Chlorfenapyr Poisoning

 SUBSTANCE

-          C₁₅H₁₁BrClF₃N₂O (https://pubchem.ncbi.nlm.nih.gov/compound/Chlorfenapyr

-          a pyrrole insecticide

           

Common name / Trade name

-          Chlorfenapyr

 

Involving SYSTEM [1]

- CV: on the respiratory or cardiovascular systems

- ANS: autonomic nervous system and prominent neurotoxicity, dose-dependent.

- Muscle: skeletal muscle system, elevated CK.

- GI: gastrointestinal system: upset.

- blood coagulopathy. 

- Renal: elevated levels of blood urea nitrogen (BUN) and total protein.

- Deposited concentration ranked: 

  Fat, Large intestine, Blood, Liver, Muscle, Kidney, bone, brain, and lung. [2]. 

 

Presentation [1]

- Epidemiology: Age is 52.2±15.6 years old     

- Fever: the highest body temperature was 40.8±1.1 degrees Celsius.

- Consciousness: decrease in spontaneous motor activity, gait abnormality, and abnormal arousal.   

– Vital signs: Hyperthermia

- Neuro: salivation, convulsion, and death in large dose intoxication, bilateral leg weakness, and urinary incontinence.

- Rhabdomyolysis: the elevated CK level (4966±5978.4 IU/L)   

  - Metabolic acidosis

- Pancreatitis.    

 

Antidote / Treatment [1]

-          No specific antidote.

-          Early gastric decontamination 

-          Prolonged dialysis may be a possible method for preventing deterioration.

-          Effective supportive care.

 

Disposition

 

- The length of stay was 10.3±6.1 days.

- Initiation of fever and a deteriorating consciousness is the warning sign of a sudden fatal outcome.

- The mortality rate was up to 80%.        

 

REFERENCES

[1] Chien SC, Chien SC, Su YJ. A fatal case of chlorfenapyr poisoning and a review of the literature. J Int Med Res. 2022 Sep;50(9):3000605221121965. doi: 10.1177/03000605221121965. PMID: 36112969; PMCID: PMC9483958.

 [2]. https://pmc.ncbi.nlm.nih.gov/articles/PMC11153369/

 

Edited by Yu-Jang Su Sep 26, 2022. 

Revised. Feb 2, 2025.

Naloxone

 

Naloxone	Situation	Concern	References
Pregnancy	Category C		[1] [2]
Contraindicated	Allergy
controversial	Seizure	Naloxone alone reduced the number and duration of seizures but increased the number of mild seizures	[3 [4][5][6]
controversial	Alcohol intoxicated	Lacks effectiveness in ethylic coma	[7]
Precautions	Bronchospasm	Hypoxia risk	[8]
Precautions	COPD	Hypoxia risk	[2]
Precautions	Respiratory failure/ distress	Hypoxia risk	[2]
Precautions	Lung edema, non-cardiogenic	Hypoxia risk	[2]
Adverse effect	BPH	Acute urinary retention. (AUR)	[9]
Adverse effect	Acute abdomen, pancreatitis	Induced.	[10]
Treatment	Acute abdomen, IBD	Efective and safe, and could be considered for the treatment of therapy refractory IBD patients	[11]
Precautions	Liver, renal impaired function	Hepatitis	[2]
Contraindicated	hypothyroidism	Increment oxygen consumption, but not ventilation.	[12]

 

References

[1] Goldfrank’s p.541, 11th ed.

[2] https://www.ncbi.nlm.nih.gov/books/NBK534811/

[3] https://pubmed.ncbi.nlm.nih.gov/32133101/

[4] https://pubmed.ncbi.nlm.nih.gov/30676832/

[5] https://pubmed.ncbi.nlm.nih.gov/34051813/

[6] https://pubmed.ncbi.nlm.nih.gov/15167188/

[7] https://pubmed.ncbi.nlm.nih.gov/8115696/

[8] https://pubmed.ncbi.nlm.nih.gov/23380114/

[9] https://pubmed.ncbi.nlm.nih.gov/31975924/

[10] https://pubmed.ncbi.nlm.nih.gov/27922226/

[11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5845217/

[12] https://pubmed.ncbi.nlm.nih.gov/7800724/

Edited by Yu-Jang Su    Aug 13, 2022

Acute Bromate intoxication

 

Bromate intoxication
Year	Country	Aage	Gender	Symptoms	Reference
2019	Korea	48	Female	12 hours later Bilateral Deafness	[1]
2014	Japan				[2]
2006	Okayama, Japan	78	Female	Acute renal failure.	[3]
2002	Japan	48	Female	Hearing loss, anuria.	[4]
1993	Taiwan		Female	Gastrointestinal irritation, hypotension, fatigue, deafness, acute renal failure, anemia, and peripheral neuropathy	[5]
1993	Japan	34		Vomiting, epigastralgia, watery diarrhea,   and anuria appeared after 30, and deaf within 12 hours. Renal function recovered after Hemodialysis.	[6]
1992	Japan			Gastrointestinal symptoms, slight acute renal insufficiency.	[7]
1976	Japan	21	Male	Anemia and hypoproteinemia neuropathy, renal insufficiency	[8]
1971	Japan			Uremic neuropathy	[9]

1.      https://pubmed.ncbi.nlm.nih.gov/31846929/

2.      https://pubmed.ncbi.nlm.nih.gov/25771671/

3.      https://pubmed.ncbi.nlm.nih.gov/16508229/

4.      https://pubmed.ncbi.nlm.nih.gov/12508969/

5.      https://pubmed.ncbi.nlm.nih.gov/7910086/

6.      https://pubmed.ncbi.nlm.nih.gov/8365061/

7.      https://pubmed.ncbi.nlm.nih.gov/1285506/

8.      https://pubmed.ncbi.nlm.nih.gov/193541/

9.      https://pubmed.ncbi.nlm.nih.gov/4338750/

 

edited by Yu-Jang Su             July 24, 2022.    

