Journal of The Korean Society of Clinical Toxicology

Volume 20(1); June 2022

Comparison of medical history based diagnosis and urine test using ultra-performance liquid chromatography-tandem mass spectrometry in drug overdose: Ja-Young Lee, Kyungman Cha, Won Jung Jeong, Hyung Min Kim, Byung Hak So; J Korean Soc Clin Toxicol. 2022;20(1):1-7. Published online June 30, 2022; DOI: https://doi.org/10.22537/jksct.2022.20.1.1

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Abstract PDF: Purpose: In patients with acute drug overdose, identification of drugs ingested is crucial to make a precise diagnosis. In most cases, the diagnoses are made on the medical history and physical examination findings. This study was undertaken to determine the concordance of diagnosis made on the basis of patient history by comparing it with urine toxicology analysis. Methods: This was a retrospective study of drug intoxicated patients over 18 years old who presented to the emergency center from 2017 to 2019. Specimens from urine were tested using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-TMS). The test results were compared with information obtained from patients. Diagnostic concordances for drug detection in intoxicated patients were calculated. Logistic regression analysis was used to examine the association between clinical characteristics and diagnostic discrepancy. Results: Totally, 370 patients were included in the analysis. Overall, 66 types of drugs were detected by UPLC-TMS. The drugs detected most frequently were zolpidem (104, 27.8%), citalopram (70, 18.7%), and paracetamol (66, 17.6%). The mean diagnostic concordance of patients was 52.7%. There were statistically significant diagnostic discrepancies in patients with underlying depression and patients intoxicated with multiple types of drugs. Conclusion: In ED patients with acute drug overdose, the diagnoses made on history alone were often inaccurate. It is essential to perform urine toxicology tests such as UPLC-TMS as a confirmatory instrument to improve accuracy in evaluating patients with drug intoxication.

Comparative Analysis of decreased Mental state Patients after Overdose with Sedative-hypnotics: Seung Jae Oh, Soo Hyung Cho, So Yeon Ryu; J Korean Soc Clin Toxicol. 2022;20(1):8-14. Published online June 30, 2022; DOI: https://doi.org/10.22537/jksct.2022.20.1.8

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Abstract PDF: Purpose: This study was undertaken to investigate how sedative-hypnotics affect the occurrence and severity of the patient's symptoms. In addition, we conducted a study to determine the type of patients who reacted severely and required hospitalization; patients were accordingly classified as hospitalized patients and patients discharged from the emergency room. Methods: From January 2017 to December 2019, we investigated the demographics, drug information, history, laboratory tests, and severity of patients who visited our emergency department and were diagnosed with benzodiazepine, zolpidem, and doxylamine succinate overdose. We further compared details of hospitalized patients and discharged patients. Results: Subjects who had overdosed and visited the ED included 120 for benzodiazepine, 147 for zolpidem, and 27 for doxylamine succinate. Comparisons between the three groups revealed differences in their early diagnosis, psychiatric history, and sleep disturbance. Differences between groups were also determined for mental state, poisoning history, treatment received in the intensive care unit, and intubation and ventilator support. In cases of benzodiazepine overdose, we obtained a high hospitalization rate (40.0%), admission to the intensive care unit (24.2%), and intubation rate (18.3%). Comparisons between hospitalized patients and discharged groups showed differences in transferred patients, early diagnosis, and mental state. Conclusion: Patients poisoned by sedative-hypnotics are increasing every year. In cases of benzodiazepine and zolpidem, the hospitalization rates were high, and benzodiazepine overdose resulted in hospitalization, intensive care unit admission, and pneumonia in a majority of cases. Therefore, active treatment and quick decisions in the emergency room are greatly required.

Inflammatory cytokines in patients with pesticide poisoning: a pilot study: Hyun Joon Kim, Wook-Joon Kim, Dong Wook Lee, Seung-Hyun Jung, Nam-Jun Cho, Samel Park, Eun Young Lee, Hyo-Wook Gil; J Korean Soc Clin Toxicol. 2022;20(1):15-21. Published online June 30, 2022; DOI: https://doi.org/10.22537/jksct.2022.20.1.15

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Abstract PDF: Purpose: Acute pesticide poisoning is lethal and can lead to death. A few studies about the effects of acute pesticide poisoning have focused on the immune system. In the current study, we preliminarily investigated the changes in blood inflammatory cytokine levels in acute pesticide poisoning patients. Methods: In this study, we prospectively investigated the inflammatory cytokines in patients with acute pesticide poisoning. This study included patients admitted from February 2021 to November 2021 with a diagnosis of intentional poisoning by pesticide ingestion. The inflammatory cytokines measured were IFN-γ, IL-1β, IL-6, and TNF-α. Results: Totally, 27 patients were enrolled in this study. The types of pesticide ingested were glufosinate (n=6), glyphosate (n=8), organophosphate (n=4), pyrethroid (n=2), and others (n=7). The levels of inflammatory cytokines obtained were as follows: IFN-γ 2.78±8.03 pg/ml, IL-1β 2.62±2.03 pg/ml, IL-6 44.58±80.16 pg/ml, and TNF-α 11.80±15.60 pg/ml. The overall mortality rate was 11.1% (3/27), and levels of IL-1β and TNF-α were significantly higher in the death group compared to the survival group. Conclusion: Increased levels of IL-6 and TNF-α were observed in patients with acute pesticide poisoning. IL-1β and TNF-α were significantly higher in the death group as compared to the survival group. Our results indicate the occurrence of an inflammatory response due to the activation of immune cells by pesticide poisoning. Future large-scale studies need to be conducted to investigate the application of inflammatory cytokines as predictors and therapeutic targets.

