Journal of The Korean Society of Clinical Toxicology

Cardiac arrest and severe encephalopathy following e-cigarette nicotine intoxication: a case report: Park Jinwon, Yun Sunghyun; J Korean Soc Clin Toxicol. 2022;20(2):82-85. Published online December 31, 2022; DOI: https://doi.org/10.22537/jksct.2022.20.2.82

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Traditionally, most cases of nicotine poisoning have been due to ingestion of nicotine pesticides. However, the increasing use of electronic cigarettes (e-cigarettes) has resulted in both intentional and unintentional exposure to concentrated liquid nicotine or “eliquid” leading to an increase in nicotine poisoning cases. However, fatalities following the ingestion of the e-liquid are extremely rare. We report a rare case of cardiac arrest and severe encephalopathy following the intentional ingestion of e-liquid. We present the case of a 20-year-old woman who intentionally ingested liquid nicotine intended for e-cigarette use. She was found in asystole and experienced a return of spontaneous circulation (ROSC) after undergoing approximately 46 mins of cardiopulmonary resuscitation. Her plasma nicotine levels were >500 ng/ml. Despite aggressive supportive care, she was found to have encephalopathy consistent with severe anoxic brain injury on magnetic resonance imaging. In recent times, there have been some reports of deaths following liquid nicotine ingestion. Our case illustrates the potential for fatal nicotine toxicity from ingestion of e-cigarettes.

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A Systematic Review on Health Impact of Electronic Cigarettes in South Korea
Eunsil Cheon, Hana Kim, Naeun Kang, Susan Park, Sung-il Cho, Jieun Hwang
Journal of the Korean Society for Research on Nicotine and Tobacco.2024; 15(2): 29. CrossRef

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.

Delayed death after chlorfenapyr poisoning: Jang Young Lee; J Korean Soc Clin Toxicol. 2021;19(1):51-54. Published online June 30, 2021; DOI: https://doi.org/10.22537/jksct.2021.19.1.51

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Chlorfenapyr is a widely used insecticide, that is very lethal if ingested. It exhibits delayed toxicity in which there are few symptoms at first which suddenly worsen after a few days. A 66-year-old female patient ingested about 90 mL of chlorfenapyr liquid hydrating agent (Chlofenapyr 10%) and showed stable vital signs with no specific symptoms and findings other than a mild fever, vomiting, and nausea. From the 3rd day of ingestion, creatine kinase was high, and rhabdomyolysis was suspected. From the 4th day of ingestion, pancreatic enzymes began to gradually increase. A diffusion-weighted image showed a multifocal high signal intensity in the white matter and corpus callosum area. On the 8th day after ingestion, she suffered a high fever and a heart attack and died. Thus, if a patient is suspected of taking chlorfenapyr, he/she needs active treatment and monitoring even if he/she does not exhibit any symptoms.

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Understanding Chlorfenapyr Toxicity: An Overview of Acute Human Exposure and Clinical Outcomes
Dalia Alsaied Moustafa Ahmed, Nermin Mahmoud Emam, Mohamed Moharram Badawy
Journal of Applied Toxicology.2026;[Epub] CrossRef
Toxicological Review of an Uncoupler, Chlorfenapyr
Sun Cheun Kim
Korean Journal of Legal Medicine.2025; 49(2): 35. CrossRef
A Fatal Case of Chlorfenapyr Poisoning and the Therapeutic Implications of Serum Chlorfenapyr and Tralopyril Levels
Ming-Jin Chung, Yan-Chiao Mao, Chia-Tien Hsu, Mu-Chi Chung, Tsai-Jung Wang, Tung-Min Yu, Po-Yu Liu, Pin-Kuei Fu, Chia-Ming Hsieh
Medicina.2022; 58(11): 1630. CrossRef

Acute Nicotine Poisoning due to Electronic Cigarette Liquid: Systematic Review of Case Reports: Si Yong Yang, Min Hong Choa, Je Sung You, Hyun Soo Chung, Sung Phil Chung; J Korean Soc Clin Toxicol. 2020;18(2):51-56. Published online December 31, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.2.51

