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Question of the Day Archives: Monday, December 5, 2016 Question: Calcium Oxalate Is a Widespread Toxin Found in Many Species of Plants

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Question of the Day Archives: Monday, December 5, 2016 Question: Calcium Oxalate Is a Widespread Toxin Found in Many Species of Plants Question Of the Day Archives: Monday, December 5, 2016 Question: Calcium oxalate is a widespread toxin found in many species of plants. What is the needle shaped crystal containing calcium oxalate called and what is the compilation of these structures known as? Answer: The needle shaped plant-based crystals containing calcium oxalate are known as raphides. A compilation of raphides forms the structure known as an idioblast. (Lim CS et al. Atlas of select poisonous plants and mushrooms. 2016 Disease-a-Month 62(3):37-66) Friday, December 2, 2016 Question: Which oral chelating agent has been reported to cause transient increases in plasma ALT activity in some patients as well as rare instances of mucocutaneous skin reactions? Answer: Orally administered dimercaptosuccinic acid (DMSA) has been reported to cause transient increases in ALT activity as well as rare instances of mucocutaneous skin reactions. (Bradberry S et al. Use of oral dimercaptosuccinic acid (succimer) in adult patients with inorganic lead poisoning. 2009 Q J Med 102:721-732) Thursday, December 1, 2016 Question: What is Clioquinol and why was it withdrawn from the market during the 1970s? Answer: According to the cited reference, “Between the 1950s and 1970s Clioquinol was used to treat and prevent intestinal parasitic disease [intestinal amebiasis].” “In the early 1970s Clioquinol was withdrawn from the market as an oral agent due to an association with sub-acute myelo-optic neuropathy (SMON) in Japanese patients. SMON is a syndrome that involves sensory and motor disturbances in the lower limbs as well as visual changes that are due to symmetrical demyelination of the lateral and posterior funiculi of the spinal cord, optic nerve, and peripheral nerves. The majority of symptoms were reversible, but permanent disability has been reported in 1000 of the 10,000 total cases of SMON noted in Japan over the two decades the drug was in use.” (Mao X and Schimmer AD. The toxicology of Clioquinol. 2008 Toxicology Letters 182:1-6) Wednesday, November 30, 2016 Question: A worker, who's job involves grinding magnets, is diagnosed with bilateral optic atrophy, retinopathy and bilateral nerve deafness. Which metal is the likely culprit? Answer: As described in the cited reference “Cobalt exerts well-known and documented toxic effects on the thyroid, heart and the hematopoietic system, in addition to the occupational lung disease, allergic manifestations and a probably carcinogenic action. Cobalt neurotoxicity is reported in isolated cases, and it has never been systematically treated. Bilateral optic atrophy and retinopathy, bilateral nerve deafness and sensory-motor polyneuropathy have been described long ago as a result of chronic occupational exposure to cobalt powder or during long-term treatment of anemia with cobalt chloride. (Catalani S et. al. Neurotoxicity of cobalt. 2012 Human Exp Tox 31(5): 421-437) Tuesday, November 29, 2016 Question: Prolonged alcohol use is the second most common cause for the development of acute pancreatitis (with the presence of gallstones being the most common cause for acute pancreatitis). What role does the type of alcohol ingested and/or the act of binge drinking of alcohol play in the development of acute pancreatitis? Answer: According to the cited reference “the type of alcohol ingested does not affect risk and binge drinking in the absence of long-term, heavy alcohol use does not appear to precipitate acute pancreatitis.” (Forsmark CE et al. Acute pancreatitis. 2016 NEJM 375:1972-1981 and Phillip V et al. Incidence of acute pancreatitis does not increase during Oktoberfest, but is higher than previously described in Germany. 2011 Clin Gastroenterol Hepatol 9(11): 995-1000.e3 Monday, November 28, 2016 Question: “Megacolon”, defined as dilatation of the colon greater than 6 cm in one or more colonic segments can be seen in individuals suffering from chronic spinal cord injury. What are the toxicologic/pharmacologic issues that may predispose to the development of megacolon in the face of chronic spinal cord injury? Answer: According to the cited reference, “Factors significantly associated with megacolon were older age, longer duration of injury, symptom of abdominal distension, radiological constipation, urinary outlet surgery, laxative use at least once weekly, use of anticholinergic drugs, and use of calcium-containing antacids…………Independent correlates of megacolon were more than 10 years elapsed since acute injury, age over 50 years, and use of > or = 4 laxative doses per month.” (Harar D and Minaker KL. Megacolon in patients with chronic spinal cord injury. 