J Med Toxicol
· 2026 Apr · PMID 41770516
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INTRODUCTION: Western bush viper (Atheris chlorechis) envenomation is rarely encountered worldwide and has been reported only very rarely in the United States (U.S.). Although there is no antivenom (AV) specific to Ather...INTRODUCTION: Western bush viper (Atheris chlorechis) envenomation is rarely encountered worldwide and has been reported only very rarely in the United States (U.S.). Although there is no antivenom (AV) specific to Atheris species, polyvalent AVs are used to treat closely related species. We discuss the case of a 49-year-old female exotic snake breeder in the U.S. who was bitten on her left thumb by a Western bush viper. CASE REPORT: The patient was initially evaluated at a community hospital emergency department before being transported to a tertiary care center for both AV administration and medical toxicologist evaluation. The patient received two vials of exotic polyvalent AV (Inoserp™ PAN-AFRICA) obtained from a nearby regional zoo for worsening cytotoxicity and an additional two vials for thrombocytopenia. Her extremity swelling, pain and laboratory values improved after AV administration, and the patient was discharged on hospital day three in stable condition. DISCUSSION: Envenomations by exotic snakes present challenges in care. If a potentially life-threatening envenomation occurs, clinicians should consult with a regional poison control center and medical toxicologist to facilitate locating both optimal AV and treatment facilities.
Ivanov I, Abouelela W, Debbie T
… +3 more, Fernández D, Nelson LS, Mudan A
J Med Toxicol
· 2026 Apr · PMID 41770515
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INTRODUCTION: Acute copper toxicity is a rare occurrence, and management guidelines are not based on robust evidence. Treatment recommendations are often extrapolated from those of chronic copper intoxication and the man...INTRODUCTION: Acute copper toxicity is a rare occurrence, and management guidelines are not based on robust evidence. Treatment recommendations are often extrapolated from those of chronic copper intoxication and the management of Wilson's disease. Although D-penicillamine, EDTA, and dimercaprol have varying success, we describe the use of chelation with succimer monotherapy in a patient with acute copper salt ingestion with subsequent improvement of clinical status and copper concentrations. CASE REPORT: A 38-year-old woman presented to an ED after ingestion of liquid copper fungicide containing 27.5% copper diammonia diacetate complex. The regional poison center initially recommended D-penicillamine along with supportive care. Due to the lack of availability of D-penicillamine, succimer was chosen as an alternative agent. The patient developed mild hemolysis and liver injury during her stay, but did not develop any kidney injury. She had a Zargar 2A caustic injury to the stomach and duodenal bulb. She received succimer for a total of 10 days, and copper concentrations decreased from 1,295 mcg/dL (reference range: 80-158 mcg/dL) to normal levels before discharge. DISCUSSION: There is limited evidence surrounding chelation therapy in acute copper poisoning. We describe a case of a patient who clinically improved while receiving aggressive supportive care and associated succimer monotherapy after acute ingestion of a copper compound.
Deutsch AB, Ebeling-Koning NE, Krotulski AJ
… +2 more, Walton SE, Katz KD
J Med Toxicol
· 2026 Apr · PMID 41770514
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INTRODUCTION: Dissociative agents, such as phencyclidine (PCP) and ketamine, belong to the arylcyclohexylamine class. During illicit synthesis, numerous analogs of PCP can be produced. To date, over 60 psychoactive "desi...INTRODUCTION: Dissociative agents, such as phencyclidine (PCP) and ketamine, belong to the arylcyclohexylamine class. During illicit synthesis, numerous analogs of PCP can be produced. To date, over 60 psychoactive "designer" derivatives have been identified, and most are undetectable by standard drug testing. This case describes the first laboratory-confirmed use of 3-methyl-PCP, a novel arylcyclohexylamine dissociative anesthetic. CASE REPORT: A 29-year-old man presented to the emergency department after a drug overdose experiencing encephalopathy, tachycardia, hypertension, nystagmus and diaphoresis. Diagnostics revealed severe rhabdomyolysis and acute kidney injury. During hospitalization, the patient disclosed the use of 3-methyl-PCP obtained online. The drug product and biological specimens were sent to the Center for Forensic Science Research and Education (CFSRE) for comprehensive drug testing, which confirmed the presence of 3-methyl-PCP using gas chromatography-mass spectrometry and liquid chromatography-quadrupole time-of-flight mass spectrometry. DISCUSSION: This confirmed case of 3-methyl-PCP intoxication not only demonstrates the potential for severe injury, but also the public health risks of rapidly emerging and unregulated dissociative synthetic anesthetics. Entities such as the CSFRE NPS Discovery Program's early drug warning system can prove critical for both timely clinical response and public health protection.
