A case of paraquat poisoning and subsequent fatality presenting to an emergency department

Paraquat (1,1'-dimethyl-4,4'-dipyridylium) is an herbicide associated with both accidental and intentional ingestion, leading to severe and often fatal toxicity. Prognosis is largely dependent on the amount of paraquat absorbed. Rapid identification of the symptoms of paraquat toxicity (burns or ulceration at the site of ingestion or injection, acute respiratory distress, and renal failure) can facilitate early treatment intervention to limit absorption. We report a case of a 71-year-old man with a suicidal ingestion of paraquat 2 days prior to presentation. Serum paraquat levels, time elapsed since ingestion, and clinical symptoms all indicated poor prognosis. The patient developed severe respiratory distress and progressive renal failure, and died 6 days after admission to the hospital.     

Metabolic catecholamine, and endurance responses to caffeine during intense exercise

This study examined the possible effects of caffeine ingestion on muscle metabolism and endurance during brief intense exercise. We tested 14 subjects after they ingested placebo or caffeine (6 mg/kg) with an exercise protocol in which they cycled for 2 min, rested 6 min, cycled 2 min, rested 6 min, and then cycled to voluntary exhaustion. In each exercise the intensity required the subject's maximal O2 consumption. Eight subjects had muscle and venous blood samples taken before and after each exercise period. The caffeine ingestion resulted in a significant increase in endurance (4.12 +/- 0.36 and 4.93 +/- 0.60 min for placebo and caffeine, respectively) and resulted in a significant increase in plasma epinephrine concentration throughout the protocol but not in norepinephrine concentration. During the first two exercise bouts, the power and work output were not different; blood lactate concentrations were not affected significantly by caffeine ingestion, but during the exercise bouts muscle lactate concentration was significantly increased by caffeine. The net decrease in muscle glycogen was not different between treatments at any point in the protocol, and even at the time of fatigue there was at least 50% of the original glycogen concentration remaining. the data demonstrated that caffeine ingestion can be an effective ergogenic aid for exercise that is as brief as 4-6 min. However, the mechanism is not associated with muscle glycogen sparing. It is possible that caffeine is exerting actions directly on the active muscle and/or the neural processes that are involved in the activity.     

Hypokalemic nephropathy and nephrogenic diabetes insipidus due to excessive consumption of a soft drink

Chronic diarrhea commonly causes hypokalemia. However, life-threatening hypokalemia due to chronic diarrhea has not been reported in the adult caused by chronic ingestion of a fructose beverage. We report an adult patient who had severe hypokalemia from chronic osmotic diarrhea as a result of drinking 4 to 6 liters of Big Red daily for several months. This resulted in sustained hypokalemia, complicated by hypokalemic nephropathy and subsequent nephrogenic diabetes insipidus. All abnormalities cleared with potassium replacement, salt restriction, modest thiazide treatment, and abstinence from Big Red.     

Brain transections selectively alter ingestion and behavioral activation in neonatal rats.

Food-deprived neonatal rats actively ingest milk that is infused into their mouths through intraoral cannulas. This ingestion is accompanied by behavioral activation. The involvement of various brain regions in ingestion and activation was examined in 2-day-old Charles River pups by making transections along the neuraxis from the olfactory bulbs to the anterior pons. Following a 24-hr deprivation period, a series of oral milk infusions was given, and milk intake and activity were measured. Intake was severely reduced only in Ss with diencephalic transections. Cuts in front of or behind the diencephalon resulted in normal or slightly decreased intake. In contrast, activity tended to decline as the level of the transection became more caudal. Thus ingestion and its accompanying behavioral activation could be separated neuroanatomically. These results suggest that 2 brain mechanisms are involved in the ingestive response of the infant rat, one in the diencephalon and another caudal to the mesencephalon. However, behavioral activation appears less discretely organized, involving most of the neuraxis. (28 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The ontogeny of feeding in rats: V. Influence of texture, home odor, and sibling presence on ingestive behavior.

Determined with Charles River rat pups in 3 experiments that terry-cloth texture, home odor, and the presence of siblings modulated Ss' ingestive behavior. Unlike warmth, which affected ingestion in pups until at least 15 days of age, the relative importance of other cues varied with age. At 3 days, ingestion was dependent on warmth but was not influenced by the other cues. At 6 days, texture and home odor enhanced ingestive behavior (intake, activity, mouthing, and probing), but the presence of siblings had no effect. Home odor or terry-cloth texture did not alter the ingestive behavior of 12-day-olds, but the presence of siblings enhanced milk intake. Thus, during development, the external sensory controls for ingestion became progressively more complex. Warmth served as a primary permissive cue for ingestion, but as Ss grew older, such other cues as odor, texture, or social stimuli also gained significance. (33 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The clinical spectrum of Jin Bu Huan toxicity

