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BACKGROUND: Although loxoscelism (bites by brown spiders of the genus Loxosceles) frequently results in dermonecrosis, no previous clinical reports have provided detailed temporal photodocumentation of the evolution of dermonecrotic lesions in a case series. METHODS: This was a retrospective cohort study involving a case series of loxoscelism. Only cases of dermonecrosis with photodocumentation of lesion evolution (from admission until complete or almost complete healing) were included. RESULTS: Eight patients (six men, two women; median age, 38 years) fulfilled the inclusion criteria. The bite sites included the thigh (n = 4), forearm (n = 2), abdomen (n = 1), and trunk (n = 1). Time interval between the bite and first contact with our service ranged from 15 to 216 h (median = 29 h). The main clinical manifestations included local erythematous and ischemic violaceous lesions overlying a base of indurated edema (livedoid plaque, 8), local pain (8), exanthema (6), serohemorrhagic vesicles/blisters (5), fever (5), and jaundice (1). Based on a previously established classification, the cases were classified as probable cutaneous-necrotic loxoscelism (CNL, n = 4), presumptive CNL (n = 3), and presumptive cutaneous-hemolytic loxoscelism (n = 1). Seven patients were treated with anti-arachnidic antivenom (AV; median time post-bite = 46 h). Complete lesion healing ranged from 34 to 98 days post-bite (median, 68 days; six patients). None of the patients required reconstructive plastic surgery. CONCLUSIONS: The sequential photographic documentation showed considerable variation in the process of wound healing, with complete epithelialization requiring up to 3 months after the bite.
Assuntos
Picada de Aranha , Adulto , Antivenenos/uso terapêutico , Eritema , Feminino , Humanos , Masculino , Estudos Retrospectivos , Pele/patologia , Picada de Aranha/complicaçõesRESUMO
ABSTRACT Background: Although loxoscelism (bites by brown spiders of the genus Loxosceles) frequently results in dermonecrosis, no previous clinical reports have provided detailed temporal photodocumentation of the evolution of dermonecrotic lesions in a case series. Methods This was a retrospective cohort study involving a case series of loxoscelism. Only cases of dermonecrosis with photodocumentation of lesion evolution (from admission until complete or almost complete healing) were included. Results: Eight patients (six men, two women; median age, 38 years) fulfilled the inclusion criteria. The bite sites included the thigh (n = 4), forearm (n = 2), abdomen (n = 1), and trunk (n = 1). Time interval between the bite and first contact with our service ranged from 15 to 216 h (median = 29 h). The main clinical manifestations included local erythematous and ischemic violaceous lesions overlying a base of indurated edema (livedoid plaque, 8), local pain (8), exanthema (6), serohemorrhagic vesicles/blisters (5), fever (5), and jaundice (1). Based on a previously established classification, the cases were classified as probable cutaneous-necrotic loxoscelism (CNL, n = 4), presumptive CNL (n = 3), and presumptive cutaneous-hemolytic loxoscelism (n = 1). Seven patients were treated with anti-arachnidic antivenom (AV; median time post-bite = 46 h). Complete lesion healing ranged from 34 to 98 days post-bite (median, 68 days; six patients). None of the patients required reconstructive plastic surgery. Conclusions The sequential photographic documentation showed considerable variation in the process of wound healing, with complete epithelialization requiring up to 3 months after the bite.
