Rationale:Paraquat, an agent highly toxic to humans and animals, is a widely used herbicide and also commonly used for suicide attempts in Taiwan. The most common route of intoxication is oral ingestion, and parenteral poisoning is respectively rare.Patient concerns:A 39-year-old illicit abuser of heroin and amphetamine injected 0.5 mL of 24% paraquat directly into his right cephalic vein due to hallucination. The patient was brought to our emergency department for management 4 hours after injection. He was fully conscious and had normal vital signs. Systemic review showed mild dyspnea, abdominal pain and right wrist pain over the injection site. The only abnormal physical finding was erythema over the injection site and epigastric tenderness.Diagnosis:Laboratory investigations, including complete blood count, liver and renal function, and electrolytes initially yielded normal results. Urinalysis showed normal findings except a positive urine paraquat test (4+). The initial plasma paraquat concentration was 0.51 μg/mL.Interventions:He was admitted to the intensive care unit and underwent one session of charcoal hemoperfusion therapy. Acute kidney injury developed on the fourth day after intoxication, with the level of serum creatinine rising rapidly from 0.96 to 4.57 mg/dL and the daily urine output decreased noticeably from > 2000 to 900 mL. The serum creatinine level improved gradually with adequate fluid supplementation.Outcomes:The patient was discharged 13 days later in a stable condition.Lessons:Intravenous paraquat intoxication is rare. Patients who suffer from intravenous intoxication may not directly suffer from mucosal irritation, but the clinical onset of systemic effects is more immediate and lethal. The prognosis of paraquat poisoning is determined by the time of poisoning and the plasma paraquat concentration before treatment. Proudfoot's curve provides a simple method of predicting the survival rate. The most effective mode of management is extracorporeal therapy, and immunosuppressive or antioxidant therapies have shown insufficient evidence of benefit.

Rationale:Spinal cord injuries could be catastrophic because they may result in severe neurovascular complications. Here, we present a case of thoracic spine-penetrating injury by a nail-gun.Patient concerns:A 60-year-old male presented to our emergency department with complaints of progressive right chest pain for 1 week that was preceded by back pain. He had a medical history of hypertension and denied any trauma history. He had alert consciousness and stable vital signs. He was a carpenter. Upon physical and neurological examination, no obvious wounds or vesicle formation were noted, and the patient was neurologically intact.Diagnosis:Laboratory test results showed abnormally elevated D-dimer levels. Electrocardiography showed normal sinus rhythm. Chest radiography showed no mediastinal widening. Chest computed tomography was performed. The formal radiology report indicated a foreign body in the T4-5 spinal cord and upper back.Interventions:A neurosurgeon was consulted with suggestion of operation. We performed T4-5 laminectomy and foreign body removal. The foreign body, stuck to the spinal cord with dural rupture, was removed and found to be a 5 cm-long broken nail.Outcomes:The pain resolved immediately post operation.Lessons:Surgical removal of the foreign body is recommended if neurovascular complications or cerebrospinal fluid (CSF) leak is detected. Obtaining the patient's complete history, including occupation, might be helpful in determining the diagnosis. Careful interpretation of diagnostic imaging is necessary for avoiding medical disputes. Even in the absence of wounds and ecchymosis, trauma-related injury should be considered.

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