Faculty Bibliography

Introduction: Infestation with Pediculus species, or common lice, is frequently diagnosed in the emergency department (ED). Because lice ingest human blood, prolonged and heavy infestation can plausibly lead to iron deficiency anemia. Severe anemia attributable to lice infestation has infrequently been reported to date. Our objective in this study was to retrospectively review cases of lice-related anemia at a single public hospital to identify risk factors and associated demographic and clinical features of this disease process. Methods: We screened the medical records for patients presenting to the ED of an urban public hospital between 2016–2024 for the diagnoses of lice infestation and severe anemia (hemoglobin < 7 grams per deciliter (g/dL). Cases were reviewed for clinical and demographic characteristics. Results: A total of 932 patients were diagnosed with pediculosis infestation in the ED during the study period; 332 (35.6%) of those patients had a complete blood count obtained by the treating team. Thirty-seven cases of severe anemia were identified (3.9% of total pediculosis cases, 11.1% of those for whom a complete blood count was obtained); 84% were microcytic, indicating iron deficiency anemia. Twenty-five patients (68%) were undomiciled, and nine patients (24%) were shelter domiciled. Twenty-three patients (62%) had comorbid psychiatric diagnoses, and 21 (51%) had substance use disorders. The median hemoglobin was 4.4 g/dL (range 2.4-6.9 g/dL). Thirty patients (81%) were admitted to a medical floor and seven patients (19%) to an intensive care unit, each with a comorbid primary condition. Conclusion: In this cohort, anemia secondary to lice infestation was seen in patients with unstable housing, substance use disorders, and psychiatric disease. Most patients were hemodynamically stable, consistent with the proposed mechanism of chronic blood loss. The prevalence of this condition may be higher than previously noted among this vulnerable population. Emergency physicians should be aware of this rare but potentially serious disease process.

INTRODUCTION/BACKGROUND:Infestation with Pediculus species, or common lice, is frequently diagnosed in the emergency department (ED). Because lice ingest human blood, prolonged and heavy infestation can plausibly lead to iron deficiency anemia. Severe anemia attributable to lice infestation has infrequently been reported to date. Our objective in this study was to retrospectively review cases of lice-related anemia at a single public hospital to identify risk factors and associated demographic and clinical features of this disease process. METHODS:We screened the medical records for patients presenting to the ED of an urban public hospital between 2016-2024 for the diagnoses of lice infestation and severe anemia (hemoglobin < 7 grams per deciliter (g/dL). Cases were reviewed for clinical and demographic characteristics. RESULTS:A total of 932 patients were diagnosed with pediculosis infestation in the ED during the study period; 332 (35.6%) of those patients had a complete blood count obtained by the treating team. Thirty-seven cases of severe anemia were identified (3.9% of total pediculosis cases, 11.1% of those for whom a complete blood count was obtained); 84% were microcytic, indicating iron deficiency anemia. Twenty-five patients (68%) were undomiciled, and nine patients (24%) were shelter domiciled. Twenty-three patients (62%) had comorbid psychiatric diagnoses, and 21 (51%) had substance use disorders. The median hemoglobin was 4.4 g/dL (range 2.4-6.9 g/dL). Thirty patients (81%) were admitted to a medical floor and seven patients (19%) to an intensive care unit, each with a comorbid primary condition. CONCLUSION/CONCLUSIONS:In this cohort, anemia secondary to lice infestation was seen in patients with unstable housing, substance use disorders, and psychiatric disease. Most patients were hemodynamically stable, consistent with the proposed mechanism of chronic blood loss. The prevalence of this condition may be higher than previously noted among this vulnerable population. Emergency physicians should be aware of this rare but potentially serious disease process.

