Gastric Washings Research Articles

Detection of Pathogenic Leptospira in Captive Chelonians (Kinosternon scorpioides-Linnaeus, 1766) in the Brazilian Amazon.

Leptospirosis is a zoonosis of great importance for One Health. In this context, the Amazonian biome may harbor numerous hosts for Leptospira spp. that contribute to the maintenance of the pathogen in the environment. Some reptiles, such as chelonians, have been little studied in terms of their involvement with leptospires. The objective of this study was to detect Leptospira spp. DNA in Kinosternon scorpioides turtles kept in captivity in a region of the Brazilian Amazon. A total of 147 samples of blood (n = 40), cloacal fluid (n = 27), cloacal lavage (n = 40), and stomach (n = 40) were collected from 40 chelonians. After DNA extraction, the samples were subjected to amplification of a 331 base pair product of the 16S rRNA gene using the Lep1 and Lep2 primers. PCR products were Sanger sequenced, assembled, and subjected to online blast search and phylogenetic analysis. Of the animals tested, 40% (16/40, 95% confidence interval [CI]: 25-55) had at least one or two samples positive for Leptospira spp. Considering the total number of samples collected, 12.93% (19/147) were positive, being blood clots (27.5%; 11/40), followed by cloacal washings (10%; 4/40), cloacal fluid (11.11%; 3/27) and gastric washings (2.5%; 1/40). Of these, 11 samples were sequenced and showed 99% to 100% identity with Leptospira interrogans sequences, which was confirmed by phylogenetic analysis. This is the first study to detect pathogenic Leptospira DNA in chelonians in a region of the Brazilian Amazon. It has been concluded that K. scorpioides turtles in captivity have been exposed to pathogenic Leptospira.

Aluminyum fosfit zehirlenmesi

Letter to Editor
 
 
 
 Aluminum phosphide poisoning
 
 
 Dear Editor,
 
 Aluminum phosphide, is a fumigant with high insecticide power in all life stages of insects, which is harmful in stored products.
 It is in the form of tablets or granules and is highlylethal and has no antidote.
 It inhibits the enyzme of cytochrome oxidase. Complications may develop as a result of inhaling phosphine gas or oral intake. Respiratory, circulatory, gastrointestinal tract andnervous system, kidney and liver may be affected. Shock, ARDS, aspration pnomony, anemia, metabolic acidosis, electrolytic disorder, coma, hipoxy, hemorrhage, pericardide are poorprognosis criterion. Leukopenia indicates severe toxicity. The lethal dose is 0.15-0.5 g and death is inevitableeven when buying 3-5 tablets
 Arrhythmia is responsible for death in the first 24 hours.The mortality rate varies between 37-100%.Treatment consists entirely of supportive treatment. (liquid, dopamine, oxygen, mechanical ventilation, gastric washing, activated charcoal,bicarbonate, hemodialysis)We aimed to present the case that developedsystemic complications in follow-up but wedischarged with healing as a result of appropriatefollow-up and treatment.
 CASE
 A 16-year old female patient was rushed to theemergency room two hours ago for drinking morethan she 
 knew the amount of the drug containing aluminum phosphide for suicidal purposes.
 When the patient arrived, his general condition wasmoderate, conscious, pale sweaty appearance and Tachypnea, BREATHING:26/min, TA:60/40mmhg,Pulse:135/min,,fever:37 degree systemic examination showed no abnormalities.
 Initial blood values, ECG and chest x-ray were normal.
 
 The patient was followed up in the emergency department. 1000ml serum physiological started
 In order to reduce the formation of phosphine gas(with alkalısm), oral bicarbonate was started. 
 Ta:100/70mmHg in the 2nd hour of follow-up andchest pain developed.
 The first TROPONIN I value was:0.02(0-0.06 ng/ml). In echocardiography, ejection fraction wasdetermined 57%. In the blood gas, PH was 7.32 and there was metabolic acidosis. Her acidosis level improved in the 6th hour of the follow up. The control TROPONİN value was 0.21. Asetilsalisilik acid started at 100 mg. At the 12th hour white blood cell (4-11 k/ml) decreased from 12000 to 4000.However no abnormality was detected in other hemogram values.
 
 At the 20th hour ,her chest pain gone and her troponin values increased up to 1.45.No ECG change detected.Her acidose improved and lokopenia not seen.The patient’s control , liver and kidney function tests and ECHO were normal.No abnormality was detected in the follow ups , polyclinic controls and laboratory values on the third day of the hospitalization. The patient was discharged from the hospital with suggestions.
 
