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Microbiological, biological, and chemical toxins have been employed in warfare and in terrorist attacks. In this era, it is imperative that health care providers are familiar with illnesses caused by these agents. Botulinum toxin produces a descending flaccid paralysis. Staphylococcal enterotoxin B produces a syndrome of fever, nausea, and diarrhea and may produce a pulmonary syndrome if aerosolized. Clostridium perfringens epsilon-toxin could possibly be aerosolized to produce acute pulmonary edema. Ricin intoxication can manifest as gastrointestinal hemorrhage after ingestion, severe muscle necrosis after intramuscular injection, and acute pulmonary disease after inhalation. Nerve agents inhibit acetylcholinesterase and thus produce symptoms of increased cholinergic activity. Ammonia, chlorine, vinyl chloride, phosgene, sulfur dioxide, and nitrogen dioxide, tear gas, and zinc chloride primarily injure the upper respiratory tract and the lungs. Sulfur mustard (and nitrogen mustard) are vesicant and alkylating agents. Cyanide poisoning ranges from sudden-onset headache and drowsiness to severe hypoxemia, cardiovascular collapse, and death. Health care providers should be familiar with the medical consequences of toxin exposure, and understand the pathophysiology and management of resulting illness.
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PMID:Microbiological, biological, and chemical weapons of warfare and terrorism. 1207 87

Following ingestion of 30 mg of presumed benztropine (Cogentin) a 39-year-old male developed nausea, vomiting and diarrhea. His admission to hospital was soon followed by collapse and death. Histological examination, however, revealed increased numbers of mitotic figures in otherwise normal epithelial cells of the esophagus and bronchioles, a feature characteristic of colchicine toxicity. Subsequent toxicological analyses confirmed the presence of colchicine in the urine, but not in the blood. A dispensing error had resulted in substitution of colchicine for Cogentin. Histological findings had, therefore, provided evidence of colchicine toxicity and had guided subsequent toxicological evaluation. In suspected cases of colchicine toxicity, histological samples should, therefore, be taken from multiple sites along the gastrointestinal and respiratory tract in addition to other organs and tissues so that diagnostic morphological changes can be looked for.
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PMID:Epithelial cell mitotic arrest--a useful postmortem histologic marker in cases of possible colchicine toxicity. 1208 92

Wasp stings generally cause local reactions like pain, wheal, flare, edema and swelling, which are generally self-limiting. Multiple stings can lead to vomiting, diarrhea, generalized edema, dyspnea, hypotension, collapse, renal failure or death. Unusually, they may cause serum sickness, vasculitis, neuritis or encephalitis. We report a case of a 40 year old male who developed focal neurological deficit 10 hours following a wasp sting, which was confirmed to be ponto-cerebellar infarction on MRI scan, and recovered within five days.
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PMID:Wasp sting induced neurological manifestations. 1239 66

Vasomax is an oral preparation of phentolamine mesilate (Zonagen Pharmaceuticals) currently undergoing worldwide regulatory approval for distribution. Phentolamine is primarily an alpha-adrenergic antagonist with mild sympatholytic action and a beta-adrenergic stimulating action. Over 30 years of clinical experience has shown it to be a strong direct vasodilator on muscular walled vessels, likely based on its inhibitory action on adenosine 5-triphosphate-sensitive potassium channels. This medication is not new, having been marketed in the United States in an oral formulation between 1952 and 1984. Phentolamine initially achieved FDA approval for preoperative use in patients with pheochromocytoma for control of blood pressure and paroxysmal hypertensive episodes. In the past it had been evaluated for hypertension, pulmonary disease, cardiac arrhythmias, angina pectoris and peripheral vascular disease. Unfortunately for most of these indications the clinical responses to oral phentolamine have been variable. The most clinically significant adverse events associated with oral phentolamine in the past were systemic hypotension and vasomotor collapse, severe gastrointestinal side effects especially diarrhea and some complaints of nasal congestion. In this review we will concentrate on phentolamine in a new preparation for on demand treatment of erectile dysfunction of mild to moderate degrees.
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PMID:Oral phentolamine (Vasomax). 1287 9

