Abstract Background Arsine poisoning is a rare but life-threatening condition characterized by severe hemolysis. Clinical data on its management remain limited. This study describes the clinical features, diagnostic approach, and treatment experience of 12 patients from a single arsine poisoning incident. Methods Clinical data from the 12 patients were retrospectively collected. Presenting symptoms, diagnostic findings, and treatment strategies were summarized. Results Ten of the 12 patients survived. Arsenic was detected in cleaning wastewater and in the red blood cells of four patients, and, together with clinical hemolysis, supported the diagnosis of arsine poisoning. Common symptoms included headache, nausea, vomiting, abdominal pain, dizziness, chest tightness, and hematuria; headache, nausea, and vomiting frequently co-occurred. All patients received high-dose methylprednisolone, vitamin C + B6, and chelation therapy. The two non-survivors additionally received mechanical ventilation, therapeutic plasma exchange, dialysis, methylene blue, and transfusions; they died on day 3 from progressive cardiovascular failure secondary to acute hemolysis. Five other patients underwent therapeutic plasma exchange and dialysis and ultimately survived. Conclusions This case series highlights the clinical presentation, diagnostic workflow, and management of arsine poisoning in a well-characterized patient cluster. Early recognition and timely intervention may facilitate clinical management. The findings are descriptive and limited by the retrospective design and small sample size.

BACKGROUND:Botulinum toxin is a neurotoxin generated during the growth of Clostridium botulinum and can lead to a rare but life-threatening disease with neurologic symptoms. Relatively little is known about the many types of botulinum toxins in China. The clinical symptoms of the different types of botulism toxin-induced illnesses appear after an incubation period and vary greatly by the serotype and degree of exposure to the toxin. CASE REPORT:We describe 4 patients who consumed vacuum-packaged salted fish and ham and then presented with severe gastrointestinal symptoms, resulting in vomiting and one death. Blood serum and urine samples tested by the botulinum neurotoxin Endopep-MS assay were positive for botulinum toxin types A, B, and E. The patient who consumed the largest amount of fish and ham died after 36 h, and the other patients were treated with botulism antitoxin after being diagnosed with a botulinum toxin-induced illness and recovered after 1 month. These cases illustrate the importance of early diagnosis and early treatment of botulism type E, in particular, because of the risk of respiratory failure and treatment delays, which can result in increased mortality and poorer overall outcomes. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our cases illustrate the importance of early diagnosis and especially the treatment of illnesses related to botulism type E because of the risk of respiratory failure and because treatment delays can result in increased mortality and worsened overall outcomes.

Objective: To investigate the efficacy of hyperbaric oxygen (HBO) combined with mannitol (MT) in the treatment of acute carbon monoxide poisoning (ACOP) and its effect on the incidence of adverse reactions. Methods: The clinical data of 103 ACOP patients in the emergency department of our hospital from March 2019 to March 2020 were retrospectively analyzed. The ACOP patients meeting the inclusion criteria were split into the conventional group (n=52) and the combination group (n=51) according to the order of admission. The conventional group received HBO treatment only after admission, while the combination group received MT combined with HBO to analyze the efficacy and incidence of adverse reactions in both groups by evaluating the neurological function and myocardial injury indexes at different times. Results: A total of 103 subjects meeting the criteria were included in this study. In the conventional group, 52 cases were collected, 2 cases were suspended, and 50 cases were finally completed. In the combination group, 51 cases were collected, 1 case was suspended, and 50 cases were finally completed. No remarkable differences in the baseline data were observed between the two groups before treatment (P<0.05). Compared with the conventional group, the combination group achieved obviously shorter hospitalization time and awakening time (P<0.001), lower ARWMC scores at 10 days, 1 month and 3 months after treatment (P<0.00), higher MoCA scores at 1 month and 3 months after treatment (P<0.001), lower myocardial injury indexes after treatment (P<0.001), higher number of cases with complete recovery after treatment (P<0.05), lower number of cases with no recovery (P<0.05), and lower total incidence of adverse reactions (P<0.05). Conclusion: The above results show that HBO combined with MT is superior to HBO alone in reducing the incidence of myocardial injury and adverse reactions in patients. Therefore, this treatment method is recommended for emergency treatment of ACOP.

