Camphor is a pleasant smelling cyclic ketone of the hydro aromatic terpene group. The mechanism by which camphor produces toxicity is unknown. Within a period of 5 to 15 minutes, patients commonly complain of mucus membrane irritation, nausea, vomiting, and abdominal pain. Generalized tonic-clonic convulsions are often the first sign of significant toxicity and can occur soon after ingestion. Central nervous system depression is commonly seen, such as headache, dizziness, confusion, agitation, anxiety, hallucinations, myoclonus, and hyperreflexia.The aim of the study is to show a unique case of generalized tonic-clonic convulsions, after 1 week of dermal applications of camphor crème in elderly patient. Case Report66-year old female was brought to the University Clinic for Toxicology in Skopje, with status epilepticus, after several generalized tonic-clonic seizures. At arrival, the patient was somnolent, with heavy headache, hypotensive (14/9 kPa), with partial amnesia, relax muscles, small amount of blood in mouth and specific odour. Five minutes later, during standard examination, the patient developed another generalized tonic-clonic seizure. An amount of 10 ml i.v. diazepam was applied to stabilize the patient, and a few minutes later the patient woke up. Heteroanamnesis taken from her husband showed that she had another similar convulsion ten days ago. EEG, CT and MRI made previously, did not show any abnormalities. The specific smelt, repeated seizures and especially the dermal application of Kamfart crème, made the suspicion of poisoning with camphor. The toxicological examination showed a positive result. After excluding the camphor crème, the patient didn't manifest any seizures.
Objective. The overlapping of pharmacokinetics and/or the pharmacodynamics of medicines causes the occurrence of overlapping clinical syndromes and diagnostic issues, potentiated in overdoses. We report a case of severe venlafaxine poisoning where the clinical presentation and the results of rapid immunoassay test overlapped with tramadol intoxication. Case presentation. An unconscious women with recurrent seizers, hypertension and supposed acute medication poisoning in suicidal attempt was transported to our clinic. Previously, she had been lavaged, rehydrated and treated with 20 mg diazepam iv, 40 mg furosemide at the local general hospital. Her regular tablet therapy consisted of losartan, levothyroxine, venlafaxine, occasionally tramadol. At admission she was comatose, with isochoric normal pupils, BP 130/80 mm Hg, SaO2 86%, and recurrent episodes of seizures treated with 10mg diazepam iv, ocular clonus, hypertonus, temperature 38.9C, diaphoresis, facial hyperaemia, dark coloured urine, hyponatremia and rhabdomyolisis. The lateral flow immunoassay (AbuGnostR) was positive for tramadol, but the homogeneous enzyme immunoassay did not confirm it. After 36 hours of intensive treatment she became somnolent and reported ingestion of 2250 mg tbl Venlafaxine. The AbuGnost R test detects tramadol at cut off urine values 200ng/ml, but present cross reactivity with O-desmethyl-venlafaxine at cut off values up to 25000ng/ml. The following days she complained of muscular weakness, headaches and cognitive impairment, which lasted for more then one month after release from hospital. Conclusion. High concentrations of venlafaxine metabolites induce false positive tramadol immunoassay (AbuGnostR) test. Overlapping clinical presentations and metabolic pathways of venlafaxine and tramadol should alert physicians when interpret rapid immunoassay test. The mandatory principle when making medical decisions should cover synthesis of critically interpreted toxicology analysis, interview data and clinical features of the poisoning, which may help to avoid misleading conclusions and improve the diagnostic and therapy decisions.
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