2020 Q1 and Q2 (+15.5% and +11.4%). Indeed, the COVID-19 leads to a mental impact on everyone. 

l  Significant decrease in the number of uses of illicit drugs especially in 2020 Q1 and Q2 (-37.5% and -66.7%).

Ref:  https://pubmed.ncbi.nlm.nih.gov/34312037/

edited by Yu-Jang Su  July 29, 2021.

Special Odor in Poisoning

 

Bitter Almond odor: cyanide

https://pubmed.ncbi.nlm.nih.gov/33643738/

-          only 40-45% of people can detect the bitter almond odor. (ref:https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2018/June%202018%20ToxTidbits.pdf)

 

 Garlic-like odor: Selenium, Arsenic

https://pubmed.ncbi.nlm.nih.gov/31775070/

 

 faint odor of Pears: Chloral hydrate

Ref: https://first10em.com/chloral-hydrate-toxicity/

 

 Rotten eggs odor: hydrogen sulfide  

https://pubmed.ncbi.nlm.nih.gov/24328850/

 

 sweet, Pungent odor: Toluene

https://www.epa.gov/sites/production/files/2016-09/documents/toluene.pdf

 

 Others: https://fpnotebook.com/er/Toxin/TxnIndcdOdrs.htm

edited by Yu-Jang Su   June 26, 2021