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The Case Of Two Accidental Suicides

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My worst night as a doctor was during my residency.  I was working the pediatric ICU and admitted a young teenager who had tried to kill herself.  Well, she didn’t really try to kill herself; she took a handful of Tylenol (acetaminophen) because some other girls had teased her.

On that night I watched as she went from a frightened girl who carried on a conversation, through agitation and into coma, and finally to death by morning.  We did everything we could to keep her alive, but without a liver there is no chance of survival.

Over ten years later, I was called to the emergency room for a girl who was nauseated and a little confused, with elevated liver tests.  I told the ER doctor to check an acetaminophen level and, sadly, it was elevated.  She too had taken a handful of acetaminophen at an earlier time.  She too was lucid and scared at the start of the evening.  The last I saw of her was on the next day before she was sent to a specialty hospital for a liver transplant.  I got the call later that next day with the bad news: she died.

The saddest thing about both of these kids is that they both thought they were safe.  The handful of pills was a gesture, not meant to harm themselves.  They were like most people; they didn’t know that this medication that is ubiquitous and reportedly safe can be so deadly.  But when they finally learned this, it was too late.  They are both dead.  Suicides?  Technically, but not in reality.

For these children the problem was that symptoms of toxicity may not show up until it is too late.  People often get nausea and vomiting with acute overdose, but if the treatment isn’t initiated within 8-10 hours, the risk of going to liver failure is high.  Once enough time passes, it is rare that the person can be cured without liver transplant.

Acetaminophen overdose is the #1 cause of liver failure in the US.  According to a Reuters article, there are 1600 cases of liver failure from this drug per year (2007).  This is a huge number.  In comparison consider that the cholesterol drug Cerivastatin (Baycol) was withdrawn from the market when there were 31 deaths from rhabdomyalysis (severe muscle break-down, which is far more common than liver failure in these drugs).  These happened mainly when the drug was used in combination with another cholesterol drug.

Should the drug be pulled from the market?  No, it is safe when used properly.  The toxic dose is generally 10 times the therapeutic dose.  My complaint is not that they have dangerous drugs available; ALL drugs should be considered dangerous.  Aspirin, decongestants, anti-inflammatories, and even antacids can be toxic if taken in high dose.  The problems with acetaminophen stem from several factors:

  1. Most people don’t realize the danger.
  2. There has been very little public education and no significant warning labels on the packages.
  3. The drug is often hidden in combination with other drugs, including prescription narcotics and over-the-counter cold medications.  This means that a person can take excess medication without knowing it.

I would advocate putting warning labels on medications containing this drug.  I am sure this doesn’t thrill the drug manufacturers, but the goal is not to make them happy.  I have thought this since that terrible night during residency.  If there was such a warning, perhaps she wouldn’t have died.

It seems a bit silly that this action by the FDA is coming after their pulling of children’s cough/cold medications. Those drugs have very small numbers of true harmful overdoses.  The reason they were pulled was probably more that they didn’t do anything over the fact that they were dangerous.  Acetaminophen, on the other hand, can be deadly.

Just ask the parents of my two patients.

*This blog post was originally published at Musings of a Distractible Mind*

Ciguatera Poisoning and Sex

Ciguatera fish poisoning involves a large number of tropical and semitropical bottom-feeding fish that dine on plants or smaller fish that have accumulated toxins from certain microscopic dinoflagellates. Therefore, the larger the fish, the greater the toxicity. The ciguatoxin-carrying fish most commonly ingested include the barracuda, jack, grouper, and snapper. Symptoms, which usually begin 15 to 30 minutes after the victim eats the contaminated fish, include abdominal pain, nausea, vomiting, diarrhea, tongue and throat numbness, tooth pain, difficulty walking, blurred vision, skin rash, itching, tearing of the eyes, weakness, twitching muscles, incoordination, difficulty sleeping, and occasional difficulty in breathing. A classic sign of ciguatera intoxication is the reversal of hot and cold sensation (hot liquids seem cold and vice versa), which may reflect general hypersensitivity to temperature. Unfortunately, the symptoms persist in varying severity for weeks to months. Victims can become severely ill, with heart problems, low blood pressure, deficiencies of the central and peripheral nervous systems, and generalized collapse. Anyone who displays symptoms of ciguatera fish poisoning should be seen promptly by a physician.

It was reported this spring that ciguatera fish poisoning has been linked to pain during sexual intercourse. Despite the sensational coverage that this announcement received by the press, the phenomenon has been known for quite some time. It is indeed a fact that a person affected by ciguatera fish poisoning may suffer symptoms of pain during sex. These symptoms include painful ejaculation in men, and a burning sensation during and after (for up to 3 hours) intercourse. What was interesting about this most recent report, which was generated by observations made in North Carolina, was quantification of the duration of the uncomfortable symptoms. One male reported that his symptoms lasted a week, and two of the women said that they were affected for a month. The fish implicated in this particular cluster of cases was amberjack.

Treatment for ciguatera fish poisoning is for the most part supportive, although certain drugs are beginning to prove useful for aspects of the syndrome. An example is intravenous mannitol for abnormal nervous system behavior or abnormal heart rhythms. These therapies must be undertaken by a physician. Prochlorperazine may be useful for vomiting; hydroxyzine or cool showers may be useful for itching. There are chemical tests (such as Cigua-Check® Fish Poison Test Kit) to determine the presence of ciguatoxins in fish, but there is not yet a specific antidote.

This post, Ciguatera Poisoning and Sex, was originally published on Healthine.com by Paul Auerbach, M.D..

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