Journal of The Korean Society of Clinical Toxicology

Review Article

Diagnosis and treatment of serotonin syndrome: Je Sung You, Sung Phil Chung; J Korean Soc Clin Toxicol. 2024;22(2):11-17. Published online December 31, 2024; DOI: https://doi.org/10.22537/jksct.2024.00008

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Abstract PDF: Serotonin syndrome is a drug-induced clinical syndrome caused by increased serotonin activity in the central nervous system. It occurs when starting a serotonergic drug, increasing its dose (including overdoses) or using a serotonergic drug in combination with other drugs. It manifests along a broad spectrum, ranging from mild side effects to life-threatening conditions. This condition should be suspected if patients have altered mental states, autonomic dysfunction, or neuromuscular symptoms such as clonus and tremor after using serotonergic drugs. Although the Hunter criteria have been widely used, new diagnostic criteria have recently been proposed to screen severe serotonin toxicity. It is necessary to differentiate it from neuroleptic malignant syndrome, which is associated with taking antipsychotic drugs that exert dopamine-antagonistic effects. If serotonin syndrome is suspected, the relevant drug should be stopped, and the patient should be treated with benzodiazepines. Severely ill patients with hyperthermia or neuromuscular symptoms require aggressive treatment. Serotonin receptor antagonists such as cyproheptadine or chlorpromazine have been tried as antidotes, but the level of evidence for their therapeutic effectiveness is very low.

Original Article

Protective effects of mealworm (Tenebrio molitor) extract on N-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)–induced cellular toxicity in SH-SY5Y neuroblastoma cells: In Ho Jo, Yoo Ji Kim, Seon Tae Kim; J Korean Soc Clin Toxicol. 2023;21(2):81-91. Published online December 29, 2023; DOI: https://doi.org/10.22537/jksct.2023.00021

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Abstract PDF: Purpose: Edible insect extracts have been used as an alternative source for medicinal supplements due to their significant antioxidative and anti-inflammatory activity. Recent studies have reported that anti-microbial peptides from insects have neuroprotective effects on dopamine toxins. The purpose of this study was to investigate the protective functions of mealworm (Tenebrio molitor) extract (MWE) on N-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)–induced cellular toxicity in SH-SY5Y neuroblastoma cells.
Methods
Cellular toxicity induced by the MPTP toxin and the impact of MWE on cell survival were analyzed using MTT assays. DAPI staining was performed to observe apoptotic phenomena caused by MPTP. Changes in caspase-3 activity and protein expression were observed using enzyme activity assays and western blot assays, respectively.
Results
MWE exerted significant antioxidant activity, which was measured by both DPPH and ABTS radical assays, with a dose-dependent relationship. Furthermore, MWE resulted in cellular proliferation in SH-SY5Y cells in a dose-dependent manner. Furthermore, MWE pretreatment significantly inhibited MPTP-induced cytotoxicity, with a dose-dependent relationship. The morphological characteristics of apoptosis and increased reactive oxygen species induced by MPTP were also significantly reduced by MWE pretreatment.
Conclusion
MWE treatment significantly attenuated MPTP-induced changes in the levels of proteins associated with apoptosis, such as caspase-3 and PARP. These findings suggest that MWE exerts neuroprotective effects on human neuroblastoma SH-SY5Y cells subject to MPTP-induced dopaminergic neurodegeneration.

A Case of Amitraz Insecticide Intoxication after Ingestion of Large Amount: Joo-Hyun Suh, Hyung-Keun Roh; J Korean Soc Clin Toxicol. 2008;6(1):52-56. Published online June 30, 2008

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Abstract PDF: Amitraz is used as farm-animal insecticide. Its side effects in humans are related to its pharmacological activity on alpha 2-adrenergic receptors. The case describes a previously healthy 46-year-old woman who intentionally ingested approximately 250mL of liquid amitraz. She presented with vomiting, altered mental status, miosis, dry mouth, hypopnea, metabolic and respiratory acidosis, hypotension, hypothermia, polyuria, metabolic acidosis, elevated serum aminotransferase and abdominal distension. Supportive treatments including mechanical ventilation, hydration, dopamine infusion, bicarbonate infusion and gastric decompression resulted in improvement. By hospital day 3, she recovered with resolution of abdominal distension. It is paramount to recognize amitraz poisoning when a pesticide-intoxicated patient presets with signs and symptoms consistent with organophosphate intoxicated patients but with greater alpha 2-adrenergic related symptoms such as decreased bowel motility and xerostomia.

