ISSN: 2251-8762

Vol. 9 No. 3 (2019)

Letter to the Editor

Original Article

Brain Structure Changes Associated With Methamphetamine Abuse in Brain Magnetic Resonance Imaging

Bita Dadpour, Roya Faghani, Maryam Vahabzadeh, Yasmin Davoudi, Fares Najari

International Journal of Medical Toxicology and Forensic Medicine, Vol. 9 No. 3 (2019), 1 July 2019 , Page 103-108

Background: Amphetamines constitute a group of central nervous system stimulators with an increasing frequency of usage and destructive outcomes on the metabolism, perfusion, and structure of the brain. This study aimed at evaluating the structural brain changes following amphetamines abuse, using Magnetic Resonance Imaging (MRI).
Methods: This cross sectional study was conducted on the individuals, who were admitted to the toxicology Emergency Room (ER) with continuous amphetamines abuse for at least six months and a positive methamphetamine urine test. Positive Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for dependency and addiction to methamphetamine were also considered as the inclusion criteria. Following informed consent, the demographic information, and data on methamphetamine use were collected. An MRI was performed for all participants as soon as relative recovery. A matched control group also underwent MRI simultaneously.
Results: Forty male (20 cases of methamphetamine addicts and 20 healthy individuals) with a mean±SD age of 28.1±5.11 years were investigated. The mean±SD age of starting methamphetamine abuse was 25.6±10 years. About (75%), (n=15) of the patients abused methamphetamine 6-9 months, while others had abused it for more than 10 months. All cases used to abuse methamphetamine at least once a week, with (85%) of them inhaling it. The results showed that the only change in the brain MRI of methamphetamine abusers was hyperintensities increase in deep and periventricular white matter (only positive MRI in 3 cases, P=0.231). Oral consumption and higher doses had induced greater changes in the brain structure.
Conclusion: Methamphetamine dependency may increase deep and periventricular white matter hyperintensities.

Role of Prophylactic Antibiotic Administration in Growth of Methicillin Resistant Staphylococcus Aureus in Rhinoplasty

Nader Akbari Dilmaghani, Masoumeh Navidinia, Latif Gachkar, Shima Arastou

International Journal of Medical Toxicology and Forensic Medicine, Vol. 9 No. 3 (2019), 1 July 2019 , Page 109-116

Background: Septoplasty and septorhinoplasty are common surgical procedures in modern surgical practice. Pre or postoperative antibiotic administration has raised concerns about the possible increase in the antibiotic-resistant species. The aim of this study was to evaluate the role of postoperative antibiotic prophylaxis in increasing Methicillin-Resistant Staphylococcus Aaureus species (MRSA) in patients, who underwent septoplasty or septorhinoplasty in Loghman Hakim Hospital in Tehran, Iran.
Methods: A total of 102 patients, who were planned to undergo septoplasty or septorhinoplasty, participated in this double-blind randomized clinical trial. The patients were divided into the case (n=60, mean age of 28.2 years) and control (n=38, mean age of 28.9 years) groups. Overall, 98 patients participated in the study. The case group received a preoperative injection of cephalothin (1g) and postoperative oral cephalexin regimen (500mg 4 times a day for 7 days). The control group only received a preoperative injection of cephalothin (1g). Vestibular nasal swab cultures were obtained preoperatively and on postoperative day 7. The samples were, then, quickly transferred to the laboratory and cultured on proper media. The results indicated that five MRSA species in the case group and tow MRSA species in the control group were present, postoperatively.
Results: The findings of this study suggest that oral antibiotic prophylaxis may lead to a statically non-significant increase in MRSA infection in patients, who require this treatment.
Conclusion: Further knowledge of the endogenous nasal flora and the microbiology of common pathogens in patients undergoing septorhinoplasty will help reduce the incidence of infectious complications to a greater level.

Investigating the Efficacy of Sumac Topical Solution Against Permethrin-resistant Human Head Lice

Mohammad Kamalinejad, Atefe Sharif, Latif Gachkar, Amir Hooshang Ehsani, Mahdi Ahmadian-Attar, Mohammad Reza Torabi, Mahmood kodadoost

International Journal of Medical Toxicology and Forensic Medicine, Vol. 9 No. 3 (2019), 1 July 2019 , Page 117-124

Background: The present study aimed at determining the efficacy of applying Rhus coriaria (Sumac) solution for the treatment of Permethrin-resistant head louse in patients, who used permethrin for at least 2 consecutive periods, but have not been cured.
Methods: This study is a before-after clinical trial performed on 100 patients with pediculosis aged between 2 and 50 years old and both sexes. All patients had used Permethrin at least twice consecutively (with at least 14 days interval) according to correct instructions (on the first and 7th day), but they have not been cured. Each patient received 60ml of Rhus coriaria solution for 3 consecutive days, and the treatment was repeated again for another 3 days; then, the patients were followed-up on the 4th, 10th, and14th days after the treatment.
Results: The results showed a significant difference in the severity of head lice infection and itching before the treatment and 14 days after the treatment (P<0.001).
Conclusion: Rhus coriaria solution was more effective in eliminating head-louse infestations on 4, 10, and 14 days after the treatment and itching disappeared in most of the patients, while negligible complications were observed.