RESUMO
OBJECTIVE: To report a near-fatal poisoning after intentional injection of ricin from a castor bean (Ricinus communis) extract. CASE REPORT: A 21 year-old man self-injected â¼3 mL of a castor bean extract intramuscularly and subcutaneously in the left antecubital fossa. Upon admission to our ED (1 h post-exposure; day 1, D1) he was awake and alert, but complained of mild local pain and showed slight local edema and erythema. He evolved to refractory shock (â¼24 h post-exposure) that required the administration of a large volume of fluids and high doses of norepinephrine and vasopressin, mainly from D2 to D4. During this period, he developed clinical and laboratory features compatible with systemic inflammatory response syndrome, multiple organ dysfunction, capillary leak syndrome, rhabdomyolysis, necrotizing fasciitis and possible compartment syndrome. The patient underwent forearm fasciotomy on D4 and there was progressive improvement of the hemodynamic status from D7 onwards. Wound management involved several debridements, broad-spectrum antibiotics and two skin grafts. Major laboratory findings within 12 days post-exposure revealed hypoalbuminemia, proteinuria, thrombocytopenia, leukocytosis and increases in cytokines (IL-6, IL-10 and TNF-α), troponin and creatine kinase. Ricin A-chain (ELISA) was detected in serum up to D3 (peak at 24 h post-exposure), with â¼79% being excreted in the urine within 64 h post-exposure. Ricinine was detected in serum and urine by LC-MS up to D5. A ricin A-chain concentration of 246 µg/mL was found in the seed extract, corresponding to the injection of â¼738 µg of ricin A-chain (â¼10.5 µg/kg). The patient was discharged on D71, with limited range of motion and function of the left forearm and hand. CONCLUSION: Ricin injection resulted in a near-fatal poisoning that evolved with septic shock-like syndrome, multiple organ dysfunction and necrotizing fasciitis, all of which were successfully treated with supportive care.
Assuntos
Ricina/intoxicação , Adulto , Alcaloides/sangue , Ricinus communis/intoxicação , Citocinas/sangue , Humanos , Injeções , Masculino , Extratos Vegetais/intoxicação , Piridonas/sangueRESUMO
OBJECTIVE: To describe a case series of severe acute toxic exposures (SATE) in individuals <20 years old followed-up by a regional Poison Control Center (PCC). METHODS: Descriptive cross-sectional study. All patients who were <20yo and classified as score 3 (severe) and 4 (fatal) following Poisoning Severity Score were included for analysis. According to the outcome, patients were classified as PSS 3 when they developed intense clinical manifestations with risk of death or important sequelae; and as PSS 4 when death had resulted from direct cause or complication of the initial exposure. The data of patients were obtained from the Brazilian electronic database system (DATATOX). RESULTS: During the biennium 2014-2015, Campinas PCC followed up 5,095 patients <20yo, with 30 being classified as SATE (PSS=3, n=24; PSS=4, n=6). The exposures circumstances were unintentional (15); intentional (14; suicide attempt = 11; street drugs consumption = 3); and not explained (1). The exposures were significantly more frequent in adolescents >14yo (n=17; p<0.01). The involved agents were venomous animals (8; scorpions=5); medicines (8; miscellaneous=6); chemicals (6); illegal rodenticides containing acetylcholinesterase inhibitors (chumbinho, 4); drugs of abuse (3); button battery (1). Three patients evolved with sequels (esophageal stricture post-corrosive ingestion). The median length of hospital stay was 6 days (IQR: 5-12 days); 26 patients were treated in intensive care units, and 22 of them needed mechanical ventilation; 12, inotropic/vasopressors; and 3, renal replacement therapy. CONCLUSIONS: Scorpion stings and poisonings caused by medicines and chemicals were the main causes of SATE. The SATE were significantly more frequent in adolescents, due to deliberate self-poisoning.
