Intoxication with Ajmaline in an Infant· Glora Ben-ShochtIt, M.D., and Yeheddel Kl8htm, MD.
We presenta case of overdosqe of ajDudine In lID infant. The appearance of atactic pit ad cIoDic toDIc seizures wen foDowed by 1081 of c:ollldoDSDeSl, apnea, mpraventrlcular taehyeardla, left bundle-bnDcIa block, and a prolollled Q-T intervaL Cardiopulmoll81'Y resuscitation, pstric lavage, and foreed diuresis were foDowed by
complete recovery. Continuo.- eleetrocardlographlc
moDitorIDg is mandatory In these caws, and the use of a cardiac pacemaker, respirator, aad therapy with antiarrhythmic . .nts should be colllldered.
jmaline (Gilurytmal), a derivative of the rauwolfia A plant, has been used for the control of dysrhythmias. With the increase in its use, a knowledge of side effects is essential. This report presents a case of severe intoxication with ajmaline, and both the clinical mani-
-From the Heart Institute, the Chaim Sheba Medical Center and Tel-Aviv University Medical School, Tel-Hashomer,
IsraeL
Reprint reque8tB: Dr. Kishon, HefJfi IfI8tUufe, Sheba Medical
Center, TeZHashomer, Israel
festations and principles of treatment are brieBy discussed. CASE
REPoRT
A 17-month-old girl was hospitalized following an accidental ingestion of five tablets of ajmaline (Gilurytmal; 50 mg each). Within half an hour, atactic gait was noted with clonic-tonic seizures appearing 20 minutes later. Two hours afterwards, the child lost consciousness and developed apnea and cyanosis. The patient was successfuDy resuscitated by mouth-to-mouth technique but remained unconscious for another hour until her arrival at the hospital. The findings from physical examination on admission, as well as the chest x-ray films were normal. The electrocardiogram (Fig 1A) showed the presence of left bundle-branch block (duration of the QRS complex of 180 msec) and a prolonged Q-T interval of 360 msec (normal corrected Q-T interval, 250 msec). Immediately upon arrival, gastric lavage was performed, and cardiac electrical activity was continuously monitored. Forced diuresis was achieved by infusion of saline solution, with urinary excretion of 31 mg of ajmaline during the first 24 hours. Eight hours following the ingestion of the drug, without additional specific therapy, the ECG showed regressive changes, sinus rhythm appeared, and left bundle-branch block disappeared, although upright T waves were noted in the right precordial leads (Fig IB). This abnormality of repolarization disappeared two hours later (Fig IC). The child was released from the intensive care unit on the next day with normal physical and electrocardiographic findings (Fig ID).
• i
FICUBE 1. E l e _ in case of intoxication with ajmaline. A, On admission (four hours after ingestion of dmg), there is supraventricular tachycardia of 160 beats per minute, complete left bundIe-branch block, and prolonged Q-T interval. B, Eight hours after ingestion, left bundle-branch block has disappeared; however, T waves in right precordial leads are abnormally upright. C, Ten hours after ingestion, abnormalities of repolarization have disappeared. D, On next morning, ECG is normal.
