Acetaminophen can lead to irreversible liver damage and even death in acute overdose. Outcome is related to the swiftness in which the antidote (N-acetylcysteine) is provided. In the United States, there are now available both the oral and intravenous forms of N-acetylcysteine, and pros and cons exist for each. With brisk and adequate treatment using either route, recovery can be complete, and liver function can be restored.
PurposeA significant increase in Coricidin HBP (high blood pressure) exposures was noted from 1999 to 2003 in our regional poison control center, with 3 exposures reported in 1999, 6 in 2000, 7 in 2001, 10 in 2002, and 31 in 2003. The purpose of our study was to describe the pattern of Coricidin HBP exposures in our region.MethodsA two-year (February 2002-January 2004) retrospective review of data collected from the Toxic Exposure Surveillance System database at our regional poison control center was performed. Data collected included age, gender, intentional or unintentional, symptoms, medical outcome, and disposition.ResultsForty-four cases occurred, including 37 adolescents. Females outnumbered males 23:20. Forty ingestions were intentional. Twelve patients were referred to and 30 patients were treated in a health care facility. Of the 44 patients, 8 had no effect, 6 minor, 24 moderate, 1 major. Eighteen patients had tachycardia, 10 lethargy, 6 hypertension, 5 agitation, 5 confusion and 5 hallucinations. Other symptoms included dizziness, mydriasis, vomiting, slurred speech, ataxia, coma, fever and diaphoresis. Ten patients were admitted to a medical floor and 3 patients to a psychiatric care unit. Treatment included naloxone in one patient and N-acetylcysteine in 2 patients. Product type included Coricidin HBP Cold and Flu (n = 20), Coricidin HBP Cough and Cold (n = 19), Coricidin HBP Maximum Strength Flu (n = 2), and Coricidin D (discontinued) (n = 3). Urine drug screens were positive for THC (n = 13), PCP (n = 9), opiates (n = 5), benzodiazepines (n = 2).ConclusionReported Coricidin HBP exposures are increasing in our region with significant symptoms present in over half the patients and 2/3 of patients being treated in a health care facility.
Repeated presentations of a rare symptom in a patient should make a physician stop and evaluate for rare conditions. This is a report of a teenager with multiple episodes of rhabdomyolysis and weakness. He was eventually diagnosed as having McArdle muscular dystrophy, or glycogen storage disease type V. His rhabdomyolysis has been severe, with a creatinine kinase level of >320,000 U/L, myoglobinuria, transaminitis, and elevated bilirubin. He has a low threshold for triggering rhabdomyolysis, such as doing an hour of aerobic exercise 2 days in a row. McArdle disease is a glycogen storage disorder in which the skeletal muscle cannot convert glycogen to glucose. Unlike other glycogen storage disorders, McArdle muscular dystrophy only affects the skeletal muscle, sparing the brain and visceral organs, leading to a vague phenotype. These patients have exercise intolerance, muscle cramps, and rhabdomyolysis. Many patients report loading with simple carbohydrates before exercise, as they have learned that this can increase their stamina. The vague symptoms can lead to decades of delay in diagnosis and significant mismanagement. Rhabdomyolysis is the most dangerous sign of McArdle disease, and it can lead to acute kidney injury, resulting in renal failure requiring dialysis in the severest cases.Rhabdomyolysis has numerous causes, but when it is recurrent, especially with seemingly insignificant triggers, one needs to develop a broader differential and pursue advanced testing. This testing can include specific exercise tests, genetic sequencing, and muscle biopsy. This case report will guide the clinician through the process of evaluating recurrent rhabdomyolysis, working through the differential diagnosis and testing options. 1
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