Herbal medications and other nontraditional medical therapies are becoming increasingly popular in the United States. We describe three children and three adults in whom severe toxic effects developed after ingestion of a Chinese herbal medication, jin bu huan, which is sold as Jin Bu Huan Anodyne Tablets. Jin bu huan produced distinct clinical syndromes after acute ingestion in children and long-term use in adults. A single, acute ingestion in children rapidly produced life-threatening neurologic and cardiovascular manifestations, while long-term jin bu huan use in adults was associated with hepatitis. Jin bu huan contains levo-tetrahydropalmatine, a potent neuroactive substance. The constituents of jin bu huan are misidentified on the package, resulting in significant delay in identifying the plant alkaloid responsible for its toxicity. Although perceived as innocuous, jin bu huan may produce major health effects. The highly concentrated formulation, the lack of childproof packaging, and the product insert listing indications for the treatment of serious medical conditions may all contribute to the development of toxic reactions.     

Effect of acute bicarbonate administration on exercise responses of COPD patients

Patients with severe chronic obstructive pulmonary disease (COPD) are limited in their exercise tolerance by the level of ventilation (VE) they can sustain. We determined whether acutely increasing blood bicarbonate levels decreased acid stimulation to the respiratory chemoreceptors during exercise, thereby improving exercise tolerance. Responses were compared with those obtained during 100% O2 breathing (known to reduce VE in these patients) and to the responses of healthy young subjects. Participants were six patients with severe COPD (forced expired volume in 1 s = 31 +/- 11% predicted) but without chronic CO2 retention and 5 healthy young subjects. Each subject performed three incremental cycle ergometer exercise tests: 1) control, 2) after ingestion of 0.3 g.kg-1 of sodium bicarbonate and 3) while breathing 100% O2. During these tests VE was measured continuously and arterialized venous blood (patients) or arterial blood (healthy subjects) was sampled serially to assess acid base variables. Bicarbonate loading increased standard bicarbonate by 4-6 mmol.L-1 and this elevation persisted during exercise. In both groups, bicarbonate loading resulted in a substantially higher arterial pH; arterial PCO2 was either unchanged (healthy subjects) or mildly (averaging 5 torr) higher (COPD patients). However, in neither group did bicarbonate loading result in an altered VE response to exercise or an increase in exercise tolerance. In contrast, superimposing hyperoxia on bicarbonate ingestion yielded, on average, 24% reduction in VE and 50% increase in peak work rate in the patients (but not in the healthy young subjects). We conclude that acute bicarbonate loading is not an ergogenic aid in patients with severe COPD.     

Kappa-opioid potentiation of tumor necrosis factor-alpha-induced anti-HIV-1 activity in acutely infected human brain cell cultures

The aim of this study was to investigate the effect of medium-chain triacylglycerol (MCT) ingestion during exercise on subsequent time-trial cycling performance. Seven well-trained cyclists performed four exercise trials consisting of 2 h at 60% of maximal oxygen uptake followed by a simulated time trial (ie, completion of a preset amount of work as fast as possible) of approximately 15 min duration. During the trials, subjects ingested 1) a 10% carbohydrate solution (CHO; 170 +/- 6 g glucose), 2) a 10% carbohydrate electrolyte with 5% MCT solution (CHO + MCT; 85 +/- 3 g MCT), 3) a 5% MCT solution, or 4) artificially colored and flavored water (placebo). Neither CHO nor CHO + MCT ingestion had any effect on performance compared with placebo ingestion, whereas ingestion of MCT had a negative effect on performance. Average work rates during the time trial were 314 +/- 19, 314 +/- 13, and 312 +/- 18 with CHO, CHO + MCT, and placebo, respectively, and was 17-18% lower in the MCT trial (263 +/- 22 W). In addition, compared with placebo ingestion, MCT ingestion had no effect on total rates of fat or carbohydrate oxidation, nor did it affect exogenous or endogenous carbohydrate utilization. The negative effect of MCT ingestion was associated with increased gastrointestinal complaints (ie, intestinal cramping). These data suggest that large amounts of MCTs (85 g) ingested during prolonged submaximal exercise may provoke gastrointestinal problems leading to decreased exercise performance.     

Diagnosis and treatment of caustic ingestion

The acute diagnostic procedures in caustic ingestion are primarily directed towards the recognition of life-threatening complications such as airway obstruction, perforation of inner organs and, in severe acid ingestion, metabolic acidosis. The endoscopic injury grading forms the basis of a differentiated treatment. Not all patients need endoscopic evaluation; the indications are discussed. The treatment is controversial. Fluid given orally is recommended within few minutes of ingestion, and thus rarely administered at the arrival to the hospital. Here, the task is to secure the vital functions and to relieve pain. The prevention of oesophageal stricture in deep, (near)-circumferential ulcerations is essential for the further treatment. Once-formed strictures are usually treated with dilatation.     