Gene Expression Survey of Serotonin Receptors (5HTR2A and 5HTR3A) and Monoamine Oxidases Enzyme After Treatment With Methadone in Addicted Individuals

Mahmood Khodadoost, Mohadeseh Khosh Andam, Seyed Davood Mirtorabi, Mohammad Reza Ghadirzadeh, Ghasem Ahangari

International Journal of Medical Toxicology and Forensic Medicine, Vol. 9 No. 3 (2019), 1 July 2019 , Page 125-132

Background: Addiction disrupts the nervous system of the reward system, stimulus, and memory in the brain. The disruption of these systems in the brain causes biological, physiological, social, and psychological complications. Addiction is considered a psychological, social, and economic disorder in terms of medicine, psychology, and sociology, as well as philosophy, law, ethics, and religion. The most important place of narcotic effect is the brain, and receptors affect these substances. Dopamine and serotonin receptors are among the most important receptors, in which drugs affect them. Methadone is also an opiate drug that is even more addictive than morphine and heroin and is often used as a preservative to control heroin and narcotic addiction.
Methods: In this study, 3 genes of 5-Hydroxytryptamine Receptor 2 A (5HT2Ra), 5-Hydroxytryptamine Receptor 3 A (5HT3Ra), and Monoamine Oxidases A (MAOA), which play an important role in serotonin function, were examined in Peripheral Blood Mononuclear Cells (PBMCs) of heroin addicts, who had been quitting addiction with methadone for 3 months. Therefore, peripheral blood PBMCs were isolated. cDNA was synthesized from mRNA; then, the expression of the gene was measured by real-time Polymerase Chain Reaction (PCR).
Results: The expression of MAOA gene in the PBMCs of the addicted patients with methadone was significantly reduced compared to the control group, while the expression of 5HT2Ra and 5HT3Ra genes showed no change in the two groups.
Conclusion: These results suggest that Methadone Maintenance Treatment (MMT) may be moderated by 5HT2Ra and 5 HT3Ra serotonin receptors and returned to their previous efficacy, but MAOA was significantly reduced.


Introduction of Dianthins: A New Promising Horizon Toward Continuous Research on Breast Cancer Bulldozing in Iran

Mohammad Hossein pour, Jamil Zargan, Hossein Honari, Ashkan Haji Nour Mohammadi, Abbas Hajizadeh, Hani Keshavarz Alikhani, Ahmad Heidari, Ehsan Zamani

International Journal of Medical Toxicology and Forensic Medicine, Vol. 9 No. 3 (2019), 1 July 2019 , Page 133-140

Background: The production and secretion of defense proteins are one of the protective mechanisms exploited by plants against pathogens. The production and secretion of defense proteins are one of the protective mechanisms exploited by plants against pathogens. Ribosome-Inactivating Proteins (RIPs), as the main class of these proteins, are considered to facilitate cancer therapy worldwide, because of the potential anticancer activity. Indeed, some of these proteins have cytotoxic and anticancer properties. Extracted from the carnation (Dianthus caryophyllus), Dianthin inhibits protein synthesis in many different cells.
Methods: In this research, the Dianthins was isolated and purified from the leaves of D. caryophyllus, using ion-exchange chromatography column (CM-Sephadex G-50). Subsequently, its cytotoxicity effect on MCF-7 cell line was investigated. The cell cytotoxicity assessment was performed, using 3-(4,5-Dimethylthiazol-2-yl)-2,5 diphenyltetrazolium bromide (MTT), neutral red uptake, and alkaline comet assays at the concentrations of 1.25μg/mL to 10μg/mL of the protein applying the MCF-7 cell line.
Results: the toxin induces cell death, mostly via necrosis rather than apoptosis, but in the special range of concentrations.
Conclusion: because of the severe side effects of chemotherapy drugs, this toxin can undergo more research as a new drug candidate against breast cancer.