The Age Distribution of Illicit Agents Users.

 

Year	Country	Age	n	Substance	Reference
2021	US	40.0 ±11.4	1362	illegal drug	https://pubmed.ncbi.nlm.nih.gov/34831700/
2022	Taiwan	36.0 ±30.0	675	illicit drugs	https://pubmed.ncbi.nlm.nih.gov/35315299/
2020	Taiwan	34.5 ± 10.0	203	illicit substance	https://pubmed.ncbi.nlm.nih.gov/32037264/
2016	Switzerland	33	210	psychoactive substances	https://pubmed.ncbi.nlm.nih.gov/27228985/
2017	Switzerland	33	503	recreational drug toxicity	https://pubmed.ncbi.nlm.nih.gov/28264690/
2021	UK	31.2 (SD 10.0)	283	ketamine	https://pubmed.ncbi.nlm.nih.gov/34092131/
2021	Spain	31	17198	acute drug toxicity	https://pubmed.ncbi.nlm.nih.gov/33724118/
2016	Japan	30	589	novel psychoactive substances	https://pubmed.ncbi.nlm.nih.gov/27314752/
2016	Germany	26.9	13	gamma hydroxybutyrate	https://pubmed.ncbi.nlm.nih.gov/26395197/
2022	Taiwan	25.5	24	Nitrous Oxide	https://pubmed.ncbi.nlm.nih.gov/35324737/

 Edited by Yu-Jang Su   June 26, 2022. 

SSRI (selective serotonin reuptake inhibitor)

 SSRI (selective serotonin reuptake inhibitor) 血清素再吸收阻斷劑

SUBSTANCE

 

-          Newer and safer antidepressant compared to TCA [1].

-          Lower ADR than TCA.

 

 

Common name or Trade name 

 

-          Fluvoxamine、Paroxetine、Sertraline、Citalopram、Escitalopram、Fluoxetine。

 

 

Involving SYSTEM

 

-          Serotonin,  about 98% in extra-CNS [2]。

-          A long elimination half-life, with sustained biological activity due to active metabolites

-          In overdose, SSRI elimination times are further prolonged by the saturation of metabolic enzymes and by delayed absorption, especially for sustained-release preparations.

-          Electrolyte imbalance: hyponatremia, easily seen in the elderly [3].

-          Neural system: extra-pyramidal, hyperreflexia, Clonus, myoclonus [4].

-          Respiratory system: failure. Cough.

-          Gastrointestinal system: nausea, upset.

 

Presentation

 

-          Cause vomiting, mild CNS depression, or tremor.

-          Hyponatremia.

-          Unstable blood pressure. Arrhythmia. VT. Arrest, QRS QTc prolongation, Torsades de pointes [5].

-Bradycardia, hypotension: Fluvoxamine (Luvox)

- hyperreflexia, Clonus, myoclonus.

- Sweating, agitation.

- fever, coma, seizure (1.9%) [6].

 

Antidote and Treatment 

 

-          BLS, gastric lavage < 1 hr.  

-          Activated charcoal.

-          Not recommended for laxative.

-ACLS, inotropic agent.

-Nitroglycerin或Nitroprusside for hypertension。

-  magnesium sulfate 2 g IV over 2 min for Torsades de points

-  wide QRS: NaHCO3 1 to 2 mEq/kg IV push

- (benzodiazepine, BZD) for seizure.

- Serotonin antagonist:

     -Cyproheptadine (oral form; sedation) [7]. 12 mg, followed by 2 mg every 2 h if symptoms continue. 

- (Extrapyramidal signs): Diphenylhydramine 50mg bid。

 

Disposition

 

-          Suspicious: observe 6-8 hours with ECG monitoring, if no symptoms, then may be discharged.

-          Citalopram, need observe longer to 12hours, observe arrhythmia / convulsion [8].

 

REFERENCES

 

[1]. https://pubmed.ncbi.nlm.nih.gov/35206480/

[2]. https://pubmed.ncbi.nlm.nih.gov/19361459/

[3]. https://pubmed.ncbi.nlm.nih.gov/34483534/

[4]. https://pubmed.ncbi.nlm.nih.gov/23391344/

[5]. https://pubmed.ncbi.nlm.nih.gov/31845095/

[6]. https://pubmed.ncbi.nlm.nih.gov/30521236/

[7]. https://pubmed.ncbi.nlm.nih.gov/20833944/

[8]. https://pubmed.ncbi.nlm.nih.gov/33489987/

 

Edited by Yu-Jang Su                 May 26, 2022,  

                                                    June 21, 2026 revision.