Alcohol is a gamma-aminobutyric acid (GABA) receptor agonist and an N-methyl-D-aspartate (NMDA) receptor antagonist. Although benzodiazepines and barbiturates are the standard treatments for alcohol withdrawal, there is some recent interest in adding dexmedetomidine. We report cases of two patients with severe alcohol withdrawal to highlight some limitations of dexmedetomidine therapy. The first case was of a 58-year-old man who presented with severe alcohol withdrawal. He received chlordiazepoxide, diazepam, and phenobarbital with resolution of his symptoms. He was later started on dexmedetomidine (0.2 mcg/kg/hr), with no other therapy, during which time he appeared sedated with a heart rate (HR) of 80 beats/minute, blood pressure (BP) of 126/80 mmHg, and respiratory rate (RR) of 18 breaths/minute. Seven hours after stopping the infusion, he said that he "had been lying in bed staring at the ceiling feeling like hell… felt extremely agitated in my head". The second patient was a 41-year-old man who developed alcohol withdrawal and required intubation seven hours after presentation. Maximal sedation was 50 mcg/kg/min of propofol and 14 mg/hr of midazolam. On hospital day 3, the team stopped propofol, decreased midazolam to 10 mg/hour, and added dexmedetomidine 0.2 mg/kg/hr. Forty minutes later, the toxicology team observed the patient unresponsive with left gaze deviation and rhythmic eye movements. Video EEG was consistent with a seizure. The patient's EEG rapidly improved with a midazolam bolus. Although dexmedetomidine controls the autonomic instability and behavior associated with alcohol withdrawal, it does not address the underlying pathophysiology, leaving patients to suffer the psychological effects of withdrawal. The role of dexmedetomidine remains to be determined, with studies that address cognitive and long-term outcomes of alcohol withdrawal rather than just vital signs, behavior, and doses of other medications used.

Hyperlactatemia is a common and concerning finding in the paediatric cardiac ICU as it may signify tissue hypoperfusion and/or hypoxia. However, it is important to include other aetiologies for an elevated lactate in the differential, especially when the lactate is significantly elevated (> 8 mmol/L). We present the case of metabolic acidosis with severe hyperlactatemia secondary to Warburg effect and presumed thiamine deficiency in a paediatric heart transplant patient with post-transplant lymphoproliferative disorder.

INTRODUCTION/UNASSIGNED:Alkyl nitrites ("poppers") are used recreationally for sexual enhancement, muscle relaxation, and euphoria. However, they can be toxic and cause adverse reactions such as methemoglobinemia. While inhalation is the typical route of usage, the New York City Poison Center has noted an increase in calls related to ingestion. Given the uncertainty of usage instructions at the point of sale, our study aimed to assess instructions provided to consumers about alkyl nitrite use and to evaluate the proximity and co-sale of alkyl nitrites with similarly appearing energy drink shots. METHODS/UNASSIGNED:We conducted a cross-sectional convenience sample survey of smoke shops, cannabis dispensaries, and exotic shops within the catchment area of an urban poison center. Plain clothes "investigators" (i.e., the researchers) visited these retailers and followed a predetermined protocol and script to request information regarding the availability and usage of alkyl nitrites. Additionally, the researchers attempted to visually assess the proximity of alkyl nitrites to similarly appearing energy drink shots during their visit. RESULTS/UNASSIGNED:drinks and alkyl nitrites were located near these energy drink shots in twenty (39%) of these fifty-one stores. DISCUSSION/UNASSIGNED:Many commercial alkyl nitrite retailers in our survey area lack knowledge or provide potentially inaccurate information regarding the use of alkyl nitrites. Additionally, alkyl nitrites are often sold alongside commercial energy drinks, potentially increasing the risk of incidental ingestion. CONCLUSIONS/UNASSIGNED:Further research is necessary to determine the impact of these patterns of sale and potential misinformation. Discussing preliminary results of our survey with the New York City Department of Health led to the rapid creation of an informational poster and local outreach. Clinicians should report cases of alkyl nitrite use to their regional poison center to allow for more targeted and timely public health intervention.