[This corrects the article DOI: 10.1093/toxres/tfab074.].

[This corrects the article DOI: 10.1093/toxres/tfab074.].

目的 研究我国一氧化碳(CO)中毒死亡的变化趋势.方法 从2017年全球疾病负担研究中收集1990至2017年我国及全球CO中毒的详细信息,根据性别、年龄、社会人口指数(SDI)等计算CO中毒年龄标准化死亡率(ASMR)的估计年百分比变化(EAPC),以量化CO中毒ASMR的变化趋势,并将我国及全球趋势进行对比.结果 2017年全球CO中毒死亡人数较1990年有所下降,而我国死亡人数上升,从1990年的13779例增长至2017年的14255例,增长了3.45％;在此期间全球及我国的CO中毒ASMR均呈下降趋势,但我国ASMR下降趋势(EAPC=-0.46;95％CI-0.56～-0.36)明显低于全球水平(EAPC=-1.83;95％CI-2.10～-1.56);我国CO中毒ASMR的下降趋势在不同性别及年龄中是不同的,其中,男性呈下降趋势,女性呈上升趋势;最明显的下降为<5岁的人群,而≥50岁的人群呈明显的上升趋势.结论 CO中毒在我国仍是一个重要的公共卫生问题,尤其应针对老年人建立更有效的预防及治疗方案.

Acute mercury poisoning, involving a number of organs, leads to severe dysfunctions, such as acute renal failure (ARF), and even threatens patients' lives. A case of acute severe mercuric chloride (HgCl2) poisoning with multiple organ failure was reported in this study. A 38-year-old woman orally took about 50 g HgCl2 powder in 2015, and showed nausea, emesis, clouding of consciousness, lip and nail cyanosis, and dark red bloody fluid from bilateral nostrils. Based on chest and abdominal CT examinations, gastroscopy, and colonoscopy, the patient was found to suffer oral mucosal hyperemia and ulceration, gastrointestinal bleeding (haematemesis and hemafecia), ARF, metabolic acidosis, collapse and shock. Despite assisted respiration and relevant active treatments, the patient's condition deteriorated gradually and she was dead eventually. The study suggests that the best treatments for acute HgCl2 poisoning accompanied with ARF are early blood purification and mercury elimination on the basis of conventional therapy.

Objective:To analyze and summarize the basic characteristics and clinical features of botulism patients caused by cosmetic injection of botulinum toxin.Methods:Retrospective investigation and analysis method were used to analyze the data of botulism patients caused by cosmetic injection of botulinum toxin admitted to the Poisoning Treatment Center of the PLA from March 2016 to June 2019.Results:Total of 380 cases were included in this study, including 114 hospitalized cases and 266 emergency cases. The majority patients (97.4%) were female, and most of them (39.5%) were among 30-39 years old. Most of the cases occurred in beauty salons or beauty studios, and most of the botulinum toxin injected was fake and inferior products. Onset latency were mainly distributed in 3 to 6 days. Common clinical symptoms included dizziness, blurred vision, eyes open weakness, dysphagia, chest tightness of breath, fatigue, diplopia, nausea, bilateral eyelid drooping, and dysarthria. The "4D" sign of cranial nerve injury occurred less frequently, mainly with mild and moderate poisoning; The occurrence rates of dysarthria, dysphagia, eyes open weakness, blurred vision, choking in drinking water, chewing weakness, bilateral eyelid drooping, decreased limb muscle strength, and chest tightness of breath in the hospitalized case were significantly higher than those in the emergency cases (all P < 0.05). Three hundred and nine patients received botulinum antitoxin therapy. The dose of botulinum antitoxin was 20 000 (20 000-30 000) U, with a total treatment duration of 4 (3-7) days in the emergence cases, and 30 000 (30 000-50 000) U with a total treatment time of 8 (5-11) days in the hospitalized cases, and there were significant differences between the two groups ( P < 0.05). All cases were followed up with good prognosis. Conclusions:Cosmetic injection of botulinum toxin has certain risk. If symptoms of poisoning occur such as dizziness, blurred vision, eyes open weakness and dysphagia, patients should be treated promptly, and early treatment with botulinum antitoxin can improve the prognosis.