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Purpose: Acute nicotine poisoning by liquid nicotine in electronic cigarettes is becoming an increasing problem worldwide. The current systematic review aimed to determine the harm of acute nicotine poisoning by reviewing published case reports. Methods: An online literature search with PubMed, Embase, Cochrane Library, and KoreaMed database was performed to identify relevant studies addressing acute nicotine poisoning with electronic cigarettes. Two investigators searched the case reports written in English or Korean. Results: Twenty-six cases were included in this study. The routes of intoxication included ingestion in 18 cases, intravenous injection in three cases, subcutaneous injection in two cases, and ocular exposure in two cases. Ten cases had a cardiac arrest, and seven of them died. Seven out of 12 cases with intentional poisoning had a cardiac arrest. Nine children under 18 years were reported, and three of them had a cardiac arrest. Sixteen cases without a cardiac arrest recovered well, except for one case with sudden sensorineural hearing loss. Conclusion: The authors reviewed the risks of electronic cigarette liquid in terms of acute poisoning through a systematic review. The nicotine solution of an e-cigarette can be life-threatening in cases of acute poisoning. Therefore, active emergency treatment with early recognition is necessary. In addition, various management methods and regulations for preventing acute nicotine poisoning, such as restriction of distribution and nicotine concentration, should be considered.

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Electronic Nicotine, Non-Nicotine Delivery Systems, and Liquid Use by Flavoring and Nicotine Concentrations
Yeun Soo Yang, Hyeon Jeong Lim, Unchong Kim, Kyoungin Na, Heejin Kimm
Journal of the Korean Society for Research on Nicotine and Tobacco.2023; 14(3): 101. CrossRef

A Case Report of Cardiac Arrest Following Intentional Ingestion of Liquid Nicotine for Electronic Cigarette: Jung Ho Kim; J Korean Soc Clin Toxicol. 2018;16(2):172-175. Published online December 31, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.2.172

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Abstract PDF: Acute nicotine poisoning by liquid nicotine for electronic cigarettes is becoming an increasing problem worldwide. On the other hand, there are no regulations regarding its concentration, container or labelling in Korea. This is the first case of a cardiac arrest after liquid nicotine ingestion that was confirmed by plasma nicotine detection in Korea. A 34-year-old male was found with a cardiac arrest at home by the emergency medical services crew, and had a return of spontaneous circulation after 27 minutes of cardio-pulmonary resuscitation. The cause of his cardiac arrest was suspected to be acute nicotine poisoning by the ingestion of liquid nicotine. Toxicology analysis of the National Forensic Service confirmed plasma nicotine, and the pharmacokinetic estimated average concentration of plasma nicotine at the time of the cardiac arrest was 29.7 mg/L, a lethal dose. He was hospitalized for further treatment, but was discharged after 20 days without any improvement. Considering the strong toxicity of nicotine, appropriate policy decisions are required for sales and distribution.

Analysis of Death Due to Poisoning in the National Capital Region (2014-2016): Meejung Park, Jongsin Park, Sangki Lee, Sangwhan In; J Korean Soc Clin Toxicol. 2017;15(2):101-106. Published online December 31, 2017; DOI: https://doi.org/10.22537/jksct.2017.15.2.101

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Abstract PDF: Purpose: This study examined the patterns of drugs, poisons, and chemicals detected in autopsy samples performed in the Seoul Institute and other regional forensic offices of the National Forensic Service (NFS) between 2014 and 2016. Methods: The investigation carried out using the laboratory information management system. Forensic toxicological identification and quantitation were performed in autopsy samples, including heart blood, peripheral blood, liver, kidney, vitreous humor and etc. Gas chromatography/mass spectrometry (GC-MS) and liquid chromatography-tandem mass spectrometry (LC-MS/MS) were used to analyze the drugs and poisons. Results: Forensic autopsies were performed on 9,674 cases in this period. Based on the autopsy reports, 699 cases (7.2%) were considered as unnatural deaths caused by fatal intoxication. The number of male deaths was higher than that of female deaths, with the age of 50-59 being the most common age group. Conclusion: Drugs comprised the largest number of deaths due to poison, followed by alcohol, agrochemicals, drug with alcohol, carbon monoxide, and cyanide, in that order. Zolpidem was the most frequently used drug in all drug-related intoxication cases.

