Pharmacotherapy of Amanita phalloides poisoning using silybin

A total of 18 cases of Amanita phalloides poisoning was treated by combined chemotherapy during 1980 and 1981. After attempted primary elimination of the toxin all patients received silybin as basic therapy mainly by infusion and, in two instances, silymarin orally. In order to investigate the effect of silybin therapy a retrospective study of the followed-up case records was made. The cases were arbitrarily classified into three groups of severity (light, medium and severe) according to clinical and laboratory findings. A close relationship was found between the severity of the intoxication and the time elapsed before commencement of silybin therapy. The time interval between mushroom intake and the commencement of the silybin administration averaged 71.5 hours in the "severe" group compared with 46 and 33.8 hours, respectively, in the "medium" and "light" groups. The mean silybin dosage was 33 mg/kg body weight/day; the mean duration of silybin therapy was 81.6 hours. With the exception of one fatality in a particularly high dosage suicidal intoxication, all patients survived. Administration of silybin within about 48 hours after mushroom intake seems to be an effective measure to prevent severe liver damage in Amanita phalloides poisoning.     

Amanita phalloides poisoning in Austria (author's transl)]

An analysis of 28 cases of amanita phalloides poisoning serves as basis for a discussion of the clinical features and therapeutic problems involved. A critical review of recent experimental investigations in animals points to new possibilities in the treatment of amanita phalloides poisoning.     

CLIF-OF >9 predicts poor outcome in patients with Amanita phalloides poisoning

PurposeAmanita phalloides poisoning with high mortality is rare but serious. The aim of this study is to identify the risk indicators of death in patients with Amanita phalloides poisoning and a good score tool to predict prognosis.MethodsIn this respective study (1/2009–12/2018), the patients (n = 105) with Amanita phalloides poisoning from two hospitals of China Medical University who met the inclusion/exclusion criteria were included. The laboratory markers and the clinical scoring systems including Child–Turcotte–Pugh (CTP), Sequential organ failure assessment (SOFA), Liver injury and Failure evaluation (LiFe), Chronic liver failure-organ failure score system (CLIF-OF), King's College criteria (KCH criteria), Model for end-stage liver disease (MELD) and Platelet-bilirubin-albumin (PALBI) within 24 h of admission to the two hospitals were analyzed and area under the curve (AUC) analyses were also performed regarding the prediction of death.ResultsThe data analysis indicated that high international normalized ratio (INR) (>3.6, AUC = 0.941) and plasma ammonia (>95.1 μmol/L, AUC = 0.805) were closely associated with mortality after multivariate logistic regression. CLIF-OF (>9) within 24 h with really good diagnostic accuracy (>90%) significantly outperformed the other scores in predicting mortality.ConclusionCLIF-OF (>9) within 24 h of admission is considered as a satisfactory and practical tool to predict a poor outcome of Amanita phalloides poisoning.     

Plasmapheresis in the treatment of Amanita phalloides poisoning: II. A review and recommendations.

Amanita phalloides poisoning is the most common cause of lethal mushroom poisoning (lethality >20% in adults, >50% in children). However, there is no standard treatment strategy and no antidote against the ensuing hepatic failure. This review of 14 investigations published over the last 20 years shows that the introduction of detoxification techniques, in particular the use of plasmapheresis, in combination with supportive therapy to prevent the absorption of aminitine toxins into blood, produced a substantial reduction in mortality. The main complications in using these techniques include infections and coagulation disorders. Because of the latency period in the development of symptoms, treatment should begin on the first suspicion that an intoxication is present. The best therapeutic results can be expected when the detoxification techniques are applied in combination with conservative therapies within the first 36--48 h. Using this approach, mortality rates in some recent studies have been below 10%.     

Retrospective evaluation of emergency service patients with poisoning: A 3-year study

The purpose of this retrospective study was to evaluate the characteristics of cases of acute poisoning in adults who were admitted to emergency service over a 3-year period. Clinical charts were analyzed retrospectively for etiologic and demographic patient characteristics. A total of 810 adults were admitted to the emergency center with acute poisoning. The female-to-male ratio was 2:1. Mean ages of female and male patients were 28.8±12.9 years and 35.1 ±15.4 years, respectively, and many patients (46.9%) were between the ages of 16 and 25 years. Medicinal drugs were found to be the primary cause (60.5%) of poisoning, and tricyclic antide-pressants were the most frequent causative agents (36.3%). Seasonal distribution of poisoning cases suggested a peak in the summer months (35.4%). Overall, 68.6% of acute poisonings were suicide attempts, and of these patients, 84.9%, 14%, and 1.1% were attempting suicide for the first, second, and third times, respectively. Among 810 cases of acute poisoning, 15 were fatal. The following conclusions were reached by investigators: (1) in the test region, younger females, especially single females, were at greater risk for poisoning than other patient groups, (2) self-poisoning cases constituted the majority of all poisonings, and (3) the main agents of self-poisoning were medicinal drugs, with antidepressants used most frequently. It was also found that unintentional poisoning commonly resulted from intake of foods, especially mushrooms.     