RATIONALE:This is the first reported severe thallium poisoning patient successfully treated with Prussian blue (PB) and plasma exchange (PE). PATIENT CONCERNS:A 42-year-old woman in a coma owing to severe thallium poisoning was admitted to our department after day 44 of poisoning. At admission, blood and urine thallium concentrations were 380.0 and 2580.0 ng/mL, respectively. DIAGNOSIS:The patient was diagnosed with toxic encephalopathy induced by thallium poisoning; in addition, she was also diagnosed with bilateral pneumonia, respiratory failure, moderate anemia, hypoproteinemia, and electrolyte imbalance based on her chest X-ray, blood gas analysis, Hb level, albumin levels, and serum electrolyte results. INTERVENTIONS:The patient was intubated and treated with PB (6600 mg/d, 15 days in total) combined with PE (once daily, 5 days in total) as well as other symptomatic supportive care measures. OUTCOMES:After treatments, her blood and urinary thallium concentrations gradually decreased and on the 13th day after admission, the blood thallium concentration decreased to 0 ng/mL. The oxygenation index gradually improved, meantime, the patient gradually regained consciousness, and on the 50th day of admission, the patient's consciousness reverted to a clear-headed state. The patient recovered mostly after 37 months of follow-up. LESSONS:Through this case, we learned that the gradual reduction in blood and urine thallium concentration and the patient's improved condition is correlated with PB and PE treatment. For patients with severe thallium poisoning, this treatment method might be effective; but the exact curative effect is unconfirmed, requiring further research to verify.

Thallium is highly toxic and its effects are cumulative. The clinical symptoms of thallium poisoning are non-specific, thereby delaying admission and treatment. This study aimed to summarize the clinical features and treatment experience of patients with delayed admission who experience thallium poisoning.We conducted a retrospective descriptive analysis of patients in our hospital from 2008 to 2018 who had thallium poisoning and experienced a delay in hospital admission. The time from symptom onset to admission was assessed. The patients were divided into 3 groups and descriptive analyses of their clinical characteristics, including basic patient information, symptoms, laboratory test results, examination findings, treatment methods, outcomes, and follow-up information, were conducted.A total of 34 patients with thallium poisoning were included: 8 were admitted to the hospital early or with mild delay, 9 had a moderate delay, and 17 had a severely delayed admission. The time from illness onset to admission was 13 (interquartile range, 7.5-26) days. Some patients with delayed admission had significant symptoms associated with central nervous system damage, and changes in magnetic resonance images and electroencephalograms were also noted. After admission, all patients received Prussian blue treatment, and some patients with relatively high blood concentration received blood purification treatments. Following treatment, the blood and urine thallium concentrations of all patients decreased significantly, and their symptoms were alleviated.Our results show that delayed patient admission in cases of thallium poisoning is associated with greater risk of central nervous system damage. Use of Prussian blue combined with blood purification treatments might improve patients' conditions.

目的 总结39例汞中毒肾病综合征(NS)患者的临床资料及治疗特点,以提高该病的诊治水平.方法 收集2012年7月至2017年9月在解放军总医院第五医学中心治疗的汞中毒NS患者的临床资料,对其病因、临床表现、化验检查、治疗、预后及随访情况进行回顾性分析.结果 共收集39例患者,其中女性33例(84.6％),平均年龄(37.44±11.17)岁.表现除全部出现泌尿系统症状外,尚有6例出现神经系统症状、1例出现皮肤表现.汞中毒NS的病理类型主要为微小病变肾病(MCD)和膜性肾病(MN),其中MCD多因患者美容所致,MN多因美容及中药偏方使用不当所致.此外,MCD患者中8例应用激素治疗,显著多于MN中应用激素的患者(4例).39例患者经过以驱汞为主的综合治疗后,症状逐渐缓解,血汞浓度显著减少,随访发现无明显后遗症.结论 美容引起的汞中毒NS的病理类型主要为MN和MCD.中药偏方引起的汞中毒NS主要为MN.及时脱离汞源并行驱汞治疗,症状缓解,预后较好.