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Centros de Controle de Intoxicações/estatística & dados numéricos , Intoxicação/mortalidade , Adolescente , Adulto , Animais , Brasil/epidemiologia , Criança , Pré-Escolar , Estudos Transversais , Evolução Fatal , Feminino , Humanos , Lactente , Masculino , Índice de Gravidade de Doença , Adulto JovemRESUMO
ABSTRACT Objective: To describe a case series of severe acute toxic exposures (SATE) in individuals <20 years old followed-up by a regional Poison Control Center (PCC). Methods: Descriptive cross-sectional study. All patients who were <20yo and classified as score 3 (severe) and 4 (fatal) following Poisoning Severity Score were included for analysis. According to the outcome, patients were classified as PSS 3 when they developed intense clinical manifestations with risk of death or important sequelae; and as PSS 4 when death had resulted from direct cause or complication of the initial exposure. The data of patients were obtained from the Brazilian electronic database system (DATATOX). Results: During the biennium 2014-2015, Campinas PCC followed up 5,095 patients <20yo, with 30 being classified as SATE (PSS=3, n=24; PSS=4, n=6). The exposures circumstances were unintentional (15); intentional (14; suicide attempt = 11; street drugs consumption = 3); and not explained (1). The exposures were significantly more frequent in adolescents >14yo (n=17; p<0.01). The involved agents were venomous animals (8; scorpions=5); medicines (8; miscellaneous=6); chemicals (6); illegal rodenticides containing acetylcholinesterase inhibitors (chumbinho, 4); drugs of abuse (3); button battery (1). Three patients evolved with sequels (esophageal stricture post-corrosive ingestion). The median length of hospital stay was 6 days (IQR: 5-12 days); 26 patients were treated in intensive care units, and 22 of them needed mechanical ventilation; 12, inotropic/vasopressors; and 3, renal replacement therapy. Conclusions: Scorpion stings and poisonings caused by medicines and chemicals were the main causes of SATE. The SATE were significantly more frequent in adolescents, due to deliberate self-poisoning.
RESUMO Objetivo: Descrever uma série de casos de exposições tóxicas agudas graves (ETAG) em pacientes <20 anos seguidos por um Centro de Informação e Assistência Toxicológica (CIATox) regional. Métodos: Estudo descritivo de corte transversal. Incluídos no estudo todos os casos classificados como escore 3 (graves) e 4 (fatais) de acordo com o escore de gravidade de intoxicações (poisoning severity score - PSS). Segundo o PSS, os casos são classificados em relação ao desfecho como escore 3 quando os pacientes desenvolveram manifestações clínicas intensas, com risco de morte ou que resultaram em sequelas importantes; e escore 4 quando a morte foi resultado de causa direta ou por complicação da exposição. Os dados analisados foram obtidos da base eletrônica brasileira do Sistema Nacional de Informações Tóxico-Farmacológicas DATATOX. Resultados: No biênio 2014-2015 o CIATox de Campinas atendeu 5.095 casos de pacientes <20 anos, dos quais 30 foram classificados como ETAG (PSS=3, n=24; PSS=4, n=6). Quanto à circunstância, 15 foram acidentais, 14 intencionais (11 por tentativas de suicídio e três por abuso de drogas) e um de causa não esclarecida, sendo significativamente mais frequentes nos adolescentes >14 anos (n=17; p<0,01). Os grupos de agentes envolvidos foram: animais peçonhentos (8; escorpiões=5); medicamentos (8; associações=6); produtos químicos de uso domiciliar/industrial (6); rodenticidas inibidores da colinesterase de uso ilegal (chumbinho=4); drogas de abuso (3); e bateria no formato de disco (1). Três pacientes evoluíram com sequelas (estenose esofágica pós-ingestão de corrosivos). O tempo mediano de internação foi de seis dias (mediana, quartis e intervalo interquartil=5-12 dias), sendo 26 pacientes admitidos em unidades de cuidados intensivos, dos quais 22 necessitaram de ventilação mecânica, 12 de inotrópicos/vasopressores e três de terapia de substituição renal. Conclusões: Escorpionismo e intoxicações por medicamentos e por produtos químicos de uso domiciliar/industrial foram as principais causas de ETAG, sendo elas significativamente mais frequentes em adolescentes, principalmente por tentativas de suicídio.
