Journal of Medical Toxicology最新文献

{"title":"Clinical Presentation of Medetomidine-Involved Opioid Overdoses-Chicago, 2024.","authors":"Kimberly Gressick, Shawn A Thomas, Amy Nham, John N Le, Maria Fiorillo, Livia Verklan-McInnes, Joshua G Schier, Alana Vivolo-Kantor, Axel Adams, Michael Wahl, Jean Y Ko, Miao Hua","doi":"10.1007/s13181-026-01148-2","DOIUrl":"10.1007/s13181-026-01148-2","url":null,"abstract":"<p><strong>Introduction: </strong>Medetomidine, an alpha-2 adrenergic agonist, emerged as a U.S. drug adulterant in 2022. In May 2024, the Chicago Department of Public Health identified a cluster of opioid overdoses with unusual clinical features linked to medetomidine.</p><p><strong>Methods: </strong>We performed a retrospective chart review of patients presenting to three Chicago emergency departments with suspected opioid-involved overdoses during May 11-17, 2024. We classified cases as confirmed, probable, or suspected based on independent clinical criteria and laboratory screening results. We performed descriptive statistics and exploratory logistic regression to assess the association between case status and hospital outcomes.</p><p><strong>Results: </strong>Out of 181 patients presenting with suspected opioid-involved overdoses during the one-week window, 15 patients identified during the initial phase of the outbreak underwent supplemental testing, yielding 12 laboratory-confirmed cases of medetomidine exposure. In patients with confirmed medetomidine exposure (n = 12), all exhibited persistent altered mental status despite naloxone administration and demonstrated marked hypertension at presentation. Bradycardia was present in 9 patients (75%). Compared to suspected cases, confirmed or probable cases had a higher odds of experiencing asymptomatic markedly elevated blood pressure (OR = 3.2, 95% Cl = 1.5-6.9), hospital admission (OR = 3.2, 95% Cl = 1.4-7.3), and admission to intensive care (OR = 4.0, 95% Cl = 1.4-11.8).</p><p><strong>Conclusion: </strong>Patients with confirmed medetomidine exposure demonstrated a toxidrome characterized by initial asymptomatic markedly elevated blood pressure, bradycardia, and a prolonged altered mental status requiring clinical stabilization. The increased likelihood of hospital and intensive care unit admission observed in this outbreak highlights the need for heightened clinical awareness and preparedness.</p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"423-429"},"PeriodicalIF":2.0,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13633185/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148669890","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Biostatistics and Epidemiology for the Toxicologist - Testing for Independence between Two Variables: The Fisher's Exact Test.","authors":"Natalie M Bertrand, Mark K Su","doi":"10.1007/s13181-026-01157-1","DOIUrl":"10.1007/s13181-026-01157-1","url":null,"abstract":"","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"501-503"},"PeriodicalIF":2.0,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13633191/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149008728","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Acrodynia and CASPR2 Autoimmunity in Elemental Mercury Toxicity.","authors":"Sammy Taha, Alexander Sidlak, Meenu Krishnasamy, Megan Aidoo, Kelly Johnson-Arbor, Megan Bauer, Katharine Wallen, Alfredo Caceres","doi":"10.1007/s13181-026-01160-6","DOIUrl":"10.1007/s13181-026-01160-6","url":null,"abstract":"<p><p>Elemental mercury exposure is associated with neurologic manifestations, which can improve after source removal with time. Autoimmune complications from mercury intoxication are rarely reported and may lead to worsening or persistent neurologic symptoms. A 2-year-old girl, in addition to her parents and sibling, developed cough and congestion initially attributed to a respiratory infection. For the next month, the child experienced intermittent episodes of sweating and increased fussiness, then later developed a pruritic erythematous rash to her distal extremities. She was hospitalized and, after toxicology testing revealed elevated whole blood (11 mcg/L) and urine mercury concentrations (79 mcg/g Cr), was treated with oral dimercaptosuccinic acid (DMSA). The source of mercury exposure was later identified as an accidental spill of elemental mercury that occurred in her residence weeks before the onset of