Digitalis intoxication: specifity and significance of cardiac and extracardiac symptoms. part II. Patients with extracardiac symptoms of digitalis intoxications (author's transl)

In 1148 cases the serum digoxin concentration (SDC) was correlated with the extracardiac signs of digitalis intoxication. There is a considerably overlap of SDC levels of patients with and without extracardiac signs of toxicity even though the mean SDC's of these two groups differ significantly. An increasing percentage of clinical intoxicated patients with increasing SDC levels was found at digoxin concentrations of 2.0 ng/ml and higher. At lower SDC levels patients with and without extracardiac signs of digitalis intoxication did not differ significantly in their mean SDC but in mean age and in mean creatinine concentration indicating that at least part of the symptoms in these patients might be due to a more severe illness. We could show that many of the extracardiac signs of digitalis intoxication are also seen in patients with impaired kidney function at low SDC levels and may lead to a wrong diagnosis. The most common complaint in patients with SDC's of 2.0 ng/ml and more is nausea (39.4%), followed by tiredness (30.4%), dizzyness (23.7%), vomiting (23.1%), headache (16.0%), visual disturbances (13,5%), colour (yellow) seeing (6;7%), diarrhea (4.2%) and severe neuro-psychiatric disturbances (3.8%). In patients with digitalis-induced arrhythmias the sequence of symptoms is the same only with a somewhat higher percentage rate. Only about one half of the patients with digitalis-induced arrhythmias and SDC values up to 2.5 ng/ml showed also extracardiac signs of intoxication. Therefore these signs are not to be taken as early symptoms of digitalis intoxication. Divided into subgroups (patients with/without digitalis-induced arrhythmias, patients with SDC values of more/less than 2.0 ng/ml) the patients with and without extracardiac signs of digitalis toxicity are compared with each other in regard to: mean body height and weight, concentration of digoxin, potassium and creatinine, digoxin dosage and mean age. The greatest differences were found between patients with combined cardiac and extracardiac signs of intoxication and patients with neither cardiac nor extracardiac signs of intoxication: These intoxicated patients are of significantly higher mean age and lower body weight, their mean concentration of digoxin and creatinine and the digoxin dosage administered are significantly greater, but there is no significant difference in potassium concentration. An important group of patients, namely the elderly with impaired kidney function, are especially prone to develop digitalis intoxication. In this group, however, the extracardial symptoms are of little benefit in the diagnosis of digitalis intoxication. In these patients rhythm disturbances and intoxication-like symptoms are frequently caused by other reasons. In most cases the SDC value can clarify the diagnosis without withdrawal of the drug.     

A specific antidote for the treatment of digitalis poisoning in uremic patients

Two chronic haemodialyzed patients with digitalis intoxication are reported. One of them took digoxin 0.25 mg three times daily for an unknown period and the other took digitoxin 0.1 mg twice daily for two weeks. The symptoms of intoxication were mainly concealed by uremic syndrome. The diagnosis was established by noticed sinus bradycardia, first- and second-degree atrioventricular block in ECG and the determination of sera levels of glycosides (serum digoxin concentration was 7.36 ng/ml, serum digitoxin concentration was 46.5 ng/ml) in both cases. Considering the probable long elimination period of digitalis and the potentially life-threatening situation the patients were given digoxin-specific antibody (Fab) fragments with potassium replacement therapy. The symptoms disappeared within a few hours after therapy, side effects and rebound toxicity did not develop. In connection with these cases the aim of this report is to publish a method which can reverse the life-threatening digitalis intoxication in patients suffering from renal failure as well. As to the above method, the authors have not found any similar case reports in the Hungarian medical literature.     

PUVA photocarcinogenesis in Cheshire

Acute and chronic intoxications caused by bromides have become rare. The psychopathology of such intoxications can present with various symptoms. We report on the case of a 55-year-old man who was admitted with an acute delirium due to chronic bromide intoxication. In this context we briefly discuss clinical, psychopathological and therapeutic aspects of substance abuse and chronic bromide intoxication.     

