Journal of The Korean Society of Clinical Toxicology

The Effect of Glehnia Littoralis on Alpha-amanitin Induced Hepatotoxicity in a Murine Model: Chang Yeon Ryu, Kyung Hoon Sun, Ran Hong, Yongjin Park; J Korean Soc Clin Toxicol. 2018;16(2):108-115. Published online December 31, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.2.108

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Abstract PDF: Purpose: Glehnia littoralis has been reported to have several pharmacological properties but no in vivo reports describing the protective effects of this plant on${alpha}$-amanitin-induced hepatotoxicity have been published. ${alpha}$-Amanitin is a peptide found in several mushroom species that accounts for the majority of severe mushroom poisonings leading to severe hepatonecrosis. In our previous in vitro study, we found that ${alpha}$-amanitin induced oxidative stress, which may contribute to its severe hepatotoxicity. The aim of this study was to investigate whether Glehnia littoralis acetate extract (GLEA) has protective antioxidant effects on ${alpha}$-amanitin-induced hepatotoxicity in a murine model. Methods: Swiss mice (n=40 in all groups) were divided into four groups (n=10/group). Three hours after giving ${alpha}$-amanitin (0.6 mg/kg, i.p.) to the mice, they were administered silibinin (50 mg/kg/d, i.p.) or Glehnia littoralis ethyl acetate extract (100 mg/kg/d, oral) therapies once a day for 3 days. After 72 hours of treatment, each subject was killed, cardiac blood was aspirated for hepatic aminotransferase measurement, and liver specimens were harvested to evaluate the extent of hepatonecrosis. The degree of hepatonecrosis was assessed by a pathologist blinded to the treatment group and divided into 4 categories according to the grade of hepatonecrosis. Results: GLEA significantly improved the beneficial functional parameters in ${alpha}$-amanitin-induced hepatotoxicity. In the histopathological evaluation, the toxicity that was generated with ${alpha}$-amanitin was significantly reduced by GLEA, showing a possible hepatoprotective effect. Conclusion: In this murine model, Glehnia littoralis was effective in limiting hepatic injury after ${alpha}$-amanitin poisoning. Increases of aminotransferases and degrees of hepatonecrosis were attenuated by this antidotal therapy.

Comparison of Silymarin, Penicillin, N-acetylcysteine in Patient with Amatoxin Poisoning: A Systematic Review: Min Woo Choi, Dong Ryul Ko, Taeyoung Kong, Min Hong Choa, Je Sung You, Sung Phil Chung; J Korean Soc Clin Toxicol. 2018;16(1):33-41. Published online June 30, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.1.33

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Abstract PDF: Purpose: This study was conducted to evaluate the clinical efficacy of pharmacologic treatment of amatoxin poisoning patients. Methods: Literature was accessed through PubMed, EMBASE, Cochrane library, KoreaMed, KISS and KMBASE. Studies relevant to human use of pharmacologic therapy including silymarin, penicillin and N-acetylcysteine (NAC) for amanita poisoning were included. Case reports, letters, editorials and papers with insufficient information were excluded. Comparison of clinical outcomes (especially mortality and liver transplantation rate) in each study was analyzed. Results: The final analysis included 13 retrospective studies. None of these studies showed direct comparisons of individual agents. Among 12 studies comparing silymarin vs penicillin, eight showed clinical superiority of silymarin. Among eight studies comparing silymarin with NAC, six showed clinical superiority of silymarin. Among seven studies of NAC vs penicillin, five showed clinical superiority of NAC. Conclusion: This systematic review suggested that clinical superiority of various pharmacological agents used to treat amatoxin poisoning is debatable. Nevertheless, the available evidence suggests it is reasonable to consider combinations of multiple agents for patients with amanita poisoning. Further studies are required to establish a treatment regimen for amanita poisoning.

