Current Awareness in Clinical Toxicology Editors: Damian Ballam Msc and Allister Vale MD

Current Awareness in Clinical Toxicology Editors: Damian Ballam MSc and Allister Vale MD

July 2015

CONTENTS General Toxicology 8 Metals 34 Management 18 Pesticides 37 Drugs 20 Chemical Warfare 38 Chemical Incidents & 28 Plants 38 Pollution Chemicals 30 Animals 38

CURRENT AWARENESS PAPERS OF THE MONTH

Fomepizole versus ethanol in the treatment of acute methanol poisoning: comparison of clinical effectiveness in a mass poisoning outbreak Zakharov S, Pelclova D, Navratil T, Belacek J, Komarc M, Eddleston M, Hovda KE. Clin Toxicol 2015; online early: doi: 10.3109/15563650.2015.1059946: Context Mass or cluster methanol poisonings are frequently reported from around the world. The comparative effectiveness of ethanol and fomepizole as antidotes for methanol poisoning is unknown due to the difficulty of performing a randomized controlled trial. Objective During an outbreak of mass poisonings in the Czech Republic in 2012–2014, we compared the effects of antidotes on the frequency of health sequelae and mortality. Methods The study was designed as a cross-sectional case series and quasi-case–control study. Patients with a diagnosis of methanol poisoning on admission to hospitals were identified for the study. Diagnosis was established when (i) a history of recent ingestion of illicit spirits

Current Awareness in Clinical Toxicology is produced monthly for the American Academy of Clinical Toxicology by the Birmingham Unit of the UK National Poisons Information Service, with contributions from the Cardiff, Edinburgh, and Newcastle Units.

The NPIS is commissioned by Public Health England

was available and serum methanol was higher than 6.2 mmol/L (20 mg/dL), or (ii) there was a history/clinical suspicion of methanol poisoning, and serum methanol was above the limit of detection with at least two of the following: pH < 7.3, serum bicarbonate < 20 mmol/L, and anion gap or AG  20 mmol/L. Fomepizole was given as a bolus dose of 15 mg/kg i.v. diluted in isotonic saline, followed by 10 mg/kg every 12 h (every 4 h during hemodialysis); ethanol was administered both intravenously as a 10% solution in 5% glucose, and per os in boluses of 20% solution. Multivariate regression was applied to determine the effect of antidote on outcome. Additionally, for a retrospective quasi-case– control study, a control group of patients treated with ethanol, matched carefully on severity of poisoning and other key parameters, was selected. Results Data were obtained from 100 hospitalized patients with confirmed poisoning: 25 patients treated with fomepizole were compared with 68 patients receiving ethanol (seven patients did not receive any antidote). More severely acidotic (p < 0.001) and late-presenting (>12 h; p = 0.028) patients received fomepizole more often than ethanol, as reflected in the higher number of fomepizole-treated patients being intubated (p = 0.009). No association was found between the type of antidote and the survival in either the case series (p = 0.205) or the quasi-control groups (p = 0.705) in which patients were very closely matched to minimize confounding by allocation. In the multivariate analysis, positive serum ethanol (odds ratio [OR], 10.8; 95% confidence interval [CI], 2.9–39.9) and arterial blood pH (OR, 3.7; 95% CI, 1.3–10.5) on admission were the only independent variables for the survival. The median intensive care unit length of stay was 6 (range, 2–22) days in the fomepizole group and 4 (range, 1–33) days in the ethanol group (p = 0.131). There were no differences in the use of elimination techniques between the two groups (neither in the full material (n = 100), nor the case-control groups (n = 50)). Conclusions This study on antidotes for methanol poisoning did not show any evidence of different clinical effectiveness. Although ethanol is generally associated with a higher incidence of complications, this study suggests that both antidotes are similarly effective and that ethanol should not be avoided on grounds of effectiveness. Full text available from: http://dx.doi.org/10.3109/15563650.2015.1059946

The efficacy of prophylactic antibiotics in the management of children with kerosene-associated pneumonitis: a double-blind randomised controlled trial Balme KH, Zar H, Swift DK, Mann MD. Clin Toxicol 2015; online early: doi: 10.3109/15563650.2015.1059943: Context Hydrocarbons, especially kerosene (paraffin), are the most common agents causing childhood poisoning in low and middle income countries (LMICs). Aspiration of kerosene causes an inflammatory sterile chemical pneumonitis, which may increase susceptibility to secondary lower respiratory tract bacterial infection. This study aimed to assess the efficacy of prophylactic antibiotics in the management of kerosene-associated pneumonitis in children and to identify risk factors associated with severity or outcome. Methods A double-blind placebo-controlled trial of prophylactic antibiotics in the management of kerosene-associated pneumonitis of children presenting to a referral hospital was performed from July 2010 to September 2011. Sequential children with a history of kerosene ingestion

