Mustard gas is a weapon, but also a prevalent environmental threat. Recognizing the immense environmental presence of mustard gas disposal sites and the signs and symptoms of exposure will help speed treatment to those accidentally or purposefully exposed.

Metabolic bone disease (MBD) refers to the conditions that produce a diffuse decrease in bone density and strength because of an imbalance between bone resorption and bone formation. MBD can be a potential complication in patients receiving chronic parenteral nutrition (PN) therapy and the management of this condition presents a challenge for many clinicians. The etiology of PN-associated MBD is poorly understood, but traditional risk factors can include malnutrition, vitamin and mineral deficiencies, toxic contaminants in the PN solution, concomitant medications, and presence of certain disease states. Although additional studies are warranted to further elucidate the development and management of this condition, the following review discusses some of the important factors that may play a role in the genesis of PN-associated MBD and evaluates some potential strategies for the diagnosis and treatment of this complication.

Case: A 33-year-old male presented to the emergency department with complaints of polydipsia, polyuria, nausea, headaches, blurry vision and malaise. Lab work revealed a serum glucose level of 1166 mg/dl (64.8 mmol/L). The patient admitted to completing a cycle of androgenic anabolic steroids (AASs) for bodybuilding. His regimen consisted of supraphysiologic intramuscular injections of a bovine growth hormone, trenbolone acetate and testosterone. The patient received intravenous fluids and insulin to restore metabolic balance. Previously healthy with a non-contributory family history, he was diagnosed with new onset diabetes. Discussion: It has been demonstrated that AAS use, specifically growth hormone, can affect glucose homeostasis through increasing cellular insulin resistance and reducing glucose uptake. Excess growth hormone has been shown to cause symptoms of acromegaly which predisposes up to 40% of patients to diabetes. As trenbolone acetate is not indicated for human use and athletes are known to use supraphysiologic doses of this underground, performance enhancing drug, the correlation of the timing of events and the use of this veterinary growth hormone likely exacerbated an underlying condition or caused this new onset diabetes. Conclusion: We report a case of a young bodybuilder with no significant past medical history who was diagnosed with new onset diabetes associated with supraphysiologic self-injections of the bovine growth hormone, trenbolone acetate, combined with testosterone. AAS have the potential to induce or exacerbate diabetic conditions due to decreased glucose tolerance and increased insulin resistance.

BackgroundWith upwards of 48% of human immunodeficiency virus (HIV)-infected persons having a probable psychiatric disorder, the possibility of cross-class drug interactions causing adverse effects or fatalities exists.AimsThis report discusses an emergent case of low-flow priapism caused by an interaction between a previously prescribed combination protease inhibitor (PI) and newly added antipsychotic medications.MethodsA 50-year-old HIV-positive man on highly active antiretroviral therapy (HAART), including the combination PI, lopinavir/ritonavir (Kaletra®), experienced an episode of priapism hours after beginning two new antipsychotic medications. Quetiapine (Seroquel®) and perphenazine (Trilafon®) were added to treat a diagnosed schizoaffective disorder.ResultsThe patient presented to the emergency department complaining of a constant, painful erection lasting approximately 42 h. Treatment with intracavernous ephedrine, irrigation, and aspiration helped achieve detumescence.ConclusionThis case displays the immediate and detrimental effects due to the addition of antipsychotic medications to previously altered cytochrome P450 (CYP450) enzyme levels. The inhibition of CYP450 enzymes 3A4 and 2D6 by the combination PI, lopinavir/ritonavir, was likely the major culprit in causing greater than expected free levels of perphenazine and quetiapine resulting in priapism.