A Case Report of Acute Nicotine Poisoning from Subcutaneous Injection of Nicotine Solution for Electronic Cigarette: Jiun Choi, Dong Ryul Ko, Je Sung You, Sung Phil Chung; J Korean Soc Clin Toxicol. 2017;15(1):60-64. Published online June 30, 2017; DOI: https://doi.org/10.22537/jksct.2017.15.1.60

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Abstract PDF: Nicotine-poisoning related to the electronic cigarettes (e-cigarette) is increasing worldwide. Moreover, the American Association of Poison Control Centers has advised the public to use caution with e-cigarette devices and highly concentrated liquid nicotine after a surge in related poisonings. We report here the first case of nicotine poisoning from self-injected e-cigarette fluid in Korea. A 17-year-old male patient subcutaneously injected himself with 0.5 ml of nicotine solution for an electronic cigarette via the dorsum of his hand, after which he complained of nausea, vomiting, dizziness and dyspnea. His vital signs were within the normal range, but his mental status was drowsy. He was admitted for observation and the symptoms disappeared the following day. Sinus bradycardia with a rate of 45/min was observed on the third hospital day, but improved after 6 hours. He was discharged without complications.

A Case of Chlorfluazuron Insectisides Poisoning with Mental Change: Eun Suk Park, Soo Kang, Ah Jin Kim, Jin Hue Baek, Hyun Min Jung; J Korean Soc Clin Toxicol. 2015;13(1):40-42. Published online June 30, 2015

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Abstract PDF: Benzoylureas are chemical compounds best known for their use as insecticides. Diflubenzuron is one of the more commonly used benzoylurea pesticides. Others include chlorfluazuron, flufenoxuron, hexaflumuron, and triflumuron. They act as insect growth regulators by inhibiting synthesis of chitin in the body of the insect. They have low toxicity in mammals because mammals have no chitin. Chlorfluazuron insecticides, which are mixed with solvent naphatha, are commonly used. Thus we assume that in the presented case mental change outcome of poisoning was connected with toxic effects of solvent naphtha rather than with chlorfluazuron action. Components of solvent naphtha, particularly trimethylbenzenes, exert strong irritant action on the gastric mucosa and are very well absorbed from the gastrointestinal tract. We report on a 67-year-old man with stuporous mentality after intentional ingestion of approximately 200 ml of liquid chlorfluazuron in a suicide attempt. He was discharged after conservative treatments including gastric irrigation, charcoal, mechanical ventilation, hydration, and antibiotics for aspiration pneumonia without complications.

Measurement of Volume of a Swallow for Liquid Swallowing in Healthy Young Adults: Su Ik Kim, Ji Hun Kang, Dong Ik Lee, Jeong Ryul Jo, Hyung Jun Kim, Jae Baek Lee, Young Ho Jin, Tae Oh Jeong, Jae Chol Yoon; J Korean Soc Clin Toxicol. 2013;11(2):114-118. Published online December 31, 2013

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Abstract PDF: Purpose: The aim of this study is to estimate one mouthful volume in a single swallow and average volume per swallow (AVS) in multiple swallows in the situation of toxic liquid poisoning. Methods: Thirty five men and 35 women were included in this study. Each subject was asked to drink one swallow and three consecutive swallows from bottle containing water and a bottle containing saline separately. We calculated one mouthful volume in a single swallow and AVS in three swallows. One mouthful volume and AVS were compared according to sex and content, respectively. One mouthful volume of water and saline was then compared with AVS of each. Results: Sixty seven adults(34 men; $26.9{pm}3.2$ years, 33 women; $25.6{pm}2.4$ years) completed the study. Men had larger one mouthful volume of water($49.1{pm}19.9$ ml vs $39.7{pm}10.2$ ml, p=0.02) and saline($20.7{pm}10.9$ ml vs $14.0{pm}4.6$ ml, p=0.004) and AVS of water($28.5{pm}11.9$ ml vs $21.5{pm}5.9$ ml, p=0.004) and saline($11.9{pm}6.3$ ml vs $7.9{pm}2.0$ ml, p=0.001) than women. One mouthful volume and AVS of saline swallow were lower than those of water swallow. AVS of three consecutive swallows was lower than one mouthful volume in water and saline swallow. Conclusion: We suggest that one mouthful volume in a single swallow is 21 ml in men and 14 ml in women and AVS in multiple swallows is 12 ml in men and 8 ml in women. AVS in multiple swallows is two-threefold lower than reference values(20~30 ml) commonly used in poisoning study.

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.