Assuntos
Humanos , Animais , Masculino , Feminino , Lactente , Pré-Escolar , Criança , Adolescente , Adulto , Adulto Jovem , Centros de Controle de Intoxicações/estatística & dados numéricos , Intoxicação/mortalidade , Índice de Gravidade de Doença , Brasil/epidemiologia , Estudos Transversais , Evolução FatalRESUMO
Objective: To report two patients who developed systemic neurotoxicity after consecutive bites by the same coral snake.Case report: Two previously healthy men (32-year-old and 34-year-old) found a coral snake in a woodpile while collecting wood for a barbecue. During the barbecue, both men became drunk and "played" with the snake, believing that they were handling a false coral snake, and were bitten within a few minutes of each other. Both patients were admitted to a referral tertiary care hospital (175 km from where the bites occurred) 16 hours and 19 hours postbite; both showed similar features of envenomation: palpebral ptosis, muscle weakness, dysphagia, and generalized myalgia. No fang marks or local pain were detected in either case. The patients were successfully treated with Brazilian coral snake antivenom (Fab´2) and discharged one-day postadmission, with improvement of myasthenia, but still showing palpebral ptosis. The offending snake was identified as a 42-cm-long Micrurus corallinus. During follow-up, both patients reported a transitory loss of taste that lasted approximately 3-4 weeks postbite.Conclusion: Consecutive bites by the same coral snake may cause systemic neurotoxicity (acute myasthenia) in more than one person, as well as transitory loss of taste, an underreported complication of snakebites.
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Ageusia/prevenção & controle , Antivenenos/uso terapêutico , Cobras Corais , Síndromes Neurotóxicas/prevenção & controle , Mordeduras de Serpentes/terapia , Adulto , Ageusia/diagnóstico , Ageusia/etiologia , Animais , Antivenenos/administração & dosagem , Brasil , Humanos , Masculino , Síndromes Neurotóxicas/diagnóstico , Síndromes Neurotóxicas/etiologia , Mordeduras de Serpentes/diagnóstico , Mordeduras de Serpentes/etiologiaRESUMO
We investigated the effect of South American coralsnake (Micrurus lemniscatus lemniscatus) venom on neurotransmission in vertebrate nerve-muscle preparations in vitro. The venom (0.1-30 µg/ml) showed calcium-dependent PLA2 activity and caused irreversible neuromuscular blockade in chick biventer cervicis (BC) and mouse phrenic nerve-diaphragm (PND) preparations. In BC preparations, contractures to exogenous acetylcholine and carbachol (CCh), but not KCl, were abolished by venom concentrations ≥ 0.3 µg/ml; in PND preparations, the amplitude of the tetanic response was progressively attenuated, but with little tetanic fade. In low Ca2+ physiological solution, venom (10 µg/ml) caused neuromuscular blockade in PND preparations within ~ 10 min that was reversible by washing; the addition of Ca2+ immediately after the blockade temporarily restored the twitch responses, but did not prevent the progression to irreversible blockade. Venom (10 µg/ml) did not depolarize diaphragm muscle, prevent depolarization by CCh, or cause muscle contracture or histological damage. Venom (3 µg/ml) had a biphasic effect on the frequency of miniature end-plate potentials, but did not affect their amplitude; there was a progressive decrease in the amplitude of evoked end-plate potentials. The amplitude of compound action potentials in mouse sciatic nerve was unaffected by venom (10 µg/ml). Pre-incubation of venom with coralsnake antivenom (Instituto Butantan) at the recommended antivenom:venom ratio did not neutralize the neuromuscular blockade in PND preparations, but total neutralization was achieved with a tenfold greater volume of antivenom. The addition of antivenom after 50% and 80% blockade restored the twitch responses. These results show that M. lemniscatus lemniscatus venom causes potent, irreversible neuromuscular blockade, without myonecrosis. This blockade is apparently mediated by pre- and postsynaptic neurotoxins and can be reversed by coralsnake antivenom.
