Journal of The Korean Society of Clinical Toxicology

Up-to-date treatment of acetaminophen poisoning: Phil Chung Sung, Moon Jeongmi, Chun Byeongjo; J Korean Soc Clin Toxicol. 2022;20(2):39-44. Published online December 31, 2022; DOI: https://doi.org/10.22537/jksct.2022.20.2.39

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Abstract PDF: N-Acetylcysteine (NAC) is the standard antidote treatment for preventing hepatotoxicity caused by acetaminophen (AAP) poisoning. This review summarizes the recent evidence for the treatment of AAP poisoning. Several alternative intravenous regimens of NAC have been suggested to improve patient safety by reducing adverse drug reactions and medication errors. A two-bag NAC infusion regimen (200 mg/kg over 4 h, followed by 100 mg/kg over 16 h) is reported to have similar efficacy with significantly reduced adverse reactions compared to the traditional 3-bag regimen. Massive AAP poisoning due to high concentrations (more than 300-lines in the nomogram) needs to be managed with an increased maintenance dose of NAC. In addition to NAC, the combination therapy of hemodialysis and fomepizole is advocated for severe AAP poisoning cases. In the case of a patient presenting with an altered mental status, metabolic acidosis, elevated lactate, and an AAP concentration greater than 900 mg/L, hemodialysis is recommended even if NAC is used. Fomepizole decreases the generation of toxic metabolites by inhibiting CYP2E1 and may be considered an off-label use by experienced clinicians. Since the nomogram cannot be applied to sustained-release AAP formulations, all potentially toxic sustained-release AAP overdoses should receive a full course of NAC regimen. In case of ingesting less than the toxic dose, the AAP concentration is tested twice at an interval of 4 h or more; NAC should be administered if either value is above the 150-line of the nomogram.

Clinical Characteristics and Risk Factors of Acute Kidney Injury in Patients with Glyphosate Poisoning: Hyung Hun Park, Kyu Ill Choi, Je Won Lee, Jung Min Park, Jinwook Park, Sang Moon Noh, Jaekyung Cho, Daero Lee, Jae Chul Cho, Dong Chan Park, Yang Hun Kim, Joo Hwan Lee; J Korean Soc Clin Toxicol. 2020;18(2):110-115. Published online December 31, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.2.110

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Abstract PDF: Purpose: Acute kidney injury (AKI) in patients with glyphosate poisoning has a poor prognosis. This study aimed to predict the risk factors for AKI in patients with glyphosate poisoning at the emergency department (ED). Methods: Clinical data on glyphosate poisoning patients at ED who were older than 18 years were collected retrospectively between January 2013 and December 2019. The clinical characteristics and clinical outcomes of the AKI group in patients with glyphosate poisoning were compared with the non-AKI (NAKI) group. Results: Of 63 glyphosate poisoning patients, AKI was observed in 15 (23.8%). The AKI patients group showed the following: old age (p=0.038), low systolic blood pressure (p=0.021), large amount of ingestion (p=0.026), delayed hospital visits (p=0.009), high white blood cells (WBC) (p<0.001), high neutrophil counts (p<0.001), high neutrophil-lymphocyte (LN) ratios (p<0.001), high serum potassium (p=0.005), low arterial blood pH (p=0.015), and low pO2 (p=0.021), low bicarbonate (p=0.009), and high Poisoning Severity Score (PSS) (p<0.001). AKI patients required hemodialysis, ventilator care (p<0.001, p=0.002), and inotropics (p<0.001). They also showed more intensive care unit admission (p<0.001), longer hospitalization (p<0.001), and high mortality (p<0.001). Logistic multivariate regression analysis showed that high WBCs (OR, 1.223) and increased LN ratios (OR, 1.414) were independently associated with the occurrence of AKI. Conclusion: In patients with glyphosate poisoning at ED, high WBCs and increased LN ratios can help predict the occurrence of AKI.

