Aluminium phosphide (AlP) is a highly toxic pesticide that inhibits cytochrome oxidase c and causes oxidative stress. Death results from refractory cardiogenic shock due to myocardial dysfunction. There is very little information regarding extracorporeal life support in severe AlP poisoning. Although several therapies are available, none are curative. We report on the use of an intra-aortic balloon pump (IABP) in a 24-year-old woman brought to our hospital after an intentional ingestion of a tablet of AlP (3 g), which caused refractory AlP-induced cardiogenic shock and acute respiratory distress syndrome (ARDS). The patient underwent gastric lavage with potassium permanganate, received sodium bicarbonate intravenously, and was admitted to the intensive care unit. Echocardiography at 36 h post ingestion showed a left ventricular ejection fraction (LVEF) of <20 %. An IABP was inserted and the patient's vital signs stabilised. After eight days, the IABP was removed and on day 20, the patient's LVEF increased to 50 %. IABP was successfully used and may improve future prognoses for severely poisoned AlP patients with refractory cardiogenic shock. We encourage clinical toxicologists to examine this new treatment.

BackgroundLead (Pb) poisoning among people using opium has been an increasing problem in Iran. The present study highlights the clinical effects of lead toxicity associated with opium use in Iran, Kerman province.MethodsBetween January 2016 and June 2016, patients with signs and symptoms of Pb poisoning were questioned to assess whether they had a history of opium dependency. In total, 249 patients were enrolled onto this cross-sectional study, all were opium dependent. Para-clinical data including blood lead level (BLL), demographic information, user preferences, and symptoms were obtained.ResultsThe patients used either opium (83.9%), refined opium (6.4%) or a combination of both (9.7%) via ingestion (71.9%), smoking (8.4%) or a combination of both (19.7%). The overall median BLL was 80.0 μg/dL [IQR: 51.7–119.0]. The median BLL did not differ significantly between opium and refined opium users. Further, BLL was not significantly affected by the type of substance, route of use, duration of use, or daily quantity consumed. Common symptoms included abdominal pain (86.9%), constipation (75.8%), anorexia (71.5%) and nausea (54.7%). Linear regression analysis showed log of BLL was significantly associated with abdominal pain, myalgia and anorexia.ConclusionsThe study unravelled an increase in opium-related Pb poisoning in the Kerman province. Raised awareness of this emerging Pb source and investigation of its aetiology is recommended. Pb poisoning should be considered among the primary differential diagnosis of opium users with gastrointestinal symptoms.

Aluminium phosphide (AlP) is used to protect stored grains from rodents. It produces phosphine gas (PH3), a mitochondrial poison thought to cause toxicity by blocking the cytochrome c oxidase enzyme and inhibiting oxidative phosphorylation, which results in cell death. AlP poisoning has a high mortality rate among humans due to the rapid onset of cardiogenic shock and metabolic acidosis, despite aggressive treatment. We report a 21-year-old male who was referred to the Afzalipour Hospital, Kerman, Iran, in 2015 after having intentionally ingested a 3 g AlP tablet. He was successfully treated with crystalloid fluids, vasopressors, sodium bicarbonate, digoxin, glucagon and antioxidant agents and was discharged from the hospital six days after admission in good clinical condition. For the treatment of AlP poisoning, the combination of glucagon and digoxin with antioxidant agents should be considered. However, evaluation of further cases is necessary to optimise treatment protocols.

BackgroundThallium (Tl) is a toxic heavy metal that exists in nature. Tl poisoning (thallotoxicosis) may occur in opioid addicts. This study was designed to evaluate the frequency and level of urinary Tl in opioid abusers. In addition, clinical findings were evaluated.MethodsA total of 150 subjects were examined. Cases with a history of at least 3 years of abuse were admitted in the Imam Reza Hospital as the case group; 50 non-opioid abusers from the target population were included as the control group. Twenty-four hour urinary qualitative and quantitative Tl analyses were performed on both groups.ResultsOut of the 150 subjects, 128 (85 %) were negative for qualitative urinary Tl, followed by 5 % (trace), 7 % (1+), 2 % (2+), and 1 % (3+). Mean (standard error (SE), Min–Max) quantitative urinary Tl level was 14 μg/L (3.5 μg/L, 0–346 μg/L). Mean urinary Tl level in the case group was 21 μg/L (5 μg/L, 0–346 μg/L) and that in the controls was 1 μg/L (0.14 μg/L, 0–26 μg/L), which were significantly different (P = 0.001). The most frequent clinical findings were ataxia (86 %), sweating (81 %), and constipation (54 %). In all cases (n = 150), the mean (SE) value for cases with positive qualitative urinary Tl was 26.8 μg/L (0.9 μg/L) and that in the negative cases was 2.3 μg/L (0.2 μg/L), which were significantly different (P = 0.002).ConclusionsThis study showed that long-term opioid abuse may lead to Tl exposure. In opioid abusers with the clinical manifestation of thallotoxicosis, urinary Tl should be determined.

Key Clinical MessageZinc phosphide (Zn3P2/ZnP) is used as a rodenticide. The most common signs of toxicity are nausea, vomiting, hypotension, and metabolic acidosis; patients presenting such signs are referred to the emergency department (ED) of the hospitals. Therefore, this study aimed to report two cases of hepatotoxicity following accidental and intentional ZnP poisoning and successful management with N‐acetylcysteine (NAC).