A Retrospective Observational Study of Accidental Carbamate Poisoning Among Children Referred to a Tertiary Care Center in Rural Maharashtra, India

Rama Krishna Sanjeev, Mohan Nagorao Pawar, Divyank Sharma

International Journal of Medical Toxicology and Forensic Medicine, Vol. 9 No. 3 (2019), 1 July 2019 , Page 141-150

Background: Carbofuran is a widely-used carbamate insecticide which is listed as highly hazardous (Class 1b) by the World Health Organization (WHO) classification of pesticides. We report the poisonings among children following exposure to carbofuran crystal form, which is used as a household remedy for head lice infestation.
Methods: The medical case records from June 2016 to January 2019 of a Tertiary Care Hospital in rural Maharashtra, India, were examined for the pediatric poisoning due to exposure to blue crystals in sachets being sold as medication for head lice infestation and its confirmation as being carbofuran. A total of 14 such exposures were found among 64 cases of pediatric poisoning (excluding bites and sting envenomation), recorded in the above period. The children were evaluated for their presentations, manner of unintentional poisonings, clinical profile, and outcomes.
Results: The results in carbofuran poisonings showed universal unintentional exposure with the majority of patients being infants and toddlers. It was the most significant single cause of poisoning, excluding bites and envenomation, in the above period. The clinical features of excessive cholinergic activity were consistent with the characteristics of carbamate poisoning. Comparison with other poisonings during the period did not show significant differences concerning variables such as age, sex, religion, and length of hospital stay.
Conclusion: Unintentional poisoning of the class1 pesticide carbofuran, among younger children, is associated with misuse and availability in the environment. Our obtained data about the agent, host, and environmental factors related to the poisoning are consistent with data available on the literature.

Case Report

Methanol Poisoning as a Trigger for the Presentation of Diabetes Mellitus: A Case Report

Seyed Reza Mousavi, Bita Dadpour, Mohammad Moshiri, Toktam Moghiman, Hamid Khosrojerdi, Fares Najari

International Journal of Medical Toxicology and Forensic Medicine, Vol. 9 No. 3 (2019), 1 July 2019 , Page 151-154

Background: The clinical and laboratory manifestations of methanol poisoning and Diabetic Ketoacidosis (DKA) might be very similar.
Case Presentation: A 15-year-old male, who lived in Mashhad, Iran, was referred to a medical toxicology center because of the loss of consciousness following the consumption of home-made alcohol. Laboratory tests revealed metabolic acidosis, the high blood levels of methanol, and ketonuria and glucosuria in urine analysis. The treatment of DKA and methanol poisoning was started simultaneously.
Conclusion: Methanol poisoning, as physical stress or because of pancreatitis as a complication, could be a trigger for diabetes in susceptible individuals, and physicians should be aware of the similarity of presentation of these situations.


Lead Poisoning Can Be Misdiagnosed as Guillain-Barre Syndrome; A Case Report

Abbas Aghabiklooei, Maryam Ameri

International Journal of Medical Toxicology and Forensic Medicine, Vol. 9 No. 3 (2019), 1 July 2019 , Page 171-174

Background: Toxic neuropathy is a global health problem affecting many people over the world, annually. Lead poisoning (LP) represents neurological complaints and neurobehavioral disorders. Therefore, its significances, especially its neurological consequences, can be misdiagnosed as other neuropathies like syndromes.

Case Presentation: In this case report, we aim at describing a 45-year-old woman with Guillain-Barre-like syndrome (GBS), who was admitted to the hospital with peripheral neuropathy and complaints of paresthesia in the lower and upper limbs. Suffering from GBS-like syndrome, she incidentally showed opium consumption during the hospitalization and taking her history. Serum lead levels were precisely elevated (88.6 µg/dL). To assess the neurologic effects, the brain CT, MRI, EMG, and NCV were performed, indicating severe sensory-motor demyelinating polyradiculopathy. The patient was admitted to the hospital again after 2 years with severe radicular pain in the lower and upper limbs and with positive myoclonus and tremor. While treated with plasma exchange and pregabalin at the first stage of admission, signs were normal and again recurred after 2 years, suggesting the reversibility of the histological findings and misdiagnosis. At the second stage, intravenous immunoglobulin (IVIG) was prescribed. The patient recovered and was discharged with chelation therapy of CaNa2EDTA for LP. The most frequent neurological complication induced by LP is severe sensory-motor demyelinating polyradiculopathy and axonal polyneuropathy. But, the clinical examination and the electrophysiological findings may also suggest a GBS-like syndrome.

Conclusions: Any discrepancies in this regard should be reconsidered to confirm LP diagnosis.