A Case of Cement Hardening Agent Intoxication with Acute Kidney Injury: Young Woo Seo, Tae Chang Jang, Gyun Moo Kim, Seung Hyun Ko; J Korean Soc Clin Toxicol. 2018;16(2):157-160. Published online December 31, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.2.157

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Abstract PDF: Chronic silica nephropathy has been associated with tubulointerstitial disease, immune-mediated multisystem disease, chronic kidney disease, and end-stage renal disease. On the other hand, acute intentional exposure is extremely rare. The authors' experienced a 44-year-old man who took rapid cement hardener (sodium silicate) in a suicide attempt whilst in a drunken state. He visited the emergency department approximately 1 hour after ingestion. Information on the material was obtained after 3 L gastric lavage. The patient complained of a sore throat, epigastric pain, and swollen to blood tinged vomitus. Proton pump inhibitors, hemostats, steroid, and fluids were administered. Nine hours after ingestion, he was administered 200 mL hematochezia. Immediately after, a gas-troenterologist performed an endoscopic procedure that revealed diffuse hyperemic mucosa with a color change and variable sized ulceration in the esophagus, whole stomach, and duodenal $2^{nd}$ portion. Approximately 35 hours later, persistent oligouria and progressive worsening of the renal function parameters (BUN/Cr from 12.2/1.2 to 67.5/6.6 mg/dL) occurred requiring hemodialysis. The patient underwent 8 sessions of hemodialysis for 1 month and the BUN/Cr level increased to 143.2/11.2 mg/dL and decreased to 7.6/1.5 mg/dL. He was discharged safely from the hospital. Follow up endoscopy revealed a severe esophageal stricture and he underwent endoscopic bougie dilatation. Acute cement hardener (sodium silicate) intoxication can cause renal failure and strong caustic mucosal injury. Therefore, it is important to consider early hemodialysis and treatment to prevent gastrointestinal injury and remote esophageal stricture.

Comparison of Clinical Characteristics and Severity of Glyphosate and Glufosinate Herbicide Poisoning Patients: Hyung Sun Joo, Tae Ho Yoo, Soo Hyung Cho; J Korean Soc Clin Toxicol. 2018;16(2):124-130. Published online December 31, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.2.124

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Abstract PDF: Purpose: The number of glyphosate and glufosinate intoxication cases are increasing in Korea. This study was undertaken is to compare the clinical manifestations of poisoning by these two herbicides and to document severities and clinical outcomes. Methods: We retrospectively evaluated cases of glyphosate or glufosinate intoxication among patients that visited our emergency department between January 1, 2013, and December 31, 2017. Incidences of intoxications were analyzed over this five year period, and underlying diseases, transportation, mental state, shock occurrence, inotropics, gastric lavage, charcoal administration, intubation and ventilator therapy, and hemodialysis were investigated. In addition, we included transfer to the intensive care unit, incidences of pneumonia and of other complications, death, and hopeless discharge. Results: There were 119 cases of glyphosate intoxication and 42 of glufosinate intoxication. Levels of consciousness were lower for glufosinate and vasopressor usage was higher due to a high shock rate (p=0.019). In addition, many patients were referred to the ICU for intubation and ventilation. The incidences of pneumonia and of other complications were significantly higher for glufosinate. Conclusion: Overall glufosinate intoxication was found to be more severe than glyphosate intoxication as determined by complication and ICU admission rates.