Current management of digitalis intoxication

Of the commonly used drugs, digitalis has one of the highest therapeutic-toxic ratios. Mortality is significantly increased in the 20% to 30% of patients on digitalis who are in a toxic state when admitted to the hospital. Successful use of digitalis depends on avoidance of its use in situations likely to result in toxicity; recognition of the signs, symptoms, and electrocardiographic findings of digitalis intoxication; and stopping digitalis completely as the initial treatment of digitalis intoxication.     

Do caregivers still care?

Plasma levels of medium molecular peptides (MMP) were measured and Paramecium test was made in 28 patients with acute otitis media purulenta (AOMP). Of these, 18 patients had complicating mastoiditis. The baseline results of both tests correlated with clinical symptoms of systemic endogenic intoxication. Paramecium test returned to normal after one day of treatment. Informative value of this test fell with detoxication contrary to plasma MMP value which correlated with the degree of intoxication and remained informative through detoxication being able to show even residual subclinical toxicity. The MMP test is a method of choice in assessing intoxication in patients with AOMP and its complications.     

Acute poisoning with L-triiodothyroinine, L-thyroxine and phendimetrazine bitartrate with suicidal intention]

It is reported on an acute intoxication after application of 8 mg L-thyroxin, 2 mg L-triiodotyronine (200 tablets Thyreotom) and 4.5 g hendimetrazine bitartrate (100 tablets Sedafamem). The clinical picture is described. An endangering of the vital function of the organism was not observed. The symptoms disappeared after 4 days. The pharmacological aspects of the intoxication after application of the hormone of the thyroid gland, its significance for the pathogenesis of the thyreotoxic crisis and its therapy are discussed     

The body-packer syndrome

In four patients, a woman of 35 and men of 27, 38, and 22 years old, body-packer syndrome was diagnosed. Body-packer syndrome is seen in people concealing drugs in special containers within the body; this may lead to rupture with acute intoxication or to ileus. The clinical presentation can be very deceptive. An abdominal X-ray often reveals the packages. If there are no symptoms treatment is with mild laxatives, acute intoxication requires immediate laparotomy. One of the four patients died, the others recovered. Legally (Dutch law), the physician best delivers the drug to the police as a lost object, without revealing the patient's identity.     

Intravenous organophosphate injection: an unusual way of intoxication

Organophosphate insecticides strongly inhibit both true cholinesterase and pseudocholinesterase activities. In this report, we have reported a patient who injected himself a strong organophosphate compound, methamidophos, and showed the typical clinical picture of organophosphate intoxication. As far as we know, this is the first case of intoxication by intravenous (i.v.) injection. With the appropriate therapy, his symptoms disappeared in a few days.     

Trichlorethylene-, carbon tetrachloride- and gasoline-intoxication in connection with arterio- and coronary sclerosis (author's transl)

On the occasion of autopsies of 4 toxicomaniac adolescents sniffing and occasionally drinking trichlorethylene, carbon tetrachloride and gasoline severe arteriosclerotic damage of the coronary vessels was encountered. Experimental intoxication of 12 rabbits with these solvents over a period of 10 weeks, each time until a prenarcotic stage, provoked pathological changes in accordance with well known findings but no arteriosclerosis. Ergometrical examination with simultaneous recording of the E.C.G. of 6 adolescents with solvent-sniffing history and of 1 man, working for years under trichlorethylene exposure conditions and showing symptoms of chronic intoxication, revealed no signs of coronary-artery insufficiency. These findings are not inconsistent with the assumption -- though not substantiating it -- of a causal relationship between the intoxication with trichlorethylene, carbon terachloride and gasoline and the development of arteriosclerosis, as the coronary sclerosis may be of the elstic type with a very high degree of adaptability and the probands proved unable to reach the limit of maximum stress. In addition to the main purpose the occurrence of epileptic seizures following chronic trichlorethylene sniffing in one case and the manifestation of pulmonary obstruction following i.v. application of Methyl-Phenidat (Ritalin) in two cases are reported.     