Fatal Abdominal Stabbing: A Confusing Picture in Differentiating Homicide and Suicide

Jaber Gharehdaghi, Masoud Ghadipasha, Mohammadjavad Hedayatshodeh, Fardin Fallah

International Journal of Medical Toxicology and Forensic Medicine, Vol. 9 No. 3 (2019), 1 July 2019 , Page 155-158

Background: Differentiating between homicide and suicide can be difficult and even impossible. In this report, we presented a fatal stabbing injury, which made a challenge in the verification of the manner of death.
Case Report: A 45-year-old man was found dead in his workplace with a knife beside him. His mouth was closed with a scarf, his clothes were intact, and no evidence of a struggle was observed in the scene investigation. There was a vertical stab wound on the midline of the victim’s belly and his intestines were tangled out of the wound. In the autopsy, no defense wound was found. There was blood in the abdominal cavity and retroperitoneal region and several perforations were observed in the intestine and liver along the superficial wound. Painful death and torturous extraction of visceral organs resembled homicide, but nothing indicative of hostility and homicide was found by the forensic exploration and police investigation. Finally, the manner of death was assigned as suicide and the cause of death was a hemorrhagic shock as a result of sharp force injuries.
Conclusion: This case represents a bizarre suicide, which is rare and highly suspicious of homicide. In such mysterious cases, the evidence of autopsy and crime scene and police investigation should be regarded to make a decision.

Effect of Chelation Therapy on Lead-induced Hepatotoxicity: A Case Series

Faezeh Shadfar, Zakaria Zakariaei, Seyed Khosro Ghasempoori, Mahmood Moosazadeh, Navid Khosravi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 9 No. 3 (2019), 1 July 2019 , Page 159-164

Background: Opium use is one of the common causes of lead toxicity. Lead poisoning can lead to hepatic, hematologic, musculoskeletal, neurological, and cardiovascular damages. In this study, we investigated the reversibility of lead-induced liver damage following chelation therapy.
Methods: We reviewed the medical records of patients with opium-induced lead poisoning regarding elevation in hepatobiliary enzymes level including Alanine Transaminase (ALT), Aspartate Transaminase (AST), and Alkaline Phosphatase (ALP) to normal level and recorded patients’ age, treatment regimen, liver enzymes level before and after treatment; we also investigated other laboratory findings to rule out other causes of liver enzymes increase.
Results: We evaluated 10 male patients with the mean age of 48.3±7.42 years. All patients were referred with the chief complain of abdominal cramps (100%). The mean lead level in patients was 84.48±9.95 µg/dL. The mean serum levels of ALT, AST, and ALP significantly decreased after the treatment with chelating agents ([ALT=117.8±60.22µg/dL-76.9±40.73µg/dL, P=0.022], [AST=100.9±63.96µg/dL-69.9±37.41µg/dL, P=0.028], [ALP=449.8±234.81 µg/dL-338.3±131.22µg/dL, P=0.037]). There was no significant correlation between patients’ lead level and liver enzymes level before and after the treatment.
Conclusion: The results of this study showed that the treatment with chelating agents reverses the liver injury following the lead intoxication.

Abortion Induced by Peganum Harmala Ingestion in a Pregnant Woman: A Case Report and Literature Review

Maryam Vahabzadeh, Ali Banagozar Mohammadi, Mohammad Delirrad

International Journal of Medical Toxicology and Forensic Medicine, Vol. 9 No. 3 (2019), 1 July 2019 , Page 165-170

Background: Peganum harmala is a medicinal plant used in Iran and other countries. Many therapeutic effects have been described for this plant; it is insect repellant, disinfectant, antimicrobial, sedative, analgesic, anti-inflammatory, emetic, and abortifacient. Roots and seeds are medicinally-active parts of the plant containing some β-carboline and quinazoline alkaloids, which are responsible for its pharmacological and toxicological effects. Poisoning with high doses of Peganum harmala can be life-threatening.
Case Report: We reported a 31-year old woman with an unwanted pregnancy, who ingested 1 glass of Peganum harmala seeds to induce abortion. On admission, she had severe nausea and vomiting, mild abdominal pain, and stable vital signs. Physical examination was unremarkable, and the leukocytosis was the only abnormal laboratory finding. The patient underwent nasogastric tube insertion, gastric lavage, as well as the administration of activated charcoal. Although she left the hospital on self-consent, further follow-up revealed that she had a spontaneous abortion without any complications.
Conclusion: Although most cases of Peganum harmala intoxication can be managed successfully, this poisoning led to abortion in our case. Physicians working in Iran and other regions, where Peganum harmala is used as traditional medicine, must be aware of its toxicity for the early diagnosis and management.