J Med Toxicol
· 2026 Apr · PMID 41634285
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INTRODUCTION: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are therapies for type 2 diabetes whose use expanded sharply after semaglutide's 2021 approval for obesity. Although gastrointestinal effects are well d...INTRODUCTION: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are therapies for type 2 diabetes whose use expanded sharply after semaglutide's 2021 approval for obesity. Although gastrointestinal effects are well described, national patterns of acute GLP-1 RA exposures are poorly characterized. This study evaluated trends in GLP-1 RA exposures reported to U.S. poison centers, focusing on demographic shifts, exposure circumstances, and clinical outcomes before and after the 2021 FDA approval. METHODS: We analyzed human GLP-1 RA exposures reported to the National Poison Data System from 2012 to 2023, using July 1, 2021, to define pre- and post-approval periods. Demographics, exposure characteristics, therapies, and medical outcomes were compared using standardized statistical tests. Quarterly call counts were modeled with segmented Poisson regression to assess changes in reporting trajectory. RESULTS: A total of 10,033 exposures were identified (3,113 pre-approval; 6,920 post-approval). Semaglutide predominated post-approval (64.2%). The exposed population shifted younger and more female. Most cases were unintentional therapeutic errors with mild gastrointestinal symptoms. The proportion managed in or referred to a health care facility increased from 23.0% to 33.5% (RR = 1.46, [95% CI: 1.36, 1.57], p < 0.001). Segmented Poisson modeling demonstrated a significant inflection in call volume, with semaglutide exposures increasing an additional 9.9% per quarter after approval. CONCLUSIONS: GLP-1 RA exposures rose sharply following semaglutide's weight-loss approval, accompanied by increased health care utilization despite generally mild clinical effects. Although multiple factors likely contributed to these trends, improved patient counseling and clearer poison center guidance may help reduce preventable therapeutic errors and unnecessary emergency evaluation.
Aldy K, Li S, Costantini M
… +5 more, Falise A, Culbreth R, Wax PM, Brent J, Toxicology Investigators Consortium Study Group
J Med Toxicol
· 2026 Jan · PMID 41501581
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Established in 2010, the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC) Core Registry has systematically captured data from in-hospital and clinic-based medical toxicology physi...Established in 2010, the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC) Core Registry has systematically captured data from in-hospital and clinic-based medical toxicology physician consultations across the United States (US) and internationally. The ToxIC Core Registry contains deidentified patient data, including patient demographics, reason for medical toxicology evaluation, exposure agents, clinical signs and symptoms, treatments and antidotes administered, and mortality outcomes. This fifteenth annual report provides data from 8,868 patients entered into the Core Registry in 2024, bringing the total number of cases to 111,276 between 2010 and 2024. These cases were submitted by 41 participating sites encompassing 67 distinct hospitals over 23 US states and 3 international countries. In 2024, ethanol was the most commonly reported exposure agent class (17.8%), followed by opioids (15.8%), non-opioid analgesics (10.5%), and sympathomimetic agents (7.6%). A total of 107 fatalities were reported, corresponding to a case fatality rate of 1.2%. Additional descriptive analyses in this annual report were conducted to describe trends for opioid and psychoactive exposures between 2010 and 2024.