Chorea caused by lithium intoxication: a case report and literature review

We report a patient who developed an acute, reversible, generalized choreiform disorder from lithium (Li) intoxication. This medication was prescribed for manic-depressive disorder, and serum levels became elevated after the addition of a diuretic for the treatment of hypertension. There were no other apparent causes for the movement disorder, and it was associated with other known features of Li intoxication, including ataxia and encephalopathy. There was a delay between the initial symptoms of Li intoxication and the onset of chorea. The chorea improved as serum Li levels diminished, with some lag time. This represents the eleventh case report of Li-induced chorea, but only the sixth in a patient without concomitant neuroleptic therapy, and the first presented with videotape confirmation. A review of these other cases is included, and possible mechanisms are discussed.     

Acute oral toxicity of the herbicide BUREX EKO in pheasants

The aim of this study was to determine the acute LD50, clinical symptoms and pathological changes of acute BUREX EKO intoxication in pheasants according to OECD No 205. Medium lethal dose (LD50) of BUREX EKO in pheasant is 3.84 ml/kg body weight with the upper level of reliability 4.50 ml and lower level of reliability 3.27 ml/kg body weight. As far as the calculation to the effective substance is concerned it is 1077 mg of chloridazone per kg body weight with the interval of reliability from 919 to 1263 mg/kg body weight. Calculated the effective substance of chloridazone (3.84 ml is LD50 of BUREX EKO which contains 1077 mg of chloridazone) BUREX EKO can be classified as the moderately toxic substance to pheasants. There were following clinical symptoms of the BUREX EKO intoxication in pheasants: apathy, drowsiness, incapability to move, ruffled feathers, slight diarrhoea, strenuous respiration, tonico-clonical cramps before death, decease with the head expressively bent rearwards. There was a relatively fast beginning of rigor mortis in dead pheasants. Pathologico-anatomical dissection of the pheasants obtained under conditions of acute intoxication did not reveal any changes on the organs of both experimental and control pheasants which would be immediately connected with the effect of the administered substance. Hyperaemia was recorded by histologico-pathological investigation of the liver and kidneys. No changes on the brain and intestine wall were recorded.     

Local mechanisms of relationship between colloid-osmotic pressure and ophthalmic tone in patients with diabetes mellitus

The paper presents 5 cases of histologically verified tuberculous peritonitis followed up by the author in 1994-1996. All patients were admitted to hospital and undergone surgical intervention for emergency indications. The main symptoms were intoxication, abdominal pain and enlargement. Two typical cases are described. Tuberculous peritonitis is recommended to be included into the differential diagnostic list of acute surgical abdominal diseases.     

Reflex sympathetic dystrophy syndrome secondary to organophosphate intoxication induced neuropathy

Reflex sympathetic dystrophy or Sudeck's atrophy is a syndrome that can usually be followed by a traumatic insult. This disorder is accompanied by signs and symptoms of vasomotor instability, trophic skin changes, and rapid development of bony demineralization. This report presents a case with reflex sympathetic dystrophy syndrome secondary to organophosphate intoxication induced neuropathy. The patient was threated with calcitonin well.     

Changes in the nervous system due to occupational metallic mercury poisoning

At the Institute of Occupational Medicine and Environmental Health, during 12 years, chronic mercury intoxication was diagnosed in 34 persons. There were male workers tending technological processes in which Hg was used as a catalyst (synthesis of acetic aldehyde and obtaining chlorine). The length of professional exposure was 13-34 years (mean 20.6). The patients were removed from the contact with Hg after Hg intoxication case was confirmed. During the following 11 years, 24 of them were reexamined in the clinical department 2-4 times. The clinical picture of the poisoning consisted mainly of neurasthenic, cerebellar (30 persons), psychoorganic symptoms (20 persons) and behavioural changes (irritability, aggressive states). Headaches, sleep and recent memory disturbances, progressive behavioral changes, dizziness, were the most frequent complaints. The authors stressed the irreversibility of central nervous disorders despite cessession of the exposure to Hg. The degree of cerebellar intensity changes did not handicap examined patients. This is especially important to show the difference between the above described clinical picture of Hg intoxication and multiple sclerosis.     