and mild respiratory illness were randomised to receive placebo or amoxicillin. Each child was followed-up at Day 3 and Day 5 post-ingestion. The primary outcome measure was the number of treatment failures in each group, defined as any child who deteriorated within this time, necessitating a change in treatment regimen. Secondary outcome measures were length of hospital stay and symptoms and signs at follow-up. Results Seventy-four patients were enrolled. Thirty-five (47%) received placebo and 39 (53%) active treatment. There was no significant difference in treatment failures between placebo (3/35, 9%; 95% CI, 3–22) and active (2/39, 5%; 95% CI, 1–17) groups (relative risk, 0.60; 95% CI, 0.11–3.37). The median length of hospital stay was identical (placebo 0.5 days; IQR, 0–1.0 and active 0.5 days; IQR, 0.5–1.0). Symptoms and signs at Days 3 and 5 post- ingestion were similar. The only significant risk factor for treatment failure was residence in formal housing. Clinical severity at presentation was similar for treatment successes and failures. Conclusion Prophylactic antibiotics do not improve the outcome in children with mild respiratory illness after kerosene ingestion. Full text available from: http://dx.doi.org/10.3109/15563650.2015.1059943

Neurotoxicity associated with exposure to 1-bromopropane in golf-club cleansing workers Wang T-H, Wu M-L, Wu Y-H, Tsai W-J, Lin K-P, Wang C-L, Yang C-C, Deng J- F. Clin Toxicol 2015; online early: doi: 10.3109/15563650.2015.1064939: Background 1-Bromopropane (1-BP) is an alternative to ozone-depleting solvent that is used in degreasing, dry cleaning, spray adhesives, and aerosol solvents. Occupational exposure to 1-BP is associated with adverse peripheral sensory, motor, and central nervous system (CNS) effects. We report our Health Hazard and Medical Evaluation of 6 patients with neurotoxicity associated with occupational exposure to 1-BP. Case series and environmental evaluation Six workers, 1 male and 5 female, were exposed to high ambient 1-BP concentrations while employed in a golf club cleaning factory. 1-BP was identified in the bulk solvent sample used by the workers and confirmed the workers' daily occupational exposure to 1-BP for 3–10 months. The major presenting symptoms were tingling pain, soreness in lower extremities, and paresthesia. N-acetyl-S-(n-propyl)-L-cysteine (AcPrCys), a 1-BP metabolite, was identified by LC/MS/MS in the urine (0.171–1.74 mg/g-Cr) of these workers 5–26 days following 1-BP exposure. Discussion and conclusion An occupational outbreak of 1-BP poisoning occurred as a result of recurrent power outages, condenser, and exhaust fans malfunction, and inadequate personal protection. Occupational exposure to 1-BP may result in peripheral neuropathy as well as adverse CNS effects. Urine AcPrCys may be a specific biomarker for 1-BP exposure. Full text available from: http://dx.doi.org/10.3109/15563650.2015.1064939

Opioid intoxications involving butyrfentanyl, 4-fluorobutyrfentanyl, and fentanyl from the Swedish STRIDA project Bäckberg M, Beck O, Jönsson K-H, Helander A. Clin Toxicol 2015; online early: doi: 10.3109/15563650.2015.1054505: Background The supply of unregulated "new psychoactive substances" (NPS) has shown a steady increase over the past six years. This report from the Swedish STRIDA project describes analytically confirmed non-fatal intoxications involving butyrfentanyl (butyrylfentanyl) or 4- fluorobutyrfentanyl (para-fluorobutyrfentanyl), two fentanyl analogues recently introduced as NPS opioids. Study design Observational case series of consecutive patients with suspected acute NPS exposure and requiring hospital care from all over Sweden. Patients and methods From May 2014 to January 2015, blood and urine samples were obtained from four intoxication cases involving butyrfentanyl and one case involving 4-fluorobutyrfentanyl (men, 19–30 years) presenting in emergency departments (ED) or intensive care units (ICU). Laboratory analysis of serum and/or urine samples was performed by multi- component liquid chromatography–mass spectrometry methods. Data on clinical features were collected during consultations with the Poisons Information Centre and retrieved from medical records. Case details Of the five patients, two were discharged home from the ED and three were admitted to the ICU, of whom two required intubation and mechanical ventilation. Clinical features included typical opioid symptoms such as unconsciousness, respiratory depression, and apnea. In one case, naloxone successfully countered the effects. All patients were discharged the same or the following day. Butyrfentanyl was detected in two serum (0.6 and 0.9 ng/mL) and three urine (2.0–65.6 ng/mL) samples from three of four cases; three cases also contained fentanyl. In the 4-fluorobutyrfentanyl case, the substance was detected in serum (~15 ng/mL) and urine (~10 ng/mL). In four cases, other NPS and/or classical drugs were also detected. Analysis of two "butyrfentanyl" NPS products (nasal spray and powder) brought to hospital by patients showed that the 10-fold more potent fentanyl was the main active ingredient (~7.5–10-fold higher amount) in both. Conclusion Typical and potentially life-threatening opioid toxicity was seen in acute intoxications involving butyrfentanyl, 4F-butyrfentanyl, and fentanyl. The incorrect labelling of butyrfentanyl NPS products which instead mainly contained fentanyl is alarming, given the narrow range between a safe and a lethal dose for opioids. Full text available from: http://dx.doi.org/10.3109/15563650.2015.1054505

Diagnosis of toxic alcohols: limitations of present methods Kraut JA. Clin Toxicol 2015; online early: doi: 10.3109/15563650.2015.1056880: Context Methanol, ethylene glycol, diethylene glycol, and propylene glycol intoxications are associated with cellular dysfunction and an increased risk of death. Adverse effects can develop quickly; thus, there is a need for methods for rapidly detecting their presence.