Feldman R, Gummin D, Hawi M
… +2 more, Lyneis J, Abourashed E
J Med Toxicol
· 2026 Jan · PMID 41413367
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BACKGROUND: Salicylate toxicity remains a significant cause of morbidity and mortality. At therapeutic levels, most salicylic acid (SA) is albumin-bound, but in overdose, the free fraction rises, driving toxicity. Albumi...BACKGROUND: Salicylate toxicity remains a significant cause of morbidity and mortality. At therapeutic levels, most salicylic acid (SA) is albumin-bound, but in overdose, the free fraction rises, driving toxicity. Albumin supplementation has been hypothesized as a strategy to reduce free SA, yet quantitative data are limited. METHODS: An in vitro model was developed to assess albumin's binding capacity for salicylic acid across overdose-relevant concentrations. Solutions of SA (SA30 ≈30 mg/dL, SA50 ≈50 mg/dL, SA100 ≈100 mg/dL, SA120 ≈120 mg/dL) were combined with albumin ranging from 1-8 g/dL, representing subphysiologic to supraphysiologic concentrations. One solution (SA120-A) was prepared at pH 7.0 to evaluate binding in acidic environments. Free SA was quantified in each sample. RESULTS: Increasing albumin reduced free salicylate under all conditions. From 1-8 g/dL, free SA decreased by 38.56 mg/dL (95% CI [37.62, 39.49] at SA50, 38.49 mg/dL (95% CI [37.77, 39.20] at SA100, 38.83 mg/dL (95% CI [37.85, 39.81] at SA120 (pH 7.4), and 52.77 mg/dL (95% CI [51.54, 54.01] at SA120 (pH 7.0). Correction of hypoalbuminemia (1-4 g/dL) reduced free SA by 11.33 mg/dL (95% CI [11.14, 11.53] at SA30, 21.07 mg/dL (95% CI [20.19, 21.94] at SA50, 18.40 mg/dL (95% CI [18.12, 18.68] at SA100, 18.27 mg/dL (95% CI [16.93, 19.61] at SA120 (pH 7.4), and 21.40 mg/dL (95% CI [21.00, 21.80] at SA120-A (pH 7.0). Increasing albumin further to 8 g/dL reduced free SA by an additional 17.49 mg/dL (95% CI [17.42, 17.56] at SA50, 20.09 mg/dL (95% CI [19.62, 20.55] at SA100, 20.57 mg/dL (95% CI [20.18, 20.95] at SA120 (pH 7.4), and 31.37 mg/dL (95% CI [30.12, 32.62] at pH 7.0. SA30 fell below quantification beyond 5 g/dL. CONCLUSION: Albumin addition reduced free salicylate, supporting its potential as a "protein sink" in salicylate toxicity. Further research is needed to determine the clinical relevance and safety of this theoretical intervention.
J Med Toxicol
· 2026 Jan · PMID 41315144
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INTRODUCTION: In Spring 2024, Oregon experienced an outbreak of paralytic shellfish poisoning following ingestion of locally harvested mussels containing elevated saxitoxin concentrations. Prior outbreak reports either d...INTRODUCTION: In Spring 2024, Oregon experienced an outbreak of paralytic shellfish poisoning following ingestion of locally harvested mussels containing elevated saxitoxin concentrations. Prior outbreak reports either do not specify clinical timelines or document variable clinical courses making it difficult to risk stratify patients or determine appropriate clinical monitoring times. We examined cases from this outbreak for symptom progression information that might help guide Poison Center recommendations on management. METHODS: This was a retrospective chart review of cases of paralytic shellfish poisoning reported to the Oregon Poison Center during the outbreak timeframe. Cases were reviewed for time of symptom onset, duration of symptoms, timeline of symptom progression, symptom severity, disposition from the emergency department, need for ventilator support, and number of shellfish ingested. RESULTS: Of eighteen cases reported to the Oregon Poison Center that met the case definition, one was excluded due to insufficient clinical data. Of the seventeen remaining cases, symptom onset occurred as late as 3.5 hours after exposure. Nine cases demonstrated progression of symptoms after initial healthcare contact. All progression to severe symptoms occurred within 6 hours of ingestion. No case demonstrated symptomatic progression beyond 13 hours. There were no deaths. Thirteen cases had a documented number of shellfish ingested, and most had“moderate” symptoms. CONCLUSION: This case series demonstrated symptom onset up to 3.5 hours after exposure and significant symptom progression within 6 hours with no symptomatic progression beyond 13 hours. These data may be useful when considering monitoring and risk-assessment of future cases.