INTRODUCTION/UNASSIGNED:Despite the widely accepted use of methylthioninium chloride (methylene blue) to treat methemoglobinemia, data regarding clinical outcomes are sparse. We sought to better elucidate the efficacy and tolerability of methylthioninium chloride. METHODS/UNASSIGNED:We identified all cases reported to the New York City Poison Center from 2000 to 2024 in which methylthioninium chloride was administered for methemoglobinemia. We extracted clinical data from these cases, which we assessed using primarily descriptive statistics. RESULTS/UNASSIGNED: = 6). Improvement after administration of methylthioninium chloride was reported in 98% of cases (95% CI: 96-100%). Adverse effects attributable to methylthioninium chloride were reported in nine cases (4.9%; 95% CI: 4.6-5.1%), including one instance of hemolysis. Glucose-6-phosphate dehydrogenase activity was found to be deficient in two of seven patients tested, only one of whom did not improve after methylthioninium chloride. Two deaths occurred in this series, both associated with sodium nitrite exposure. DISCUSSION/UNASSIGNED:Most patients with methemoglobinemia improved after 1-2 mg/kg of methylthioninium chloride, supporting current treatment recommendations. Despite few instances of glucose-6-phosphate dehydrogenase activity testing, major adverse effects attributable to methylthioninium chloride were extremely rare. A relatively large proportion of cases receiving multiple doses were associated with dapsone exposure. CONCLUSIONS/UNASSIGNED:In this series, methylthioninium chloride was both efficacious and well tolerated in patients with methemoglobinemia, with a single dose of 1-2 mg/kg being sufficient to treat most patients.

INTRODUCTION/UNASSIGNED:Unfortunately, children are not spared from the devastating effects of the ongoing opioid epidemic. In rare cases, young children exposed to opioids present with unique neuroimaging findings affecting the white matter, reminiscent of what was once seen with diacetylmorphine (heroin)-associated leukoencephalopathy. This constellation of findings is termed the pediatric opioid use-associated neurotoxicity with cerebellar edema (POUNCE) syndrome. CASE SUMMARY/UNASSIGNED:A 31-month-old child was found floppy and unresponsive. Upon hospital arrival, there was right gaze deviation, shaking of the arms and legs, miosis, and bradypnea. Response to naloxone was incomplete, and methadone was confirmed in the child's urine. IMAGES/UNASSIGNED:Magnetic resonance imaging of the brain performed 24 h after admission showed abnormal T2/FLAIR hyperintensity with associated restricted diffusion symmetrically involving the cerebellar hemispheres. CONCLUSION/UNASSIGNED:The imaging findings, although far from pathognomonic, should be recognizable by radiologists and toxicologists when considering possible opioid exposure in a young child.

We report a case of Western Gaboon viper (Bitis rhinoceros) envenomation in which the patient's symptoms progressed despite treatment with North American crotalid antivenom but improved after receiving South African Institute for Medical Research (SAIMR) polyvalent antivenom. A 59-year-old man was hospitalized after reportedly being bitten by a Gaboon viper (Bitis gabonica). On arrival, he had normal vital signs, two puncture wounds on his left hand, and edema distal to the wrist. The hospital contacted the local poison center who conveyed that crotalid antivenom would be ineffective and recommended transfer to a snakebite center for species-appropriate antivenom. However, this recommendation was disregarded. Initial laboratory tests 2 hours after envenomation revealed a platelet count of 77 x 10⁹/L; other parameters were normal. He received six vials of crotalid antivenom (CroFab®) followed by three maintenance doses (total 12 vials). The next morning, swelling had progressed proximal to the elbow and platelets decreased to 37 x 10⁹/L. He was subsequently transferred and received SAIMR polyvalent antivenom. Six hours later, his platelets were 130 x 10⁹/L. The next morning, his swelling had significantly improved. He was discharged the following day. After discharge, it was discovered that the snake was a Bitis rhinoceros. Bitis gabonica and Bitis rhinoceros are popular captive snakes in the United States. Bitis rhinoceros was formerly a sub-species of B. gabonica, and they are often referred to interchangeably. Their venoms cause tissue edema, coagulopathy, and in severe cases, hemorrhage, dysrhythmias, and death. Antivenom is not widely available in the United States often necessitating patient transfer or antivenom delivery. This case addresses the question of whether crotalid antivenom, which is ubiquitous in the United States, can treat B. gabonica and B. rhinoceros envenomations and highlights the need for consultation with a poison center to facilitate administration of species-appropriate antivenom.