her symptoms. Her family temporarily moved away from their residence while mercury remediation was initiated, but continued episodes of altered mental status necessitated hospital readmission. A lumbar puncture was performed, additional chelation with N-acetylcysteine was administered, and an autoimmune encephalitis panel was sent to a reference laboratory. The patient's repeat urine mercury concentration was undetectable, but she had still not returned to her baseline mental status. The autoimmune encephalitis panel was positive for contactin-associated protein 2 (CASPR2) IgG antibodies. After treatment with intravenous immunoglobulin, high-dose methylprednisolone, and oral prednisolone, her mental status gradually improved and returned to baseline over the next several weeks. CASPR2-IgG autoimmune encephalitis is a rare complication of elemental mercury intoxication, characterized by neuropsychiatric symptoms that persist despite traditional chelation treatment and systemic clearance of mercury. Treatment of affected patients may involve the administration of intravenous immunoglobulin and high-dose corticosteroids.</p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"493-497"},"PeriodicalIF":2.0,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13633214/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149075100","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Kratom-Associated Pulmonary Toxicity: A Systematic Review of Case Reports and Forensic Series with a Proposed Clinical Phenotype Classification.","authors":"Venkatkiran Kanchustambham, Swetha Saladi","doi":"10.1007/s13181-026-01153-5","DOIUrl":"10.1007/s13181-026-01153-5","url":null,"abstract":"<p><strong>Introduction: </strong>Kratom use has increased, including concentrated 7-hydroxymitragynine products, but pulmonary toxicity has not been systematically synthesized.</p><p><strong>Methods: </strong>We systematically reviewed human case reports, conference abstracts, and forensic/autopsy series describing pulmonary outcomes after kratom, mitragynine, or 7-hydroxymitragynine exposure (PROSPERO CRD420261427143). Five databases were searched through 24 June 2026. Two reviewers independently screened, extracted, and appraised reports; causality was graded using Naranjo criteria for clinical reports and WHO-UMC criteria for forensic reports. Synthesis was narrative.</p><p><strong>Results: </strong>Twenty-four reports were included: 14 clinical and 10 forensic. Five categories were identified in two tiers: primary pulmonary syndromes-diffuse alveolar hemorrhage (n = 3), acute respiratory distress syndrome (ARDS)/diffuse acute lung injury (n = 3), and eosinophilic/hypersensitivity pneumonitis (n = 2)-and secondary consequences of systemic toxicity-central respiratory depression (n = 6) and post-mortem pulmonary edema/congestion (n = 10). All clinical patients survived; all forensic decedents died. Attribution was Probable in 9 reports, Possible in 13, and Unlikely in 2. Pulmonary edema/congestion was the most common forensic finding but was nonspecific; single-agent fatalities had high mitragynine concentrations (2,325-7,500 ng/mL).</p><p><strong>Conclusions: </strong>Reported kratom-associated pulmonary presentations cluster into five provisional, hypothesis-generating categories spanning primary lung injury and secondary systemic effects. Clinicians should consider kratom and 7-hydroxymitragynine in unexplained acute lung injury, alveolar hemorrhage, eosinophilic pneumonitis, or opioid-type respiratory depression; targeted toxicology and standardized reporting are needed to refine this framework.</p><p><strong>Registration: </strong>PROSPERO CRD420261427143.</p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"480-489"},"PeriodicalIF":2.0,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13633207/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148840344","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Octreotide Administration Methods in Sulfonylurea Poisoning: A Retrospective Chart Review.","authors":"Mayank Gupta, David Kuai, Nicole McElroy, Joseph Carpenter","doi":"10.1007/s13181-026-01156-2","DOIUrl":"10.1007/s13181-026-01156-2","url":null,"abstract":"<p><strong>Introduction: </strong>Octreotide is used to treat sulfonylurea induced hypoglycemia, but the effectiveness of intravenous bolus, intravenous infusion, and subcutaneous routes of octreotide administration has not been compared.