Poisoning/ Intoxicated caused Skin discoloration

 

Substance	Skin	Year	Country	Reference
Carbon monoxide	cherry-red colour in the skin	1988	South Africa	Br J Dermatol. 1988 Jul;119(1):45-51. doi: 10.1111/j.1365-2133.1988.tb07099.x. PMID: 3408663.
Silver	darkly grayish "discolored" skin	2002	USA	Vet Hum Toxicol. 2002 Oct;44(5):291-2. PMID: 12361115.
dipyridamole (Persantin Depot) corresponding to 34 g	drug has a distinct yellowish colour	2003	Swedish	Lakartidningen. 2003 Dec 11;100(50):4194-5. Swedish. PMID: 14717009.
Rohypnol 1 film tablets (containing the coloring agent indigocarmine in its core)	bluish-turquoise coloration nostril and within the oral cavity	2004	German	Arch Kriminol. 2004 Sep-Oct;214(3-4):93-8. German. PMID: 15553282.
Cresol	black urine and dark skin	2010	Malyasia	Clin Toxicol (Phila). 2010 Nov;48(9):959-60. doi: 10.3109/15563650.2010.523830. Epub 2010 Oct 6. PMID: 20923396.
300 mg of vitamin B6 per day over 6 months	brown-coloured skin	2015	Kiel, Germany	Eur J Clin Nutr. 2015 Jul;69(7):862-3. doi: 10.1038/ejcn.2015.83. Epub 2015 Jun 3. PMID: 26039319.
2,3-dimercapto-1-propanesulfonic acid (DMPS)	Fixed drug eruption (ADR)* Annular, purple color plaque on penis	2019	Ankara , Turkey	Acta Clin Belg. 2019 Jun;74(3):200-202. doi: 10.1080/17843286.2018.1484983. Epub 2018 Jun 18. PMID: 29912651.
2,4-dinitrophenol (DNP) and clenbuterol	yellowish skin colour	2020	Paris, France.	Int J Legal Med. 2020 May;134(3):1003-1006. doi: 10.1007/s00414-020-02268-2.

l  * ADR= adverse reaction.

edited by Yu-Jang Su   March 2, 2022. 

 

Poisoning / Intoxicated related Intracranial Hemorrhage.

 

Date	Country	Age	Gender	Substance	hemorrhage
2019	China	44	Female	Bromadiolone, often called a super-warfarin	SAH [1]
2018	France	47	Man	Ticagrelor	ICH [2]
2018	Japan		Male	Cocaine	SAH [3]
2017	China	Neonatus	Male	Bromadiolone, often called a super-warfarin	severe SDH, bilateral IVH  and SAH [4]
2017	Iran	70	Male	Methanol	expanding hemorrhagic transformation in previous hypodensities.[5]
2017	Canada		Female	Diethylene glycol (DEG)	right basal ganglia hemorrhage[6]
2016	Saudi Arabia	47	Man	Methanol	basal ganglia; putamen, IVH, SAH[7]
2015	Korea			Methanol	IVH [8]
2006	Turkey	35	Male	Methanol	ICH[9]
2005	France	50	Male	Ethylene glycol	Bipallidal haemorrhage[10]
1995	Brazil			Methanol	Bilateral putaminal hemorrhage[11]
1988	Canada			Methanol	13.5% ICH [12]

  The table does not contain trauma, secondary causes, and substance leading to intracranial hemorrhage with unclear, unexplained mechanisms. SAH =  subarachnoid hemorrhage; ICH = intracranial hemorrhage; IVH = intra-ventricular hemorrhage.

 

References

 

1.      Zuo W, Zhang X, Chang JB, Ma WB, Wei JJ. Bromadiolone poisoning leading to subarachnoid haemorrhage: A case report and review of the literature. J Clin Pharm Ther. 2019 Dec;44(6):958-962. doi: 10.1111/jcpt.13005. Epub 2019 Sep 26. PMID: 31556967.

2.      Willeman T, Marlu R, Böhle H, Francony G, Jourdil JF, Fonrose X, Stanke-Labesque F. Lethal cerebral hemorrhage after ticagrelor intoxication: a specific antidote is urgently needed. Clin Toxicol (Phila). 2018 Dec;56(12):1200-1203. doi: 10.1080/15563650.2018.1480026. Epub 2018 Jun 11. PMID: 29889575.

3.      Takayama M, Waters B, Fujii H, Hara K, Kashiwagi M, Matsusue A, Ikematsu N, Kubo SI. Subarachnoid hemorrhage in a Japanese cocaine abuser: Cocaine-related sudden death. Leg Med (Tokyo). 2018 May;32:43-47. doi: 10.1016/j.legalmed.2018.02.008. Epub 2018 Mar 2. PMID: 29518652.