Treatment of patients with hypertonic disease with plasmapheresis

The paper presents a discussion on therapeutic results obtained with plasmapheresis treatment in 16 patients with stage II essential hypertension. Thirty-three comparable patients entered a control group of conventional treatment. The test and control patients with stage II hypertension were examined for time-course changes in T- and B-lymphocytes counts, the activity of the energetic enzymes (alpha-glycerophosphate dehydrogenase, succinic dehydrogenase, lactate dehydrogenase), serum immunoglobulins and circulating immune complex levels. It was established that the standard antihypertensive treatment failed to restore normal parameters of immunity and to favor positive alterations in the activity of the enzymes in the blood lymphocytes, whereas therapeutic plasmapheresis was found to stimulate immunity, especially cellular one. This occurred in line with a rise in the levels of lymphocytic dehydrogenases.     

Treatment of Goodpasture's syndrome with immunosuppression and plasmapheresis.

A 14-year-old boy with Goodpasture's syndrome induced by anti-glomerular-basement-membrane (gmb) antibody exhibited declining renal function, in association with a progressive increase in the level of serum anti-GBM antibody. Treatment with prednisone, cyclophosphamide, and plasmapheresis was associated with rapid disappearance of the serum anti-GMB antibody and temporary stabilization of renal function.     

Therapeutic plasmapheresis in geriatric patients: Favorable results

Therapeutic plasma exchange is generally a tolerable procedure, although several complications should be considered. Since geriatric population has been growing worldwide, the aim of this study was to retrospectively analyze 4709 TPE data from 981 geriatric procedures (20.8%) and to compare them with 3728 non-geriatric procedures (79.2%). The most common indications for TPE in both groups were sepsis/adult respiratory distress syndrome and multiple organ dysfunction. In geriatric patient group, contrary to expectations of aggravation, complication rate was statistically similar with non-geriatric group (P > 0.05). Therefore, TPE appeared to be a safe procedure in geriatric patients when performed by experienced practitioners.     

群发性急性砷化氢中毒的救治

目的探究群发性急性砷化氢中毒的临床特点及治疗。方法采用单纯药物及血浆置换等不同方法对36例急性群发性砷化氢中毒患者进行治疗,观察其急性溶血、肝脏、肾脏、心脏酶学等动态变化,以及血、尿砷浓度的清除情况。结果急性砷化氢中毒临床表现明显的接触时间-效应关系,血砷与尿砷浓度呈显著线性相关(r=0．718,P=0．019)。但血砷、尿砷浓度与临床中毒程度无明显相关性,血砷、尿砷浓度与肌酸激酶(CK)、乳酸脱氢酶(LDH)、碱性磷酸酶(ALP)、丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、α-羟丁酸脱氢酶(HHBD)、间接胆红素(TBIL)、直接红素(DBIL)、尿素氮(BUN)、肌酐(Cr)等均无相关性(P＞0．05);血浆置换治疗可快速控制溶血继续发生(24 h内溶血控制),缩短急性肾功能衰竭少尿期,同时血HBDH、AST、LDH、CK、IBIL、DBIL、BUN在治疗后12～72 h内快速下降(P＜0．05)。结论轻度急性砷化氢中毒单纯药物治疗预后良好,对急性重度砷化氢中毒血浆置换是治疗的有效手段之一,宜尽早使用。     

Early plasmapheresis in patients with thrombotic thrombocytopenic purpura.

OBJECTIVES: To investigate the relationship of thrombotic thrombocytopenic purpura to adult respiratory distress syndrome (ARDS) and study the responses of thrombotic thrombocytopenic purpura patients to early plasmapheresis. DESIGN: Case series. SETTING: ICU of a university hospital. PATIENTS: Twenty-four consecutive patients with thrombotic thrombocytopenic purpura, with various periods of time (1 to 18 days) having elapsed since the onset of this condition. Patients ranged in age from 17 to 66 yrs. INTERVENTIONS: Plasmapheresis, using intermittent flow separators, was instituted soon after the patients' ICU admission. The retinoscopic findings on admission and the relationship of Pao2 to platelet counts before and after plasmapheresis therapy were recorded. Antiplatelet agents were given to the survivors to prevent relapses. MEASUREMENTS AND MAIN RESULTS: Eighteen patients survived and six died. Plasmapheresis was administered for a range of 1 to 5 days (mean 3) and 3 to 18 days (mean 9.8) in survivors and nonsurvivors, respectively (p less than .001). Four patients with confluent fundus hemorrhages died and seven without these fundoscopic findings had easily controlled disease. Increases in Pao2 paralleled increases in platelet counts after plasmapheresis (p less than .001) in this small series of patients. Three of 18 discharged survivors relapsed over a period of 3 to 56 months of follow-up. CONCLUSIONS: Early introduction of plasmapheresis in thrombotic thrombocytopenic purpura seems to increase the survival rate and to halt the development of ARDS. Fundus findings may be a prognostic factor in thrombotic thrombocytopenic purpura. The antiplatelet agents seem to be efficacious in the prevention of relapses.     