 Aluminum phosphide is an extremely mortal toxic substance.During the follow ups unwanted complications can develop. Merely satisfactory results can be achieved with valid , timely and appropriate supportive treatments

ROLE OF FIBEROPTIC BRONCHOSCOPY IN DIAGNOSIS OF SPUTUM NEGATIVE PULMONARY TUBERCULOSIS

Tuberculosis is a disease caused by Mycobacterium tuberculosis. It is a systemic disease, predominantly affecting the lungs. Globally, tuberculosis affects around 10.4 million people per year, and kills around million of them, with the majority of patients presenting with pulmonary disease. One of the key challenges to global tuberculosis control is correct diagnosis. The diagnosis of Pulmonary Tuberculosis can be obtained from microscopy and culture of a number of different sources including expectorated sputum, induced sputum, gastric washings and bronchoscopy. Fiberoptic bronchoscopy (FOB) can provide an early conrmative diagnosis in such patients. Among the bronchoscopic materials, bronchoalveolar lavage (BAL) is the best diagnostic material for the diagnosis of PTB.

Fibrosing mediastinitis in a child with Mendelian susceptibility to mycobacterial disease possibly due to Bacillus Calmette-Guérin

BackgroundMendelian susceptibility to mycobacterial disease (MSMD) is an uncommon disorder with increased susceptibility to less virulent mycobacteria including bacillus Calmette-Guérin (BCG). Fibrosing mediastinitis (FM) is also a rare condition defined by excessive fibrotic reactions in the mediastinum. So far, some infectious organisms and autoimmune diseases have been introduced as possible etiologies of FM. However, no study has ever discussed the possible association of BCG infection and FM.Case presentationIn this study, we report a 3-year-old female presenting with persistent fever, weakness, and bloody diarrhea in addition to mediastinal lymphadenopathy, hepatosplenomegaly, and pleural and pericardial effusion. Further examinations established a diagnosis of MSMD based on her clinical condition, immunologic data, positive tests for mycobacterial species, positive family history, and genetic study (IL12RB1 gene, c.G1193C, p.W398S). A year and a half later, she was referred with submandibular lymphadenitis and underwent immunologic work-up which revealed high inflammatory indices, a slight reduction in numbers of CD3 + and CD4 + cells as well as elevated CD16/56 + cell count and hyperimmunoglobulinemia. Purified protein derivative (PPD), QuantiFERON, and gastric washing test were all negative. Her chest computed tomography (CT) scan revealed suspicious para-aortic soft tissue and her echocardiography was indicative of strictures in superior vena cava and pulmonary veins. She further underwent chest CT angiography which confirmed FM development. Meanwhile, she has been treated with anti-mycobacterial agents and subcutaneous IFN-γ.ConclusionIn summary, we described a novel case of MSMD in a child presenting with granulomatous FM possibly following BCG infection. This is the first report introducing aberrant BCG infection as the underlying cause of FM. This result could assist physicians in identifying early-onset FM in suspicious cases with MSMD. However, more studies are required to support this matter.

Effective anti-mycobacterial treatment for BCG disease in patients with Mendelian Susceptibility to Mycobacterial Disease (MSMD): a case series

BackgroundPost-vaccination BCG disease typically attests to underlying inborn errors of immunity (IEIs), with the highest rates of complications in patients with Mendelian susceptibility to mycobacterial disease (MSMD). However, therapeutic protocols for the management of BCG-osis (disseminated) and persistent BCG-itis (localized) are still controversial.MethodsTwenty-four Iranian patients with MSMD (BCG-osis or BCG-itis), followed from 2009 to 2020 in Tehran, were included in the study. Their medical records were retrospectively reviewed for demographics, clinical features, laboratory findings, and molecular diagnosis. The therapeutic protocol sheets were prepared to contain the types and duration of anti-mycobacterial agents.ResultsBCG disease either as BCG-itis (33.3%) or BCG-osis (66.7%) was confirmed in all patients by positive gastric washing test (54.2%), microbial smear and culture (58.3%), or purified protein derivative (PPD) test (4.2%). The duration between BCG-osis onset and MSMD diagnosis was 21.6 months.All except three patients were initiated on second-line anti-mycobacterial agents with either a fluoroquinolone (levofloxacin: 15 mg/kg/day, ciprofloxacin: 20 mg/kg/day, ofloxacin: 15 mg/kg/day), aminoglycoside (amikacin: 10–15 mg/kg/day, streptomycin: 15 mg/kg/day), and/or macrolide (clarithromycin: 15 mg/kg/day) along with oral rifampin (10 mg/kg/day), isoniazid (15 mg/kg/day), and ethambutol (20 mg/kg/day). Three patients showed a clinical response to rifampin, despite in vitro resistance. Fourteen (58.3%) patients received also adjuvant subcutaneous IFN-γ therapy, 50 µ/m2 every other day. At the end of survey, most patients (n = 22, 91.7%) were alive and two patients died following BCG-osis and respiratory failure.ConclusionsWe recommend the early instigation of second-line anti-mycobacterial agents in MSMD patients with BCG disease.