4.      Ma M, Zhang M, Tang X, Li Z. Massive neonatal intracranial hemorrhage caused by bromadiolone: A case report. Medicine (Baltimore). 2017 Nov;96(45):e8506. doi: 10.1097/MD.0000000000008506. PMID: 29137047; PMCID: PMC5690740.

5.      Hassanian-Moghaddam H, Bahrami-Motlagh H, Zamani N, Fazeli SA, Behnam B. Intracranial Hemorrhage in Methanol Toxicity: Challenging the Probable Heparin Effect during Hemodialysis. J Res Pharm Pract. 2017 Jul-Sep;6(3):186-189. doi: 10.4103/jrpp.JRPP_17_39. PMID: 29026846; PMCID: PMC5632941.

6.      Gupta A, Diaz FJ, Lal A, Sung L, Aaron CK. Basal Ganglion Hemorrhage as Delayed Complication of Diethylene Glycol Ingestion. Am J Forensic Med Pathol. 2017 Mar;38(1):39-42. doi: 10.1097/PAF.0000000000000295. PMID: 28085681.

7.      Aisa TM, Ballut OM. Methanol intoxication with cerebral hemorrhage. Neurosciences (Riyadh). 2016 Jul;21(3):275-7. doi: 10.17712/nsj.2016.3.20150592. PMID: 27356664; PMCID: PMC5107299.

8.      Lee SM, Moon JM, Chun BJ, Song KH. Unusual intracranial hemorrhage in severe methanol intoxication. Am J Emerg Med. 2015 Nov;33(11):1717.e1-2. doi: 10.1016/j.ajem.2015.03.031. Epub 2015 Mar 18. PMID: 25892398.

9.      Sebe A, Satar S, Uzun B, Topal M, Yesilagac H, Avci A. Intracranial hemorrhage associated with methanol intoxication. Mt Sinai J Med. 2006 Dec;73(8):1120-2. PMID: 17285208.

10.  Caparros-Lefebvre D, Policard J, Sengler C, Benabdallah E, Colombani S, Rigal M. Bipallidal haemorrhage after ethylene glycol intoxication. Neuroradiology. 2005 Feb;47(2):105-7. doi: 10.1007/s00234-005-1347-y. Epub 2005 Feb 16. PMID: 15714272.

11.  Giudicissi Filho M, Holanda CV, Nader NA, Gomes SR, Bertolucci PH. Bilateral putaminal hemorrhage related to methanol poisoning: a complication of hemodialysis? Case report. Arq Neuropsiquiatr. 1995 Sep;53(3-A):485-7. doi: 10.1590/s0004-282x1995000300020. PMID: 8540827.

12.  Phang PT, Passerini L, Mielke B, Berendt R, King EG. Brain hemorrhage associated with methanol poisoning. Crit Care Med. 1988 Feb;16(2):137-40. doi: 10.1097/00003246-198802000-00008. PMID: 3342624.

edited by Yu-Jang Su                 Feb, 14, 2022

ECG Changes on Poisoning / Intoxication

 ECG changes on poisoning/ intoxication

 

ECG	Substance	Date	Origin
Asystole	Lithium	1991	UK[1]
First degree AV block	Carbon monoxide Lithium	2013 2018	Riyadh[2] Taiwan[3] Kaohsiung Medical University Hospital
QRS complex widening	Hydrofluoric acid tricyclic antidepressant	2005 2016	USA [4] New Orleans[5] Spain [6]
QT interval prolongation	Hydrofluoric acid organophosphate	2005 2009	USA [4] Iran [7]
R wave in aVR ≥ 3 mm		2012	Spain [6]
Scooping of the T waves	Digoxin	2017	Lebanon[8]
Sinus bradycardia	Calcium channel blockade Beta-adrenergic receptor blockade
Sinus Dysfunction	Lithium	1995	Japan [9]
Tall T wave	Hydrofluoric acid	2001	Taiwan [10] MacKay Memorial Hospital.

 

References

1.      Ong AC, Handler CE. Sinus arrest and asystole due to severe lithium intoxication. Int J Cardiol. 1991 Mar;30(3):364-6. doi: 10.1016/0167-5273(91)90021-g. PMID: 2055679.

2.      Salih SB, Alenezi H, Alghamdi A. A case of first degree AV block in carbon monoxide poisoning patient. J Saudi Heart Assoc. 2013 Oct;25(4):255-9. doi: 10.1016/j.jsha.2013.05.004. PMID: 24198450; PMCID: PMC3818633.

3.      Chien SC, Liu KT, Wu YH. Lithium intoxication presenting as altered consciousness and arrhythmia with cardiogenic shock: A case report. Medicine (Baltimore). 2018 Nov;97(45):e13129. doi: 10.1097/MD.0000000000013129. PMID: 30407335; PMCID: PMC6250446.