Intragastric carbohydrate exerts both intake-stimulating and intake-suppressing effects.

Ingestion-contingent infusions of 6% carbohydrate did not affect saccharin intake during the first ingestive bout, but later they greatly stimulated ingestion, slowed the rate of decline of ingestion during bouts, and increased the average bout size. This suggests that the intake-stimulating effect of carbohydrate infusions is partly attributable to conditioned desatiation. Satiation can also be conditioned because more concentrated infusions (24% carbohydrate) did not increase daily intake or average bout size, even though both concentrations stimulated ingestion during the first 0.5-6.0 min of a test session, as well as during extinction tests when only water was infused. Increased intake may be partly mediated by a hedonic mechanism because naloxone, an opioid antagonist, decreased intake in rats infused with carbohydrate to a greater degree than it decreased intake in rats infused with water. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Raw egg ingestion and salmonellosis in body builders

Four patients with Salmonella enteritidis infection are reported. All were body builders who regularly consumed substantial quantities of raw eggs. They presented with a severe febrile illness and diarrhoea--presumably reflecting a large bacterial inoculum. Advice regarding the potential hazards of raw egg ingestion has been repeatedly issued by the Department of Health--but this report highlights the fact that this practice continues in spite of this. The epidemiology of S. enteritidis infection in relation to raw egg ingestion is discussed.     

Identification of an HLA-C variant allele, Cw*0805, by sequencing based typing

CASE REPORT: Oleic acid and oleate are pulmonary toxins used to create laboratory models of acute respiratory distress syndrome, but there is little information on human toxicity. We report the intentional ingestion of 50 mL sodium oleate 20% by a 22-year-old woman with no symptoms for the first 2 days after ingestion. Her respiratory status deteriorated rapidly on day 3 progressing to acute respiratory distress syndrome (PaO2/FIO2 < 100 mm Hg) on day 4. Treatment with high-dose steroids and intensive respiratory support including high-frequency jet ventilation were associated with gradual but complete recovery by day 39. The delayed onset of symptoms suggested that the lung injury was due to the systemic circulation of oleate to the lungs rather than to direct aspiration. In oral poisoning by sodium oleate, the lung is the first and most lethally affected target organ in humans. This case demonstrates that ingestion of a relatively small amount of sodium oleate can cause delayed, progressively severe, lung injury.     

Severe hepatocellular damage after administration of paracetamol and chlorzoxazone in therapeutic dosage

A 64 year old patient developed severe hepatocellular damage with jaundice and coagulopathy during ingestion of a combination of paracetamol and chlorzoxazone in therapeutic dosage. The risk factors for the development of liver cell necrosis following ingestion of paracetamol in therapeutic dosage are discussed. In particular in patients with risk factors (e.g. alcoholics and patients with heart failure) paracetamol-induced liver failure has to be considered in the presence of high transaminases, even when paracetamol was ingested in therapeutic dosage. Chlorzoxazone itself rarely can induce an idiosyncratic hepatocellular damage.     

Control of ingestion by oral habituation in rat pups.

The role of habituation of mouthing activity in the control of ingestion was investigated in 6-, 12-, and 18-day-old rat pups. In pups at all ages, oral habituation to a flavored diet inhibited ingestion of a continuous oral infusion of that same diet. 12-day-old pups that had orally habituated to a diet continued to consume less of a continuous oral infusion of that diet both 30 min and 3 hrs later, and the duration of suppressed ingestion was shown to be dependent on the rate of stimulus presentation during habituation experience. These data suggest that oral habituation may be a diet-specific influence on both intra- and intermeal patterning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Phenolphthalein poisoning: a case report

A case of severe poisoning due to the ingestion of phenolphthalein in the form of a patent medication, is described.     

Mushroom poisoning. New possibilities for treatment

Poisonous species of fungi in Germany are very few. Dangerous is the ingestion of raw, spoiled or poisonous mushrooms. There exist no reliable tests to determine whether a mushroom is safe except by expert examination and identification of the mushroom. In clinical practice the classification of mushroom poisoning is possible in muscarine-syndrome, gastroenteritic syndrome and in two-phase-syndrome. 90-95% of lethal mushroom poisonings are due to ingestion of Amanita phalloides. In severe cases extensive hepatic necrosis occurs, characterized by profound abnormalities in liver function caused by hepatic coma. In deep coma mortality rates amount to 70% or more. A new therapeutic measure (coated charcoal hemoperfusion)-first applied in liver failure by Chang (1972) and Williams (1973)-has been performed in 3 patients with severe poisoning after ingestion of Amanita phalloides (each patient had eaten at least 7-10 fungi Amanita phalloides). Two of the patients survived.     

