Journal of The Korean Society of Clinical Toxicology

Volume 17(1); June 2019

Scombroid Fish Poisoning and Histamine Food Poisoning: Sung Phil Chung; J Korean Soc Clin Toxicol. 2019;17(1):1-6. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.1

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Abstract PDF: Scombroid fish poisoning (SFP) is a form of histamine food poisoning caused by the ingestion of improperly stored fish. The term "scombroid" derives from the family name of the fish family first implicated, such as tuna and mackerel. On the other hand, non-scombroid fish species, such as sardine and herring, can also cause histamine poisoning. The histamine is converted from histidine by a bacterial enzyme in the causative fish. Because the symptoms of SFP can easily be confused with food allergies, it is believed to have been significantly under-reported. In 2016, an outbreak of SFP occurred among primary school students who had eaten yellowtail steak in Korea. The most common findings consisted of a rapid onset of flushing of the face and trunk, erythematous and urticarial rash, diarrhea, and headache occurring soon after consuming the spoiled fish. Usually, the course is self-limiting and antihistamines can be used successfully to relieve symptoms, but several life-threatening SFP cases have been reported. Clinical toxicologists should be familiar with SFP and have competency to make a differential diagnosis between fish allergy and histamine poisoning. SFP is a histamine-induced reaction caused by the ingestion of histamine-contaminated fish, whereas a fish allergy is an IgE-mediated reaction. This review discusses the epidemiology, pathophysiology, diagnosis, treatment, and preventive measures of SFP.

A Study of Predicting the Severity Following Glufosinate Ammonium Containing Herbicide Poisoning Experienced in Single Emergency Medical Institution: Doo Sung Lee, Kyoung Ho Choi; J Korean Soc Clin Toxicol. 2019;17(1):7-13. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.7

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Abstract PDF: Purpose: Owing to the increased agricultural use of the herbicide glufosinate ammonium (GLA), the incidence of GLA poisoning has recently increased. Therefore, we investigated the possible predictive factors associated with severe complications following GLA poisoning. Methods: A retrospective analysis of medical records was conducted based on 76 patients who had visited our regional emergency medical center with GLA poisoning from 2006 to 2017. Severe complications were defined as respiratory failure requiring intubation, systolic blood pressure less than 90 mmHg, Glasgow Coma Scale (GCS) less than 8, and presence of seizure. Results: Age, ingested amount and ingested amount per weight were significantly greater in the severe group (p<0.001). PSS grade 2 or higher was more common in the severe group (p<0.001), and In addition, the APACHE II score was significantly higher in the severe group (p<0.001), as were the SOFA scores (p=0.002). Serum ammonia levels were significantly higher in the severe group (p=0.007), while MDRD-GFR was smaller in the severe group (p=0.002). The spot urine protein levels were significantly higher in the severe group (p=0.005), as was the urine protein to creatinine ratio (p=0.001). Upon multivariate analysis, the amount ingested per weight and PSS grade 2 or higher were identified as significant predictors. Conclusion: Our study showed that MDRD-GFR was significantly lower in the severe group after GLA poisoning. PSS grade 2 or higher and ingested amount per weight may be useful to evaluate the severity of complications after GLA poisoning.

Risk Factors of Delirium in ICU Patients with Acute Poisoning: Hee Yeon Kim, Kyung Man Cha, Byung Hak So; J Korean Soc Clin Toxicol. 2019;17(1):14-20. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.14

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Abstract PDF: Purpose: This study estimated the incidence of delirium and associated risk factors and outcomes in ICU patients with acute poisoning. Methods: Data were collected from ICU patients over 18 years of age that were admitted via the emergency center after presenting with poisoning from 2010 to 2015. Delirium was assessed retrospectively using the Intensive Care Delirium Screening Checklist (ICDSC). Risk factors were evaluated by univariate and multivariate analysis. Results: A total of 199 patients participated in this study and 68 (34.2%) were diagnosed with delirium based on the ICDSC score. The delirium group showed a significantly higher association with prolonged length of stay in the hospital and ICU in comparison with the non-delirium group. The delirium group was associated with greater use of physical restraint. A statistically greater number of patients with pharmaceutical substance poisoning developed delirium over a short period of time than those with non-pharmaceutical substance poisoning. There was no significant difference between the two groups with respect to age, sex, past history, GCS score, vital signs, application of ventilator care and renal replacement therapy. Conclusion: The finding that the delirium group had a greater length of stay in both the hospital and the ICU is consistent with the results of previous worldwide studies of the effects of delirium on the prognosis of patients who were admitted to the ICU, suggesting the possibility for domestic application. Additionally, use of physical restraint was positively related to the incidence of delirium. Thus, interventions for minimizing the use of physical restraints and considering alternatives are needed.

Comparison of Mortality Rate according to Hospital Level among Patients with Poisoning Based on Korean Health Insurance and Assessment Service: Soyoung Kim, Sangchun Choi, Hyuk-Hoon Kim, Hee Won Yang, Sangkyu Yoon; J Korean Soc Clin Toxicol. 2019;17(1):21-27. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.21