L-carnitine vs Extracorporeal Elimination for Acute Valproic acid Intoxication: A Systematic Review: Byung Keun Yang, Jae Eun Ku, Young Seon Joo, Je Sung You, Sung Phil Chung, Hahn Shick Lee; J Korean Soc Clin Toxicol. 2014;12(2):39-45. Published online December 31, 2014

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Abstract PDF: Purpose: The purpose of this study is to review the evidence comparing the efficacy and safety between L-carnitine and extracorporeal elimination therapy in the management of acute valproic acid L-carnitine vs Extracorporeal Elimination for Acute Valproic acid Intoxication Methods: PubMed, Embase, Cochrane library, Web of Science, KoreaMed, KMbase, and KISS were searched, using the terms carnitine and valproic acid. All studies, regardless of design, reporting efficacy or safety endpoints were included. Reference citations from identified publications were reviewed. Both English and Korean languages were included. Two authors extracted primary data elements including poisoning severity, presenting features, clinical management, and outcomes. Results: Thirty two articles including 33 cases were identified. Poisoning severity was classified as 3 mild, 11 moderate, and 19 severe cases. Nine cases were treated with L-carnitine while 24 cases received extracorporeal therapy without L-carnitine. All patients except one expired patient treated with hemodialysis recovered clinically and no adverse effects were noted. A case report comparing two patients who ingested the same amount of valproic acid showed increased ICU stay (3 vs 11 days) in case of delayed extracorporeal therapy. Conclusion: Published evidence comparing L-carnitine with extracorporeal therapy is limited. Based on the available evidence, it is reasonable to consider L-carnitine for patients with acute valproic acid overdose. In case of severe poisoning, extracorporeal therapy would also be considered in the early phase of treatment.

Dabigatran Toxicity Secondary to Acute Kidney Injury: Hyoung Ho Moon, Seung Eun Lee, Dong Jun Oh, Hee Bum Jo, Ki Hwan Kwon, Yoon Jin Kim, Kyung Soo Kim, Sung Joon Shin; J Korean Soc Clin Toxicol. 2014;12(2):92-96. Published online December 31, 2014

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Abstract PDF: Dabigatran is the first oral direct thrombin inhibitor approved by the US Food and Drug Administration (FDA) for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Because dabigatran is excreted mainly by the kidneys, serum levels of dabigatran can be elevated to a supratherapeutic range in patients with renal failure, predisposing to emergent bleeding. We describe the case of a 66-year-old man taking dabigatran 150 mg twice daily for atrial fibrillation and cerebral infarction who presented with hematochezia and disseminated intravascular coagulation. Laboratory evaluation showed a hemoglobin level of 6.3 g/dL, platelets of $138,000/mm^3$, activated partial thromboplastin time (aPTT) of 10 s, and an international normalized ratio (INR) of 8.17. Colonoscopy showed a bleeding anal fissure. Hemostasis was provided by hemoclips and packed red blood cells and fresh frozen plasma were transfused. Since then, there was no further hematochezia, however, bleeding including oral mucosal bleeding, hematuria, and intravenous site bleeding persisted. At presentation, his serum creatinine was 4.96 mg/dL (baseline creatinine, 0.9 mg/dL). Dabigatran toxicity secondary to acute kidney injury was presumed. Because acute kidney injury of unknown cause was progressing after admission, he was treated with hemodialysis. Fresh frozen plasma transfusion was provided with hemodialysis. At 15 days from admission, there was no further bleeding, and laboratory values, including hemoglobin, partial thromboplastin time, and prothrombin time were normalized. He was discharged without bleeding. After 2 months, he undergoes dialysis three times per week and no recurrence of bleeding has been observed.

Two Cases of Ethylene Glycol Poisoning: Jae Jin Kim, Sung Hyun Yun, Hyun Min Jung, Ji Hye Kim, Seung Baik Han, Jun Sig Kim, Jin Hui Paik; J Korean Soc Clin Toxicol. 2013;11(1):36-40. Published online June 30, 2013

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Abstract PDF: Ethylene glycol poisoning is treated mainly by alcohol dehydrogenase inhibition therapy and hemodialysis. Early recognition and initiation of treatment is important because toxic metabolites increase over time by hepatic metabolism; however, there is no confirmative diagnostic tool in our clinical setting. Therefore, diagnosis is dependent on history, high anion gap acidosis, high osmolal gap, etc.. Diagnosis and treatment are delayed in cases where history taking is not possible, such as a mental changed patient. Authors report on two cases of ethylene glycol poisoning by contrasting clinical outcomes, demonstrating the importance of early diagnosis and treatment for achievement of a good outcome.