Kompleksna i retka prezentacija trovanja pirinčanom tabletom - prikaz slučaja

Aluminum phosphide, known as "rice tablet" (RT), is a common cause of suicide in adult women in Iran, with a high rate of lethal outcome. We report a patient with RT toxicity, with a complex syndrome of hepatic failure, renal failure, Brugada electrocardiography (ECG) patterns, and pleuropericardial effusion. The patient received conventional management with fluid therapy, gastric washing, activated charcoal followed by intra-aortic balloon pump insertion, inotropic drugs support, and mechanical ventilation. The unique features of our case are related to a combination of multiorgan failure with Brugada atypical ECG patterns and pleuropericardial effusion. Among the aforementioned complications, pleuropericardial effusion, ascites, and Brugada syndrome are exceedingly rare events. The patient was treated with high-dose inotropic drugs and intra-aortic balloon pump insertion. Despite tremendous management of metabolic acidosis, all efforts failed, and the patient died with sudden cardiac arrest.

Burden of Tuberculosis in South African Children During Treatment for Underlying Malignancies: A Single-center Experience in Johannesburg.

Children with cancer are immunocompromised with increased susceptibility to infections. We evaluated the burden of tuberculosis in children with cancer. Children with cancer were enrolled and screened for Mycobacterium tuberculosis infection using the tuberculin skin test and enzyme-linked immune absorbent spot (T-SPOT.TB; Oxford Immunotec Ltd, Oxford, United Kingdom). Children with physician-suspected tuberculosis were investigated for M. tuberculosis using microscopy and culture on sputum or gastric washings. We enrolled 169 children; 10.7% were living with HIV. The tuberculin skin test was positive in 2.9% of patients, who were treated for tuberculosis and excluded from further analysis. The enzyme-linked immune absorbent spot (T-SPOT.TB) was either negative or indeterminate in the first 100 children screened. The incidence of tuberculosis was 7.6 per 100 child-years; 35.3% were culture-confirmed. Tuberculosis was diagnosed at a mean of 5.5 months from cancer diagnosis. A greater proportion of children living with HIV (44.4%) developed tuberculosis than those without (17.2%; adjusted P = 0.042). Children treated for high-risk acute lymphoblastic leukemia, advanced stage non-Hodgkin lymphoma and acute myeloid leukemia (P = 0.009) and those with a higher exposure-period (per 100 child-years) to corticosteroids courses (350 vs. 29.4; P < 0.001) had a higher incidence of tuberculosis. Twenty-six of 34 children (76.5%) with tuberculosis died; multiple infections were identified at the time of death. Screening children for tuberculosis infection at cancer diagnosis was of limited value. The high rate of tuberculosis and poor outcomes emphasize the need for a high index of suspicion to diagnose tuberculosis and consideration for antituberculosis treatment, especially for those with identified risk factors.

Xpert MTB/RIF performance to diagnose tuberculosis and rifampicin resistance in a reference centre in southern Brazil.