A Case of Aconite Poisoning Successfully Recovered after Intravenous Fat Emulsion Therapy: Hee Jun Shin, Hoon Lim; J Korean Soc Clin Toxicol. 2016;14(1):60-65. Published online June 30, 2016

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Abstract PDF: Aconitum is a genus of various species of flowering plants that belongs to the Family Ranunculaceae. Most Aconitum sp. have extremely toxic alkaloid substances such as aconitine, mesaconitine and hypaconitine. Among these substances, aconitine can cause fatal cardiotoxicity by activating sodium channels followed by calcium channels in myocardial cells. Even though there have been various therapeutic plans suggested comprising antidotes based on diverse case reports and studies, there is no confirmatory treatment protocol for aconite poisoning. Here, we report an aconite poisoning patient who had refractory ventricular tachyarrhythmia that did not respond to intravenous amiodarone therapies even though they were sustained for over 2 hours, but showed successful recovery following intravenous fat emulsions (IFE) therapy.

A Patient Presenting with Elevations of Cardiac Enzyme Levels after Veratrum Oxysepalum Ingestion: Ji Young Hwang, Hyun Kim; J Korean Soc Clin Toxicol. 2015;13(2):111-116. Published online December 31, 2015

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Abstract PDF: Veratrum patulum has toxicological relevance because of the potential for misidentification of this plant as mountain garlic. Veratrum patulum has an ester-alkaloid that provokes cardiac arrhythmias by excessive vagal stimulation and depression of the sinoatrial and atrioventricular nodes of the heart and hypotension, cardiomegaly. We report on a retrospective case of successful outcome in patients with veratrum patulum poisoning through active treatment from the early phase after ingestion. We report on a case involving a patient who experienced dizziness, dyspnea, hypotension, and elevation of cardiac enzyme, cardiomegaly. These cases were kept under observation and generally recovered with supportive care. We report on cases of veratrum patulum poisoning with review of literature.

Three Cases with Manic Symptoms and Cognitive Dysfunction after Wild Plant Ingestion: Doo Hyun Lee, Gi Joong Kim, Ga Eul Kim, Dae Jin Chung, Jun Yeol Lee, Joon Ho Bae, Yoon Seong Kim, Chan Woo Park, Hui Young Lee, Jun Hwi Cho; J Korean Soc Clin Toxicol. 2013;11(2):130-132. Published online December 31, 2013

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Abstract PDF: Distinguishing wild plants in spring from ingestible plants is difficult. Differentiation of budding plants from other plants is particularly difficult. Many people want to find edible plants for health during the spring season. Scopolia japonica can cause symptoms of mania. The author experienced three cases of poisoning by Scopolia japonica. We reported on the cases with literature reviews.

Four Cases of Phytolacca Esculenta Van Houtte Intoxication due to Misidentification as a Ginseng: Jun Ho Bae, Ga Eul Kim, Gi Joong Kim, Doo Hyun Lee, Jun Yeol Lee, Dae Jin Jeong, Yoon Seong Kim, Chan Woo Park, Hui Young Lee, Jun Hwi Cho; J Korean Soc Clin Toxicol. 2013;11(2):133-135. Published online December 31, 2013

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Abstract PDF: Poisoning by Phytolacca esculenta commonly occurs by misidentification as other edible plants. The root of Phytolacca esculenta is similar to other roots, such as kudzu, balloon flower, codonopsis lanceolata, and ginseng. The author experienced four cases of Phytolacca esculenta intoxication due to misidentification as a ginseng. We report on these cases with a review of the literature.

Recent 10-Year Experience of One Regional Emergency Center and Recommendation for Hyperbaric Oxygen Therapy (HBOT): Jung-Hoon Yoon, Gi-Woon Kim, Yoon-Seok Jung, Cheol-Soo Han, Young-Gi Min, Joon-Pil Cho, Sang-Cheon Choi; J Korean Soc Clin Toxicol. 2013;11(2):81-88. Published online December 31, 2013

