Ann Emerg Med 2002 May;39(5):576
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PMID: 11973572, UI: 21969073
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Ann Emerg Med 2002 May;39(5):558-61
Poison Control Center, the Division of Emergency Medicine, The Children's Hospital of Philadelphia, PA 19104, USA. osterhoudtk@email.chop.edu
We report a case of Lyme disease with clinical features resembling those described from brown recluse spider bites. The most striking manifestation was a necrotic skin wound. Brown recluse spider bites may be overdiagnosed in some geographic regions. Tick bite and infection with Borrelia burgdorferi should be considered in the differential diagnosis of necrotic arachnidism in regions endemic for Lyme disease.
PMID: 11973566, UI: 21969067
Ann Emerg Med 2002 May;39(5):544-6
PMID: 11973562, UI: 21969063
Ann Emerg Med 2002 May;39(5):541-3
PMID: 11973561, UI: 21969062
Ann Emerg Med 2002 May;39(5):528-36
Department of Virus Diseases, Walter Reed Army Institute of Research, Silver Spring, MD 20910-7500, USA. robert.gibbons@na.amedd.army.mil
Human rabies is rare in the United States; however, an estimated 40,000 patients receive rabies postexposure prophylaxis each year. Misconceptions about the transmission of rabies are plentiful, particularly regarding bats. Most cases of human rabies caused by bat variants have no definitive history of animal bite. Three hypotheses are proposed and reviewed for the transmission of rabies from bats to human beings. They include nonbite transmission (including aerosol transmission), the alternate host hypothesis (an intermediate animal host that acquires rabies from a bat and then transmits rabies to human beings), and minimized or unrecognized bat bites. Nonbite transmission of rabies is very rare, and aerosol transmission has never been well documented in the natural environment. The known pathogenesis of rabies and available data suggest that all or nearly all cases of human rabies attributable to bats were transmitted by bat bites that were minimized or unrecognized by the patients.
PMID: 11973559, UI: 21969060
Ann Emerg Med 2002 May;39(5):475-80
Department of Emergency Medicine, University of Michigan Medical Center, Hurley Medical Center, Flint, MI 48503-5993, USA. dkrywko@umich.edu
STUDY OBJECTIVE: Loxosceles species spider envenomations may produce necrotic, disfiguring dermal inflammatory lesions resembling neutrophilic dermatoses. With definitive treatment options lacking, clinicians are reluctant to obtain invasive biopsy specimens for diagnostic analysis. We compared less invasive venom collection methods and determined the time limit after inoculation for feasible venom recovery in an animal model. METHODS: Nine New Zealand rabbits were randomized to 1 of 3 groups (n=3). Groups 1 and 2 were inoculated intradermally with 3 microg of L reclusa venom at 5 inoculation sites per rabbit. Albumin (3 microg) was injected intradermally in each rabbit as a negative control. Hair (group 1) and aspirate samples (group 2) were collected (1 time per site) over a 1-week period after inoculation. Group 3 was inoculated with 3 microg of Loxosceles species venom on 1 flank and 3 microg of albumin on the opposite flank. Daily serum specimens were collected over a 7-day period. On day 7, dermal punch biopsy specimens were taken from the venom and control inoculation sites. Hair, aspirate, biopsy, and serum specimens were assayed for venom by using an enzyme-linked immunosorbent assay. A generalized linear model was fit with the generalized estimating equation method to estimate the mean differences between groups. RESULTS: Venom was detected in hair, aspirate, and biopsy specimens on all days of the study period. Hair samples yielded venom recovery on day 1 (median 0.062 ng/100 microL; mean difference 0.054 ng/100 microL; 95% confidence interval [CI] 0.048 to 0.059) through day 7 (median 0.020 ng/100 microL; mean difference 0.020 ng/100 microL; 95% CI 0.013 to 0.027). Aspirates were positive for venom recovery on day 1 (median 0.275 ng/100 microL; mean difference 0.231 ng/100 microL; 95% CI 0.192 to 0.271) through day 7 (median 0.0 ng/100 microL; mean difference 0.032 ng/100 microL; 95% CI -0.18 to 0.078). The highest venom yield was from the biopsy specimens (median 1.75 ng/100 microL; mean difference 0.041 ng/100 microL; 95% CI 0.033 to 0.027). Venom was undetectable in all serum samples. CONCLUSION: Loxosceles species venom is detectable in hair, aspirate, and dermal biopsy specimens at least 7 days after venom inoculation and undetectable in serum by using the rabbit model.