Effective treatment of tuberculosis (TB) remains a serious public health problem in many countries, including Brazil, especially when considering drug-resistant disease. Xpert MTB/RIF has been implemented in many countries to reduce the time to TB diagnosis and to rapidly detect rifampicin resistance. The study aimed to describe and evaluate Xpert MTB/RIF performance in diagnosing pulmonary TB and rifampicin resistance in a tertiary healthcare facility in Brazil.A cross-sectional study was performed, which included all isolates of confirmed pulmonary TB patients from 2015 to 2018. Both Xpert MTB/RIF and GenoType MTBDRplus assays were performed to detect rifampicin and isoniazid resistance. In addition, isolates with detected resistance to rifampicin and/or isoniazid were analysed by phenotypic testing using MGIT-960 SIRE kit and whole-genome sequencing (WGS) using Illumina MiSeq Sequencing System.2148 respiratory specimens tested with Xpert MTB/RIF were included: n=1556 sputum, n=348 bronchoalveolar lavage and n=244 gastric washing. The overall Xpert MTB/RIF sensitivity in sputum was 94% and the overall specificity was 98%. The negative predictive value in sputum of all the patients was 99% with a positive predictive value of 89%. The concordance between Xpert MTB/RIF and phenotypic susceptibility test was 94.1%, while its concordance with WGS was 78.9%.Xpert MTB/RIF is a rapid and accurate diagnostic strategy for pulmonary TB, which can contribute to improvement in TB control. However, detection of rifampicin resistance might be associated with false-positive results.

52 - Ranitidine treatment impairs vascular redox biology and function

Proton pump inhibitors (PPIs) are considered safe drugs. However, recent studies suggest that omeprazole adversely affects vascular function, impairs vascular redox biology and promotes endothelial dysfunction. These findings are relevant to patients with cardiovascular diseases using PPIs, and therefore investigating whether other drugs used to treat dyspeptic diseases cause similar problems is important. In this context, the impact of ranitidine on vascular biology and function remains unknown. We examined the effects of ranitidine on blood pressure, vascular function and redox biology. Male Wistar rats (180-200 g) were treated once daily for four weeks with vehicle (V) or ranitidine (R) 100 mg/kg orally. Omeprazole (O) 10 mg/kg i.p. was used as a positive control. Systolic blood pressure (SBP) was assessed weekly by tail-cuff plethysmography. By the end of the fourth week of treatment, the animals were euthanized and the gastric washing pH was evaluated. Endothelial integrity was examined by assessing the relaxation in response to acetylcholine. To assess vascular oxidative stress, two independent biochemical assays were used: dihydroethidium (DHE) and chemiluminescent lucigenin assay. Results Ranitidine or omeprazole did not affect SBP. Gastric pH increased with both treatments. Ranitidine or omeprazole decreased the maximum responses of aortic rings in response to acetylcholine (Emax: V=106.5±2.0%; O=92.2±2.1%; R=93.9±1.7%; both P Conclusion Ranitidine and omeprazole have similar pro-oxidant effects on the vasculature and cause endothelial dysfunction.

Multilocus sequence typing (MLST) of Klebsiella oxytoca from clinical specimens from Mthatha, South Africa

Background: Klebsiella oxytoca (K. oxytoca) is an opportunistic pathogen that has been involved in various nosocomial infections such as urinary tract infections, pneumonia, wound infections, septicemia, neonatal septicemia and also hemorrhagic colitis associated with antibiotic use. Multilocus sequence typing (MLST) is a nucleotide sequence-based approach for characterising bacterial isolates. The genetic diversity and the clinical relevance of the drug-resistant K. oxytoca from Mthatha are largely unknown. For this reason, prospective, experimental study of the molecular epidemiology of selective K. oxytoca isolates from patients being treated in Mthatha was analysed. Methods & Materials: PCR amplification and sequencing of the drug-resistance-associated genes, and multilocus sequence typing (MLST) using seven housekeeping genes mdh, pgi, infB, FusAR, phoE, gapA and rpoB were conducted. A total of five isolates were analysed. Specimen types: Sputum, Eye swab, Pus (ENT source), swab of skin lesions and gastric washing. Results: Two out of five isolates were ESBL-positive and three ESBL-negative. By Sanger sequencing three isolates of K. oxytoca were misidentified as K. pneumoniae with two automated phenotypic methods. We detected 3/5 (60%) blaCTX-M and blaSHV while blaTEM were 2/5 (40%). Conclusion: With the analysis MLST using seven housekeeping genes we determined three K. oxytoca, which were mistakenly identified as K. pneumoniae by phenotypic methods.

Gastric washing by distilled water can reduce free gastric cancer cells exfoliated into the stomach lumen.