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Antivenenos/farmacologia , Venenos Elapídicos/toxicidade , Junção Neuromuscular/efeitos dos fármacos , Transmissão Sináptica/efeitos dos fármacos , Animais , Cálcio/metabolismo , Galinhas , Cobras Corais , Diafragma/efeitos dos fármacos , Relação Dose-Resposta a Droga , Venenos Elapídicos/administração & dosagem , Feminino , Masculino , Camundongos , Camundongos Endogâmicos BALB C , Nervo Frênico/efeitos dos fármacosRESUMO
CONTEXT: Erucism, envenomation caused by dermal contact with larval forms of moths, may result in intense local pain, mainly after contact with puss caterpillars (family Megalopygidae). OBJECTIVE: To evaluate the response to different treatments for controlling severe pain in a case series of erucism in Campinas, southeastern Brazil. PATIENTS AND METHODS: Prospective cohort study. A Numeric Pain Rating Scale (NPRS 0-10) was used to assess pain intensity in the Emergency Department (ED). Pain was considered as severe upon ED admission (T0) when the NPRS was ≥8. INCLUSION CRITERIA: age ≥8 years old, severe pain at T0, with continuous assessment of pain intensity in all patients using the NPRS during the ED stay (T5, T15, T30, T60 min and at discharge). RESULTS: Fifty-five patients fulfilled the inclusion criteria and were divided into three groups according to the initial treatment at T0: local anesthesia alone with 2% lidocaine (group 1, n = 15), local anesthesia and analgesics (group 2, n = 26) and analgesics without local anesthesia (group 3, n = 14). Most patients were admitted within 2 h after dermal contact with the stinging bristles of caterpillars (median =90 min, IQR: 40-125 min). In 22 cases (40%), the caterpillar was brought for identification (Podalia spp., n = 18; Megalopyge spp., n = 4). There was a significant decrease in pain from T5 onwards with all of the treatments. When the short-term response (T5 and T15) was considered, analgesia was more effective in groups 1 and 2 compared to group 3 (p < .01). Additional analgesia (from T5 until discharge) was frequently required (n = 25/55), mainly in group 1 (n = 11/15). The median length of stay in the ED was 120 min (IQR: 80-173 min). CONCLUSIONS: The association of local anesthesia with analgesics was apparently a good combination for the rapid management of severe pain in the ED.
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Analgésicos/administração & dosagem , Anestésicos Locais/administração & dosagem , Venenos de Artrópodes/efeitos adversos , Mordeduras e Picadas de Insetos/tratamento farmacológico , Mariposas/embriologia , Dor/tratamento farmacológico , Adolescente , Adulto , Idoso , Animais , Criança , Quimioterapia Combinada , Feminino , Humanos , Mordeduras e Picadas de Insetos/diagnóstico , Mordeduras e Picadas de Insetos/etiologia , Larva , Masculino , Pessoa de Meia-Idade , Dor/diagnóstico , Dor/etiologia , Medição da Dor , Estudos Prospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
CONTEXT: Thrombotic microangiopathy (TMA) is an uncommon and severe complication of snakebites, and is similar, in general, to hemolytic-uremic syndrome (HUS). We describe a case of TMA following envenomation by Bothrops jararaca. CASE DETAILS: A 56-y-old-woman with controlled hypertension was transferred from a primary hospital to our ER â¼7 h after being bitten by B. jararaca in the distal left leg. She developed edema extending from the bite site to the proximal thigh, associated with intense radiating local pain, local paresthesia and ecchymosis at the bite site. Laboratory features upon admission revealed coagulopathy (20 min whole blood clotting time - WBCT20 > 20 min), thrombocytopenia (76,000 platelets/mm3) and slight increase in serum creatinine (1.58 mg/dL; RV < 1.2 mg/dL). Upon admission, the patient was treated with bothropic antivenom and fluids replacement. During evolution, her thrombocytopenia and anemia worsened, with blood films showing fragmented red cells, haptoglobin consumption, increase in serum lactate dehydrogenase, and progressive increase of serum creatinine (KDIGO stage = 3). No RBC transfusion, renal replacement therapy or plasmapheresis was done. The patient showed progressive improvement from day nine (D9) onwards and was discharged on D20; there was complete recovery of hemoglobin levels at follow-up (D50). ADAMTS-13 activity, assayed 10 months post-bite, was within reference values. DISCUSSION: TMA following snakebite has been reported mainly in India, Sri Lanka and Australia, with several patients needing renal replacement therapy. Although controversial, plasmapheresis has also been used in some cases. Our patient developed microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury, a triad of features compatible with TMA similar to HUS. Despite the severity, the outcome following conservative treatment was good, with complete recovery.