CHEST, 76: 1, JULY, 1979
INTOXICAnON WITH AJMAUNE IN AN INFANT 97
DISCUSSION
Ajmaline has been reported to be effective in the treatment of various types of dysrhythmias, particularly those resulting from intoxication with digitalis and mechanically induced dysrhythmias, and in the Wolff-Parkinson-White syndrome," The drug changes the permeability of the cellular membrane to both sodium and potassium ions, thus slowing depolarization, repolarization, and the rate of conduction. In high dosages, ajmaline has a negative inotropic effect, and both atrioventricular and intraventricular blocks are not uncommon. Venbicular arrest and fibrillation have been reported only when the venous route of administration was used. Both hemodynamic and electrophysiologic effects of the drug have been recently reviewed.s The drug may affect the central nervous system, resulting in respiratory depression, convulsions, and death. The liver may be also affected, while both central and peripheral cardiovascular reflexes usually are spared. We were able to find only three cases of severe intoxication due to the ajmaline in the literature, one in a child and two in adults. 8--3 The oral ingestion of about 30 mg of ajmaline per kilogram of body weight in the first two cases caused severe respiratory depression with cyanosis, convulsions, and loss of consciousness, with widening of the QRS complex in the ECG;3 ventricular fibrillation followed in one of these cases. In the case presented herein, 23mg of ajmaline per kilogram of body weight was ingested. The clinical picture became fully manifest within -half an hour, when complete absorption was unlikely to have taken place. It can be assumed that because of the prompt institution of resuscitation and the use of gastric lavage and forced diuresis, serious dysrhythmias and life-threatening respiratory depression were avoided. The following are guidelines for the treatment of overdosage of ajmaline: (1) gastric lavage should be performed as soon as possible; (2) forced diuresis with saline solution should be instituted, keeping the electrolyte balance; (3) continuous electrocardiographic monitoring is mandatory, with cardiopulmonary resuscitative measures available; (4) antiarrhythmic agents should be used whenever needed, and the appearance of highdegree abioventricular block caDs for the use of a cardiac demand pacemaker; and (5) the use of an artificial respirator should be considered whenever respiratory function is markedly impaired. The benefit of using either peritoneal lavage or hemodialysis is as yet unknown. t•
1 Bazika V, Lang TW, Pappelbaum S, et at: Ajmaline, a Rauwolfia alkaloid for the treatment of digitoxic arrhythmias. Am J CardioI17:227-231, 1966 2 Obayashi K, Nagesawa K, Mandel WJ, et at: Cardiovascular effects of ajmaline. Am Heart J 92:487-496, 1976 3 Jomod Je, Barrelet JA: Suicidal attempt by overdosage of ajmaline. Am Heart J 70:719-720, 1965 4 KalIfelz HC, Rotthauwe HW: Ajmalin Intoxikation im
88 GIGLIA, MORGAN, BATES
Kindesalter. Med lOin 59:338-342, 1964 5 Gelbke HP, Schlicht HI: Suicide by an overdosage of Npropylajmalinium bitartrate. Arch Tcuicol (Berlin) 37:135141, 1977
Rapid Definitive Diagnosis of Legionnaires' Disease* Anthony R. Giglia, M.D.; Paul N. Morgtm~ Joseph H. Bate8~ M.D.~ F.C.C.P.
Ph.D.; and
We describe a sporadic case of LegiolUUlires' dJIease ID which the diaposis was made by direct imm_08uo.... eeaee of material obWDed by pemdaDeous aspIratiOD of the Involved lunl via a needle. Employment of this technique BlDolII selected patients with suspected LegiolUl8ires' disease would provide for more rapid dial· nosis and more prompt Ioitlation of definitive therapy fer some patients.
F
ollowing the initial description of Legionnaires' diseasel and its etiologic agent.s the illness began to be widely recognized in localized epidemics or as sporadic cases. Although the typical clinical picture" is weD known by most clinicians, definitive diagnosis in most cases must await serologic confirmation, which may require up to six weeks or more after the illness is first suspected. During this interim the clinician must rely upon empirical treatment. In a few cases the organism has been cultured from or demonstrated microscopically in pulmonary tissue or pleural fluid, but this process requires several days for bacteriologic confirmation. The purpose of this communication is to report the findings in a patient with Legionnaires' disease in whom the diagnosis was established within hours after hospitalization by direct immunofluorescence, which demonstrated the etiologic agent in material obtained from the lung by percutaneous aspiration via a needle. This procedure is associated with a low risk of significant complicationsv" and may provide rapid diagnosis for a substantial number of these patients.
CASE
REPoRT
A 76-year-old man came to a local hospital with complaints of congestion, shortness of breath, fever, chills, and abdominal pain. An infiltrate was noted in the left upper lobe, and he was treated with ampicillin, without improvement. Upon transfer to our hospital, the chest roentgenogram showed a rapidly advancing infiltrate, and analysis of arterial blood showed the following levels: arterial oxygen tension, 41 mm Hg, arterial carbon dioxide tension, 36 mm Hg, and pH, 7.50. The patient had toxic symptoms and was disoriented and unresponsive. He had fever to 40.6°C (105.1OF). Soon after admission, the patient was judged to require therapy with mechanical ventilation, and a transthoracic aspiration of the lung was performed with a needle prior to tracheal
-From the Medical Service, Vetenms Administration Medical Center-Universibt of ArbDsas for Medical Sciences Complex, Little Rock. Reprint requests: Dr. Giglia, 4301 West Markham, Little Rock 72201
CHEST, 76: 1, JULY, 1979
We presenta case of overdosqe of ajDudine In lID infant. The appearance of atactic pit ad cIoDic toDIc seizures wen foDowed by 1081 of c:ollldoDSDeSl, apnea, mpraventrlcular taehyeardla, left bundle-bnDcIa block, and a prolollled Q-T intervaL Cardiopulmoll81'Y resuscitation, pstric lavage, and foreed diuresis were foDowed by
complete recovery. Continuo.- eleetrocardlographlc
moDitorIDg is mandatory In these caws, and the use of a cardiac pacemaker, respirator, aad therapy with antiarrhythmic . .nts should be colllldered.