目的 探讨经皮扩张气管切开术(PDT)在中毒危重症患者中的应用价值.方法 对2015年1月-2018年8月解放军总医院第五医学中心中毒救治科20例中毒危重患者行PDT治疗的临床资料进行回顾性分析.结果 20例患者手术成功,出血量少,操作时间短,住院期间无导管脱位、皮下气肿、纵隔气肿等并发症,1例患者并发切口感染,回访2例患者出现气管前壁肉芽组织过度生长致气管狭窄.结论 PDT是一项可在中毒救治ICU床旁实施的微创技术,由中毒救治ICU医师独立完成,预计短期内不能拔除气管的中毒患者及神志不清者应尽早行PDT.

OBJECTIVE:To analyze the clinical manifestation and therapeutic method in patients with acute mushroom poisoning.METHODS:A retrospective study was conducted. The clinical data of 48 patients with acute mushroom poisoning admitted to Department of Poisoning Treatment of the 307th Hospital of PLA from January 2016 to May 2017 were analyzed. The clinical data including gender, age, clinical symptoms, onset season, initial symptoms, incubation time, the length of hospital stay, treatment, and prognosis. In addition to the conventional treatment, the patients with severe liver damage were treated with continuous blood purification (CBP). The changes in routine blood test, biochemical parameters, blood ammonia and coagulation function before and 1, 3 and 7 days after CBP were observed.RESULTS:There were 29 of male (60.4%) and 19 of female (39.6%) in 48 patients with acute mushroom poisoning, with an average age of (48.10±13.14) years. There were 9 patients suffering from gastroenteritis type, 26 suffering from liver damage type, 8 suffering from neuro-psychosis type, 2 suffering from hemolytic type, and 3 suffering from renal damage type. All of the poisoned patients had evident seasonal characteristic, mainly concentrated in the autumn, especially in August, according for 66.7% (32/48). The initial symptoms of poisoning patients were mainly manifested as nausea and vomiting (50.0%). In five kinds of poisoned patients, the incubation time [(1.44±1.15) hours] and the length of hospital stay [(3.50±2.33) days] of neuro-psychosis type was the shortest, and the incubation time of liver-damaged type [(10.63±3.50) hours] and the length of hospital stay of renal damage type [(20.67±0.58) days] was the longest. Patients received symptomatic treatment according to different types, among whom 12 patients with severe liver damage received additional treatment for CBP. After the treatment, alanine aminotransferase (ALT), aspartate aminotransferase (AST), MB isoenzyme of creatine kinase (CK-MB), lactate dehydrogenase (LDH), and prothrombin activity (PTA) were significantly improved as compared with those before CBP treatment, with significant differences between 7 days after CBP and before CBP [ALT (U/L): 213.08±127.30 vs. 2 766.83±1 909.66, AST (U/L): 50.00 (41.00, 85.00) vs. 2 142.00 (1 225.00, 3 126.00), CK-MB (U/L): 24.09±8.87 vs. 44.75±22.09, LDH (μmol×s-1×L-1): 3.70±1.46 vs. 13.03±12.77, PTA: (79.08±24.29)% vs. (35.25±19.85)%, all P < 0.01]. Among 48 patients, 47 were cured and discharged, and 1 patient with liver failure died due to aggravation of liver dysfunction, abnormal coagulation and bleeding, and massive hemorrhage of gastrointestinal tract.CONCLUSIONS:Acute mushroom poisoning patients demonstrated obvious seasonal characteristics, mostly liver-damaged type, and its initial symptoms were mainly presented as nausea, vomiting and other gastrointestinal manifestations. Early clarification of diagnosis, timely treatment, as well as providence with CBP treatment in severe patients should be carried out as soon as possible. In such a way the curative effect can be enhanced, the mortality can be reduced, and the prognosis of the patients could be improved.