A Case of Multi-organ Failure due to Acute Chromic Acid Poisoning: Hyun Min Jung, Hee Min Eun, Jin Hui Paik, Ji Hye Kim, Jun Sig Kim, Seung Baik Han; J Korean Soc Clin Toxicol. 2012;10(2):118-121. Published online December 31, 2012

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Abstract PDF: Chromic acid is a strong metal acid and acute poisoning is very rare. However, chromic acid causes serious complications, such as skin injuries, as well as renal and hepatic failure. We report on a case of a 47-year-old male who accidentally had chromic acid spilled over his nose and face. For the first few days, he was treated with ascorbic acid and massive hydration. However, after three days, his condition began to worsen. He was treated with hemodialysis for anuria and acute renal failure, and antibiotics for pneumonia. On day 10 of hospitalization, he expired of multi-organ failure. We suggest firm control and close supervision of chromic acid in the work place, and, considering severe complications of chromic acid, we propose a nearly and aggressive treatment.

Clinical Review of Toxic Alcohol Poisoning Cases in Korea: Nu-Ga Rhee, Sung-Phil Chung, In-Cheol Park, Kyeong-Ryong Lee, Hyun-Jin Kim, Gun-Bea Kim, Young-Soon Cho, In-Ho Kwon, Seung-Whan Kim; J Korean Soc Clin Toxicol. 2012;10(1):15-21. Published online June 30, 2012

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Abstract PDF: Purpose: Toxic alcohols are responsible for accidental and suicide motivated poisonings, resulting in death or permanent sequelae for the afflicted patients. Major therapeutic modalities in these cases include treatment with alcohol dehydrogenase inhibitors and extracorporeal elimination. There have been a number of case reports of toxic alcohol intoxication in Korea. The purpose of this study was to review the clinical characteristics of patients suffering toxic alcohol intoxication. Methods: We retrospectively reviewed the medical records of patients who presented with toxic alcohol intoxication at 8 emergency departments (ED) from Jun 2005 to Nov 2011. Patients who ingested methanol, isopropyl alcohol, ethylene glycol, and other alcohols except ethanol, were included in this study. The clinical characteristics of these patients were analyzed to include anion and osmolar gap, and estimated concentration of alcohol in the body. Results: During the study period, 21 patients were identified who had ingested toxic alcohol (methanol; 12 patients, ethylene glycol; 9 patients). At ED arrival, the mean anion gap was $18.7{pm}6.9$ and the osmolar gap was elevated in 13 patients. Oral and IV ethanol were administrated to 11 patients in order to inhibit alcohol dehydrogenase. Extracorporeal elimination procedures such as hemodialysis were performed in 9 patients. There were no fatalities, but the one patient suffered permanent blindness. Conclusion: This study found that ethylene glycol and methanol were the substances ingested which produced toxic alcohol intoxication. The patients presented with high anion gap metabolic acidosis and were typically treated with oral ethanol and hemodialysis.

Clinical Characteristics of Patients with Neonicotinoid Insecticide Poisoning: Jin-Chul Kim, Byung-Hak So, Han-Joon Kim, Hyung-Min Kim, Jung-Ho Park, Se-Min Choi, Kyu-Nam Park, Kyoung-Ho Choi; J Korean Soc Clin Toxicol. 2010;8(1):24-29. Published online June 30, 2010