Intragastric free cancer cells in patients with gastric cancer have rarely been studied. The purpose of this study was to investigate the detection rate of intragastric free cancer cells in gastric washes using two types of solutions during endoscopic examination. We further clarified risk factors affecting the presence of exfoliated free cancer cells. A total of 175 patients with gastric cancer were enrolled. Lactated Ringer's solution (N = 89) or distilled water (DW; N = 86) via endoscopic working channel was sprayed onto the tumor surface, and the resultant fluid was collected for cytological examination. We compared the cancer-cell positivity rate between the two (Ringer and DW) groups. We also tested the correlation between cancer-cell positivity and clinicopathological factors in the Ringer group to identify risk factors for the presence of exfoliated cancer cells. The cancer-cell positivity rate was significantly higher in the Ringer group than that in the DW group (58 vs 6%). Cytomorphology in the Ringer group was well maintained, but not in the DW group. The larger tumor size (≥ 20mm) and positive lymphatic involvement were significant risk factors of exfoliated free cancer cells. Cancer cells can be highly exfoliated from the tumor surface into the gastric lumen by endoscopic irrigation in large gastric cancer with lymphatic involvement. Gastric washing by DW can lead to cytoclasis of free cancer cells; therefore, it may minimize the possibility of cancer-cell seeding in procedures carrying potential risks of tumor-cell seeding upon transluminal communication, such as endoscopic full-thickness resection and laparoscopy-endoscopy cooperative surgery.

Tuberculosis in HIV-infected South African children with complicated severe acute malnutrition.

Academic tertiary referral hospital in Durban, South Africa. To describe the incidence and diagnostic challenges of tuberculosis (TB) in human immunodeficiency virus (HIV) infected children with severe acute malnutrition (SAM). Post-hoc analysis of a randomised controlled trial that enrolled antiretroviral therapy naïve, HIV-infected children with SAM. Trial records and hospital laboratory results were explored for clinical diagnoses and bacteriologically confirmed cases of TB. Negative binomial regression was used to explore associations with confirmed cases of TB, excluding cases where the clinical diagnosis was not supported by microbiological confirmation. Of 82 children enrolled in the study, 21 (25.6%) were diagnosed with TB, with bacteriological confirmation in 8 cases. Sputum sampling (as opposed to gastric washings) was associated with an increased risk of subsequent diagnosis of TB (adjusted relative risk [aRR] 1.134, 95%CI 1.02-1.26). Culture-proven bacterial infection during admission was associated with a reduced risk of TB (aRR 0.856, 95%CI 0.748-0.979), which may reflect false-negative microbiological tests secondary to empiric broad-spectrum antibiotics. TB is common in HIV-infected children with SAM. While microbiological confirmation of the diagnosis is feasible, empiric treatment remains common, possibly influenced by suboptimal testing and false-negative TB diagnostics. Rigorous microbiological TB investigation should be integrated into the programmatic management of HIV and SAM.

Characterization of Epstein-Barr virus-encoded small RNA gene variations in virus associated lymphomas in Northern China.

Epstein-Barr virus (EBV)-encoded small RNAs (EBER1 and EBER2) are highly expressed in all forms of EBV latency in EBV-associated malignancies. EBER gene variations and their association with EBV-associated disease still remain poorly characterized. To investigate the patterns of EBER gene variations and their roles in tumorigenesis, EBER gene sequences were analyzed by nested-PCR and DNA sequencing in 101 lymphomas from Northern China, a non-nasopharyngeal carcinoma (NPC) endemic area. In addition, EBV type 1 and type 2 classifications were made by using nested-PCR assays across type-specific regions in the EBNA2 gene. EB-6m was the dominant subtype (95.0%, 96/101) in lymphoma. The distribution of the EBER subtypes in the four lymphoma groups was not significantly different (p>0.05), neither was that of the EBNA2 type (p>0.05). Compared with previous data in the same area, the distribution of EBER subtypes in lymphoma was similar to that in EBV-associated gastric carcinoma (EBVaGC) and throat washing (TW) from healthy donors (p>0.05), but was significantly different from that of NPC. The EBNA2 type distribution between lymphoma and the other three groups was significantly different (p<0.05). The proportion of type 1 and type 2 dual infections was higher in lymphoma than that in GC, NPC and TW. The mutation 7123nt A→T was identified in 11 of 101 (10.9%, 11/101) lymphomas, significantly more than that in EBV-associated gastric carcinomas (EBVaGC) (0%, 0/50) and throat washings (TWs) from healthy donors (3.3%, 3/92) (p<0.05). These findings indicate that EBER subtypes may not be associated with pathogenesis of lymphoma, but that a point mutation at position 7123nt (A→T) provides a new area for further exploration. Furthermore it is necessary to investigate the role of EBNA2-subtype mixed infections in the establishment of lymphoma.

