Acute renal failure due to intravascular hemolysis in the North Indian patients

"Campfire corrosive: Isolated gastrointestinal injury following ingestion of copper salts"

Human exposures to "fire color changing" agents containing copper salts (CS) are rare. We report the case of an intentional mixed CS ingestion with resulting corrosive gastrointestinal injury absent classic laboratory abnormalities. A 23-year-old male with a history of bipolar disorder presented to the emergency department two hours after intentional ingesting an unknown quantity of the fire colorant "Mystical Fire," which contains cupric sulfate (CuSO4) and cupric chloride (CuCl2). He subsequently developed nausea and abdominal pain and had several episodes of vomiting. Physical examination was notable for diffuse abdominal tenderness without peritoneal signs. Laboratory evaluation was without signs of hemolysis, metabolic derangements, or acute kidney or liver injury. He was noted to have a methemoglobin concentration of 2.2%, which did not require treatment. Serum copper testing was within normal limits. Abdominal CT imaging showed no significant findings. Endoscopy was performed and revealed diffuse esophagitis and gastritis. The patient was started on a proton pump inhibitor and discharged. In this case, the absence of classic laboratory findings of copper did not rule out the presence of gastrointestinal injury. Further investigation is needed to determine the most effective means of ruling out clinically significant CS ingestions.

Acute Kidney Injury Following Naphthalene (Mothball) Poisoning

Naphthalene is a widely available moth repellant in the Asian subcontinent. Toxicity can occur either accidentally or intentionally as a suicide attempt. An overdose can lead to a variety of clinical symptoms, including intravascular hemolysis, and can sometimes lead to life-threatening clinical situations. A young male was admitted to our center with an alleged history of ingesting an unknown quantity of naphthalene balls (mothballs). He developed methemoglobinemia, intra-vascular hemolysis, anuria, and acute kidney injury (AKI), followed by cardiorespiratory arrest. He was treated successfully with intravenous methylene blue and dialysis. Naphthalene toxicity can lead to methemoglobinemia and intravascular hemolysis. This can result in AKI caused by pigment nephropathy.

Biogeographic venom variation in Russell's viper (Daboia russelii) and the preclinical inefficacy of antivenom therapy in snakebite hotspots

BACKGROUND

Snakebite in India results in over 58,000 fatalities and a vast number of morbidities annually. The majority of these clinically severe envenomings are attributed to Russell's viper (Daboia russelii), which has a near pan-India distribution. Unfortunately, despite its medical significance, the influence of biogeography on the composition and potency of venom from disparate D. russelii populations, and the repercussions of venom variation on the neutralisation efficacy of marketed Indian antivenoms, remain elusive.

METHODS

Here, we employ an integrative approach comprising proteomic characterisation, biochemical analyses, pharmacological assessment, and venom toxicity profiling to elucidate the influence of varying ecology and environment on the pan-Indian populations of D. russelii. We then conducted in vitro venom recognition experiments and in vivo neutralisation assays to evaluate the efficacy of the commercial Indian antivenoms against the geographically disparate D. russelii populations.

FINDINGS

We reveal significant intraspecific variation in the composition, biochemical and pharmacological activities and potencies of D. russelii venoms sourced from five distinct biogeographic zones across India. Contrary to our understanding of the consequences of venom variation on the effectiveness of snakebite therapy, commercial antivenom exhibited surprisingly similar neutralisation potencies against the majority of the investigated populations, with the exception of low preclinical efficacy against the semi-arid population from northern India. However, the ability of Indian antivenoms to counter the severe morbid effects of Daboia envenoming remains to be evaluated.

CONCLUSION

The concerning lack of antivenom efficacy against the north Indian population of D. russelii, as well as against two other 'big four' snake species in nearby locations, underscores the pressing need to develop pan-India effective antivenoms with improved efficacy in high snakebite burden locales.

Naphthalene Mothballs Poisoning Leading to Intravascular Hemolysis: A Case Report

BACKGROUND

Naphthalene is widely used in households as an insect repellent, but its poisoning is rare, especially in adults. Naphthalene is a strong oxidant with a pungent smell.