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Abstract PDF: Purpose: Neonicotinoid insecticides are widely used as they have been proven by experimental studies to have low toxicity to mammals, including humans. As the use of neonicotioids increases, the number of patients with neonicotinoid poisoning has also increased. We conducted a study to investigate the clinical manifestations of neonicotinid poisoning. Methods: We retrospectively analyzed the patients who ingested neonicotinids and who visited the emergency department located in Korea from March 2002 to February 2010. We reviewed the patients' age, gender, the amount of exposure, the elapsed time to presentation, the treatment and the outcome. According to the poisoning severity score, we divided the patients with a Poisoning severity score (PSS) of 0 or 1 into the mild/moderate toxicity group and the patients with a PSS of 2 or 3 into the severe/fatal toxicity group. Results: A total of 24 patients were analyzed. The most common clinical manifestations of neonicotinoid insecticide toxicity were gastrointestinal symptoms (66.7%) such as nausea, vomiting and abdominal pain and the others are respiratory symptoms (16.7%), cardiovascular symptoms (12.5%), metabolic imbalance (12.5%), renal dysfunction (8.3%), CNS symptoms (8.3%), and asymptomatic (29.2%). Twenty patients (83.3%) showed mild/moderate toxicity and 4 patients (16.7%) showed fatal conditions such as shock and mutiorgan failure. The mortality rate was 4.2%. In these fatal cases, the patients developed respiratory failure, hypotension, altered mentality and renal failure at the acute stage and they deteriorated to a more serious condition. This severe toxicity was caused by decreased renal excretion of neonicotinid metabolite, and this was improved after hemodialysis. Conclusion: Most patients with neonicotinoid poisoning and who showed mild toxicity usually improved after symptomatic treatment. However, some patients showed significant toxicity with respiratory failure and renal function deterioration, and intensive care needed, including mechanical ventilation and hemodialysis.

Clinical Experience with Continuous Renal Replacement Therapy as a Method of Extracorporeal Elimination and as performed by Emergency Room Physicians for Patients with Poisoning: Jung-Hwan Ahn, Sang-Cheon Choi, Yoon-Seok Jung, Young-Gi Min; J Korean Soc Clin Toxicol. 2009;7(2):150-155. Published online December 31, 2009

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Abstract PDF: Purpose: Extracorporeal elimination of drugs is a critical part of managing poisonings, although the indications and optimal method remain a matter of debate. The aim of this study is to report our clinical experiences with continuous renal replacement therapy (CRRT), as performed by emergency room physicians, as method of extracorporeal drug elimination in patients with poisoning. Methods: This study was a retrospective study of the consecutive patients who underwent CRRT, as performed by an emergency room physician, for acute poisoning. The patient characteristics, the kinds of drugs and the method of extracorporeal elimination were analyzed by reviewing the patients' charts. Results: During eleven months, 26 patients with acute poisoning underwent extracorporeal elimination (2 patients; intermittent hemodialysis, 24 patients; CRRT). The mean time from the decision to performing extracorporeal elimination was $206.0{pm}36.8$ minutes for intermittent hemodialysis, $62.9{pm}8.5$ minutes for continuous venoveno-hemodiafiltration (CVVHDF) and $56.6{pm}6.8$ minutes for charcoal hemoperfusion. For the patients with CRRT, CVVHDF was conducted in 10 patients (3 patients; valproic acid, 2 patients; Lithium, 1 patient; salicylates, 1 patient; methanol) and charcoal hemoperfusion by using CRRT was done in 14 patients (13 patients; paraquat, 1 patient; dapsone). For the 12 patients who required hemodialysis due to severe poisoning, 7 patients underwent CRRT because of their unstable vital signs. Conclusion: CRRT was an effective method of extracorporeal drug elimination in patients with acute poisoning, and especially for the cases with unstable vital sign and for those patients who required an early start of extracorporeal elimination according to the characteristics of the drug. (ED note: the writing of the abstract was not clear. Check it carefully.)