Study of 9 Cases of Tuberculosis Pneumonia in Children at Chu of Brazzaville, Congo.

In the Republic of Congo, a country where tuberculosis is endemic, there have not been many reports about tuberculosis pneumonia. This study aimed to describe the epidemiology, clinical features, and outcome of tuberculosis pneumonia in children. This was a retrospective study of 9 cases of children admitted from 2002 to 2015, that is, 0.7 cases per year. The average age was 37 months. The mean delay from the beginning of symptoms to the visit to a medical center was 36 days (range = 4-93 days). Physical examination indicated a pulmonary consolidation in 6 cases. Chest X-ray revealed a unilateral opacity in all cases. Sputum and gastric washing bacilloscopies were positive in all cases, and HIV serology was positive in 2 cases. Therapeutic observance was perfect and the evolution favorable. Tuberculosis pneumonia must be systematically proposed for children under 5 years of age, who present symptoms that are in contrast with the seriousness of chest X-ray injuries.

The Role of Flexible Bronchoscope in the Diagnosis of the Pulmonary Tracheobronchial Tuberculosis in Children-Report of Four Cases and Review of Literature

The diagnosis of tracheobronchial tuberculosis (TBTB) on the grounds of clinical and radiological findings in children is more difficult due to the lack of etiological confirmation. We aimed to elucidate the application of flexible bronchoscopy (FB) in the diagnosis of tuberculosis (TB) with involvement of tracheobronchial wall named TBTB. Pathological changes typically include mucosal and submucosal edema and hyperemia. It also comprises of tubercular-like nodules, caseous necrosis and fibrous hyperplasia. Acid-fast bacilli staining is done from tissue slices or bronchial alveolar lavage fluid (BALF) sediment and a positive stain confirms the diagnosis. It also aids in differential diagnosis of complicated and refractory pneumonia. Furthermore, it can be beneficial in gastric washing and sputum collection. Flexible bronchoscopy can be performed for pediatric purposes efficiently and effectively. It is a safe and easy procedure.

Utility of intranasal Ketamine and Midazolam to perform gastric aspirates in children: a double-blind, placebo controlled, randomized study

BackgroundWe performed a prospective, randomized, placebo-controlled study aimed to evaluate the efficacy and safety of a sedation protocol based on intranasal Ketamine and Midazolam (INKM) administered by a mucosal atomizer device in uncooperative children undergoing gastric aspirates for suspected tuberculosis. Primary outcome: evaluation of Modified Objective Pain Score (MOPS) reduction in children undergoing INKM compared to the placebo group. Secondary outcomes: evaluation of safety of INKM protocol, start time sedation effect, duration of sedation and evaluation of parents and doctors’ satisfaction about the procedure.MethodsIn the sedation group, 19 children, mean age 41.5 months, received intranasal Midazolam (0.5 mg/kg) and Ketamine (2 mg/kg). In the placebo group, 17 children received normal saline solution twice in each nostril. The child’s degree of sedation was scored using the MOPS. A questionnaire was designed to evaluate the parents’ and doctors’ opinions on the procedures of both groups.ResultsFifty-seven gastric washings were performed in the sedation-group, while in the placebo-group we performed 51 gastric aspirates. The degree of sedation achieved by INMK enabled all procedures to be completed without additional drugs. The mean duration of sedation was 71.5 min. Mean MOPS was 3.5 (range 1-8) in the sedation-group, 7.2 (range 4-9) in the placebo-group (p <0.0001). The questionnaire revealed high levels of satisfaction by both doctors and parents in the sedation-group compared to the placebo-group. The only side effect registered was post-sedation agitation in 6 procedures in the sedation group (10.5%).ConclusionsOur experience suggests that atomized INKM makes gastric aspirates more acceptable and easy to perform in children.Trial registrationUnique trial Number: UMIN000010623; Receipt Number: R000012422.

Methylene blue unresponsive methemoglobinemia.

