Transcript 0629 toxi

2012.06.29
指導醫師：顏宗海醫師
報告者：fellow 1 陳筱惠
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Name: 李o榮
Sex: male
Age: 60 years old
Chart number: 20222571
Date of admission: 2012/05/03
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Hematemesis at afternoon
Underlying diseases: diabetes mellitus
 Chinese herb intake at 1pm  nausea, then
vomiting few times with fresh blood
 Abdominal pain, hematuria, bloody stool, dyspnea,
shock, and consciousness disturbance developed at
ER.
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 Lab data: leukocytosis, left shift and AKI, RIFLE-I, with
lactic acidosis
Intubation for impending respiratory failure at ER.
 Herb was identified as 斑螫.
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He had diabetes mellitus, but denied other
significant systemic diseasess, such as
heart, kidney, lung diseases, or bleeding
diathesis.
Operation history: nil
Current medicine: oral hypoglycemia
agent
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Allergy: no known allergy
Alcohol: denied; betel-nut: denied; cigarette:
denied
Over-the-counter medication or chinese herb:
sometimes
No other family members took the chinese herb,
like him.
 No family history of malignancy, heart, liver,
kidney, or hereditary diseases
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Vital signs: blood pressure: 234/138mmHg; temperature: 36’C;
pulse rate: 69/min; respiratory rate: 20/min
General appearance: acute ill looking
Eye: conjunctiva: not pale, sclera: no icteric
Neck: supple, no lymphadenopathy or jugular vein engorgement
Chest: symmetric expansion
breathing sound: bilateral clear, no wheezing or crackles
heart sound: regular heart beats, no S3 or S4, no
murmurs
Abdomen: soft, not distended, no tenderness
liver/spleen: impalpable
bowel sound: normoactive
Extremities: no muscle weakness or lower limb pitting edema
Skin: intact, no rash
WBC
28.2x1000/ul
Hgb
19.0 g/dl
PLT
150 x1000/uL
Myelocyte
0.5 %
Segment
90.0 %
Band
3%
Monocyte
3.5 %
Lymphocyte
3.0 %
Eosinophil
0.0 %
Basophil
0.0 %
INR
1.1
aPTT
29.6
Fibrinogen
196 mg/dl
Nor. Plasma mean
27.4
FDP
> 80 ug/ml
Urea N
20.5 mg/dl
Creatinine
1.89 mg/dl
GPT
26 IU/L
NA
138 mEq/L
K
4.7 mEq/L
PH
7.175
PaO2
107.8 mmHg
PaCO2
18.8 mmHg
HCO3
6.8 mm/L
Sa02
96.8 %
Cholinesterase
7.85 IU/ml
Salicylate
< 0.5 mg/dl
Pb
1.5 ug/dl
Cd
0.27 ug/dl
Hg
5.8 ug/dl
As
10.8 ug/dl
Cu
43.6 ug/dl
Lactate
84.0 mg/d
Methanol
< 0.1mg/dl
Myoglobin
992.4 ng/ml
Color
Red
Blood
3+
Turbidity
Bloody
RBC
>500/uL
SP. Gravity
1.020
WBC
5/uL
PH
7.5
Epithelial cell
1/uL
Leukocyte
-
Nitrite
-
Protein
3+
Glucose
1+
Ketone
-
Urobilinogen
0.1
Bilirulin
-
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Cantharidin poisoning, complicated with UGI
bleeding, hematuria, shock, acute kidney
injury, and lactic acidosis
Diabetes mellitus
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Temporal hemodialysis and hemoperfusion
for 6 hours on 5/3
Expired on 5/4
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斑蝥：鞘翅類，屬芫菁科斑蝥的乾燥蟲體。
其味辛性寒，有毒。有效成分為班蝥素。臨床
上主要外用於疥癬、惡瘡、疣痣。因其毒性大
，很少用於內服。
斑蝥素有抑制腫瘤細胞生長、抗皮膚真菌的作
用，所以也用於治療癌瘤、皮膚病、關節炎等
。
斑螯素的致死量為30mg，口服斑螯0.6g可出現中
毒症狀，1.5-3g可致死。
 對組織和黏膜有很強的腐蝕作用，口服10min至
2hr出現口腔、咽喉燒灼感，麻木，口腔潰爛，流
涎，惡心、嘔吐，腹痛、腹瀉，便血。
 嚴重中毒時譫語、痙攣、血壓下降、大汗、少尿
、血尿等，可因急性腎功能衰竭或全身衰竭而死
亡。
 外用多在2h後出現中毒症狀，有報導外用斑螯
15.6g出現局部紅腫，起大水泡，潰瘍，疼痛，
4hr後死亡。
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西班牙蒼蠅：奇摩知識
用途：強力催情
西班牙蒼蠅水會不會有副作用？
----肯定的回答，沒有！
西班牙原裝進口………
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Cantharidin: 斑螫素, well known toxin and
vesicant
 The active ingredient of ‘’Spanish Fly‘’
 Derived from the powder of the dried blister
beetle Cantharis vesicatoria (斑螫) or several
other species of beetles
 Odorless and colorless crystal, poorly soluble in
water, and slightly soluble in alcohol, acetone,
ether, and fats
 Bind to albumin when entering circulation
 Form a biologically active, water-soluble salt
when reacting with alkali
 Eliminated slowly by the kidneys
 The male beetle synthesizes it for defense
mechanism, and the female acquires it when
copulatoion.
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Used by herbalists in Southern Africa
 Abortifacients
 Claimed aphrodisiac effects in males
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Chinese traditional medicine for more than
2000 years
In dermatology, a vesicant for the treatment
of warts and molluscum
 FDA has proposed that cantharidin should be
limited to “topical use in the professional office
setting only.”
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Blister beetle dermatosis:
 Vesiculobullous skin disorder, occurs several hours
after contacting the insect
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As little as 10 mg of the pure chemical
causing death in an adult (10-65mg, 1 mg/kg;
Most beetles of the Mylabris species contain
not less than 1% cantharidin, 0.6~5% of dry
body weight.)
Potent inhibitor of both protein phosphatases
types 1 and 2A
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S/S:
 Vomiting, GI bleeding, abdominal pain,
haematuria: mucosa irritation
 Proteinuria, renal dysfunction, oligurin: acute
tubular necrosis and glomerular destruction
 Coagulopathy, seizures, and a Guillain-Barre´–like
flaccid paralysis
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For topical exposures:
 Acetone, fatty soap, or alcohol to clean
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No known antidote
For oral ingestions:
 Swallow generous quantities of water
 Avoid fatty foods (such as milk), because they
increase cantharidin absorption
 Gastric lavage: patients who present early and do
not have severe esophageal involvement
 Activated charcoal: no evidence that cantharidin
binds to this material
 Symptomatic and supportive care: replace fluids
and electrolytes
 Alkinasation to reduce nephrotoxicity??
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Cantharidin poisoning due to ``Blister beetle'‘
ingestion
Toxicon 38 (2000) 1865-1869
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Cantharidin Revisited
ARCH DERMATOL/VOL 137, OCT 2001
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Poisoning From "Spanish Fly" (Cantharidin)
Am J Emerg Med 1996;14:478-483