Esophageal Stricture and Acute Renal Failure after Formic Acid Poisoning: - A Case Report -: Kyung-Il Song; J Korean Soc Clin Toxicol. 2009;7(1):32-37. Published online June 30, 2009

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Abstract PDF: Formic acid or formate is a common industrial compound used in the production of ensilage, disinfectants, decalcifying agents and mainly as a precursor in industrial chemical synthesis. It is also a well-known toxic metabolite produced in methanol poisoning. Thus, formate is a potential source of both accidental and deliberate poisoning. Very few reports have been published thus far, on the toxicology of direct formic acid poisoning. Here, we report a case of a 74-year-old man without a history of depression, who ingested about 30 gm of formic acid. The patient presented with profound high anion gap metabolic acidosis, acute renal failure and esophageal stricture. The patient was successfully treated with hemodialysis and supportive measures. But permanent esophageal stricture was complicated by formic acid burns in the gastrointestinal tract. We discuss the pathophysiology and treatment of this case.

A Case of Intoxication of Ingested Formalin: Seon-Hee Baek, Kyung-Hwan Kim, Jun-Seok Park, Dong-Wun Shin, Jun-Young Roh, Kyoung-Mi Lee, Ah-Jin Kim; J Korean Soc Clin Toxicol. 2009;7(1):38-40. Published online June 30, 2009

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Abstract PDF: Formalin is a water-soluble, colorless, pungent, irritating and highly reactive gas. A 40% solution of formaldehyde in water, also known as formalin, is used as a disinfectant, antiseptic, deodorant, tissue fixative and embalming fluid. Ingestion can lead to immediate deleterious effects on almost all systems of the body including gastrointestinal tract, central nervous system, cardiovsacular system and hepato-renal system, causing gastrointestinal hemorrhage, cardiovsacular collapse, unconsciousness or convulsions, severe metabolic acidosis and acute respiratory distress syndrome. We treated a 39-year-old woman who ingested 300 ml formalin in a suicidal attempt. Despite hemodialysis, death occurred after 23 h.

A Case of Hair Neutralizer Induced Non-oliguric Acute Renal Failure: Ah Jin Kim, Kyung Hwan Kim, Jun Seok Park, Dong Wun Shin; J Korean Soc Clin Toxicol. 2005;3(2):119-121. Published online December 31, 2005

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Abstract PDF: Sodium bromate or potassium bromate has been used as hair cold neutralizer. Sodium bromate intoxications occurred in children incidentally early days of marketing, but recently in adult suicidally. This chemical intoxication result in renal failure, ototoxicity, neurotoxicity, hemolytic anemia and so on. We experienced a 39-year-old woman of hairdresser with non-oliguric acute renal failure after ingestion hair neutralizer 500 ml. She received hemodialysis 3 times and discharged without complication on 8th admission days.

A Case of Cardiac Arrest Due to Severe Lithium Intoxication - Difficult Diagnosis -: Jung Hwan Ahn, Sang Cheon Choi, Sang Kyu Yoon, Yoon Seok Jung; J Korean Soc Clin Toxicol. 2005;3(2):130-134. Published online December 31, 2005

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Abstract PDF: Lithium is mainly prescribed for manic and depressive disorder, also frequently prescribed for the other diseases such as migraine, cluster headache, alcoholism, and obsessive-compulsive disorder. An acute lithium intoxication occurs in cases of patients ingesting large amount lithium at a time, a chronic lithium intoxication occurs in patients on chronic lithium therapy. Acute or chronic lithium poisoning occurs frequently in case of patients on chronic lithium therapy ingesting larger dose than prescribed. Manifestations of lithium poisoning are various. It is possible nervous, cardiovascular, renal, gastrointestinal and endocrine systems to be involved. Due to intracellular high concentration, mortality rate is high in acute lithium intoxication patients on chronic lithium therapy. We report a case of acutely intoxicated 40-year-old male on chronic lithium therapy. His chief complaints were deterioration and high fever. On his arrival to an emergency department, he was in cardiac arrest. He restored return of spontaneous circultion (ROSC) 5 minutes later after cardiopulmonary cerebral resuscitation (CPCR) and referred to department of internal medicine for hemodialysis. Vigorous treatment was given to the patient, but he was expired at 4th hospital day.

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