Sir, I read with great interest the article by Patnaik et al. published recently in your Journal.[1] The authors defined an 18-month-old boy who was presented with central nervous system manifestations (irritability and seizure), cyanosis, metabolic acidosis, and confirmed methemoglobinemia. The major points in this case were: (1) Unknown toxicologic origin despite thorough history taking and (2) the methemoglobinemia unresponsive to methylene blue and vitamin C that then was treated successfully by blood transfusion. I would like to address some missed points in this report. The authors stated that they were not able to establish the exact etiology, but according to the situation of patient's home and history of relatives it was likely that the child was intoxicated with a chemical. If this is true, it is not clear how the child was resuscitated at the presentation with a likely intoxication. Were gastric washing and gavage of an absorbent agent implemented? Was a toxicologist consultation requested for the patient despite the fact methemoglobinemia was not responded to intravenous methylene blue and presence of likely occurrence of a chemical exposure? By the way, how the authors have ruled out one the most important etiologies of methemoglobinemia in toxicologic settings, namely aluminum phosphide, that is the cause of great burden of morbidity and mortality in countries such as India.[2] Toxic-induced methemoglobinemia occurs in a diverse variety of drug and chemical exposures with oxidizing mechanisms.[3] Although in some reported cases, it has been shown that methemoglobinemia can develop in more rare situations such as acetaminophen overdose,[4,5] metoclopramide overdose,[6] and aluminum phosphide poisoning,[7] but the mechanism of action is more complex and less elaborated. Mostafazadeh et al. in a case series study showed that methemoglobinemia develops in aluminum phosphide poisoning in some degrees, but severe methemoglobinemia requiring therapeutic intervention is a rare finding.[8] Furthermore, Shadnia et al. have described that methemoglobinemia in aluminum phosphide poisoning is unresponsive to methylene blue administration.[7] This poisoning, in this case, could be ruled out by a bedside rapid spot test by silver nitrate impregnated paper.[9] Furthermore, anemia, in this case, has intensified the severity and lack of response to conventional treatment. As noted by authors, chemical exposure is one of the causes of inadequate response to methylene blue therapy in methemoglobinemia, and I think aluminum phosphide poisoning should be borne in mind in cases in which therapy seems to be resistant to methylene blue and ascorbic acid. Thank you for the interesting case discussion.

Aluminum Phosphide Poisoning: A Case Series in North Iran

Background: Aluminum phosphide (AlP) poisoning is one of the most life threatening emergencies. In this study, demographic characteristics, clinical profiles and outcomes of a series of patients presented with AlP poisoning in north Iran are described. Methods: The study was a retrospective descriptive medical chart review of AlP poisoned patients who were admitted to internal ward of Imam Khomeini hospital, Sari, Iran, from July 1st 2011 to July 1st 2012. Collected data included gender, age, intention of poisoning, amount of AlP ingested, clinical manifestations at admission, therapeutic interventions, laboratory tests and outcome. Results: During the one-year period, 8 patients which were all men with mean (SD) age of 40.5 (22.5) years were admitted with AlP (rice tablet) poisoning. The most common signs and symptoms at admission were nausea and vomiting (100%), metabolic acidosis (100%) and hemodynamic instability (87.5%). All cases were poisoned as a result of suicidal attempt leading to 5 (62.5.6%) deaths. Compared with the patients who survived, those who died had taken higher doses of AlP, developed hepatic dysfunction in higher rates and had severer metabolic acidosis. All patients were admitted to intensive care unit and received gastric washing with sodium bicarbonate, followed by activated charcoal therapy and intravenous calcium gluconate for decontamination purposes. The median (IQR) of length of hospital stay was 2 (1-4) days. Conclusion: AlP is a low-cost highly-toxic rodenticide. It is easily available and used as a toxic compound for suicide in the Asia region. There has been no effective antidote available for treatment of AlP poisoned patients; thus, symptomatic management should be taken into consideration as soon as possible.

Polymerase chain reaction to diagnose mushroom intoxication

(Hall & Barton 2013). I also was fascinated to read the editorial on “sea-sonal canine illness” (SCI) in the same issue (Robin & Newton 2013). The truth is, I didn’t know much about the former, and I knew even less about the latter! But the possibility that SCI might be a mycotoxicosis is tantalising.I wish to draw these authors’ attention to the value of recently developed PCR assays for mushrooms and related fungi using vomitus and gastric washings from clinical patients (Maeta

Shigella Keratitis in an HIV-exposed Infant

Shigella Keratitis in an HIV-exposed Infant