jmaline (Gilurytmal), a derivative of the rauwolfia A plant, has been used for the control of dysrhythmias. With the increase in its use, a knowledge of side effects is essential. This report presents a case of severe intoxication with ajmaline, and both the clinical mani-
-From the Heart Institute, the Chaim Sheba Medical Center and Tel-Aviv University Medical School, Tel-Hashomer,
IsraeL
Reprint reque8tB: Dr. Kishon, HefJfi IfI8tUufe, Sheba Medical
Center, TeZHashomer, Israel
festations and principles of treatment are brieBy discussed. CASE
REPoRT
A 17-month-old girl was hospitalized following an accidental ingestion of five tablets of ajmaline (Gilurytmal; 50 mg each). Within half an hour, atactic gait was noted with clonic-tonic seizures appearing 20 minutes later. Two hours afterwards, the child lost consciousness and developed apnea and cyanosis. The patient was successfuDy resuscitated by mouth-to-mouth technique but remained unconscious for another hour until her arrival at the hospital. The findings from physical examination on admission, as well as the chest x-ray films were normal. The electrocardiogram (Fig 1A) showed the presence of left bundle-branch block (duration of the QRS complex of 180 msec) and a prolonged Q-T interval of 360 msec (normal corrected Q-T interval, 250 msec). Immediately upon arrival, gastric lavage was performed, and cardiac electrical activity was continuously monitored. Forced diuresis was achieved by infusion of saline solution, with urinary excretion of 31 mg of ajmaline during the first 24 hours. Eight hours following the ingestion of the drug, without additional specific therapy, the ECG showed regressive changes, sinus rhythm appeared, and left bundle-branch block disappeared, although upright T waves were noted in the right precordial leads (Fig IB). This abnormality of repolarization disappeared two hours later (Fig IC). The child was released from the intensive care unit on the next day with normal physical and electrocardiographic findings (Fig ID).
• i
FICUBE 1. E l e _ in case of intoxication with ajmaline. A, On admission (four hours after ingestion of dmg), there is supraventricular tachycardia of 160 beats per minute, complete left bundIe-branch block, and prolonged Q-T interval. B, Eight hours after ingestion, left bundle-branch block has disappeared; however, T waves in right precordial leads are abnormally upright. C, Ten hours after ingestion, abnormalities of repolarization have disappeared. D, On next morning, ECG is normal.