Objective To examine the value and limitations of present methods to diagnose patients with possible toxic alcohol exposure. Methods I searched MEDLINE for articles published between 1969 and 2014 using the terms: toxic alcohols, serum osmolality, serum osmol gap, serum anion gap, metabolic acidosis, methanol, ethylene glycol, diethylene glycol, propylene glycol, and fomepizole. Each article was reviewed for additional references. Results The diagnosis of toxic alcohol exposure is often made on the basis of this history and physical findings along with an increase in the serum osmol and anion gaps. However, an increase in the osmol and/or anion gaps is not always present. Definitive detection in blood requires gas or liquid chromatography, laborious and expensive procedures which are not always available. Newer methods including a qualitative colorimetric test for detection of all alcohols or enzymatic tests for a specific alcohol might allow for more rapid diagnosis. Conclusions Exposure to toxic alcohols is associated with cellular dysfunction and increased risk of death. Treatment, if initiated early, can markedly improve outcome, but present methods of diagnosis including changes in serum osmol and anion gap, and use of gas or liquid chromatography have important limitations. Development of more rapid and effective tests for detection of these intoxications is essential for optimal care of patients. Full text available from: http://dx.doi.org/10.3109/15563650.2015.1056880

Acetaminophen concentrations prior to 4 hours of ingestion: Impact on diagnostic decision-making and treatment Seifert SA, Kirschner RI, Martin TG, Schrader RM, Karowski K, Anaradian PC. Clin Toxicol 2015; online early: doi: 10.3109/15563650.2015.1059942: Background Consensus recommendations for acute acetaminophen exposure include plotting an acetaminophen concentration at  4 h post ingestion on the Rumack-Matthew nomogram to determine the need for acetylcysteine treatment. We studied the frequency of acetaminophen concentrations drawn within 4 h post ingestion and whether the Rumack– Matthew nomogram was properly used in making acetylcysteine treatment decisions. Methods This was a retrospective, observational case series at three regional poison centers of acute acetaminophen exposures between 1/1/13 and 12/31/13. Cases were analyzed for demographics, timing of acetaminophen concentrations, and application of the Rumack- Matthew nomogram in acetylcysteine initiation or termination. Results 1,123 cases of acute acetaminophen exposure were reviewed. Of 520 acute acetaminophen exposure cases presenting < 4 h post ingestion, 323 (62%) had a pre-4-hour acetaminophen concentration measured and 197 (38%) did not. Those with a known pre-4-hour acetaminophen concentration were less likely to have a 4-hour acetaminophen concentration (59% vs. 93%) or an acetaminophen concentration within 8 h (87% vs. 99%) and were more likely to be treated with acetylcysteine (29% vs. 17%) and less likely to be treated based on the Rumack–Matthew nomogram (72% vs. 97%). Conclusions Patients with a known exposure time and presenting within 4 h of acetaminophen ingestion

had a pre-4-hour acetaminophen concentration obtained 62% of the time. Pre-4-hour acetaminophen concentrations cannot be used to determine the need for acetylcysteine therapy and are associated with an increased likelihood of not obtaining optimally timed acetaminophen concentrations and acetylcysteine management not based on the proper application of the Rumack–Matthew nomogram. Current practice results in additional cost, unnecessary treatment, potential adverse medication effects, and the possibility of non- treatment of patients at risk of hepatotoxicity. Full text available from: http://dx.doi.org/10.3109/15563650.2015.1059942

Target biomarker profile for the clinical management of paracetamol overdose Vliegenthart ADB, Antoine DJ, Dear JW. Br J Clin Pharmacol 2015; online early: doi: 10.1111/bcp.12699: Abstract and full text available from: http://dx.doi.org/10.1111/bcp.12699

Synthetic cannabinoid–related illnesses and deaths Trecki J, Gerona RR, Schwartz MD. N Engl J Med 2015; 373: 103-7. Full text available from: http://dx.doi.org/10.1056/NEJMp1505328

Intravenous lipid emulsion therapy for acute synthetic cannabinoid intoxication: clinical experience in four cases Aksel G, Güneysel Ö, Tasyürek T, Kozan E, Çevik SE. Case Rep Emerg Med 2015; 2015: 180921.