CASE REPORT

We report a case of a 16-year-old female who ingested three naphthalene mothballs 3 days prior to admission and presented with history of recurrent vomiting, severe pallor, jaundice, and hemoglobinuria. Investigation found severe hemolytic anemia, indirect hyperbilirubinemia, acute kidney injury, and evidence of intravascular hemolysis. Her urine output was normal throughout the course of illness. She was managed conservatively with i.v. fluid, oral ascorbic acid, and blood transfusion. With treatment our patient improved completely and was discharged in hemodynamically stable condition. She is doing fine after further follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physician should keep the possibility of poisoning by an oxidizing agent, such as naphthalene, when a patient presents to the emergency department with rapid onset pallor, jaundice, and hemoglobinuria.

Naphthalene Toxicity: Methemoglobinemia and Acute Intravascular Hemolysis

Naphthalene poisoning is a rare form of toxicity that may occur after ingestion, inhalation, or dermal exposure to naphthalene-containing compounds such as mothballs. Clinically, patients present with acute onset of dark brown urine, watery diarrhea, and non-bloody bilious vomiting 48-96 hours after exposure. Vital sign abnormalities include fever, tachycardia, hypotension, and persistent pulse oximetry readings of 84%-85% despite oxygen supplementation. Laboratory workup demonstrates hyperbilirubinemia with indirect predominance, hemolytic anemia, methemoglobinemia, and renal dysfunction. Treatment options include supportive care, red cell transfusion, ascorbic acid, methylene blue, and N-acetylcysteine. We present a case of naphthalene toxicity in a 20-year-old autistic male, who improved with supportive care, red blood cell transfusion, and ascorbic acid.

Glucose-6-Phosphate Dehydrogenase Deficiency Mimicking Atypical Hemolytic Uremic Syndrome

A 4-year-old boy presented with nonimmune hemolysis, thrombocytopenia, and acute kidney injury. Investigations for an underlying cause failed to identify a definitive cause and a putative diagnosis of complement-mediated atypical hemolytic uremic syndrome (aHUS) was made. The patient was started initially on plasma exchange and subsequently eculizumab therapy, after which his kidney function rapidly improved. While on eculizumab therapy, despite adequate complement blockade, he presented 2 more times with hemolytic anemia and thrombocytopenia, but without renal involvement. Genetic analysis did not uncover a mutation in any known aHUS gene (CFH, CFI, CFB, C3, CD46, THBD, INF2, and DGKE) and anti-factor H antibodies were undetectable. Whole-exome sequencing was undertaken to identify a cause for the eculizumab resistance. This revealed a pathogenic variant in G6PD (glucose-6-phosphate dehydrogenase), which was confirmed by functional analysis demonstrating decreased erythrocyte G6PD activity. Eculizumab therapy was withdrawn. Complement-mediated aHUS is a diagnosis of exclusion and this case highlights the diagnostic difficulty that remains without an immediately available biomarker for confirmation. This case of G6PD deficiency presented with a phenotype clinically indistinguishable from complement-mediated aHUS. We recommend that G6PD deficiency be included in the differential diagnosis of patients presenting with aHUS and suggest measuring erythrocyte G6PD concentrations in these patients.

Naphthalene Poisoning following Ingestion of Mothballs: A Case Report

Naphthalene is a widely used industrial and household chemical in the form of mothballs. But it has rarely been an agent of poisoning worldwide. We describe a case of ingestional naphthalene poisoning with a good outcome after proper management. A 29-year-old girl ingested 8 mothballs, and presented two days later with haemolysis and methaemoglobinaemia. She was given intravenous methylene blue, N-acetylcysteine and ascorbic acid, besides supportive treatment. Renal replacement therapy in the form of SLED of 8 hours was done on a daily basis. She was discharged after ten days on twice a week outpatient follow-up haemodialysis.

Naphthalene poisoning manifesting as hemoglobinuria

Reddish black discoloration of urine in absence of red blood cells (RBCs) can be a manifestation of hemoglobinuria or myoglobinuria. We report a patient who was admitted for persistent vomiting. On 2^nd day of admission, his urine turned reddish black. The patient then revealed that he had ingested mothballs 1 day back to commit suicide. The patient was managed conservatively with intravenous (IV) fluids and antiemetics. Mothballs are rarely reported as a suicidal agent and most cases are related to accidental exposure of children while playing. IV hemolysis is also reported with mothball ingestion. Our patient quickly became normal within 24 h and there was no residual organ damage.