</p><p><strong>Methods: </strong>This is a multi-center, retrospective chart review of patients with suspected sulfonylurea induced hypoglycemia who received octreotide, comparing intravenous bolus, intravenous infusion, and/or subcutaneous routes of octreotide administration. The primary outcome was number of hypoglycemic events after octreotide initiation. Secondary outcomes included total octreotide dose, dextrose administered before and after first octreotide dose, and hospital length of stay.</p><p><strong>Results: </strong>Of 29 included cases, the intravenous bolus group had 10 patients, intravenous infusion group had four patients, and the subcutaneous group had 15 patients. Median post-octreotide hypoglycemic events were zero, 1.5, and zero for bolus, infusion, and subcutaneous groups, respectively. Median total octreotide dose was 50 mcg [IQR: 49 - 100 mcg], 693 mcg [IQR: 402 - 939 mcg], and 100 mcg [IQR: 50 - 150 mcg] for bolus, infusion, and subcutaneous groups, respectively. The bolus (115 grams [41 - 152 grams]) and subcutaneous groups (80 grams [53 - 189 grams]) received less post-octreotide dextrose than the infusion group (256 grams [86 - 560 grams]). Median length was 40, 60, and 62 hours between the bolus, infusion, and subcutaneous groups, respectively.</p><p><strong>Conclusion: </strong>The infusion group had a higher incidence of hypoglycemia and received more post-octreotide dextrose than intravenous bolus or subcutaneous groups, despite a larger total octreotide dose. These findings suggest octreotide infusions may be inferior, but further studies are needed to determine the optimal octreotide administration route for sulfonylurea induced hypoglycemia.</p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"415-422"},"PeriodicalIF":2.0,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13633227/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148880787","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Adult U.S. Poison Center Exposure Case Trends Involving Nonprescription Dextromethorphan Amid the COVID-19 Pandemic: a Quasi-experimental Interrupted Time Series Study.","authors":"Sara Karami, Christian Angelo I Ventura, Ellen Pinnow, Nana Dwumfour, Ajoa Asonye, Gerald Dal Pan, Esther H Zhou","doi":"10.1007/s13181-026-01159-z","DOIUrl":"10.1007/s13181-026-01159-z","url":null,"abstract":"<p><strong>Introduction: </strong>Nonprescription dextromethorphan (DXM) is widely available in the United States and was commonly recommended for managing dry cough associated with COVID-19. This retrospective study of Poison Center data evaluated whether the COVID-19 pandemic impacted monthly adult exposure case trends involving nonprescription DXM cold and cough preparations.</p><p><strong>Methods: </strong>We performed interrupted time series analyses using a pre-pandemic baseline period of January 2015-February 2020, and pandemic period of April 2020-April 2023. The pandemic's immediate impact (level change, March 2020) and sustained trend effects were modeled separately by exposure reason categories.</p><p><strong>Results: </strong>Monthly nonprescription DXM exposure cases declined immediately at the pandemic's onset, and remained low for approximately one year across all age and sex subgroups. Unintentional-therapeutic error exposures subsequently rebounded for some subgroups, particularly females (+ 3 cases/month; 95% CI: 2.7-3.4; p < 0.0001), surpassing pre-pandemic levels by the study's end. Intentional-abuse/misuse exposures had been dramatically declining pre-pandemic; significant trend increase changes were observed among males (+ 0.8 cases/month; 95% CI: 0.5-1.1; p < 0.0001) and adults aged 18-29 years (+ 0.9 cases/month; 95% CI: 0.7-1.1; p < 0.0001) during the pandemic, though the absolute magnitude of these changes was small and warrant cautious interpretation.</p><p><strong>Conclusions: </strong>Nonprescription DXM exposures declined sharply at the pandemic's onset, with unintentional-therapeutic errors subsequently rebounding - especially among females - surpassing pre-pandemic levels toward the end of the pandemic's public health emergency declaration, while intentional exposures showed modest changes following initial declines. These findings underscore the need for targeted prevention strategies regarding inappropriate nonprescription DXM use and enhanced medication safety messaging during prolonged public health crises.