目的:探讨影响百草枯中毒患者预后的相关因素,为患者预后评估提供参考.方法:回顾分析2009-04-2013-10期间百草枯中毒住院患者272例,根据存活、死亡分为两组,分析服药剂量、就诊时间、住院天数、A-PACHE Ⅱ评分、生化指标(血清钾、钠、氯、钙、谷丙转氨酶、谷草转氨酶、总胆红素、肌酐、尿素氮、CK-MB、乳酸脱氢酶、二氧化碳结合力、超敏C反应蛋白)与患者预后的相关性,然后采用多因素logistic回归分析筛选出有效因素,并通过ROC曲线评价其相关因素在百草枯中毒预后的诊断价值.结果:272例百草枯中毒患者中,死亡133例,通过多因素logistic回归分析,得出服毒量、血清百草枯浓度、尿液百草枯浓度、血清Ca2+、Cl-、肌酐、尿素氮为影响患者预后的因素,差异有统计学意义(P＜0.05),对相关因素进行ROC曲线分析,得出尿液中百草枯的浓度、血清钙、Cl-、BUN的OR值小于1,是保护因素;服毒量、血液中百草枯浓度、Cr的OR值大于1,是危险因素.对服毒量、血液中百草枯浓度、尿液中百草枯的浓度、血清钙、Cl-、肌酐、尿素氮进行ROC曲线下面积分析,其各自的曲线下面积依次为0.8425、0.7972、0.6959、0.6941、0.6636、0.5089、0.4829.结论:百草枯的服毒量及血浆中百草枯的浓度是影响预后的两个关键因素,尿液中百草枯的浓度、血清钙、Cl-、尿素氮是保护因素;服毒量、血液中百草枯浓度、肌酐是危险因素.

铊是一种无臭、无色、无味的重金属 , 铊及其化合物均为剧毒类毒物,具有很强的蓄积作用 [1].铊于 1920 年开始以杀虫剂运用于德国.铊中毒国内外均有报道,根据美国毒物数据中心报道,1995 年至 2005 年共有 830 例铊中毒患者,包括 1 例死亡报道,近年来每年有约 20 例铊中毒的新发病例 [2].国内铊中毒案例也时有报道 [3].

OBJECTIVETo investigate the efficacy of prussian blue (PB) or its combination with hemoperfusion (HP) in the treatment of acute thallium poisoning.METHODSForty-seven patients with acute thallium poisoning with complete data hospitalized in the 307th Hospital of PLA from September 2002 to December 2017 were enrolled, and they were divided into mild poisoning group (blood thallium < 150 μg/L, urinary thallium < 1 000 μg/L) and moderate-severe poisoning group (blood thallium ≥ 150 μg/L, urinary thallium ≥ 1 000 μg/L) according to the toxic degrees. All patients were given symptomatic supportive treatments such as potassium supplementation, catharsis, vital organ protections, neurotrophic drugs, and circulation support. The mild poisoning patients were given PB with an oral dose of 250 mg×kg-1×d-1, while moderate-severe poisoning patients were given PB combined HP continued 2-4 hours each time. The PB dose or frequency of HP application was adjusted according to the monitoring results of blood and urine thallium. Data of gender, age, pain grading (numeric rating scale NRS), clinical manifestations, blood and urine thallium before and after treatment, length of hospitalization and prognosis were collected.RESULTSOf the 47 patients, patients with incomplete blood and urine test results, and used non-single HP treatment such as plasmapheresis and hemodialysis for treatment were excluded, and a total of 29 patients were enrolled in the analysis. (1) Among 29 patients, there were 20 males and 9 females, median age of 40.0 (34.0, 49.0) years old; the main clinical manifestations were nervous system and alopecia, some patients had digestive system symptoms. There were 13 patients (44.8%) in the mild poisoning group with painless (grade 0) or mild pain (grade 1-3) with mild clinical symptoms, the length of hospitalization was 17.0 (14.2, 21.5) days. There were 16 patients (55.2%) in the moderate-severe poisoning group with moderate pain (grade 4-6) or severe pain (grade 7-10) with severe clinical symptoms, the length of hospitalization was 24.0 (18.0, 29.0) days. (2) After treatment, the thallium concentrations in blood and urine in the mild poisoning group were significantly lower than those before treatment [μg/L: blood thallium was 0.80 (0, 8.83) vs. 60.00 (40.00, 120.00), urine thallium was 11.30 (0, 70.10) vs. 370.00 (168.30, 610.00), both P < 0.01], the thallium concentrations in blood and urine in the moderate-severe poisoning group were also significantly lower than those before treatment [μg/L: blood thallium was 6.95 (0, 50.50) vs. 614.50 (245.00, 922.00), urinary thallium was 20.70 (1.95, 283.00) vs. 5 434.00 (4 077.20, 10 273.00), both P < 0.01]. None of the 29 patients died, and their clinical symptoms were improved significantly. All the 27 patients had good prognosis without sequela in half a year follow-up, and 2 patients with severe acute thallium poisoning suffered from nervous system injury.CONCLUSIONSIn the acute thallium poisoning patients, on the basis of general treatment, additional PB in mild poisoning group and PB combined with HP in moderate-severe poisoning group can obtain satisfactory curative effects.