Goodpasture's syndrome in childhood: Treatment with plasmapheresis and immunosuppression

Goodpasture's syndrome rarely affects children. Therefore, we present our experience in a young boy whose pulmonary hemorrhage was dramatically resolved by three plasma exchanges. We believe the hemorrhage was caused primarily by acute capillaritis. He received cytoxan and steroids and a series of plasma exchanges which removed/suppressed his anti-glomerular basement membrane (anti-GBM) antibody production. However, after a year, his renal function did not return, and he required renal transplantation and continues to do well.     

Adipose replacement and wall motion abnormalities in right ventricle arrhythmias: evaluation by MR imaging. Retrospective evaluation on 124 patients

We reevaluated the magnetic resonance (MR) examinations of 38 healthy volunteers (control group, CG) and of 124 patients with RV arrhythmia with left bundle branch block (LBBB) morphology: 45 with episodes of RV sustained tachycardia and of polymorphic RV premature beats (RVST-PPB group); 36 with only RV outflow tract sustained or not sustained tachycardia (RVOTT group); 43 with RV monomorphic premature beats (RVMPB group). All the examinations were reevaluated in a blinded fashion for detecting myocardial adipose replacement (AR) and wall bulges or aneurysms. In RVST-PPB patients, no AR was observed in 9%; 1 RV region involvement, 0%; 2 regions, 4%; ≥ 3 regions, 87%; left ventricle (LV), 15%. RVOTT patients: 28%, 53%, 14%, 5%, and 0%, respectively. RVMPB patients: 33%, 46%, 19%, 2%, and 0%, respectively. In CG, AR was observed in 11% (in RV outflow tract). RV bulges were detected in 75% of RVST-PPB , 39% of RVOTT, and 14% of RVMPB patients, none of the CG; RV aneurysms in 33% of RVST-PPB patients, none of RVOTT patients, RVMBP patients, and CG. A significant difference among groups for RV and LV AR as well as RV bulges and aneurysms was found (p < 0.0001). In the direct comparisons, significant differences were found for: disease duration (RVST-PPB vs. RVMPB, p = 0.0396); RV AR (all the patients groups vs. CG, RVST-PPB vs. RVOTT or RVMPB, p < 0.0001); RV aneurysms (RVST-PPB vs. CG. RVST-PPB vs. RVOTT or RVMPB, p < 0.0002); bulges (all comparisons, p < 0.0174). AR is confirmed as a structural substrate in RV arrhythmias. Number and extension of MR abnormalities are correlated to different degrees of RV arrhythmias.     

Adipose replacement and wall motion abnormalities in right ventricle arrhythmias: evaluation by MR imaging. Retrospective evaluation on 124 patients

We reevaluated the magnetic resonance (MR) examinations of 38 healthy volunteers (control group, CG) and of 124 patients with RV arrhythmia with left bundle branch block (LBBB) morphology: 45 with episodes of RV sustained tachycardia and of polymorphic RV premature beats (RVST-PPB group); 36 with only RV outflow tract sustained or not sustained tachycardia (RVOTT group); 43 with RV monomorphic premature beats (RVMPB group). All the examinations were reevaluated in a blinded fashion for detecting myocardial adipose replacement (AR) and wall bulges or aneurysms. In RVST-PPB patients, no AR was observed in 9%; 1 RV region involvement, 0%; 2 regions, 4%; ≥3 regions, 87%; left ventricle (LV), 15%. RVOTT patients: 0%, 53%, 14%, 5%, and 28%, respectively. RVMPB patients: 0%, 46%, 19%, 2%, and 33%, respectively. In CG, AR was observed in 11% (in RV outflow tract). RV bulges were detected in 80% of RVST-PPB, 39% of RVOTT, and 14% of RVMPB patients, none of the CG; RV aneurysms in 33% of RVST-PPB patients, none of RVOTT patients, RVMBP patients, and CG. A significant difference among groups for RV and LV AR as well as RV bulges and aneurysms was found (p < 0.0001). In the direct comparisons, significant differences were found for: disease duration (RVST-PPB vs. RVMPB, p = 0.0396); RV AR (all the patients groups vs. CG, RVST-PPB vs. RVOTT or RVMPB, p < 0.0001); RV aneurysms (RVST-PPB vs. CG, RVST-PPB vs. RVOTT or RVMPB, p < 0.0002); bulges (all comparisons, p < 0.0174). AR is confirmed as a structural substrate in RV arrhythmias. Number and extension of MR abnormalities are correlated to different degrees of RV arrhythmias.     

Treatment of pruritus and polyneuropathy in patients with chronic renal failure by intermittent plasmapheresis

Fourteen patients with chronic renal failure treated with hemodialysis received intermittent plasmapheresis with the purpose of treating skin pruritus and polyneuropathy. Skin pruritus and polyneuropathy were completely eliminated in 10 patients, the intensity of pruritus could be considerably reduced in 3 patients, and one patient did not respond to the treatment. About half of the procedures were carried out on an outpatient basis. No serious complications mandating the procedure discontinuation were noted.