HIV-1 encodes for one of the human glutathione peroxidases. As a consequence, as it is replicated, its genetic needs cause it to deprive HIV-1 seropositive individuals not only of glutathione peroxidase, but also of the four basic components of this selenoenzyme, namely selenium, cysteine, glutamine, and tryptophan. Eventually this depletion process causes severe deficiencies of all these substances. These, in turn, are responsible for the major symptoms of AIDS which include immune system collapse, greater susceptibility to cancer and myocardial infarction, muscle wasting, depression, diarrhea, psychosis and dementia. As the immune system fails, associated pathogenic cofactors become responsible for a variety of their own unique symptoms. Any treatment for HIV/AIDS must, therefore, include normalization of body levels of glutathione, glutathione peroxidase, selenium, cysteine, glutamine, and tryptophan. Although various clinical trials have improved the health of AIDS patients by correcting one or more of these nutritional deficiencies, they have not, until the present, been addressed together. Physicians involved in a selenium and amino-acid field trial in Botswana, however, are reporting that this nutritional protocol reverses AIDS in 99% of patients receiving it, usually within three weeks.
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PMID:How HIV-1 causes AIDS: implications for prevention and treatment. 1505 Jan 5

The goal of the German drug safety program in psychiatry AMSP (Arzneimittelsicherheit in der Psychiatrie) is the assessment of severe or new adverse drug reactions (ADRs). Here we report on 53,042 of 122,562 patients treated with antidepressants who were monitored from 1993 to 2000 in 35 psychiatric hospitals in German-speaking countries. The overall incidence of severe ADRs of antidepressants was 1.4 % of exposed patients; when only ADRs rated as probable or definite were considered, a rate of 0.9 % in patients treated with antidepressants was observed. ADR rates were higher for TCAs (imputed in 1.0 % of patients overall, respectively in 0.6 % of patients when only ADs were imputed) and lower for MAO inhibitors and SSRIs (0.7 % for both, respectively 0.3 % and 0.4 %). Within the TCA group there was a difference among clomipramine (2.1 %, respectively 1.0 %), amitriptyline (1.0 %, respectively 0.6 %), and doxepin or trimipramine (both 0.6 %, respectively 0.3 %). With regard to single SSRI, similar rates were observed for paroxetine (0.8 %, respectively 0.5 %) and for citalopram (0.7 %, respectively 0.4 %). Of the new dual-acting antidepressants, venlafaxine ranged at 0.9 %, (respectively 0.5 %) and mirtazapine at 0.6 % (respectively 0.5 %). In particular, TCAs were associated with known risks, such as toxic delirium, grand mal seizures, and hepatic (i. e., increased liver enzymes), urologic (i. e., urinary retention), allergic (i. e., exanthema), or cardiovascular (i. e., mainly orthostatic collapse) reactions. In SSRI-treated patients (non-delirious) psychic and neurological ADRs were most prominent, followed by gastrointestinal, dermatologic, and endocrinological/electrolyte reactions, with agitation, hyponatremia (probably as part of the SIADH syndrome and associated with severe neurologic or psychiatric symptoms in 64 % of all cases), increased liver enzymes, nausea, and the serotonin syndrome as leading unwanted symptoms. Venlafaxine (in the immediate-release formulation) was associated with adverse CNS and somatic symptoms such as severe agitation, diarrhea, increased liver enzymes, hypertension, and hyponatremia. Mirtazapine was mostly connected with increased liver enzymes, cutaneous edema, and collapse, but with no case of significant hyponatremia. For drugs that potently inhibit serotonin uptake, serum sodium concentration should be controlled when applied in high-dose therapy or in vulnerable patients.
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PMID:Severe adverse drug reactions of antidepressants: results of the German multicenter drug surveillance program AMSP. 1505 13