2000 Spinal Cord 38:331-339) Friday, November 25, 2016 Question: Some have postulated a link between metal on metal joint arthroplasties and the development of a variety of cancers. What is the evidence for a causal link between cancer and metal on metal joint replacements? Answer: Credible evidence has not been developed to support the notion that metal on metal arthroplasties cause cancer. One study reported on 110,792 total hip and 29,800 total knee arthroplasties and found no causal link between cancer development and metal on metal arthroplasties. (Therani R et al. The risk of cancer following total hip or knee arthroplasty. 2001 J Bone Joint Surg (Am) 83-A: 774-780) Thursday, November 24, 2016 Question: Which areas of the brain are considered to be the primary brain regions involved in substance use disorders? Answer: According to the recently promulgated U.S. Surgeon Generals Report on Alcohol, Drugs and Health (Facing Addiction in America), …”the key components of networks that are intimately involved in the development and persistence of substance use disorders are the basal ganglia, the extended amygdala and the prefrontal cortex. The basal ganglia control the rewarding or pleasurable, effects of substance use and are also responsible for the formation of habitual substance taking. The extended amygdala is involved in stress and the feelings of unease, anxiety, and irritability that typically accompany substance withdrawal. The prefrontal cortex is involved in executive function (i.e., the ability to organize thoughts and activities, prioritize tasks, manage time, and make decisions), including exerting control over substance taking. These brain areas and their associated networks are not solely involved in substance use disorders. Indeed, these systems are broadly integrated and serve many critical roles in helping humans and other animals survive. ( https://addiction.surgeongeneral.gov/chapter-2-neurobiology.pdf; accessed November 2016) Wednesday, November 23, 2016 Question: What factors are thought to exacerbate the development of QT prolongation in patients suffering from acute promyleocytic leukemia (APL) who are treated with arsenic trioxide? Answer: According to the cited reference “Because most of the patients receiving arsenic trioxide have been [previously] exposed to cardiotoxic chemotherapy [including all-trans retinoic acid and anthracycline based drugs], cardiac dysfunction is thought to be universal before arsenic trioxide therapy begins. In addition, hypokalemia and hypomagnesemia are among the most common arsenic trioxide-related side effects. Thus it has been proposed that QT prolongation and ventricular arrhythmias associated with arsenic could be exacerbated by concurrent electrolyte disturbances or previous chemotherapy-induced cardiac damage.” (Drolet B et al. Unusual effects of a QT prolonging drug, arsenic trioxide on cardiac potassium currents. 2004 Circulation 109:26-29) Tuesday, November 22, 2016 Question: What is the most common cause of acquired nephrogenic diabetes insipidus? What is the current management for this problem? Answer: According to the cited reference, “The most common cause of acquired nephrogenic diabetes insipidus is long-term lithium treatment. The management of lithium- induced nephrogenic diabetes insipidus is challenging, even when the drug is discontinued and therapy is changed to thiazide diuretics, amiloride, and reduced sodium intake. Amiloride inhibits lithium entry into renal collecting-duct cells through the epithelial sodium channel. Thiazide diuretics and a low-sodium diet result in hypovolemia-induced activation of the renin–angiotensin–aldosterone which stimulates proximal tubule sodium and water resorption resulting in less volume delivery to the distal nephron.” (Gordon CE et al. Acetazolamide in lithium-induced nephrogenic diabetes insipidus. 2016 NEJM 375:2008-2009 and Sands JM and Bichet DG. Nephrogenic diabetes insipidus. Ann Intern Med 2006;144:186-94) Monday, November 21, 2016 Question: What is Bismacine? Answer: According to the cited reference (dated July 2006) “FDA notified healthcare professionals and consumers not to use an injectable product called Bismacine, also known as Chromacine. Bismacine is not a pharmaceutical and has not been approved to treat any condition; however, it is being prescribed or administered by doctors of "alternative health" to treat Lyme disease. This product contains high amounts of bismuth, a heavy metal that is used in some medications taken by mouth to treat Helicobacter pylori, a bacteria that can cause stomach ulcers. However, Bismacine is not approved in any form for use by injection. The FDA is investigating one report of a death and several reports of injury related to the administration of Bismacine. Individuals who believe they have suffered adverse events from receiving Bismacine should seek medical attention. Possible effects of bismuth poisoning include
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