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Abstract PDF: Purpose: The aim of this study is to investigate current status, indications, and complications of hyperbaric oxygen therapy. Methods: A retrospective investigation of patients who underwent hyperbaric oxygen therapy at a university medical center from September 2004 to August 2013 was conducted based on patients' medical records and results of an email survey for 99 emergency centers. Results: During the study period, a total of 233 patients underwent hyperbaric oxygen therapy. Indications for hyperbaric oxygen treatment of illness or injury were as follows: 1) 151 cases of acute carbon monoxide poisoning(65.4%), 2) flap wound management, including 42 cases(18.2%), 3) skin care transplanted, including 23 cases(10.4%), 4) Burger's disease, including 5 five cases(2.1%), respectively. Total application time$^*$ frequency was 1,088 and total time was 1,239 hours. Among 233 patients who underwent hyperbaric oxygen therapy, 32 patients(13.7%) had complications: 1) otalgia in 21 cases(9.0%), 2) mastoiditis?in six cases(2.6%), 3) hemotympanum in five cases(2.1%), respectively. There were only 8 emergency centers that currently had an operational hyperbaric oxygen chamber in 77 emergency centers(10.4%). Conclusion: Indications identified through this study showed difference from current indications worldwide. It seems necessary that physicians' perception regarding application of hyperbaric oxygen therapy for more indications be changed and improved. A hyperbaric chamber capable of providing respiratory assistance and intensive care is also needed. A good network for sharing treatment experiences and a specialized team for administration of hyperbaric oxygen therapy is also required.

Clinical Features of Pokeweed Intoxication Experienced in a University Hospital: Dong Kil Jeong, Hyung Jun Moon, Jung Won Lee, Sae Hoon Park, Hyung Jung Lee, Seung Whan Seol, Ah Reum Kim, Jae Hyung Choi, Jae Woo Kim; J Korean Soc Clin Toxicol. 2012;10(2):86-90. Published online December 31, 2012

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Abstract PDF: Purpose: Although Pokeweed intoxication is relatively less severe, there is little data on the clinical presentation of Pokeweed intoxication in Korea. This study examined the clinical aspects to provide basic data for evaluating Pokeweed intoxication. Methods: A retrospective study by a chart review was performed on 19 patients who ingested Pokeweed and presented to an academic emergency department with an annual census of 40,000 between March 2012 and May 2012. Results: Nineteen patients were identified. All patients were intoxicated unintentionally. The most common symptoms were vomiting with diarrhea and abdominal pain. The onset time varied, but occurs 30 minutes to 5 hours post ingestion of Pokeweed. All patients were discharged without fatal complications. Conclusion: Compared to previous reports, most pokeweed poisoning patients complain of gastrointestinal symptoms. Supportive care is the mainstay of the management of pokeweed intoxication. All symptoms were resolved over a 24 to 48 hour period.

Three Cases of Cardiac Toxicity after Intake of Symplocarpus Renifolius: Tae-Hoon Kim, Hyun Kim, Oh-Hyun Kim, Yong-Sung Cha, Kyoung-Chul Cha, Kang-Hyun Lee, Sung-Oh Hwang; J Korean Soc Clin Toxicol. 2012;10(1):41-45. Published online June 30, 2012

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Abstract PDF: Recently, some patients have visited the emergency department for treatment of different symptoms of acute poisoning after intake of unidentified herbs, which can be mistaken for wild edible greens, because wild edible greens are good for health and contain vitamins, enzymes, minerals, fibers, and anticancer materials. Winter or early spring, is extremely high, with rapid onset of severe symptoms of poisoning. There have been no reports of poisoning by SymplocarpusRenifolius in Korea, however, we report on three severe cases involving patients who experienced cardiogenic shock with nausea, vomiting, abdominal pain, chest discomfort, dizziness, numbness, and general weakness.