Abstract and full text available from: http://dx.doi.org/10.1155/2015/180921

A modern literature review of carbon monoxide poisoning theories, therapies, and potential targets for therapy advancement Roderique JD, Josef CS, Feldman MJ, Spiess BD. Toxicology 2015; 334: 45-58. Abstract and full text available from: http://dx.doi.org/10.1016/j.tox.2015.05.004

A review of epidemiologic studies of low-level exposures to organophosphorus insecticides in non-occupational populations Reiss R, Chang ET, Richardson RJ, Goodman M. Crit Rev Toxicol 2015; 45: 531-641. Abstract and full text available from: http://dx.doi.org/10.3109/10408444.2015.1043976

Adverse events associated with flumazenil treatment for the management of suspected benzodiazepine intoxication – A systematic review with meta-analyses of randomised trials Penninga E, Graudal N, Ladekarl MB, Jürgens G. Basic Clin Pharmacol Toxicol 2015; online early: doi: 10.1111/bcpt.12434: Abstract and full text available from: http://dx.doi.org/10.1111/bcpt.12434

NOS-2 inhibition in phosgene-induced acute lung injury Filipczak PT, Senft AP, Seagrave JC, Weber W, Kuehl PJ, Fredenburgh LE, McDonald JD, Baron RM. Toxicol Sci 2015; 146: 89-100. Abstract and full text available from: http://dx.doi.org/10.1093/toxsci/kfv072

Antibody treatment against pulmonary exposure to abrin confers significantly higher levels of protection than treatment against ricin intoxication Sabo T, Gal Y, Elhanany E, Sapoznikov A, Falach R, Mazor O, Kronman C. Toxicol Lett 2015; 237: 72-8. Abstract and full text available from: http://dx.doi.org/10.1016/j.toxlet.2015.06.003

Antidepressant use late in pregnancy and risk of persistent pulmonary hypertension of the newborn Huybrechts KF, Bateman BT, Palmsten K, Desai RJ, Patorno E, Gopalakrishnan C, Levin R, Mogun H, Hernandez-Diaz S. JAMA 2015; 313: 2142-51. Abstract and full text available from: http://dx.doi.org/10.1001/jama.2015.5605

Scorpion stings in pregnant women: an analysis of 11 cases and review of literature Kaplanoglu M, Helvaci MR. Clin Exp Obstet Gynecol 2015; 42: 228-30. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/26054125

Risks of congenital malformations in offspring exposed to valproic acid in utero: a systematic review and cumulative meta-analysis Tanoshima M, Kobayashi T, Tanoshima R, Beyene J, Koren G, Ito S. Clin Pharmacol Ther 2015; online early: doi: 10.1002/cpt.158:

Abstract and full text available from: http://dx.doi.org/10.1002/cpt.158

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Szymanska-Chabowska A, Laczmanski T, Jedrychowska I, Plutonium Chabowski M, Gac P, Janus A, Goslawska K, Smyk B, Zöllner S, Sokolnikov ME, Eidemüller M. Solska U, Mazur G, Poreba R. Beyond two-stage models for lung carcinogenesis in the The relationship between selected VDR, HFE and ALAD Mayak workers: implications for plutonium risk. gene polymorphisms and several basic toxicological PLoS ONE 2015; 10: e0126238. parameters among persons occupationally exposed to lead. Toxicology 2015; 334: 12-21. Uranium Shiu J, Gaitens J, Squibb KS, Gucer PW, McDiarmid MA, Xu X, Chen X, Zhang J, Guo P, Fu T, Dai Y, Lin SL, Huo X. Gaspari AA. Decreased blood hepatitis B surface antibody levels linked Significance of dermatologic findings in a cohort of to e-waste lead exposure in preschool children. depleted uranium-exposed veterans of Iraqi conflicts. J Hazard Mater 2015; 298: 122-8. Dermatitis 2015; 26: 142-7.

PESTICIDES Pang Z, Hu C-MJ, Fang RH, Luk BT, Gao W, Wang F, Chuluun E, Angsantikul P, Thamphiwatana S, Lu W, Jiang General X, Zhang L. Brito JG, de Godoy Martins CB. Detoxification of organophosphate poisoning using nano- Accidental intoxication of the infant-juvenile population in particle bioscavengers. households: profiles of emergency care. ACS Nano 2015; online early: Rev Esc Enferm USP 2015; 49: 372-9. doi: 10.1021/acsnano.5b02132:

Hongsibsong S, Kerdnoi T, Polyiem W, Srinual N, Reddy SD, Reddy DS. Patarasiriwong V, Prapamontol T. Midazolam as an anticonvulsant antidote for organo- Blood cholinesterase activity levels of farmers in winter and phosphate intoxication – A pharmacotherapeutic appraisal. hot season of Mae Taeng District, Chiang Mai Province, Epilepsia 2015; 56: 813-21. Thailand. Environ Sci Pollut Res 2015; online early: Reiss R, Chang ET, Richardson RJ, Goodman M. doi: 10.1007/s11356-015-4916-6: A review of epidemiologic studies of low-level exposures to organophosphorus insecticides in non-occupational Mamane A, Baldi I, Tessier J-F, Raherison C, Bouvier G. populations. Occupational exposure to pesticides and respiratory Crit Rev Toxicol 2015; 45: 531-641. health. Eur Respir Rev 2015; 24: 306-19. Valente NIP, Tarelho S, Castro AL, Silvestre A, Teixeira HM. Analysis of organophosphorus pesticides in whole blood by GC-MS-ECD with forensic purposes. Aluminium phosphide J Forensic Leg Med 2015; 33: 28-34. Karthik SK, Kumari D, Nagaraj BM, Jayaprakash G, Mohana J. Chlorpyrifos Aluminium phosphide poisoning – A case report. Li D, Huang Q, Lu M, Zhang L, Yang Z, Zong M, Tao L. Indian J Forensic Med Toxicol 2015; 9: 13-5. The organophosphate insecticide chlorpyrifos confers its genotoxic effects by inducing DNA damage and cell Carbamate insecticides apoptosis. Mancozeb Chemosphere 2015; 135: 387-93.

