An unexpected prolonged coma due to a pharmacobezoar formed from Vegetamine A® tablet ingestion

Case

A 49-year-old man ingested massive quantities of Vegetamine A® tablets that contain two anticholinergic agents in addition to phenobarbital. The patient remained in an unexpectedly prolonged coma 4 days post-hospitalization. An acute gastroscopy revealed a pinkish-white pharmacobezoar on the lesser curvature of the stomach, which was extracted using a net. Direct hemoperfusion and treatment with multiple-dose activated charcoal was then initiated. Phenobarbital serum concentrations eventually decreased, resulting in complete recovery of the patient.

Outcome

On day 30, the patient was transferred to the Psychiatric Department.

Conclusion

An intragastric pharmacobezoar should be suspected in patients with promoted and prolonged toxicity or if high serum concentrations of agents indicate their continuous absorption.

A multicenter retrospective survey of poisoning after consumption of products containing synthetic chemicals in Japan

OBJECTIVE

We conducted a multicenter retrospective survey of patients poisoned by synthetic chemicals (SCs) in Japan.

METHODS

Letters were sent to 467 emergency facilities requesting participation in the study, and questionnaires were mailed to facilities that agreed to participate. Patients The study participants were patients who were transported to emergency facilities between January 2006 and December 2012 after consuming SC-containing products.

RESULTS

We surveyed 518 patients from 60 (12.8%) facilities. Most patients were male (82.0%), in their 20s or 30s (80.5%), and had inhaled SCs (87.5%) contained in herbal products (86.0%). Harmful behavior was observed at the scene of poisoning for 56 patients (10.8%), including violence to others or things in 32, traffic accidents in seven, and self-injury or suicide attempts in four. Other than physical and neuropsychiatric symptoms, some patients also had physical complications, such as rhabdomyolysis (10.0%). Of the 182 patients (35.1%) admitted to hospitals, including 29 (5.6%) who needed respirators, all of the 21 (4.1%) hospitalized for at least seven days were male, and 20 had physical complications (rhabdomyolysis, 12; liver dysfunction, 5; renal dysfunction, 11; and physical injuries, 3). Most patients (95.6%) completely recovered, although 10 (1.9%) were transferred to a psychiatric department or hospital, and three (0.6%) were handed over to the police due to combative or violent behavior. SCs such as synthetic cannabinoids, synthetic cathinones, or methoxetamine were detected in 20 product samples.

CONCLUSION

Consuming products containing SCs can result in physical complications, including rhabdomyolysis, injuries, and physical or neuropsychiatric symptoms, which may require active interventions, such as respirator use or prolonged hospitalization.

A multicenter retrospective survey on a suicide trend using hydrogen sulfide in Japan

CONTEXT

In Japan, suicide by inhaling hydrogen sulfide (H2S) by mixing commercial products escalated into a nationwide trend in April 2008.

OBJECTIVE

We conducted a multicenter retrospective survey on the demographics, clinical features, treatments, and outcomes of patients exposed to H2S suicide attempts.

MATERIALS AND METHODS

Subjects included patients transported to emergency facilities in Japan from January 2005 to December 2011 following H2S suicide attempts. Among 277 facilities to which a letter requesting data collection was sent, questionnaires were sent to and filled out by the 47 (18%) facilities that agreed to provide data. Questionnaires were collected and data were extracted at Kitasato University.

RESULTS

A total of 156 patients were included in this survey. Patients involved in an H2S suicide attempt increased from 1 in 2007 to 51 in 2008, and gradually decreased from 44 in 2009 to 37 in 2010 and 23 in 2011. Ninety-two patients attempted H2S suicide (primary exposure group), and 64 were secondarily affected by the suicide attempt (secondary exposure group). Patients in the primary exposure group were young (mean, 30.3 years (10.9)), and male patients (n = 62) were approximately two times more likely to attempt H2S suicide than females (n = 30). Forty-eight patients in cardiopulmonary arrest at the scene did not survive. Five non-cardiopulmonary arrest patients died, and five patients who presented with a Glasgow coma scale (GCS) < 8 and lactic acidosis had neurological or cardiac signs or symptoms at discharge. Antidote therapy was performed on 26 of the primary group patients, but with poor outcomes. None of the secondary group patients were in cardiopulmonary arrest at the scene, five received antidotal therapy after arriving at the hospital, and all completely recovered from H2S exposure.

DISCUSSION AND CONCLUSION

Mortality (58%) among patients who attempted H2S suicide was very high, likely resulting from inhaling high concentrations of H2S after mixing commercial products in a sealed and confined space.