Ventilatory impairment in asthma: perceptions vs measurements

Three university students were exposed to toxic vapours (acryloyl chloride 96% and methacrylic anhydride 94%) in a laboratory accident. They all gave a history of minimal exposure and presented with mild symptoms. One patient died on the same day. The other two cases were uneventful. This paper reports on these three cases, followed by a discussion on irritant gas intoxication.     

The clinico-laboratory characteristics of pseudotuberculosis in persons with chronic opisthorchiasis

Clinical and laboratory parameters investigated in pseudotuberculosis patients with and without CO proved patients with mixed infection to be more seriously affected. They had more pronounced polymorphism of clinical symptoms, more severe intoxication, fever, hepato- and splenomegaly, longer convalescence, more frequent relapses, worse laboratory findings. Complicated course of pseudotuberculosis patients with CO may be due to hypersensitization of the body and hepatobiliary disorders resultant from parasitic invasion.     

Acute poisoning with clenbuterol--a case report

In the paper we have described a case of acute, unintentional intoxication with clenbuterol, a selective beta 2-agonist. A 21-year-old bodybuilder to improve his physical fitness and to increase his muscle bulk was using clenbuterol in a dose of two tablets (20 mg) daily for a week before poisoning. On a day of acute intoxication he drank orange juice containing 48 tablets (4.8 g) of clenbuterol, which had been placed there by his friends. The patient was admitted to our clinic with tachycardia at rate 160 bpm, headache, dizziness, tremor, sweats, muscle weakness, agitation. Serum potassium concentration was 2.6 mmol/L, blood glucose level 18.7 mmol/L. All the symptoms and biochemical abnormalities disappeared after intravenous treatment with propranolol (1.0 mg) and potassium chloride (60 mmol) within five hour period. This case indicates that more attention should be paid to clenbuterol widely used as a stimulant by athletes, especially by bodybuilders.     

Severe polyneuropathy in a 3-year-old child after dichlorophenoxyacetic herbicide--chwastox intoxication, treated successfully with plasmapheresis (PF)

The clinical picture of intoxication with dichlorophenoxy acetic herbicides is well recognised in adults and some treatment recommendations are established. To the best of our knowledge there is scarcity of well documented cases of intoxication with this substance in children. Our report describes the clinical picture of Chwastox intoxication in a 3-year-old child. Some similarities and differences between adults and children are discussed, as well as the indications for plasmapheresis, which could be a valuable mode of treatment in such cases.     

The discrimination of marijuana intoxication

Forty Ss, 20 males and 20 females, observed a videotape that showed four males interacting in a social setting under four different drug conditions; coltsfoot, placebo, marijuana low dose, and marijuana high dose. The observers attempted to discriminate the level of intoxication of the four males in each condition. The observers accurately detected the level of intoxication in the high dose condition. While marijuana experienced users were more successful in detecting levels of intoxication, the sex of the observer was not significant. Behaviors used to discriminate intoxication and the implications of these results to defining intoxication are discussed.     

Risk of phosphate enemas in the infant

BACKGROUND: Hypertonic sodium phosphate enema (Fleet) are available for relief of constipation. They may be responsible for life-threatening electrolyte disturbances (hyperphosphatemia, hypernatremia, hypocalcemia) and severe dehydration. OBSERVATION: A 14-month-old child with a neonatal repaired Hirschsprung's disease was urgently admitted for apathy. The clinical diagnosis was sepsis from intestinal origin. A few hours before admission, the child had received a pediatric phosphate enema ("Fleet Enema"). The clinical symptoms and the observed electrolyte disturbances were the consequences of the intoxication by the enema. CONCLUSION: In children with renal insufficiency or bowel dysfunction, phosphate enemas are dangerous. Even in normal children, they should not be used under 2 years of age and only with extreme caution between 2 and 5 years.