Zakharov S, Csomor J, Urbanek P, Pelclova D. Phung DT, Connell D, Chu C. Toxic epidermal necrolysis after exposure to dithiocarbamate A new method for setting guidelines to protect human fungicide mancozeb. health from agricultural exposure by using chlorpyrifos as Basic Clin Pharmacol Toxicol 2015; online early: an example. doi: 10.1111/bcpt.12430: Ann Agric Environ Med 2015; 22: 275-80.

Organochlorine pesticides Dichlorvos DDT Manzoor F, Bashir N, Bhat S, Bashir Y. Cohn BA, La Merrill M, Krigbaum NY, Yeh G, Park J-S, Hemolysis caused by accidental exposure to dichlorovos: a Zimmermann L, Cirillo PM. rare manifestation. DDT Exposure in utero and breast cancer. Indian J Forensic Med Toxicol 2015; 9: 163-4. J Clin Endocrinol Metab 2015; online early: doi: 10.1210/jc.2015-1841: Paraoxon Žunec S, Radic B, Kuca K, Musilek K, Vrdoljak AL. Organophosphorus insecticides Comparative determination of the efficacy of bispyridinium oximes in paraoxon poisoning. General Arh Hig Rada Toksikol 2015; 66: 129-34. Akoto O, Oppong-Otoo J, Osei-Fosu P. Carcinogenic and non-carcinogenic risk of organochlorine Paraquat and diquat pesticide residues in processed cereal-based complementary Li T, Xu M, Wang N, Zhao M. foods for infants and young children in Ghana. Superantigen staphylococcal enterotoxin C1 mutant can Chemosphere 2015; 132: 193-9. reduce paraquat pulmonary fibrosis.

Toxicol Mech Methods 2015; online early: Coskun R, Gundogan K, Sezgin GC, Topaloglu US, Hebbar doi: 10.3109/15376516.2015.1056863: G, Guven M, Sungur M. A retrospective review of intensive care management of Mohamed F, Buckley NA, Jayamanne S, Pickering JW, organophosphate insecticide poisoning: single center Peake P, Palangasinghe C, Wijerathna T, Ratnayake I, experience. Shihana F, Endre ZH. Niger J Clin Pract 2015; 18: 644-50. Kidney damage biomarkers detect acute kidney injury but only functional markers predict mortality after paraquat How V, Hashim Z, Ismail P, Omar D, Said SM, Tamrin SBM. ingestion. Characterization of risk factors for DNA damage among paddy Toxicol Lett 2015; online early: farm worker exposed to mixtures of organophosphates. doi: 10.1016/j.toxlet.2015.06.008: Arch Environ Occup Health 2015; 70: 102-9. Myung W, Lee G-H, Won H-H, Fava M, Mischoulon D, Nyer Mufti SA, Mir FA, Ahmad J, Kumar S. M, Kim DK, Heo J-Y, Jeon HJ. Acute poisoning due to organophosphate contaminated Paraquat prohibition and change in the suicide rate and cherries. methods in South Korea. Indian J Forensic Med Toxicol 2015; 9: 55-61. PLoS ONE 2015; 10: e0128980.

Tan C, Harianto H, Oziemski P. Toxicol Appl Pharmacol 2015; online early: Paraquat poisoning: first case report in Australia. doi: 10.1016/j.taap.2015.06.010: Internet J Toxicol 2015; 11: 22280.

Pyrethroid insecticides PLANTS Permethrin General Peacock RE, Hosgood G, Swindells KL, Smart L. Mounanga MB, Mewono L, Angone SA. A randomized, controlled clinical trial of intravenous lipid Toxicity studies of medicinal plants used in sub-Saharan emulsion as an adjunctive treatment for permethrin Africa. toxicosis in cats. J Ethnopharmacol 2015; online early: J Vet Emerg Crit Care 2015; online early: doi: 10.1016/j.jep.2015.06.005: doi: 10.1111/vec.12322: Calotropis procera (Madar) Rodenticides Mishra AK, George A, Devakiruba NS, Sathyendra S. Brodifacoum A rare case of Calotropis poisoning. Ware KM, Feinstein DL, Rubinstein I, Weinberg G, Rovin Indian J Forensic Med Toxicol 2015; 9: 62-4. BH, Hebert L, Muni N, Cianciolo RE, Satoskar AA, Nadasdy T, Brodsky SV. Gloriosa superba (Flame lily) Brodifacoum induces early hemoglobinuria and late Khanam PS, Sangeetha B, Kumar BV, Kiran U, hematuria in rats: novel rapid biomarkers of poisoning. Priyadarshini PI, Ram R, Sridhar MS, Kumar VS. Am J Nephrol 2015; 41: 392-9. Gloriosa superba ingestion: hair loss and acute renal