Community-acquired acute kidney injury in tropical countries

Community-acquired acute kidney injury (AKI) in developing tropical countries is markedly different from AKI in developed countries with a temperate climate, which exemplifies the influence that environment can have on the epidemiology of human diseases. The aetiology and presentation of AKI reflect the ethnicity, socioeconomic factors, climatic and ecological characteristics in tropical countries. Tropical zones are characterized by high year-round temperatures and the absence of frost, which supports the propagation of infections that can cause AKI, including malaria, leptospirosis, HIV and diarrhoeal diseases. Other major causes of AKI in tropical countries are envenomation; ingestion of toxic herbs or chemicals; poisoning; and obstetric complications. These factors are associated with low levels of income, poor access to treatment, and social or cultural practices (such as the use of traditional herbal medicines and treatments) that contribute to poor outcomes of patients with AKI. Most causes of AKI in developing tropical countries are preventable, but strategies to improve the outcomes and reduce the burden of tropical AKI require both improvements in basic public health, achieved through effective interventions, and increased access to effective medical care (especially for patients with established AKI).

Community-acquired acute kidney injury in Asia

Asia, the largest continent in the world, is heterogeneous in the ethnic, socioeconomic, and developmental status of its populations. A vast majority of it is poor with no adequate access to modern health care, making an accurate estimation of the nature and extent of acute kidney injury (AKI) difficult. Community-acquired AKI in otherwise healthy individuals is common, and the population developing AKI is younger compared with its counterparts in Europe or North America. The etiologic spectrum varies in different geographic regions of Asia depending on environmental, cultural, and socioeconomic factors. Some of the etiologic factors include AKI in relation to infectious diseases, intravascular hemolysis caused by glucose 6-phosphate dehydrogenase deficiency, poisonings caused by industrial chemicals or copper sulphate, animal venoms, natural medicines, heat stroke, and after complications of pregnancy. Preventive opportunities are missed because of failure to recognize the risk factors and early signs of AKI. Patients often present late for treatment, leading to multi-organ involvement and increased mortality. The exact etiologic diagnosis cannot be established in many instances because of a lack of appropriate laboratory support. Modern methods of renal replacement therapy are not universally available; and intermittent peritoneal dialysis is still widely practiced in many areas.

Neonatal screening for glucose-6-phosphate dehydrogenase deficiency

OBJECTIVE

This study was carried out to detect the incidence of erythrocytic Glucose-6 -Phosphate dehydrogenase (G-6-PD) deficiency, to compare the incidence of hyperbilirubinemia in G-6-PD deficient neonates as compared to G-6-PD normal neonates and to asses the usefulness of neonatal screening for G-6-PD deficiency.

METHOD

In a retrospective hospital based study 2,479 male and female neonates consecutively born at Indraprastha Apollo hospital between July 1998 to June 2003 who were screened for G-6-PD levels were evaluated for the incidence of G-6-PD deficiency.

RESULTS

Incidence of G-6-PD deficiency was found to be 2.0%. Incidence in males was 283% and female was 1.05%. The incidence of hyperbilirubinemia was found to be 32% in G-6-PD deficient neonates which was significantly higher than the incidence of hyperbilirubinemia in neonates with normal G-6-PD, which was 12.3% (P< 0.001).

CONCLUSION

Our data suggests that neonatal screening for G-6-PD deficiency is a useful test for preventing and early treatment of complications associated with it.

Glucose-6-phosphate dehydrogenase deficiency in India

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the commonest red cell enzymopathy in humans and has an X-linked inheritance. It has been reported from India more than 30 years ago and the prevalence varies from 0-27% in different caste, ethnic and linguistic groups. The major clinical manifestations are drug induced hemolytic anemia, neonatal jaundice and chronic non-spherocytic hemolytic anemia. Individuals with G6PD deficiency have a selective advantage against falciparum malaria. Thirteen biochemically characterized variants have been reported from India. At the molecular level, G6PD Mediterranean is the most common deficient variant in the caste groups whereas, G6PD Orissa is more prevalent among the tribal of India. The third common variant seen in India is G6PD Kerala-Kalyan.

Russell's viper snakebite in Taiwan: differences from other Asian countries

Formosan Russell's viper (Daboia russelli siamensis) is the sixth most frequent cause of snakebite in Taiwan. Its venom has been thought to have both neurotoxic and hematoxic properties. This viper's snakebite is rare and thus scarcely subjected to systemic studies. In this paper, we retrospectively analyzed and described 18 cases of viper snakebite from 1987 to 1999. Like that of the Russell's viper snakebite in other South East Asian areas, varied degrees of acute renal failure, incoagulable blood with bleeding diathesis and hemolysis were the major symptoms found in the systemic envenoming patients. Systemic thrombosis seems to be the distinguishing feature in Formosan Russell's viper snakebite. Neither symptoms nor signs of neuromuscular junction blocking effects were observed, which is another difference from symptoms observed after bites of some other Russell's viper subspecies, suggesting a significant geographic variation. These findings confirmed the clinical importance of Russell's viper snakebite in Taiwan.