 

4.      Holstege C, Baer A, Brady WJ. The electrocardiographic toxidrome: the ECG presentation of hydrofluoric acid ingestion. Am J Emerg Med. 2005 Mar;23(2):171-6. doi: 10.1016/j.ajem.2004.04.032. PMID: 15765339.

5.      Glancy DL. ECG Of the Month: Suicide. J La State Med Soc. 2016 Mar-Apr;168(2):66-7. Epub 2016 Apr 15. PMID: 27383860.

6.      Yates C, Manini AF. Utility of the electrocardiogram in drug overdose and poisoning: theoretical considerations and clinical implications. Curr Cardiol Rev. 2012 May;8(2):137-51. doi: 10.2174/157340312801784961. PMID: 22708912; PMCID: PMC3406273.

7.      Shadnia S, Okazi A, Akhlaghi N, Sasanian G, Abdollahi M. Prognostic value of long QT interval in acute and severe organophosphate poisoning. J Med Toxicol. 2009 Dec;5(4):196-9. doi: 10.1007/BF03178266. PMID: 19876851; PMCID: PMC3550412.

8.      Mansour MJ, Kalaoui M, Chammas E, Hamoui O, Fawaz T, AlJaroudi WA. Unusual digoxin toxicity with myocardial injury. J Electrocardiol. 2017 Nov-Dec;50(6):909-911. doi: 10.1016/j.jelectrocard.2017.07.013. Epub 2017 Jul 12. PMID: 28807352.

9.      Nakamura H, Takahashi F, Matsuzaka T, Tanaka H, Akashi N, Sato N, Kikuchi K. [A case of lithium induced sinus mode dysfunction]. Nihon Naika Gakkai Zasshi. 1995 Jan 10;84(1):127-9. Japanese. PMID: 7722356.

10.  Su YJ, Lu LH, Choi WM, Chang KS. Survival after a massive hydrofluoric acid ingestion with ECG changes. Am J Emerg Med. 2001 Sep;19(5):458-60. doi: 10.1053/ajem.2001.24503.

edited by Yu-Jang Su            

Theophylline Intoxication

 Substance

 -  theophylline intoxication.   

 -  (45.5%) had acute, (40.4%) had chronic, and (14.0%) had acute-on-therapeutic poisoning. [1]

Common name or Trade name

 -  definition: Therapeutic ranges are usually achieved between 10–20 μg/mL. Toxic effects are often seen above 20 μg/mL plasma concentrations. [2]

 

Involving system

-       Effect: diuretic, smooth muscle relaxant, cardiac, nervous system, and ventilator stimulant [2]

-       GI system: nausea, vomiting, gastrointestinal reflux [2]

-       Neuro: restlessness, and headache, convulsions (8.2%) [2, 3]

-       CV: severe cardiac arrhythmias (20.8%), hypotension (may result fromβ2-stimulated peripheral vasodilation) and even death occur at higher theophylline concentrations (usually 80–100 μg/mL). [1, 2]

 

Presentation 

-       severe cardiac arrhythmias, refractory hypotension, and convulsions [2]

-       Hypokalemia, hypercalcemia, hyperglycemia, and acidosis are metabolic disturbances that commonly occur after an acute overdose [2]

-       May complicate with Coma Blister. [4]

 

Antidote and Treatment

-       Gastrointestinal decontamination with activated charcoal. [2]

-       The use of beta-blockers is an acceptable approach to control tachydysrhythmias [2]

-       aggressive fluid administration + conventional vasopressors in cases of refractory hypotension.

-        

-       standard hemodialysis is a suitable alternative when severe theophylline toxicity [2].

Disposition 

-       Carefully DDx with a thyroid storm.  

-       4.2% fatality [D].  

REFERENCES

 [1]. Shannon M. Life-threatening events after theophylline overdose: a 10-year prospective analysis. Arch Intern Med. 1999 May 10;159(9):989-94. doi: 10.1001/archinte.159.9.989. PMID: 10326941.

 [2]. Aggelopoulou E, Tzortzis S, Tsiourantani F, Agrios I, Lazaridis K. Atrial Fibrillation and Shock: Unmasking Theophylline Toxicity. Med Princ Pract. 2018;27(4):387-391. doi: 10.1159/000490145. Epub 2018 Jun 22. PMID: 29936503; PMCID: PMC6170900.

[3]. Kopacz P, Kula K. Lethal poisoning with theophylline in the form of rectally administered tablets. Arch Med Sadowej Kryminol. 2014;64(3):158-64. doi: 10.5114/amsik.2014.48879. PMID: 25693173.

[4]. Tsokos M, Sperhake JP. Coma blisters in a case of fatal theophylline intoxication. Am J Forensic Med Pathol. 2002 Sep;23(3):292-4. doi: 10.1097/00000433-200209000-00019. PMID: 12198361.

 

edited by Yu-Jang Su            Dec 7, 2021