A Case of a Patient with Stuporous Mentality and Hypotension after Amitraz Ingestion: Si-Young Jung, Jin-Hee Jung, Eun-Kyung Eo; J Korean Soc Clin Toxicol. 2007;5(2):123-125. Published online December 31, 2007

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Abstract PDF: Amitraz is a formamidine-derived insecticide and acaricide which is commonly used throughout the world. Amitraz intoxication is mediated through ${alpha}_2$ adrenergic receptor agonist effects, similar to those of the ${alpha}_2$ agonist clonidine. We report a case of a patient who experienced coma and hypotension after amitraz ingestion. A 37-year-old woman visited the ER with symptoms of vomiting and altered mental state. She had ingested a mouthful of liquid amitraz concentrate (12.5%), which rapidly led to vomiting, hypotension, bradycardia, hyperglycemia, and mental stupor. Supportive treatment, including mechanical ventilation and administration of inotropics, resulted in full recovery within four days.

Salicylate Poisoning After Accidental Ingestion of Chinese Medicated Oil: Soo-Youl Lee, Ji-Yeong Ryu, Gyu-Chong Cho, Ji-Young You; J Korean Soc Clin Toxicol. 2007;5(2):138-141. Published online December 31, 2007

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Abstract PDF: Because of the ready availability of aspirin, salicylate poisoning remains a common problem in many countries. Another potential source of salicylate poisoning is medicated oil containing methyl salicylate (oil of wintergreen). Methyl salicylate poses a much greater safety threat than aspirin tablets because of its liquid, concentrated form and high lipid solubility. Because of this danger, the toxic potential of medicated oil containing methyl salicylate should be fully appreciated both by physicians and by the general public. We encountered two cases of salicylate poisoning resulting from accidental ingestion of Chinese medicated oil. We report these cases along with a review of the literature.

A Case of Trichloroethylene Poisoning: Jae-Cheon Jean, Sung-Won Jang, Seung-Joan Yang, Jae-Won Lee, Sang-Chan Jin, Myeong-Don Joo, Woo-Ik Choi; J Korean Soc Clin Toxicol. 2007;5(1):61-66. Published online June 30, 2007

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Abstract PDF: Trichloroethylene (TCE) is an unsaturated chlorinated hydrocarbon in the form of a colorless, volatile liquid, which is used as an industrial organic solvent for spot removal and for metal degreasing. In general, the primary complications of TCE poisoning result from involvement of the central nervous and respiratory systems, including aspiration pneumonia. A case is reported of a 54-year-old man who presented in a comatose state after accidental ingestion of 100 ml of TCE, and who recovered after conservative treatment and mechanical ventilation. We discuss this case and present a literature review.

A Case Report of Liquid-Lye (NaOH) Ingestion Complicated with Gastroesophageal Perforation: Hee-Bum Yang, Young-Mo Yang, Sung-Youp Hong; J Korean Soc Clin Toxicol. 2005;3(2):99-102. Published online December 31, 2005

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Abstract PDF: The caustic drugs are classified into acid and alkali. Oral intake of these drugs cause histological injuries to the surfaces of oral cavity, laryngopharynx, and esophagus. Caustic drugs such as detergents and brilliants are easily contacted at homes. However, until now, the epidemiology and the clinical statistics of caustic drug ingestion in Korea were not carried out. This is a case report of sodium hydroxide - lye, a caustic drug more toxic than the others - ingestion with complication of gastroesophageal perforation, rapidly progressed mediastinitis and prompt death in the course of treatment.

Effect of Dialysis and Perfusion on Phosphamidon in vitro: Sae Yong Hong, Hyo Wook Gil, Jong Oh Yang, Eun Young Lee; J Korean Soc Clin Toxicol. 2005;3(1):17-21. Published online June 30, 2005

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Abstract PDF: Purfose: This study was to observe the phosphamidon reduction rate after haemoperfusion (HP) and Hemodialysis (HD) in vitro. Methods: We started off by measuring the clearance of HD and HP for the phosphamidon in vitro. Phosphamidon was measured hourly by High-pressure liquid chromatography. Results: Phosphamidon clearance was effectiveness in HP and HD. Phosphamidon reduction rate was no difference between HD and HP; $64\%$ versus $91.\%1$ at starting, $82.2\%$ versus $80.2\%$ at 1 hours, $82.2\%$ versus $73.8\%$ at 2 hours, $34.4\%$ versus $14.0\%$ at 3 hours, $14.1\%$ versus $27.4\%$ at 4 hours, $0\%$ versus $3.3\%$ at 5 hours. Conculsion: Extracorporeal elimination of phosphamidon is effective by hemoperfusio and hemodialysis in vitro. We suggest hemoperfusion may be effective in organophsphate intoxication patients.

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