This study was conducted to analyze the clinical characteristics of and treatment strategies for botulism among patients receiving cosmetic injection of botulinum toxin (BoNT). A total of 86 botulism patients caused by cosmetic injection of BoNT were enrolled in our study. All of the patients were diagnosed according to their history of cosmetic BoNT injection, clinical symptoms and signs, and other auxiliary examinations (including those on renal and liver functions, blood index detection, and chest X-ray). All of the patients received comprehensive treatments and botulinum antitoxin serum injection. The main symptoms of botulism patients included headache, dizziness, insomnia, fatigue, blurred vision, eye opening difficulty, slurred speech, dysphagia, bucking, constipation, and anxiety. These clinical symptoms occurred 0∼36 days after BoNT injection, especially from 2nd to 6th day after the operation. Furthermore, the usage dose of BoNT was negatively related to latent period. Finally, patients all discharged from our hospital 1∼20 days after treatments, and their symptoms relieved or disappeared. Botulism is a severe side effect for BoNT injection. Injecting botulinum antitoxin serum may be an effective approach to improve clinical outcomes of botulism cases.

目的:随着草甘膦及草铵膦应用的增多,其中毒患者也逐渐增多,本文探讨其中毒的临床特点,为其诊断治疗提供科学依据.方法:总结分析我院2016年1月—2017年6月收治的23例草甘膦与草铵膦中毒患者的临床表现、实验室检查、诊治经过及预后.结果:急性草甘膦中毒15例,急性草铵膦中毒8例.其中男性13例,女性10例,年龄14～70岁.口服量20～400 ml,临床表现主要为消化道、呼吸道、心血管系统及神经系统等多脏器损伤,2例严重病例出现呼吸衰竭.经综合治疗全部好转出院.结论:草甘膦及草铵膦中毒症状相似,大部分中毒患者症状较轻、预后良好,但重症患者也存在呼吸衰竭等致死情况,需早期诊断及处理.

Objective To analyze clinical characteristics and misdiagnosis causes of anticoagulant rodenticide poisoning in order to improve final diagnosis rate.Methods Clinical data of 27 misdiagnosed patients with anticoagulant rodenticide poisoning admitted during December 2013 and September 2016 was retrospectively analyzed.Results The misdiagnosed time was 1 day-7 months, and the average time was 24.8 days.Clinical manifestations were 23 patients with hematuria, 10 patients with gingival (oral) bleeding, 8 patients with otorrhagia or nasal bleeding, 5 patients with limb pain or activity limitation, 4 patients with vaginal bleeding or menorrhagia, 2 patients with back pain, 2 patients with abdominal pain and 1 patient with hematochezia and 1 patient with disorders of hemostasis.The misdiagnosed time was 43 times including 14 diseases, and the top four misdiagnosed diseases were as follow ureteral calculi, coagulation disorders, urinary infection and gingival bleeding.There were 21 patients with different degrees of anemia and 19 patients with coagulation disorders.There were 18 patients with brodifacoum, 18 patients with bromadiolone and 9 patients with brodifacoum and bromadiolone by blood detection.After confirming the diagnosis, the patients received treatments such as fluid replacement and decorporation, vitamin K1 supplement, plasma infusion and hemoperfusion with good prognoses.Conclusion Anticoagulant rodenticide poisoning is insidious with various clinical manifestations, and therefore clinicians should give related examinations in time in order to avoid misdiagnosis and mistreatment for highly suspected patients with anticoagulant rodenticide poisoning.