Asiatic cholera reached Britain for the first time in late 1831, with the main epidemic occurring during 1832. The disease caused profuse diarrhea, severe dehydration, collapse, and often death. There was widespread public fear, and the political and medical response to this new disease was variable and inadequate. In the summer of 1832, a series of "cholera riots" occurred in various towns and cities throughout Britain, frequently directed against the authorities, doctors, or both. The city of Liverpool, in the northwest of England, experienced more riots than elsewhere. Between 29 May and 10 June 1832, eight major street riots occurred, with several other minor disturbances. The object of the crowd's anger was the local medical fraternity. The public perception was that cholera victims were being removed to the hospital to be killed by doctors in order to use them for anatomical dissection. "Bring out the Burkers" was one cry of the Liverpool mobs, referring to the Burke and Hare scandal four years earlier, when two men had murdered people in Edinburgh in order to sell their bodies for dissection to the local anatomy school. This issue was of special concern to the Liverpool citizenry because in 1826, thirty-three bodies had been discovered on the Liverpool docks, about to be shipped to Scotland for dissection. Two years later a local surgeon, William Gill, was tried and found guilty of running an extensive local grave-robbing system to supply corpses for his dissection rooms. The widespread cholera rioting in Liverpool was thus as much related to local anatomical issues as it was to the national epidemic. The riots ended relatively abruptly, largely in response to an appeal by the Roman Catholic clergy read from church pulpits, and also published in the local press. In addition, a respected local doctor, James Collins, published a passionate appeal for calm. The Liverpool Cholera Riots of 1832 demonstrate the complex social responses to epidemic disease, as well as the fragile interface between the public and the medical profession.
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PMID:The Liverpool cholera epidemic of 1832 and anatomical dissection--medical mistrust and civil unrest. 1614 59

An HIV-1-infected adult presented with a short history of dyspnoea, productive cough and myalgia with fever. Shortly after presentation, he developed the abrupt onset of high-volume watery diarrhoea: stool culture grew Shigella sonnei. At the same time, he became hypoxaemic, and thoracic imaging showed bilateral lower lobe consolidation/collapse. Culture of sputum and blood was negative. The patient recovered with fluid resuscitation and ciprofloxacin monotherapy. This is the first reported case of pneumonia complicating S. sonnei dysentery in an HIV-infected adult.
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PMID:Pneumonia complicating Shigella sonnei dysentery in an HIV-infected adult male. 1630 74

Four dead canine pups (5-12 days old) from 3 litters in Douglas County of north central Colorado were submitted to the Colorado State University Diagnostic Laboratory for necropsy. Pups were originally presented to the referring clinics for respiratory tract illness, with or without diarrhea. At necropsy, the lungs from all pups had similar lesions, including random foci of hemorrhage and failure to collapse on opening of the thoracic cavity. The lungs were histologically characterized by subacute interstitial pneumonia, with alveolar septa expanded by a histiocyte-rich infiltrate with a few lymphocytes and neutrophils. The alveolar spaces were filled with moderate amounts of proteinaceous fluid, foamy macrophages, and a few neutrophils. Lungs from 3 of the 4 pups were test positive for canine distemper virus (CDV) by use of reverse transcriptase-polymerase chain reaction (RT-PCR) analysis. Immunohistochemically stained lungs, including those from the pup that were CDV negative, by use of RT-PCR analysis, were test positive for CDV antigen in bronchial and bronchiolar epithelial cells and in a few alveolar macrophages. Central nervous system lesions were not observed in any of the 4 pups. These cases represent an unusual presentation of canine distemper in neonatal pups marked by respiratory tract lesions without central nervous system involvement. Canine distemper should be considered in the differential diagnosis of neonatal canine respiratory tract illness.
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PMID:Interstitial pneumonia in neonatal canine pups with evidence of canine distemper virus infection. 1661 3

A 2-year-old, Quarter Horse filly was referred to Michigan State University, Veterinary Teaching Hospital with a 2-3 day history of depression and partial anorexia progressing to severe, watery diarrhea with severe neurologic abnormalities, including repetitive muscle fasciculations, muscle stiffening, and collapse. Laboratory findings included severe polycythemia, neutropenia, metabolic acidosis, and electrolyte and fluid loss, consistent with watery diarrhea and endotoxic shock. Increased creatine kinase and aspartate transaminase activities were consistent with recent transport and the muscle abnormalities. Severe hyperammonemia (1369.0 micromol/L; control value, 15.3 micromol/L) was found, without other substantial laboratory evidence of hepatic dysfunction. The horse was euthanized because of poor prognosis and rapid clinical deterioration. Necropsy findings were unremarkable with the exception of severe diffuse colitis. Culture of colonic contents recovered >1000 colony-forming units of Clostridium perfringens. Based on these findings, marked hyperammonemia in this filly was attributed to changes in colonic flora leading to increased bacterial production of ammonia that was readily absorbed through the inflamed bowel wall, exceeding the hepatic capacity for deamination. Intestinal bacteria as a source of hyperammonemia in the absence of hepatic disease has been linked rarely to positive culture results for clostridial organisms.
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PMID:Diarrhea and hyperammonemia in a horse with progressive neurologic signs. 1678 24


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