Aseptic meningitis in association with glyphosate-surfactant herbicide poisoning

INTRODUCTION

The mechanisms underlying early central nervous system (CNS) signs and symptoms of glyphosate-surfactant herbicide (GlySH) poisoning are unclear.

CASE PRESENTATION

A 58-year-old woman ingested approximately 150 mL of GlySH containing 41% glyphosate and 15% polyoxyethyleneamine. Two days later, she was admitted in the Emergency Center in a semicomatose state. Acute respiratory distress syndrome, circulatory collapse, acute renal failure, and disseminated intravascular coagulopathy were diagnosed. Meningitis was also suspected as she demonstrated Kernig's sign and significant neck stiffness with rigidity of the extremities as well as consciousness disturbance and fever (38.4°C). Investigations of cerebrospinal fluid (CSF) revealed the presence of glyphosate (122.5 μg/mL), significant elevation of IL-6 (394 μg/mL), and pleocytosis (32 cells/μL) with monocyte dominance. All bacteriological and virological tests were later found to be negative. She recovered completely after responding to aggressive supportive care in the intensive care unit. All signs and symptoms suggesting meningitis resolved as the concentration of glyphosate in CSF decreased. She was discharged on day 39 of hospitalization.

DISCUSSION

These findings suggest that the present case involved aseptic meningitis in association with GlySH poisoning.

CONCLUSION

CNS signs and symptoms induced by aseptic meningitis should be considered in cases of glyphosate-surfactant herbicide poisoning.

Notable pink excreta and severe myocardial suppression in superwarfarin (difethialone) intoxication

Patients rarely consult physicians before developing coagulopathy or bleeding in most reported cases of superwarfarin intoxication. A 57-year-old woman ingested red-dyed pellets of anticoagulant rodenticide containing difethialone and warfarin as well as tablets of nitrazepam. Although she presented to the hospital in a comatose state, notable pink-colored excreta hinted at the consumption of anticoagulant rodenticide, which led to the early diagnosis of superwarfarin intoxication. Supplementation of large doses of intravenous and oral vitamin K successfully prevented coagulopathy and bleeding. On the other hand, temporary and reversible myocardial suppression was extremely severe, and required the introduction of percutaneous cardiopulmonary support.

Severe carbon monoxide poisoning complicated by hypothermia: a case report

It is proposed that the significant elevation of interleukin-6 (>400 pg/mL) in cerebrospinal fluid during the early phase of carbon monoxide poisoning may be a predictive biomarker for the development of delayed encephalopathy. A 52-year-old man presented to the emergency department with severe carbon monoxide poisoning. On arrival, the patient was comatose with decorticate rigidity (Glasgow Coma Scale, E1V1M3). His core body temperature, measured in the urinary bladder, was 32.4°C. Laboratory blood analysis revealed elevated CO-Hb (36.0%) and metabolic acidosis with elevated lactate (pH 7.081; base excess [BE], -19.2 mmol/L; HCO3, -9.8 mmol/L; lactate, 168.8 mg/dL). After treatment with hyperbaric oxygen and several different rewarming techniques, he became alert and his core body temperature increased to normal. Interleukin-6 in cerebrospinal fluid at 5.5 hours after his last exposure to carbon monoxide was significantly elevated (752 pg/mL). However, he did not develop delayed encephalopathy. In this case, hypothermia in the range of therapeutic hypothermia (32°C to 34°C) may have suppressed formation of reactive oxygen species and subsequent lipid peroxydation, preventing the development of delayed encephalopathy. Therapeutic hypothermia initiated soon after the last exposure to carbon monoxide may be an effective prophylactic method for preventing the development of delayed encephalopathy.

Exploration of factors related to hara-kiri as a method of suicide and suicidal behavior

OBJECTIVE

The objective of this study was to explore factors associated with hara-kiri as a method of suicide and suicidal behavior in contemporary Japan.

METHODS

A retrospective study was conducted on medical records of 421 patients (174 male; 247 female) who were considered suicidal and treated at the Kitasato University Hospital Emergency Medical Center in Japan between January 2006 and March 2008. We compared hara-kiri and all other methods regarding sociodemographics and clinical features of all suicidal patients.

RESULTS

Instances of hara-kiri suicide attempt had the highest proportion of males (63%) among all suicide and suicidal behavior. One-way analysis of variance revealed significant differences between hara-kiri and other suicide attempt methods in the age of the suicidal patients. Result of multiple logistic regression analysis indicated that those who attempted hara-kiri suicide were likely to be male, be diagnosed with schizophrenia, survive, and be married.

CONCLUSION

Our findings indicate that hara-kiri as a method of suicide and suicidal behavior remains prevalent in Japan, and the study findings also suggest that both clinical and cultural factors might play a role in hara-kiri as a method of suicide and suicidal behavior.