Accidental ingestion of a zinc and copper sulfate preparation

CASE REPORT

An 86-year-old woman accidentally ingested a preparation containing zinc and copper sulfate. At ninety minutes after ingestion, the peak plasma concentration was 1979 micrograms/dL for zinc and 209 micrograms/dL for copper, suggesting preferential absorption of zinc. The major complications were gastric and bronchial inflammation due to the corrosive properties of these compounds. Systemic manifestations also developed with cardiovascular failure and renal insufficiency, but the patient made a complete recovery. In addition to symptomatic treatment, chelation therapy with dimercaprol and D-penicillamine was given for 48 h.

CONCLUSION

The available clinical and toxicokinetic data do not support the benefits of chelation in addition to supportive therapy.

A major lethal factor of the venom of Burmese Russell's viper (Daboia russelli siamensis): isolation, N-terminal sequencing and biological activities of daboiatoxin

A major lethal factor, daboiatoxin (DbTx), showing strong PLA2 activity (specific activity 91.7 nmoles/min/mg), was purified to homogeneity from the venom of Burmese Russell's viper (Daboia r. siamensis) by a combination of gel filtration on Sephadex G-75 and ion-exchange chromatography on CM-Sephadex C-25, followed by purification on high-performance gel filtration Shim-pack Diol-150 column. DbTx is a single-chain PLA2 toxin with approximate mol. wt 15,000 as determined by HPLC gel filtration and SDS-PAGE. It constitutes 12% of total venom protein and is the main lethal component of Burmese Russell's viper venom with an LD50 i.p. (0.05 mg/kg) 12-fold greater than that of the whole venom (LD50 i.p. 0.6 mg/kg). DbTx produces neurotoxic symptoms in mice and exhibits potent oedema-inducing activity (minimum oedema dose 0.05 microgram), indirect haemolytic activity and a strong myonecrotic activity, but no haemorrhagic activity. DbTx is cytotoxic to HeLa cells causing cytolysis of the cells 24 hr post-exposure to toxin (50 micrograms/ml). The first 20 N-terminal amino acid sequence (NFFQF AEMIV KMTGK EAVHS) shows a significant resemblance to those of the PLA2s from the venoms of Bulgarian viper (V. a. ammodytes) and Taiwan Russell's viper (V. r. formosensis).

Acute intravascular haemolysis in glucose-6-phosphate dehydrogenase deficiency

Thirty-five children with G6PD deficiency, who presented with acute intravascular haemolysis, were evaluated to define its aetiology, clinical features and ultimate outcome. All were boys with ages ranging from 6 months to 12 years. Pallor of abrupt onset and passage of cola-coloured urine were universal presenting symptoms. Incriminating factors responsible for haemolysis include hepatitis (7), malaria (4), bacterial sepsis (3) and drug intake (24), with more than one predisposing condition existing in some children. Marked elevations in serum bilirubin, coinciding with intravascular haemolysis, was a feature in all the seven children with hepatitis. Azotaemia was noted in 20 patients, of whom 14 did not have oliguria. All four children with malaria presented with protracted renal failure. Therapy focused on maintaining a high urine output in those without oliguria. A total of 15 peritoneal dialyses and five haemodialyses were required in six patients with acute renal failure, all of whom were oliguric. Supportive therapy consisted of blood transfusions and treatment of the predisposing diseases. Thirty-two children recovered completely while three died, the cause of death being severe anaemia and congestive cardiac failure, malaria with oliguric renal failure and hepatic encephalopathy, respectively.