Mass Poisoning with Veratrum Grandiflonum: Hyung-Min Lee, Jun-Seok Park, Kwang-Hyun Cho; J Korean Soc Clin Toxicol. 2005;3(2):114-118. Published online December 31, 2005

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Abstract PDF: Ingestion of plant material rarely manifest in clinical intoxication. This is due to the relatively low toxicity of most plants in Korea. But, veratrum is an important plant on account of its highly toxic alkaloids. Five cases of Veratrum grandiflonum mass poisoning are described. Clinical symptoms occurred quickly, within 30 min. Vomiting, a fall in blood pressure and bradycardia was observed. Treatments in the emergency department included gastric lavage, activated charcoal, and administration of atropine and dopamine for bradycardia and hypotension. Although one of them experienced profound hypotension, bradycardia and mental change, the outcomes were favorable in all cases, producing a complete cure without any sequellae at discharge.

The Clinical Aspects of Wild Plant Poisoning: Taek-Gun Ok, Chan-Woo Park, Jun-Hwi Cho, Seung-Whan Cheon, Seung-Young Lee, Sung-Eun Kim, Ki-Hoon Choi, Ji-Hoon Bae, Jeong-Yeul Seo, Hee-Cheol Ahn, Moo-Eob Ahn, Byung-Ryul Cho, Yong-Hoon Kim; J Korean Soc Clin Toxicol. 2005;3(2):79-85. Published online December 31, 2005

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Abstract PDF: Purpose: With the recent boom in 'eating healthy', many adults are interested in dieting to prevent future diseases. However only well trained experts can distinguish between what are edible vegetables and herbs from their poisonous look-alikes. In cases where a patient unknowingly ingests a poisonous herb, is caught off guard by the poisonous side effects that occur because of their lack of knowledge of what they have ingested. This paper will focus on the need to educate the public about the risks involved with ingesting wild vegetables and herbs and study the emergency diagnosis and treatment of poisoned patients that enter the emergency room. Method: This study was done in the spring of 2004 (from March to May) in the Kangwon Young-Seo districts of Korea. 15 subjects used in this study, entered the emergency room showing signs of toxic symptoms. Data was collected by examining subject's records. Additional data was collected by collaborating with physicians in the hospital that diagnosed and treated the subjects. Identifying the poisonous vegetable or herb is the first step to proper diagnosis and treatment. Subjects admitted to the emergency room, underwent a battery of tests: laboratory examination, ECG, radiological exam and etc. Results: The demographics of the study encompassed subjects with the average age of $50{pm}19$ years old. There were 10 men and 5 women. Common symptoms of this study included; gastrointestinal symptoms such as nausea, vomiting, epigastric pain and so on. In the case of Caltha palustris ingestion, additional symptoms were present; bradycardia and hypotension which lasted for a long time. While cases that ingested Scopolia parviflora had little effect on vital signs but manic episodes lasted for about three days. Veratrum patulum ingestion showed signs of bradycardia and hypotension but contrary to Caltha palustris recovery was shorten by treating with dopamine. However, dizziness, headache and paresthesia of the extremities continued for a long time. Finally Sium ninsi ingestion showed visual disturbance, paresthesia of the extremities, dizziness as their initial symptoms. Conclusion: The risks involved with ingesting wild plants without the proper knowledge can lead to serious side effects and steps need to be taken to educate the public. In addition, all emergency physicians need to have a working knowledge of the symptoms and signs associated with ingesting toxic wild plants and need to treat accordingly.

