Mushroom poisoning with Russula subnigricans can lead to severe rhabdomyolysis. Here we describe a case of severe mushroom poisoning that resulted in severe rhabdomyolysis with acute kidney injury, hypotension, and shock 12 h after oral ingestion of R. subnigricans. The patient's serum myoglobin was 6,475 ng/mL and his creatine phosphokinase (CK) level was 38,100 IU/L on admission. Although aggressive fluid resuscitation and on-line hemodiafiltration (OHDF) were initiated, vascular permeability and shock failed to improve. Continuous hemodiafiltration (CHDF) and OHDF was repeated, but their effects were limited. He later developed generalized edema, and his weight increased from 55 kg to 72.5 kg within 4 days. On day 5, his CK level reached 203,800 IU/L. He died 160 h after oral ingestion of R. subnigricans. CHDF and OHDF filter out circulating myoglobin, potassium, and some toxic substances released due to muscle cell disruption. Although OHDF was performed nearly 24 h a day in our patient, it failed to remove toxic intracellular components from muscle cells due to the severe R. subnigricans mushroom poisoning in this case.

We encountered a case in which decreased cardiac afterload due to intra-aortic balloon pumping (IABP) caused left ventricular outflow tract obstruction (LVOTO), resulting in cardiogenic shock in a patient with hypertrophic obstructive cardiomyopathy (HOCM). The patient was a woman in her 60 with HOCM and angina, which were had been diagnosed before endometrial cancer surgery. An intra-aortic balloon pump was placed before surgery to maintain coronary artery blood flow, and increases in diastolic blood pressure were observed. However, she went into shock upon induction of anesthesia and required a large dose of vasopressor. The patient remained in shock after surgery and was admitted to the ICU while unresponsive and intubated. Transthoracic echocardiography showed LVOTO and mitral regurgitation, indicating the possibility that lowered cardiac afterload by IABP caused LVOTO. Discontinuation of IABP resulted in striking recovery from shock such that no vasopressor was required, and echocardiography findings improved. Although IABP offers a variety of benefits such as maintenance of coronary artery blood flow, we should keep in mind that decreased cardiac afterload due to IABP may cause LVOTO in patients with HOCM.

Deep neck abscess can cause upper airway stenosis and obstruction, and sometimes emergency airway management is required. Here we present a case of deep neck abscess in which awake intubation with a video laryngoscope (McGRATH™ MAC) was more useful than with flexible bronchoscope. A man in his 80s was transported to our hospital with throat and chest pain. Contrast-enhanced computed tomography revealed a deep neck abscess (right peritonsillar abscess). The otolaryngologist attempted drainage by puncture, but this was ineffective. There was a risk of upper airway obstruction, and emergency airway management was required. First, we attempted endotracheal intubation with a flexible bronchoscope but could not secure the field of view because of the upper airway edema and stenosis. Next, we attempted tracheal intubation using a video laryngoscope, which ultimately was successful. The blade of the video laryngoscope compressed and lifted the soft tissue and then it secured the space of the upper airway.

BACKGROUND: Pyrethroid (PYR) insecticides are widely used for controlling various pests. There are two types that differ in terms of usage: agricultural-purpose PYR (agriculture-PYR) and hygiene purpose PYR (hygiene-PYRs). Few studies exist on the exposure to these chemicals in small children. In this study, we conducted biomonitoring of urinary pyrethroid metabolites in 1.5-year-old children throughout the year. METHODS: Study subjects were 1075 children participating in an Aichi regional sub-cohort of the Japan Environment and Children's Study as of 18-month health check-up. The concentrations of four specific hygiene-PYR metabolites including 2,3,5,6-tetrafluoro-1,4-benzenedimethanol (HOCH₂-FB-Al), and five common metabolites of hygiene- and agriculture-PYRs including 3-phenoxybenzoic acid (3PBA) and cis- and trans-3-(2,2-dichlorovinyl)-2,2-dimethylcyclopropane-1-carboxylic acid (DCCA), were measured in urine samples extracted from soiled diapers using a triple quadrupole gas chromatograph-mass spectrometer. RESULTS: The highest detection frequencies were for 3PBA, followed by DCCA, 1R-trans-chrysanthemum dicarboxylic acid, and HOCH₂-FB-Al. Among the six metabolites, urinary concentrations were seasonally varied. However, this variation was not observed in the most studied PYR metabolite, 3PBA. Spearman's correlation analysis demonstrated a significant positive correlation between FB-Al and DCCA (r = 0.56) and HOCH₂-FB-Al and 4-methoxymethyl-2,3,5,6-tetrafluorobenzyl alcohol (r = 0.60). CONCLUSIONS This biomonitoring survey found widespread and seasonally specific exposure to multiple hygiene- and agriculture-PYRs in 1.5-year-old Japanese children.
Agriculture ; Child, Preschool ; Environmental Exposure/analysis* ; Humans ; Infant ; Insecticides ; Japan ; Mass Spectrometry ; Pyrethrins/urine*

BACKGROUND: Low-dose exposure to organophosphate (OP) insecticides during pregnancy may adversely affect neurodevelopment in children. To evaluate the OP exposure levels, single urine sampling is commonly adopted to measure the levels of dialkylphosphates (DAPs), common OP metabolites. However, the inter-day variations of urinary DAP concentrations within subjects are supposed to be large due to the short biological half-lives of the metabolites, and it is thus considered difficult to accurately assess OP exposure during pregnancy with single sampling. This study aimed to assess intra-individual variations of DAP concentrations and the reproducibility of the exposure dose categorization of OPs according to DAP concentration ranges in pregnant women in Japan. METHODS: Urine samples were collected from 62 non-smoking pregnant women (12-22 weeks of gestation) living in Aichi Prefecture, Japan. First morning void (FMV) and spot urine samples taken between lunch and dinner on the same day were collected on five different days during 2 weeks. The concentrations of DAP and creatinine in urine samples were measured using an ultra performance liquid chromatography with tandem mass spectrometry. Creatinine-adjusted and unadjusted concentrations were used for the intraclass correlation coefficient (ICC) calculations and surrogate category analyses. RESULTS: For all DAP metabolites, the creatinine-adjusted single ICCs exceeded 0.4, indicating moderate reliability. Overall, ICCs of spot urine samples taken in the afternoon were better than those taken as FMV. Surrogate category analyses showed that participants were categorized accurately into four exposure dose groups according to the quartile points. CONCLUSION This study indicated that a single urine sample taken in the afternoon may be useful in assessing OP exposure as long as the exposure is categorized into quartiles when conducting epidemiological studies in early to mid-pregnant women in Japan.
Adult ; Chromatography, Liquid ; Creatinine ; urine ; Environmental Exposure ; analysis ; Environmental Monitoring ; methods ; Environmental Pollutants ; urine ; Female ; Humans ; Japan ; Mass Spectrometry ; Organophosphates ; urine ; Pesticides ; urine ; Pregnancy ; Pregnant Women ; Young Adult