Snake venoms in science and clinical medicine. 1. Russell's viper: biology, venom and treatment of bites

Russell's viper, Vipera russelli (Shaw), is distributed erratically in 10 south Asian countries and is a leading cause of fatal snake bite in Pakistan, India, Bangladesh, Sri Lanka, Burma and Thailand. In Burma it has been the 5th most important cause of death. Its venom is of great interest to laboratory scientists and clinicians. The precoagulant activity of the venom was used by Macfarlane and others to elucidate the human clotting cascade. Up to 70% of the protein content is phospholipase A2, present in the form of at least 7 isoenzymes. Possible clinical effects of the enzyme include haemolysis, rhabdomyolysis, pre-synaptic neurotoxicity, vasodilatation and shock, release of endogenous autacoids and interaction with monoamine receptors. Russell's viper bite is an occupational hazard of rice farmers throughout its geographical range. Defibrination, spontaneous haemorrhage, shock and renal failure develop with frightening rapidity. In several countries, Russell's viper bite is the commonest cause of acute renal failure. There is a fascinating geographical variation in the clinical manifestations, doubtless reflecting differences in venom composition. Conjunctival oedema is unique to Burma, acute pituitary infarction to Burma and south India, and rhabdomyolysis and neurotoxicity to Sri Lanka and south India. Treatment with potent specific antivenom rapidly controls bleeding and clotting disorders, but may not reverse nephrotoxicity and shock. Causes of death include shock, pituitary and intracranial haemorrhage, massive gastrointestinal haemorrhage and acute tubular necrosis or bilateral renal cortical necrosis. The paddy farmer and the Russell's viper coexist in fragile symbiosis. The snake controls rodent pests but inevitably interacts with man, often with mutually disastrous results.

Snake-bite-induced acute renal failure in India

Acute renal failure complicates the course in 5% to 30% of victims of severe viper poisoning. No consensus exists on the single mechanism causing acute renal failure after viper bite. It is known, however, that viper venom induces several clinical abnormalities that favor the development of acute renal failure. These alterations include a varying degree of bleeding, hypotension, circulatory collapse, intravascular hemolysis, and disseminated intravascular coagulation with or without microangiopathy. A direct cytotoxic action of snake venom on the kidney is suspected, but convincing evidence is still lacking. Severe hypocomplementemia is consistently present, but I doubt its role in the causation of renal lesions. Hypersensitivity to venomous or antivenomous protein occasionally causes acute renal failure. In sea snake poisoning, myonecrosis and myoglobinuria appear to play the predominant pathogenetic role. The renal lesions of clinical significance in envenomed patients are acute tubular and patchy or diffuse cortical necrosis. Glomerulonephritis, interstitial nephritis, and papillary necrosis have been reported in rare patients. I trust that this overview of the clinical and basic-science aspects of snake-bite-induced acute renal failure will prompt investigators to further define the pathogenetic mechanisms involved. Lessons learned may aid patients with acute renal failure of diverse causes, both here in India and around the world.

Mothball toxicity

Accidental mothball ingestion is very common in children. Mothballs consist either of naphthalene or paradichlorobenzene, the toxicities of which are very different. This article focuses on the management of mothball ingestion with reference to these major ingredients.

Acute renal failure due to non-traumatic rhabdomyolysis

Seventeen patients with acute renal failure of diverse aetiology showed myoglobinuria and elevated levels of serum creatine phosphokinase (mean 119·2 Sigma u./ml) and adolase (mean 88·5 Sibley-Lehninger (SL)u./ml), indicating the presence of diffuse muscle cell injury. The primary conditions which led to rhabdomyolysis and acute renal failure were burns, eclampsia, prolonged labour, crush injury, epileptiform convulsions, status asthmaticus, viral myositis and intoxication with chemicals including copper sulphate, mercuric chloride and zinc phosphide. In 10 non-myoglobinuric patients with acute renal failure, serum creatine phosphokinase was normal (mean 8·9 Sigma u./ml) and serum aldolase was only slightly elevated (mean 11·2 SL u./ml). Although uric acid was elevated in both groups, the values were significantly higher in myoglobinuric (mean 0·728 ± 0·199 mmol/l) compared to non-myoglobinuric patients (mean 0·583 ± 0·093 mmol/l). During the oliguric phase, hypocalcaemia was observed in 82·2% of myoglobinuric patients and in 20% of non-myoglobinuric patients. Ten out of 15 patients with myoglobinuric renal failure developed hypercalcaemia during the diuretic phase whereas only 3 non-myoglobinuric patients showed a transient hypercalcaemia. Although the mean serum potassium was somewhat higher in the myoglobinuric patients, the difference between the 2 groups was not significant. It is concluded that acute renal failure associated with non-traumatic rhabdomyolysis is not infrequent and may occur in a variety of conditions where gross evidence of muscle injury is lacking.