The Shock with Bradycardia after Ingestion of Caltha palustris: Chan-Woo Park, Taek-Gun Ok, Jun-Hwi Cho, Dong-Wook Choi, Ae-Young Her, Hee-Young Lee, Yong-Hoon Kim, Byung-Ryul Cho, Sung-Eun Kim, Ki-Hoon Choi, Ji-Hoon Bae, Jeong-Yeul Seo, Jae-Bong Chung; J Korean Soc Clin Toxicol. 2004;2(1):41-44. Published online June 30, 2004

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Abstract PDF: With a recent well-being boom, our interest in chemical-free vegetables is also increasing. So, some people are trying to take in wild plants chosen by themselves. However, others often come to their rescue in an emergency department after eating them, caused by their misunderstanding poisonous herbs as edible vegetables. We have ever seen two persons carried into the emergency department with bradycardia and shock incurred by his intake by confusion between Caltha palustris and Ligularia fischeri lately. There were symptoms such as epigastric pain, nausea, vomiting and so on in their cases, and the symptoms of bradycardia and hypotension continued. Owing to sustained bradycardia and hypotension states, we applied a dopamine to a patient, and then the in-patient left the hospital two days later. We presumed the cause of the two symptoms appeared in two cases to be a saponin in Caltha palustris. For that reason, if someone has the bradycardia and hypotension symptoms from an unknown cause after taking in wild plants, they have to consider a toxication by the Caltha palustris. Therefore, this paper focused on the issue that unexpected poisoning would have to be prevented by studying about wild plants much more and informing the toxic risk from the plants.

A case of Hypothermia Resulting from Disulfiram-Ethanol Reaction: Hyun-A Bae, Eun-Kyung Eo; J Korean Soc Clin Toxicol. 2004;2(1):54-57. Published online June 30, 2004

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Abstract PDF: Disulfiram (tetraethylthiuram disulphid) is used in the treatment of chronic alcoholism since it causes an unpleasant aversive reaction to alcohol. It works by inactivating hepatic aldehyde dehydrogenase, leading to pronounced rise in the acetaldehyde concentration when ethanol is metabolized. Acetaldehyde causes alcohol sensitivity, which involve vasodilation associated with feeling of hotness and facial flushing, increased heart rate and respiration rates, lowered blood pressure, nausea, headache. One of its metabolites, diethyldithiocarbamate (DDC) can inhibit the enzyme dopamine $eta$-hydroxylase (DBH), this may account for the profound refractory hypotension and hypothermia seen with the disulfiram-ethanol reaction (DER), resulting from norepinephrine depletion. This report is presents the case of a patient we met, who presented with hypothermia caused by the disulfiram-ethanol reaction, and along with a brief review of the subject.

Neurobiological Effects of Methamphetamine Abuse on Neurotransmitters: A Review: Tae Kyung Lee, E. Grant Jon, Suck Won Kim, Dong Yul Oh; J Korean Soc Clin Toxicol. 2003;1(1):21-26. Published online June 30, 2003

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Abstract PDF: Methamphetamine (MA) is a major drug of abuse in Korea. Currently preliminary evidence suggests that MA dependence may cause long-term neural damage in human. Repeated exposure to psychostimulants such as methamphetamine results in behavioral sensitization, a paradigm thought to be relevant to drug craving and addiction in human. Sensitization alters neural circuitry involved in normal processes of incentrive, motivation, and reward. However the precise mechanism of this behavioral sensitization has not yet been fully elucidated. Repeated use of high dose MA causes neurotoxicity which is characterized by a long-lasting depletion of striatal dopamine (DA) and tyrosin hydroxylase activity of DA, DA-transporter binding sites in the striatum. The loss of DA transporters correlates with memory problems and lack of motor coordination. DA fuels motivation and pleasure, but it' s also crucial for learning and movement. This selective review provides a summary of studies that assess the neurobiological mechanisms of MA.

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