failure. CHEMICAL WARFARE, Indian J Nephrol 2015; 25: 174-6. BIOLOGICAL WARFARE AND Mushrooms and other fungi RIOT CONTROL AGENTS Mushrooms Biological warfare Garcia J, Costa VM, Costa AE, Andrade S, Carneiro AC, Ricin Conceição F, Paiva JA, Guedes de Pinho P, Baptista P, de Pincus SH, Bhaskaran M, Brey RNI, Didier PJ, Doyle- Lourdes Bastos M, Carvalho F. Meyers LA, Roy CJ. Co-ingestion of amatoxins and isoxazoles-containing Clinical and pathological findings associated with aerosol mushrooms and successful treatment: a case report. exposure of macaques to ricin toxin. Toxicon 2015; 103: 55-9. Toxins (Basel) 2015; 7: 2121-33.

Fungi Sabo T, Gal Y, Elhanany E, Sapoznikov A, Falach R, Mazor Thomas S, Hassan I, Barker J, Ashworth A, Barnes A, O, Kronman C. Fedor I, Feddy L, Hayes T, Malagon I, Stirling S, Antibody treatment against pulmonary exposure to abrin Szentgyorgyi L, Mutton K, Richardson M. confers significantly higher levels of protection than Chronic mould exposure as a risk factor for severe treatment against ricin intoxication. community acquired pneumonia in a patient requiring Toxicol Lett 2015; 237: 72-8. extra corporeal membrane oxygenation.

Respir Med Case Rep 2015; 15: 39-41. Chemical warfare Mustard gas Mycotoxins Zamani Pozveh E, Seif A, Ghalayani P, Maleki A, Mottaghi A. Wallin S, Gambacorta L, Kotova N, Lemming EW, Nälsén The effect of mustard gas on salivary trace metals (Zn, C, Solfrizzo M, Olsen M. Mn, Cu, Mg, Mo, Sr, Cd, Ca, Pb, Rb). Biomonitoring of concurrent mycotoxin exposure among PLoS ONE 2015; 10: e0126162. adults in Sweden through urinary multi-biomarker analysis.

Food Chem Toxicol 2015; online early: Phosgene doi: 10.1016/j.fct.2015.05.023: Filipczak PT, Senft AP, Seagrave JC, Weber W, Kuehl PJ, Fredenburgh LE, McDonald JD, Baron RM. NOS-2 inhibition in phosgene-induced acute lung injury. Papaver rhoeas (Corn poppy) Toxicol Sci 2015; 146: 89-100. Günaydin YK, Dündar ZD, Çekmen B, Akilli NB, Kõylü R, Cander B. Nerve agents Intoxication due to Papaver rhoeas (Corn poppy): five case reports. Valiveti AK, Bhalerao UM, Acharya J, Karade HN, Gundapu Case Rep Med 2015; 2015: 321360. R, Halve AK, Kaushik MP. Synthesis and in vitro kinetic study of novel mono- pyridinium oximes as reactivators of organophosphorus ANIMALS (OP) inhibited human acetylcholinesterase (hAChE). Chem Biol Interact 2015; online early: Eretmochelys imbricata (Hawksbill doi: 10.1016/j.cbi.2015.06.007: turtle) Pavlin BI, Musto J, Pretrick M, Sarofalpiy J, Sappa P, Sarin Shapucy S, Kool J. Smith CD, Wright LKM, Garcia GE, Lee RB, Lumley LA. Mass poisoning after consumption of a hawksbill turtle, Hormone-dependence of sarin lethality in rats: sex Federated States of Micronesia, 2010. differences and stage of the estrous cycle. Western Pac Surveill Response J 2015; 6: 25-32.