Raising milk energy content retards gastric emptying of lactose in lactose-intolerant humans with little effect on lactose digestion

Lactose digestion improves when the energy content of a meal is raised, perhaps due to delayed gastric emptying; however, this has not been demonstrated directly. It is not known whether lactose-intolerant subjects should consume full-fat or high energy milk instead of half-skimmed milk. In this study, breath 13CO2 and hydrogen (H2) measurements were combined to assess simultaneously the effect of increasing milk energy content on gastric emptying, digestion, and tolerance of lactose. On two separate days, 11 adult lactose maldigesters ingested, in the fasting state, a single dose of 710 kJ half-skimmed milk or 1970 kJ high energy milk. Both contained 18 g lactose and were supplemented with 100 mg 13C-glycine for breath 13CO2 measurement. For 6 h after milk ingestion, samples of expired breath were collected, and subjects scored their symptoms on a four-grade questionnaire. Gastric emptying was measured from excretion of breath 13CO2. The mean gastric emptying half-time was significantly longer after ingestion of high energy milk than after half-skimmed milk (84 +/- 4 vs. 64 +/- 4 min, P = 0.004). The mean area under the breath H2 excretion curve measured for 6 h was 330 +/- 61 microL/L after subjects consumed high energy milk vs. 470 +/- 82 microL/L after they consumed half-skimmed milk (P = 0.07). Mean symptom scores did not differ after ingestion of the two milks, but only two subjects experienced disturbing symptoms after high energy milk ingestion compared with five subjects after ingestion of half-skimmed milk (P = 0.56). Although ingestion of high energy milk delayed the gastric emptying of lactose for significantly longer than the ingestion of half-skimmed milk (P < 0.01), it did not lead to significant improvement in symptoms and reflected only a trend toward improved lactose digestion (P = 0.07), as measured by the area under the breath H2 excretion curve. These results indicate that it is not beneficial for most lactose-intolerant subjects to replace consumption of half-skimmed milk by milk with a higher energy content.     

Complementary therapies for asthma: what patients use

To determine the effect of pharmacological fiber supplements, we measured levothyroxine (LT4) absorption without and with simultaneous ingestion of either calcium polycarbophil or psyllium hydrophilic mucilloid. Serum thyroxine (T4) levels in 8 volunteers were measured following ingestion of 600 microg of LT4 on 3 separate occasions at 4-week intervals: (1) LT4 alone; (2) LT4 together with 1000 mg polycarbophil; and (3) LT4 together with 3.4 g psyllium. The amount of absorbed LT4 was calculated as the incremental rise in serum T4 level during the first 6 hours multiplied by the volume of distribution for the hormone, and expressed as a percentage of the dose administered. Absorption of LT4 alone averaged 89% (95% confidence interval [CI]: 75%-104%), occurring at a median of 180 minutes. After simultaneous ingestion of calcium polycarbophil, LT4 absorption was 86% (95% CI: 74%-97%), occurring at 180 minutes. With simultaneous ingestion of psyllium and LT4, the absorption was 80% (95% CI: 64%-95%), occurring at 240 minutes. In summary, neither calcium polycarbophil nor psyllium hydrophilic mucilloid are likely to cause malabsorption of LT4 that could be detected by these methods.     

Preexercise meal composition alters plasma large neutral amino acid responses during exercise and recovery

This study was designed to determine metabolic and physical performance responses to ingestion of pre-exercise meals with different macronutrient and fiber profiles. Twelve physically active subjects (6 males and 6 females) were used to investigate the metabolic and physical performance consequences of consuming pre-exercise meals consisting of oat, corn, or wheat cereals. A fasting trial served as the control, and all subjects received each treatment in a Latin-square design. Blood samples were drawn before and 85 min after meal ingestion, during 90 min of cycling exercise (60% VO2peak), after a 6.4 km performance ride, and during 60 min of recovery. Expired air samples were collected to determine nutrient utilization. Resting carbohydrate oxidation rates and plasma insulin concentrations after oat ingestion were less than after wheat, and corn and wheat ingestion, respectively (P < 0.05). During exercise, the change in plasma glucose from pre-exercise was greater after consuming wheat and corn compared with oat (P < 0.05), and it was inversely related to pre-exercise plasma insulin concentration (r = -0.55, P = 0.0001). Plasma free fatty acid concentrations were inversely related to plasma lactate concentrations (r = -0.58, P = 0.0001). Free fatty acid concentrations and fat oxidation were greater in fasting trials than all others, but performance ride times did not differ among treatments. Plasma branched-chain amino acid concentrations resembled their respective meal profiles throughout exercise, the performance ride, and recovery. These results indicate that pre-exercise meal composition can influence glucose homeostasis during early exercise and plasma branched-chain amino acid concentrations over a substantial range of metabolic demands.