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Abstract PDF: Purpose: Mortality rate in the health services research field is frequently considered as a proxy for measuring healthcare quality. We compared the mortality rate and hospitalization levels among patients with poisoning. Methods: A population-based study of hospital size and level based on the Korean health insurance and assessment service was conducted to identify the impact of hospital level on patient mortality. Results: We analyzed a total of 16,416 patients, of which 7,607 were from tertiary hospitals, 8,490 were from general hospitals, and 319 were from hospitals. The highest mortality rate of diagnosis regarding poisoning was T60.31 (other herbicides and fungicides, 16%), followed by T60.0 (organophosphate and carbamate insecticides, 12.7%). There was no statistical difference in mortality among hospital levels for gender. Among age groups, tertiary hospitals had lower mortality than general hospitals and hospitals for patients aged more than 70 years (11.9% mortality at tertiary vs 14.2% at general and 23% at hospital; p=0.003, adjusted z score=-6.9), general hospitals had lower mortality than tertiary hospitals and hospitals for patients aged 18 to 29 (0.6% at general vs 2.4% at tertiary and 3.7% at hospital; p=0.01, adjusted z score=-4.3), and hospitals had lower mortality than tertiary hospitals and general hospitals for patients between 50 and 59 years of age (0% at hospital vs 6.4% at general and 8.3% at tertiary; p=0.004). Conclusion: Overall, there was no significant difference between mortality and hospital level among poisoned patients. However, to establish an efficient treatment system for patients with poisoning, further studies will be needed to identify the role of each facility according to hospital level.

A Case of Treatment with QRS Widening in Electrocardiogram after Glyphosate Herbicide Poisoning: Joo Hwan Lee; J Korean Soc Clin Toxicol. 2019;17(1):28-31. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.28

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Abstract PDF: Glyphosate herbicides, which are widely used worldwide, are known to have low toxicity. However, excessive intake may cause serious life-threatening complications; therefore, caution is needed when using them. A 51-year-old man visited the hospital after ingesting glyphosate herbicide. At the time of admission, his vital signs were 80/60 mmHg-115/min-20/min-$37.3^{circ}C$. Electrocardiogram (ECG) showed QRS widening and corrected QT (QTc) prolongation, and blood tests showed metabolic acidosis. Treatment with gastric lavage, activated charcoal, sodium bicarbonate and intravenous lipid emulsion therapy was performed. After 2 hours, his blood pressure increased to 130/90 mg, and no QRS widening was observed on ECG.

A Case of Zaltoprofen Induced Kounis Syndrome: Seong You Lee, Won Young Sung, Jang Young Lee, Sang Won Seo, Won Suk Lee; J Korean Soc Clin Toxicol. 2019;17(1):32-37. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.32

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Abstract PDF: Kounis syndrome is defined as the occurrence of acute coronary syndrome associated with vasoactive mediators, such as histamines in the setting of hypersensitivity and allergic reactions or anaphylactic insults. The condition can be caused by various drugs, foods, or environmental factors that cause allergic reactions. A 35-year-old male visited the emergency room with anaphylaxis accompanied by chest pain approximately 20 minutes after taking zaltoprofen, a nonsteroidal anti-inflammatory drug. After acute treatment for the anaphylaxis, the patient was stabilized and all symptoms disappeared, but the ischemic changes in the electrocardiogram and elevation of the cardiac enzymes were observed. The emergency cardiac angiography and echocardiography were all normal. The allergic reaction of this patient to zaltoprofen was believed to cause a temporary coronary arterial vasospasm, inducing Type 1 Kounis syndrome. Thus far, there have been case reports of Kounis syndrome caused by a range of nonsteroidal anti-inflammatory drugs, but there are no reports of the condition being caused by zaltoprofen. According to the pathophysiology, both cardiac and allergic symptoms must be solved simultaneously, so rapid treatment and diagnosis are needed. Doctors treating acute allergic reactions and anaphylaxis patients must check the cardiovascular symptoms thoroughly and consider the possibility of Kounis syndrome.

Elevation of Procalcitonin in an Adolescent Acetaminophen Intoxication: So Eun Kim, Jae Baek Lee, Young Ho Jin, Jae Chol Yoon, Si On Jo, Tae Oh Jeong; J Korean Soc Clin Toxicol. 2019;17(1):38-41. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.38

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Abstract PDF: Procalcitonin (PCT) is commonly employed in medical practice as a diagnostic biomarker of bacterial infection and also as a monitoring biomarker for antimicrobial therapy. There have been a few published reports concerning elevated PCT levels in people with acute liver injury caused by an overdose of acetaminophen. We report here on a case of PCT elevation in an adolescent with acute acetaminophen poisoning without any bacterial infection or liver injury. A 15-year-old girl had deliberately ingested 20 tablets of 650 mg acetaminophen (13 g) and she presented to our emergency department. The PCT level on admission was elevated to 65.64 ng/mL (reference range: 0-0.5 ng/mL). Her PCT level on the second day peaked up to 100 ng/mL and then it gradually decreased. There was no evidence of liver injury or infection on the computed tomography examination and other lab tests. The patient regained her good health and was discharged on the sixth day of hospitalization.

Symptomatic Hypocalcemia Associated with Dioscorea tokoro Toxicity: Jae Chol Yoon, Jae Baek Lee, Tae Oh Jeong, Si On Jo, Young Ho Jin; J Korean Soc Clin Toxicol. 2019;17(1):42-45. Published online June 30, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.1.42

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Abstract PDF: Dioscorea tokoro has long been used in Korean traditional medicine as a pain killer and anti-inflammatory agent. A 53-year-old male who consumed water that had been boiled with raw tubers of D. tokoro as tea presented with numbness and spasm of both hands and feet. Laboratory results showed hypocalcemia, hypoparathyroidism, and vitamin D insufficiency. During his hospital stay, colitis, acute kidney injury, and toxic encephalopathy developed. The patient received calcium gluconate intravenous infusion and oral calcium carbonate with alfacalcidol. His symptoms improved gradually, but hypocalcemia persisted despite the calcium supplementation. We suggest that ingestion of inappropriately prepared D. tokoro can cause symptomatic hypocalcemia in patients with unbalanced calcium homeostasis.

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