Fish/marine poisoning Vongphoumy I, Phongmany P, Sydala S, Prasith N, Diaz JH. Reintjes R, Blessmann J. Rhabdomyolysis after cooked seafood consumption (Haff Snakebites in two rural districts in Lao PDR: community- disease) in the United States vs China. based surveys disclose high incidence of an invisible public Ochsner J 2015; 15: 170-5. health problem. PLoS Negl Trop Dis 2015; 9: e0003887. Ciguatera Chan TYK. Brown snake (Pseudonaja spp.) Ciguatera fish poisoning in east Asia and southeast Asia. Ou J, Haiart S, Galluccio S, White J, Weinstein SA. Mar Drugs 2015; 13: 3466-78. An instructive case of presumed brown snake (Pseudonaja spp.) envenoming. Clin Toxicol 2015; online early: doi: doi: Cnidaria 10.3109/15563650.2015.1059947: Jouiaei M, Yanagihara AA, Madio B, Nevalainen TJ, Alewood PF, Fry BG. Ancient venom systems: a review on cnidaria toxins. Crotalinae (Pit vipers) Toxins (Basel) 2015; 7: 2251-71. Valenta J, Stach Z, Michálek P. Envenoming by crotalid snake Chinese moccasin Scombroid Agkistrodon acutus bite - A case report. Nordt SP, Pomeranz D. Prague Med Rep 2015; 116: 155-60. Scombroid poisoning from Tilapia. Am J Emerg Med 2015; online early: Rattlesnake doi: 10.1016/j.ajem.2015.06.017: Bonasso P, Lucke-Wold B, Jacob G. Osteonecrosis of interphalangeal joint of thumb two Tetrodotoxin months after rattlesnake bite. Tsujimura K, Yamanouchi K. Hand Surg 2015; 20: 330-2. A rapid method for tetrodotoxin (TTX) determination by LC-MS/MS from small volumes of human serum, and Viperinae (True vipers) confirmation of pufferfish poisoning by TTX monitoring. Al Hatali BA, Al Mazroui SA, Alreesi AS, Geller RJ, Morgan Food Addit Contam Part A Chem Anal Control Expo Risk BW, Kazzi ZN. Assess 2015; 32: 977-83. Report of a bite from a new species of the Echis genus - Echis omanensis. Scorpions J Med Toxicol 2015; 11: 242-4. Kaplanoglu M, Helvaci MR. Scorpion stings in pregnant women: an analysis of 11 Nishimoto M, Miyahara Y, Ebina Y, Deguchi M, Matsuoka cases and review of literature. S, Yamada H. Clin Exp Obstet Gynecol 2015; 42: 228-30. Viper bite during pregnancy: case report. Clin Exp Obstet Gynecol 2015; 42: 243-5. Snake bites Maduwage K, Buckley NA, De Silva HJ, Lalloo DG, Isbister GK. Spiders Snake antivenom for snake venom induced consumption Lucas SM. coagulopathy. The history of venomous spider identification, venom Cochrane Database Syst Rev 2015; 6: CD011428. extraction methods and antivenom production: a long journey at the Butantan Institute, São Paulo, Brazil. Pore SM, Ramanand SJ, Patil PT, Gore AD, Pawar MP, J Venom Anim Toxins Incl Trop Dis 2015; 21: 21. Gaidhankar SL, Ghanghas RR. A retrospective study of use of polyvalent anti-snake venom and risk factors for mortality from snake bite in a tertiary care setting. Indian J Pharmacol 2015; 47: 270-4.

INDEX

Abrin ...... 30 Anabolic steroids ...... 21 Acetaminophen ...... 27 Anaesthetics...... 21 Acetylcysteine ...... 18 Analytical toxicology ...... 8 Agomelatine ...... 22 Animals, general ...... 38 Air pollution ...... 28 Antiarrhythmic drugs ...... 21 Alcohol ...... 30 Antibiotics ...... 18, 21 Alkaloids ...... 30 Anticoagulants...... 21 Aluminium ...... 35 Anticonvulsants ...... 22 Aluminium phosphide ...... 37 Antidepressants ...... 22 Amfetamines ...... 21 Antidotes ...... 18 Aminoglycosides ...... 21 Antiemetics ...... 21 Amiodarone ...... 21 Antineoplastic drugs ...... 22 Amlodipine ...... 23 Antipsychotics ...... 22 Ammonium ...... 30 Antithyroid drugs ...... 23 Amoxicillin ...... 21 Antituberculous drugs ...... 23