CHEST, 76: 1, JULY, 1979
INTOXICAnON WITH AJMAUNE IN AN INFANT 97
DISCUSSION
Ajmaline has been reported to be effective in the treatment of various types of dysrhythmias, particularly those resulting from intoxication with digitalis and mechanically induced dysrhythmias, and in the Wolff-Parkinson-White syndrome," The drug changes the permeability of the cellular membrane to both sodium and potassium ions, thus slowing depolarization, repolarization, and the rate of conduction. In high dosages, ajmaline has a negative inotropic effect, and both atrioventricular and intraventricular blocks are not uncommon. Venbicular arrest and fibrillation have been reported only when the venous route of administration was used. Both hemodynamic and electrophysiologic effects of the drug have been recently reviewed.s The drug may affect the central nervous system, resulting in respiratory depression, convulsions, and death. The liver may be also affected, while both central and peripheral cardiovascular reflexes usually are spared. We were able to find only three cases of severe intoxication due to the ajmaline in the literature, one in a child and two in adults. 8--3 The oral ingestion of about 30 mg of ajmaline per kilogram of body weight in the first two cases caused severe respiratory depression with cyanosis, convulsions, and loss of consciousness, with widening of the QRS complex in the ECG;3 ventricular fibrillation followed in one of these cases. In the case presented herein, 23mg of ajmaline per kilogram of body weight was ingested. The clinical picture became fully manifest within -half an hour, when complete absorption was unlikely to have taken place. It can be assumed that because of the prompt institution of resuscitation and the use of gastric lavage and forced diuresis, serious dysrhythmias and life-threatening respiratory depression were avoided. The following are guidelines for the treatment of overdosage of ajmaline: (1) gastric lavage should be performed as soon as possible; (2) forced diuresis with saline solution should be instituted, keeping the electrolyte balance; (3) continuous electrocardiographic monitoring is mandatory, with cardiopulmonary resuscitative measures available; (4) antiarrhythmic agents should be used whenever needed, and the appearance of highdegree abioventricular block caDs for the use of a cardiac demand pacemaker; and (5) the use of an artificial respirator should be considered whenever respiratory function is markedly impaired. The benefit of using either peritoneal lavage or hemodialysis is as yet unknown. t•
1 Bazika V, Lang TW, Pappelbaum S, et at: Ajmaline, a Rauwolfia alkaloid for the treatment of digitoxic arrhythmias. Am J CardioI17:227-231, 1966 2 Obayashi K, Nagesawa K, Mandel WJ, et at: Cardiovascular effects of ajmaline. Am Heart J 92:487-496, 1976 3 Jomod Je, Barrelet JA: Suicidal attempt by overdosage of ajmaline. Am Heart J 70:719-720, 1965 4 KalIfelz HC, Rotthauwe HW: Ajmalin Intoxikation im
88 GIGLIA, MORGAN, BATES
Kindesalter. Med lOin 59:338-342, 1964 5 Gelbke HP, Schlicht HI: Suicide by an overdosage of Npropylajmalinium bitartrate. Arch Tcuicol (Berlin) 37:135141, 1977
Rapid Definitive Diagnosis of Legionnaires' Disease* Anthony R. Giglia, M.D.; Paul N. Morgtm~ Joseph H. Bate8~ M.D.~ F.C.C.P.
Ph.D.; and
We describe a sporadic case of LegiolUUlires' dJIease ID which the diaposis was made by direct imm_08uo.... eeaee of material obWDed by pemdaDeous aspIratiOD of the Involved lunl via a needle. Employment of this technique BlDolII selected patients with suspected LegiolUl8ires' disease would provide for more rapid dial· nosis and more prompt Ioitlation of definitive therapy fer some patients.
F
ollowing the initial description of Legionnaires' diseasel and its etiologic agent.s the illness began to be widely recognized in localized epidemics or as sporadic cases. Although the typical clinical picture" is weD known by most clinicians, definitive diagnosis in most cases must await serologic confirmation, which may require up to six weeks or more after the illness is first suspected. During this interim the clinician must rely upon empirical treatment. In a few cases the organism has been cultured from or demonstrated microscopically in pulmonary tissue or pleural fluid, but this process requires several days for bacteriologic confirmation. The purpose of this communication is to report the findings in a patient with Legionnaires' disease in whom the diagnosis was established within hours after hospitalization by direct immunofluorescence, which demonstrated the etiologic agent in material obtained from the lung by percutaneous aspiration via a needle. This procedure is associated with a low risk of significant complicationsv" and may provide rapid diagnosis for a substantial number of these patients.
CASE
REPoRT
A 76-year-old man came to a local hospital with complaints of congestion, shortness of breath, fever, chills, and abdominal pain. An infiltrate was noted in the left upper lobe, and he was treated with ampicillin, without improvement. Upon transfer to our hospital, the chest roentgenogram showed a rapidly advancing infiltrate, and analysis of arterial blood showed the following levels: arterial oxygen tension, 41 mm Hg, arterial carbon dioxide tension, 36 mm Hg, and pH, 7.50. The patient had toxic symptoms and was disoriented and unresponsive. He had fever to 40.6°C (105.1OF). Soon after admission, the patient was judged to require therapy with mechanical ventilation, and a transthoracic aspiration of the lung was performed with a needle prior to tracheal
-From the Medical Service, Vetenms Administration Medical Center-Universibt of ArbDsas for Medical Sciences Complex, Little Rock. Reprint requests: Dr. Giglia, 4301 West Markham, Little Rock 72201
CHEST, 76: 1, JULY, 1979