PMID: 11973554, UI: 21969055
Ann Emerg Med 2002 May;39(5):469-74
Department of Emergency Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109-0305, USA. hfg@umich.edu
STUDY OBJECTIVE: Dermal lesions from unrelated arthropod species and medical causes appear similar to Loxosceles species (brown recluse spider) bites. This may result in delayed diagnosis and treatment. We developed a sensitive Loxosceles species venom enzyme-linked immunosorbent assay (ELISA) and characterized the specificity of the assay by evaluating antigenic cross-reactivity from a variety of North American arthropod venoms. METHODS: North American arthropod (14 spiders, 2 scorpions, and 1 bee) venoms were studied. Three venom amounts (diluted in 100 microL of ELISA buffer) were assayed: 16,000 ng, 2,000 ng, and 40 ng. The latter quantity was selected because this is the observed maximum amount of venom we detect when inoculating dermis with amounts likely to be deposited by a spider bite. The larger venom amounts are overwhelming quantities designed to test the limits of the assay for arthropod venom cross-reactivity. Similar amounts of Loxosceles species venom and bovine albumin served as positive and negative controls, respectively. RESULTS: At the lowest amount of venom tested (40 ng), the ELISA detected only the Loxosceles species positive control. When 2,000 ng was assayed, only Scytodes fusca and Kukulcania hibernalis arachnid venoms (in addition to Loxosceles species) cross-reacted to the assay. Finally, at 16,000 ng, the ELISA assay modestly detected Diguetia canities, Heteropoda venatoria, Tegenaria agrestis, Plectreurys tristes, Dolomedes tenebrosus, and Hadrurus arizonensis arachnid venoms. CONCLUSION: Cross-reactivity was observed in 8 of 17 North American arthropod venoms when large venom amounts were assayed with a Loxosceles species ELISA. By using a relevant quantity of venom, 40 ng, the assay was specific for Loxosceles species venom. The venom specificity of the ELISA may allow clinical application in Loxosceles species endemic regions of North America.
PMID: 11973553, UI: 21969054
J Toxicol Clin Toxicol 2002;40(1):49-57
Department of Pharmacology and Toxicology, Ponce School of Medicine, Puerto Rico 00732, USA. mattajaime@hotmail.com
INTRODUCTION: Ciguatera fish poisoning arises from consumption of any of the 400 species of tropical marine reef fish containing polyether toxins. No laboratory method is available for clinical diagnosis of acute ciguatera poisoning. The objective of this pilot study was to ascertain the potential usefulness of a bioassay to detect ciguatoxins in humans suspected of acute intoxication. We analyzed plasma of healthy volunteers (asymptomatic negative controls), participants with gastrointestinal (GI) illness but without recent fish consumption (symptomatic negative controls), and participants with GI illness who had recently consumedfish. MATERIALS AND METHODS: Blood samples, questionnaires, and consent forms were collected from 11 symptomatic negative controls and 86 patients that visited emergency rooms in southern Puerto Rico over a 1-year period. Patients had consumed fish within 24 hour prior to the symptoms. Plasma samples were analyzed by a neuroblastoma cell bioassay that detects seafood toxins active at the sodium voltage-gated channel in a dose-dependent fashion. Concentrations were expressed in terms of brevetoxin-1 equivalents (ng PbTx-1 equiv/mL). RESULTS: The mean plasma concentration of 14 asymptomatic negative controls was 39.4 ng PbTx-1 equiv/mL (range 2-74). Of 86 potential ciguatoxic patients who reported fish consumption, 43 had values within the range of normal volunteers, and 9 had concentrations in the nondiagnostic range (73.9-100 ng). Thirty-four patients (40%) had concentrations 3 standard deviations above asymptomatic negative controls (>100 ng PbTx-1 equiv/mL). They had a mean concentration of 1,074 +/- 244.5 ng PbTx-1 equiv/mL (range 101-7,056ng). CONCLUSION: Preliminary findings of elevated PbTx-1 equivalents in 40% of the patients with both ciguatera symptomatology and fish consumption in a geographical area where ciguatera is common suggest that the neuroblastoma bioassay may be a potential diagnostic tool for acute ciguatera intoxication.
PMID: 11990204, UI: 21985575
J Toxicol Clin Toxicol 2002;40(1):35-47
Reanimation Medicale et Toxicologique, Hjpital Lariboisiere, Paris, France.
OBJECTIVE: We tested the hypothesis that the mechanism of respiratory insufficiency in drug-induced coma involving benzodiazepines is an increase in upper airway resistance. METHODS: Eighteen nonintubated and seven intubated (control) patients were poisoned with hypnotic sedatives involving benzodiazepines. Neurological and respiratory parameters were measured by polysomnography before and after flumazenil. Flumazenil was administered as escalating bolus doses followed by a continuous infusion. RESULTS: Upon entry, Glasgow Coma Score was 7 +/- 1 in nonintubated and 5 +/- 1 in intubated patients. Snoring with flow limitation and obstructive apnea were recorded in 16 and 5 among the 18 nonintubated patients, respectively. Central apnea was not observed. Total pulmonary resistance was 2.5-fold higher in nonintubated patients than in intubated patients. Total and resistive work of breathing (WOB) was significantly greater in the nonintubated group. Flumazenil bolus administration was associated with an improvement in Glasgow Coma Score from 7 +/- 1 to 13 +/- 1 in the nonintubatedpatients, and from 5 +/- 1 to 11 +/- in the intubated patients. Mean effective bolus doses were 0.3 +/- 0.1 mg in nonintubated patients and 0.6 +/- 0.1 mg in intubated patients. Tidal and minute volumes increased significantly, and WOB decreased significantly in nonintubated patients. In nonintubated patients, the decrease in total WOB resulted from a significant decrease in resistive WOB. CONCLUSION: Drug-induced coma involving benzodiazepines is characterized by snoring with flow limitation and obstructive apnea. The mechanism of respiratory insufficiency in nonintubated patients with drug-induced coma involving benzodiazepines is an increase in upper airway resistance and WOB.
PMID: 11990203, UI: 21985574
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