Antivenom ...... 18 Ethnic remedies ...... 24 Antiviral drugs ...... 23 Ethylene glycol ...... 32 Apixaban ...... 22 E-waste ...... 32 Arsenic ...... 35 Exhaust fumes ...... 29 Asbestos...... 30 Extracorporeal treatments ...... 19 Ascorbic acid ...... 19 Fab fragments ...... 18 Baclofen ...... 19, 23 Fentanyl...... 26 Benzene ...... 30 Fish/marine poisoning ...... 39 Benzo[a]pyrene ...... 31 Flame lily ...... 38 Benzodiazepines ...... 23 Flame retardants ...... 32 Beta blockers ...... 23 Flumazenil ...... 18 Biological warfare...... 38 Fluoride ...... 32 Biomarkers ...... 8 Fluorouracil ...... 22 Bisphenol A ...... 31 Folic acid ...... 28 Body packers ...... 9 Fomepizole...... 19 Brodifacoum ...... 38 Foreign body ingestion ...... 12 Bromopropane ...... 31 Forensic toxicology ...... 12 Brown snake ...... 39 Formaldehyde ...... 32 Buprenorphine ...... 23 Formic acid ...... 32 Cadmium ...... 35 Fungi ...... 38 Calciferol ...... 28 Gamma hydroxybutyrate ...... 24 Calcium channel blockers...... 23 Genotoxicity ...... 12 Calotropis procera ...... 38 Ginseng ...... 25 Cannabis ...... 23 Gloriosa superba ...... 38 Carbamate insecticides ...... 37 Glutathione ...... 19 Carbon monoxide ...... 31 Haemodialysis ...... 19 Carcinogenicity ...... 9 Hawksbill turtle ...... 38 Cardiotoxicity ...... 9 Hazardous waste ...... 29 Carfilzomib ...... 22 Hepatotoxicity ...... 12 Cetuximab ...... 22 Herbal medicines ...... 24 Chelating agents ...... 18 Heroin ...... 25 Chemical incidents ...... 29 Imatinib ...... 22 Chemical warfare, general ...... 38 Inhalation toxicity ...... 13 Chemicals, general ...... 30 Iodine ...... 32 Chlorine...... 31 Ionic liquids ...... 32 Chlorpyrifos ...... 37 Isoniazid ...... 23 Chromium ...... 35 Isopropyl alcohol ...... 32 Ciguatera ...... 39 Isotretinoin ...... 25 Ciprofloxacin ...... 21 Kerosene ...... 32 Cisplatin ...... 22 Kinetics ...... 13 Clobazam ...... 23 Labetalol ...... 25 Clozapine...... 22 Lead ...... 35 Cnidaria ...... 39 Lipid emulsion therapy ...... 19 Cobalt ...... 35 Lithium ...... 25, 36 Cocaine ...... 23 Madar ...... 38 Contrast media ...... 31 Management, general ...... 18 Copper ...... 35 Mancozeb ...... 37 Corn poppy ...... 38 Manganese ...... 36 Crotalinae ...... 39 Marijuana ...... 23 Dabigatran ...... 22 MDMA ...... 21 Dapsone ...... 23 Medication errors ...... 13 DDT ...... 37 Meperidine ...... 26 Dermal toxicity...... 9 Mercury ...... 36 Designer drugs ...... 23 Metabolism ...... 13 Developmental toxicology ...... 10 Metals, general ...... 34 Diacetylmorphine ...... 25 Methadone ...... 19, 26 Dichlorvos ...... 37 Methanol...... 32 Dietary supplements ...... 24 Methcathinone ...... 24 Diethylene glycol ...... 31 Methiopropamine...... 24 Digoxin ...... 24 Methylchloroisothiazolinone ...... 32 Diquat ...... 37 Methylone ...... 24 Domperidone ...... 24 Methylphenidate ...... 25 Driving under the influence ...... 10 Metoprolol ...... 23 Drugs, general ...... 20 Midazolam ...... 19, 23 Dust ...... 31 Morphine ...... 19 Ecstasy ...... 21 Mushrooms ...... 38 E-liquids ...... 32 Mustard gas ...... 38 Epidemiology ...... 10 Mycotoxins ...... 38 Eretmochelys imbricata ...... 38 Naloxone ...... 20, 26 Essential oils ...... 32 Nanoparticles ...... 19, 32 Estrogens ...... 24 Nephrotoxicity ...... 13 Ethanol...... 19, 30 Nerve agents ...... 38

Neurotoxicity ...... 14 Propofol ...... 21 Nitrogen dioxide ...... 32 Propylene glycol ...... 34 Occupational toxicology ...... 14 Pseudonaja spp...... 39 Ocular toxicity ...... 15 Psychiatric aspects ...... 17 Olanzapine ...... 22 Psychotropic drugs ...... 27 Ondansetron ...... 21 Pyrethroid insecticides, general ...... 38 Opioid maintenance therapy ...... 19 Rattlesnake ...... 39 Opioids ...... 25 Reprotoxicity ...... 17 Organochlorine pesticides, general ...... 37 Resveratrol ...... 20 Organophosphorus insecticides, general ...... 37 Ricin ...... 38 Oximes ...... 19 Risk assessment ...... 17 Oxycodone ...... 27 Rodenticides ...... 38 Oxymorphone ...... 27 Salicylate ...... 27 Ozone ...... 33 Sarin ...... 38 Paediatric toxicology ...... 15 Scombroid ...... 39 Papaver rhoeas ...... 38 Scorpions ...... 39 Parabens ...... 33 Snake bites ...... 39 Paracetamol ...... 27 Solvents ...... 34 Paraoxon ...... 37 Spiders ...... 39 Paraphenylenediamine ...... 33 SSRIs...... 27 Paraquat ...... 37 Substance abuse ...... 27 Perchlorates ...... 33 Suicide ...... 17 Perfluorinated compounds ...... 33 Synthetic cannabinoids ...... 24 Permethrin ...... 38 Synthetic cathinones ...... 24 Pesticides, general ...... 37 Terpenes ...... 34 Phenethylamines ...... 24 Tetrodotoxin ...... 39 Phenobarbital ...... 20 Theophylline ...... 20 Phenol ...... 33 Tobacco ...... 34 Phenytoin ...... 22 Toxicology, general ...... 8 Phosgene ...... 38 Trichloroethylene ...... 34 Phthalate esters ...... 33 Trimethoprim ...... 21 Pit vipers ...... 39 True vipers...... 39 Plants, general ...... 38 Uranium ...... 36 Plutonium ...... 36 Valproate ...... 22 PM10 ...... 29 Vilazodone ...... 27 Podophyllin ...... 27 Viperinae ...... 39 Pollution ...... 29 Vitamin B6 ...... 28 Polychlorinated biphenyls ...... 33 Vitamins...... 28 Polycyclic aromatic hydrocarbons ...... 33 Water ...... 34 Polyethylene glycol...... 33 Water pollution ...... 29 Polymorphisms ...... 17 Welding fumes ...... 34

The NPIS is commissioned by Public Health England