</p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"448-460"},"PeriodicalIF":2.0,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13633208/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149030772","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Practice Variation in the Pharmacologic Management of Severe Alcohol Withdrawal: a Survey of Medical Toxicology and Critical Care Physicians.","authors":"Anthony F Pizon, David T Huang, Timothy D Girard","doi":"10.1007/s13181-026-01161-5","DOIUrl":"https://doi.org/10.1007/s13181-026-01161-5","url":null,"abstract":"<p><strong>Background: </strong>Severe alcohol withdrawal is associated with substantial morbidity, mortality, and resource utilization, yet evidence guiding optimal pharmacologic management remains limited. Although benzodiazepines have traditionally been recommended as first-line therapy, current professional guidelines vary. The overall aim is to determine if treatment heterogeneity or practice patterns exist for severe alcohol withdrawal.</p><p><strong>Methods: </strong>A scenario-based, self-administered survey of attending physicians who regularly treat severe alcohol withdrawal was performed. Survey invitations were distributed to members of the American College of Medical Toxicology and the University of Pittsburgh Medical Center ICU Service Center. Questions assessed initial medication choice, dosing, drug changes after inadequate response, assessment tools, strategies, physician demographics, and willingness to participate in future clinical trials.</p><p><strong>Results: </strong>Among 787 physicians invited, 252 responded. Respondents most commonly selected phenobarbital as initial therapy (53.0%), followed by benzodiazepines (41.4%). Phenobarbital was also the most frequently continued drug when selected initially and the most common alternative when initial therapy failed. However, practice patterns varied by specialty. Most respondents preferred symptom-triggered dosing guided by an alcohol withdrawal assessment scale, CIWA-Ar.</p><p><strong>Conclusions: </strong>This survey demonstrates that phenobarbital and benzodiazepines are the reported preferred treatments for severe alcohol withdrawal among medical toxicologists and critical care medicine physicians, with a slight overall preference for phenobarbital. Respondents also favored symptom-triggered dosing guided by a withdrawal-specific assessment scale, such as the CIWA-Ar. Importantly, these findings underscore substantial variability in clinical practice and clinician interest in randomized trials to identify optimal treatment strategies for severe alcohol withdrawal.</p>","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2026-09-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149081128","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Articles You Might Have Missed.","authors":"Tyler J Yates, Kathleen Q Chen, Zackery L G Fowler, Haley A Kelly, Austin W Gay","doi":"10.1007/s13181-026-01150-8","DOIUrl":"https://doi.org/10.1007/s13181-026-01150-8","url":null,"abstract":"","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2026-08-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148760154","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is Beta Blocker Toxicity Associated With Hypoglycemia?","authors":"Megan Audette, Grant Comstock","doi":"10.1007/s13181-026-01134-8","DOIUrl":"10.1007/s13181-026-01134-8","url":null,"abstract":"","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"357-363"},"PeriodicalIF":2.0,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13407399/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147574339","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Narrative Summary of Strategies to Mitigate Intradialytic Hypotension in Poisoned Patients Requiring Extracorporeal Toxin Elimination.","authors":"David K Carroll, Andrew M King, Andrew Isaacson, Brandtly Yakey, Aria Darling, Varun Vohra, Josh D King","doi":"10.1007/s13181-026-01133-9","DOIUrl":"10.1007/s13181-026-01133-9","url":null,"abstract":"","PeriodicalId":16429,"journal":{"name":"Journal of Medical Toxicology","volume":" ","pages":"375-386"},"PeriodicalIF":2.0,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13407404/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147645619","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}