A Case of Cobra Antivenom Therapy in a Patient Bitten by Elapid Snake in South Korea: Ji Eun Kim, In Ho Kwon; J Korean Soc Clin Toxicol. 2022;20(1):22-24. Published online June 30, 2022; DOI: https://doi.org/10.22537/jksct.2022.20.1.22

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Abstract PDF: Elapid snakes have neurotoxic venom which causes diverse neuroparalytic manifestations, including fatal respiratory failure. In South Korea, since elapid snakebites are very rare, the cobra antivenom, which is effective against neurotoxicity, was only introduced recently. Most physicians in South Korea have little experience in the treatment of patients who have been bitten by elapid snakes. A 19-year-old man was brought to the emergency department with sudden diplopia, 1 hour after a snakebite on the left 2nd finger. The patient presented with drowsiness and complained of mild dizziness and binocular diplopia. After 1 hour, he had sudden onset of dyspnea and dysphagia and appeared to be agitated. He was immediately intubated and received mechanical ventilation as he was unable to breathe on his own. A total of 2.5 mg of neostigmine diluted with normal saline was slowly infused, and 1 vial of cobra antivenom was infused for an hour, 5 times every 2 hours, for a total of 5 vials. He slowly recovered self-breathing; on the 3rd day of hospitalization, he showed tolerable breathing and was extubated. He was discharged without any neurological deficits or other complications.

A case of severe organophosphate poisoning used a high-dose atropine: Hyoung Ju Lee, Dae Sik Moon, Young Yun Jung, June Seob Byun, Chong Myung Kim; J Korean Soc Clin Toxicol. 2022;20(1):25-30. Published online June 30, 2022; DOI: https://doi.org/10.22537/jksct.2022.20.1.25

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Abstract PDF

In this study, we report the case of a 59-year-old male patient with organophosphate pesticide poisoning. He visited the local emergency medical center after ingesting 250 ml of organophosphate pesticide. The patient's symptoms improved after the initial intravenous infusion of pralidoxime 5 g and atropine 0.5 mg. However, 18 hours after admission, there was a worsening of the symptoms. A high dose of atropine was administered to improve muscarinic symptoms. A total dose of 5091.4 mg of atropine was used for 30 days, and fever and paralytic ileus appeared as side effects of atropine. Anticholinergic symptoms disappeared only after reducing the atropine dose, and the patient was discharged on the 35th day without any neurologic complications.

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The effects of case management program completion on suicide risk among suicide attempters: A 5-year observational study
Hyun Jo Shin, Gwan Jin Park, Yong Nam In, Sang Chul Kim, Hoon Kim, Suk Woo Lee
The American Journal of Emergency Medicine.2019; 37(10): 1811. CrossRef

Cerebellar Hippocampal and Basal Nuclei Transient Edema with Restricted diffusion (CHANTER) syndrome due to antidepressant: Sangun Nah, Han Bit Kim, Sangsoo Han, Sungwoo Choi, Hoon Lim; J Korean Soc Clin Toxicol. 2022;20(1):31-34. Published online June 30, 2022; DOI: https://doi.org/10.22537/jksct.2022.20.1.31

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Abstract PDF: Cerebellar Hippocampal and Basal Nuclei Transient Edema with Restricted diffusion (CHANTER) syndrome is characterized by an altered mental status. The acute MRI lesions show abnormal restricted diffusion imaging bilaterally and symmetrically in the cerebellum, hippocampus, and basal nuclei. This syndrome is an unknown syndrome and is presumed to be mainly an opioidinduced toxidrome. Here, we present a case study wherein we show that it can also be caused by an antidepressant overdose.

Ocular chemical burns following accidental instillation of tinea pedis treatment solution: A report of two cases: Jung Ho Kim, Han Sol Chung; J Korean Soc Clin Toxicol. 2022;20(1):35-38. Published online June 30, 2022; DOI: https://doi.org/10.22537/jksct.2022.20.1.35

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Abstract PDF: Many commonly used household chemicals and medical eye drops look alike, resulting in a worldwide increase in incidences of accidents caused by confusion between similar-looking agents. In this case report, we present two patients who visited the emergency department following inadvertent instillation of tinea pedis treatment solution instead of eye drops. Both patients developed corneal chemical burns following the accidental application. Notably, the visual acuity and symptoms eventually recovered for both patients after hospitalization. However, complete recovery occurred only after several weeks. Both patients were relatively old and had been prescribed eye drops after previous ophthalmic surgery. Since the eye is a sensory organ that receives visual information, ocular injuries significantly affect the quality of life and social functioning of the patient. Incidences of accidental misidentification of eye drops are steadily increasing in South Korea; unfortunately, regulatory policies are unavailable to avoid such hazards. Therefore, physicians should be mindful of the potential risks associated with misidentification of everyday household products and must spend time educating patients when prescribing eye drops. Policy regulations are warranted for products with containers that resemble eye drop bottles. Such items need to be clearly labeled with additional warnings to prevent misidentification and accidental ocular instillation.

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