Comparison between Emergency Patient Poisoning Cases and the Tox-Info System Database: Hyun-Jong Kim, Yang-Weon Kim, Hyun Kim, Chang-Bae Park, Byung-Hak So, Kyeong-Ryong Lee, Kyung-Woo Lee, Kyung-Won Lee, Sung-Woo Lee, Jang-Young Lee, Gyu-Chong Cho, Jun-Ho Cho, Sung-Phil Chung; J Korean Soc Clin Toxicol. 2012;10(1):8-14. Published online June 30, 2012

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Abstract PDF: Purpose: The Tox-Info system is a poisonous substance information database developed by the Korean National Institute of Food and Drug Safety Evaluation. The aim of this study was to estimate the coverage effectiveness of the Tox-Info system by comparing the toxic substances included in the database with the distribution of the toxic substances implicated in the cases of intoxicated patients presenting to emergency departments. The secondary aim of the study was to propose any additional substances that should be added to the database. Methods: We retrospectively reviewed the medical records of patients suffering with toxic exposure who had visited any of 12 selected emergency departments in Korea from January 2010 to December 2011. The identified toxic substances were classified into groups including prescription drugs, agricultural chemicals, household products, animals or plants, herbal drugs, and others. We calculated the coverage rate of the Tox-Info database relative to the number of intoxication cases and the type of toxic substances involved. Results: A total of 5,840 intoxicated patient records were collected. Their mean age was $46.6{pm}20.5$ years and 56.2% were female. Of the total intoxication cases, 87.8% of the identified toxic substances were included in the Tox-Info database, while only 41.6% of all of the types of identified toxic substances were included. Broken down by category, 122 prescription drugs, 15 agricultural chemicals, 12 household products, 14 animals or plants and 2 herbal drugs involved in poisoning cases were not included in the Tox-info database. Conclusion: This study demonstrated the clinical usefulness of the Tox-Info system. While 87.8% of the substances involved in the cases were included in the Tox-Info database, the database should be continuously updated in order to include even the most uncommon toxic substances.

Radiological Accident and Acute Radiation Syndrome: Hyung-Keun Roh; J Korean Soc Clin Toxicol. 2011;9(2):39-48. Published online December 31, 2011

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Abstract PDF: In mass casualty situation due to radiological accidents, it is important to start aggressive management with rapid triage decisions. External contamination needs immediate decontamination and internal contamination should be treated with special expertise and equipment to prevent the rapid uptake of radionuclides by target organs. Acute radiation syndrome shows a sequence of events that varies with the severity of the exposure. More severe exposures generally lead to more rapid onset of symptoms and severe clinical findings. After the massive exposure, various systems of the body reflect their severe damages that can lead to death within hours or up to several months. The disease progression has classically been divided into four stages: prodromal, latent, manifest illness, and recovery or death. Three characteristic clusters of symptoms including the hematopoietic syndrome, the gastrointestinal syndrome and the cerebrovascular syndrome are all associated with the acute radiation syndrome. The standard medical management of the patients with a potentially survivable radiation exposure includes good medical, surgical and supportive measures. Specific treatment with cytokines and bone marrow transplantation should be considered. The management of internal contamination is much the same as the treatment of poisoning. The standard decontamination should be applied to reduce uptake, and the chelating agents can be administered to enhance the clearance of radioisotopes. Radioactive iodine ($^{131}I$) as one of the nuclear fission products can increase the incidence of thyroid cancer in children. Potential benefit of potassium iodide prophylaxis is greater especially in neonates, infants and small children.

A Case of Bentazone Poisoning Mimicking Organophosphate Intoxication: Hyun-Min Jung, Ji-Hye Kim, Seung-Baik Han, Jin-Hui Paik, Ji-Yoon Kim, Jun-Sig Kim; J Korean Soc Clin Toxicol. 2010;8(2):122-124. Published online December 31, 2010

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Abstract PDF: $Basagran^{(R)}$ is a herbicide that is widely used in the field and it acts by interfering with photosynthesis in plants. It consists of bentazone, 2-methyl-4-chlorophenoxyacetic acid (MCPA) and surfactants. Bentazone is commonly used, but poisoning due to Bentazone has not been previously reported in Korea. The patients with toxic effects of bentazone show mild to severe symptoms and various complications. We report here on a case of a woman who intentionally ingested 500 ml of $Basagran^{(R)}$ and she was discharged without complication. As soon as the patient visited the emergency department, we started to treat her as if she had organophosphate intoxication because of the cholinergic symptoms. We could not detect the bentazone in her serum and urine, and we could confirm $Basagran^{(R)}$ ingestion only after getting information from her husband. Bentazone poisoning may induce harmful complications like muscle rigidity, rhabdomyolysis, respiratory failure and cardiac arrest. A detailed history taking, an accurate analysis method and early conservative management will be helpful for patients with acute bentazone poisoning.