Silvester A, Koutsogiannis Z, Richards S
… +2 more, Thomson D, Wong A
J Med Toxicol
· 2026 Jan · PMID 41249632
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INTRODUCTION: 2,4-dinitrophenol (DNP) is an uncoupler of oxidative phosphorylation and is highly toxic in overdose. CASE REPORT: We present a case of an 18-year-old female who survived an acute-on-chronic DNP overdose re...INTRODUCTION: 2,4-dinitrophenol (DNP) is an uncoupler of oxidative phosphorylation and is highly toxic in overdose. CASE REPORT: We present a case of an 18-year-old female who survived an acute-on-chronic DNP overdose resulting in hypermetabolic state and widespread ST depression with associated troponin I elevation. Serial DNP levels are plotted for this patient, demonstrating first order kinetics with a half-life of 18 h. DISCUSSION: Survival in this case may be attributed to early management of hyperthermia and hypermetabolic state, as well as the acute-on-chronic nature of the overdose. Human pharmacokinetic data for DNP in overdose are rare, as are cases with ST-segment changes.
J Med Toxicol
· 2026 Jan · PMID 41222838
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INTRODUCTION: Hexahydrocannabinol (HHC) is a semi-synthetic hydrogenated derivative of delta-9-tetrahydrocannabinol (THC). HHC emerged within global markets in 2021and has been detected within unregulated cannabis produc...INTRODUCTION: Hexahydrocannabinol (HHC) is a semi-synthetic hydrogenated derivative of delta-9-tetrahydrocannabinol (THC). HHC emerged within global markets in 2021and has been detected within unregulated cannabis products. CASE REPORT: A 32-year-old male presented to hospital 1.5 h following ingestion of a single gummy, which had been sold as a THC product. Symptoms included nausea, vomiting, slurred speech, a subjective feeling of whole-body numbness, and an inability to move his head. Examination revealed an apparent dissociative state, sinus tachycardia (118 beats per minute), mydriasis, confusion, and tachypnoea (24 breaths per minute). There was no objective focal neurological deficit. Investigations including haematology and biochemistry were normal. Management was supportive and symptoms resolved within eight hours of ingestion. Serum analysis revealed the HHC isomers 9R-hexahydrocannabinol (9R-HHC) and 9 S-hexahydrocannabinol (9 S-HHC). No other pharmaceutical or psychoactive substance was detected. DISCUSSION: HHC can be manufactured using cannabidiol as a precursor and can be administered via inhalation, orally and sublingually. The 9R-HHC isomer is the primary psychoactive component. HHC is rapidly absorbed, crosses the blood-brain-barrier and is hepatically metabolised. User reports of HHC adverse effects include anxiety, nausea, and "paralysing effects". Cases of HHC exposure reported in the literature describe palpitations, chest tightness, 'respiratory pause', seizures, dysarthria, dyskinesia, hallucinations, mydriasis, myalgias and acute psychosis. This case of analytically confirmed HHC exposure describes multi-system toxicity including gastrointestinal effects, and dissociative-like neurological effects, and serves as a reminder of the dangers of unregulated products sold within the illicit drug market.
J Med Toxicol
· 2026 Jan · PMID 41214415
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The 2025 ACMT Ward and Ryan Donovan Memorial Fund lecture was presented by Daniel Ciccarone, MD, MPH from Department of Family and Community Medicine at the University of California San Francisco (UCSF). This article is...The 2025 ACMT Ward and Ryan Donovan Memorial Fund lecture was presented by Daniel Ciccarone, MD, MPH from Department of Family and Community Medicine at the University of California San Francisco (UCSF). This article is an edited version of his keynote address during ACMT's 2025 Annual Scientific Meeting. During the course of his talk, Dr. Ciccarone discussed polysubstance use in the "Fentanyl-plus" era. The epidemiology and economics of the four waves of opioid overdose deaths were examined, and promising harm reduction strategies to assist in reducing overdose mortality were highlighted.