A Fatal Case of Methylene Chloride Poisoning: Kyoung Sook Jeong, Hyun-Sul Lim; J Korean Soc Clin Toxicol. 2009;7(1):41-43. Published online June 30, 2009

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Abstract PDF: A 52-year-old man was found dead in the driver's seat of his tank lorry. The tank lorry was used to transport industrial wastewater to a disposal plant; the material was transferred into a storage tank with the help of compressed air. The wastewater contained methylene chloride and 2-chloropyridine. No respiratory protective equipment was used while working under these conditions. The autopsy report showed extensive edema and congestion of the brain, lung, and intraperitoneal organs. The concentrations of methylene chloride in lung and brain were reported at 398 and 67 mg/kg, respectively.

Liver Transplantation for Acute Toxic Hepatitis due to Herbal Medicines and Preparations: Chang-Hwan Sohn, Myung-Il Cha, Bum-Jin Oh, Woon-Hyung Yeo, Jae-Ho Lee, Won Kim, Kyoung-Soo Lim; J Korean Soc Clin Toxicol. 2008;6(2):110-116. Published online December 31, 2008

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Abstract PDF: Purpose: Acute toxic hepatitis is a common cause of acute liver failure (ALF). We investigated the causes, clinical manifestation, and outcomes of ALF patients who underwent liver transplantation due to acute toxic hepatitis caused by herbal medicines and preparations. Methods: Between January 1992 and May 2008, we retrospectively reviewed the medical records of 24 patients who were transplanted due to acute toxic hepatitis caused by herbal medicines and preparations. We applied the RUCAM score to patients with acute toxic hepatitis and assessed the relationship between herbal preparations and liver injury. We studied the patients' medication history, liver function tests, and clinical outcomes. Results: The type of liver injury was divided into three groups: hepatocellular type, 14 patients (58.3%); cholestatic type, 4 patients (16.7%); and mixed type, 6 patients (25%). Polygonum multiflorum Thunberg (3 cases) was the most common cause of acute toxic hepatitis, followed by Acanthopanax senticosus (2 cases), pumpkin juice (2 cases), Dictamnus dasycarpus Turcz (2 cases), Hovenia dulcis (1 case), Phellinus linteus (1 case), and Artemisia capillaries (1 case). One year survival after liver transplantation was 76%. Conclusion: We identified the herbal preparations leading to acute liver failure. Many patients consider herbal remedies to be completely free of unwanted side effects. However, we found that many herbal products have biological activities that can lead to severe hepatotoxicity.

Two Cases of Phytolacca Americana Intoxication with Confusion and Abdominal Cramping: Yang-Weon Kim, Yoo-Sang Yoon, Mi-Ran Kim, Sang-Hoon Park, Jun-Cheol Choi; J Korean Soc Clin Toxicol. 2008;6(2):146-148. Published online December 31, 2008

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Abstract PDF: Phytolacca americana poisoning is a benign plant intoxication that causes gastrointestinal symptoms, including abdominal cramps, vomiting, diarrhea, and gastrointestinal bleeding. Other signs and symptoms include diaphoresis, salivation, visual disturbance, and seizures or mental changes. We report two cases of patients who experienced confusion and abdominal pain, vomiting, and hematemesis after oral ingestion of pokeweed. A 60-year-old female with confusion and a 67-year-old female with abdominal pain, vomiting, and diarrhea were admitted to the emergency department after pokeweed poisoning. After supportive treatment of hydration and gastrointestinal medication, the two patients showed full recovery within 24 h and were discharged from the hospital.

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