1 med tox board review: buzzwords for the boards gp daubert 2014

1

Med Tox Board Med Tox Board Review:Review:

Buzzwords for the Buzzwords for the BoardsBoards

GP Daubert 2014

2Buzzwords for the Boards

““Egg-shell” calcifications of Egg-shell” calcifications of hilar lymph nodes, increase hilar lymph nodes, increase risk of tuberculosis, upper risk of tuberculosis, upper

lung disease lung disease


SilicosisSilicosis


Pneumoconiosis with hilar Pneumoconiosis with hilar adenopathy; clinically and adenopathy; clinically and pathologically identical to pathologically identical to sarcoidosis except no eye sarcoidosis except no eye involvement; lymphocyte involvement; lymphocyte

transformation test transformation test


Berylliosis Berylliosis


Porphyria, pemba yara, Porphyria, pemba yara, spongiform encephalopathy, spongiform encephalopathy, outbrake in Turkey in 1956 outbrake in Turkey in 1956


Hexachlorobenzene Hexachlorobenzene


Isolated thrombocytopenia, Isolated thrombocytopenia, “bathtub refinisher’s lung”, “bathtub refinisher’s lung”, sensitizing agent - largest sensitizing agent - largest

recognized cause of recognized cause of occupational asthma occupational asthma


Toluene di-isocyanate (TDI) Toluene di-isocyanate (TDI)


Hepatic angiosarcoma Hepatic angiosarcoma


Vinyl chloride Vinyl chloride


Pesticide operator with Pesticide operator with sterility, altered sex ratio in sterility, altered sex ratio in

offspringoffspring


DibromochloropropaneDibromochloropropane

(DBCP)(DBCP)

Re: “Da Balls Can’t Produce” Re: “Da Balls Can’t Produce”


Phossy jaw Phossy jaw


Yellow phosphorus Yellow phosphorus


Brown lung, “Monday morning Brown lung, “Monday morning tightness”, byssanosistightness”, byssanosis


CottonCotton


Hypertension, Saturnine gout, Hypertension, Saturnine gout, renal failure, microcytic renal failure, microcytic

anemia anemia


Adult lead poisoningAdult lead poisoning


““Silver solderers”, proximal Silver solderers”, proximal RTA, itai-itai disease in Jintsu RTA, itai-itai disease in Jintsu

River basin, acute lung River basin, acute lung injury, renal failure injury, renal failure


Cadmium Cadmium


Perforated nasal septum, lung Perforated nasal septum, lung cancer, painless ulcers, cancer, painless ulcers,

“blackjack disease”, Type “blackjack disease”, Type IV hypersensitivity IV hypersensitivity

dermatitisdermatitis


ChromiumChromium


Hairdresser with hearing loss, Hairdresser with hearing loss, renal failure, renal failure,

methemoglobinemiamethemoglobinemia


BromateBromate


The cholera toxin activates The cholera toxin activates cAMP, which intern stimulate cAMP, which intern stimulate

CFTR CFTR causing a dramatic efflux causing a dramatic efflux of ions and water from infected of ions and water from infected

enterocytes. enterocytes. What popular ‘pop’ band was What popular ‘pop’ band was associated with this disease?associated with this disease?


The Go-GosThe Go-Gos


Acute psychosis with elevated Acute psychosis with elevated serum chloride levelserum chloride level


BromideBromide


Solvent, epoxide metabolite Solvent, epoxide metabolite (hepatotoxicity), (hepatotoxicity),

“Degreaser’s flush”, “Degreaser’s flush”, trigeminal neuralgiatrigeminal neuralgia


TrichloroethyleneTrichloroethylene


Viscous rayon, increase rate of Viscous rayon, increase rate of atherosclerosis; disulfiram and atherosclerosis; disulfiram and

metam sodium metabolites; basal metam sodium metabolites; basal ganglia toxin; associated with ganglia toxin; associated with

spontaneous abortions; decreased spontaneous abortions; decreased spermatogenesis, craniofacial spermatogenesis, craniofacial abnormalities; optic nerve and abnormalities; optic nerve and

retinal degeneration retinal degeneration


Carbon disulfideCarbon disulfide


The percentage of sick people who The percentage of sick people who are identified as having the are identified as having the

conditioncondition

oror

The likelihood of a test being The likelihood of a test being positive if the condition is presentpositive if the condition is present


SensitivitySensitivity


A result of A result of 100%100% means that the means that the test recognizes all healthy people test recognizes all healthy people

as healthyas healthyoror

The likelihood of the unaffected The likelihood of the unaffected individuals correctly having a individuals correctly having a

negative test negative test


SpecificitySpecificity


True Positive False Positive(Type I error)

False Negative(Type II error)

True Negative

↓Sensitivity

↓Specificity

→ PPV

→ NPV

Condition

Testoutcome

+

+ -

-

A B

C D

Attributable Risk (Risk Difference) = ARE – ARU

→ Absolute RiskExposed (ARE)

A/(A+B)

Condition

RiskFactor

Yes

Yes No

No→ Absolute Risk

Unexposed (ARU)C/(C+D)

Relative Risk = ARE/ARU

Odds Ratio = (A/C)/(B/D)


Solvent, acute CNS Solvent, acute CNS depression, arrhythmias, depression, arrhythmias,

AML, Hodgkin’s lymphoma, AML, Hodgkin’s lymphoma, paroxysmal nocturnal paroxysmal nocturnal

hemoglobinuriahemoglobinuria


BenzeneBenzene


Wastewater treatment Wastewater treatment worker with sensory and worker with sensory and

motor distal axonal motor distal axonal neuropathy (axonopathy)neuropathy (axonopathy)


What singer is associated with What singer is associated with Hymonoptera-induced Hymonoptera-induced

anaphylaxis?anaphylaxis?


StingSting


Wastewater treatment worker with Wastewater treatment worker with sensory and motor distal axonal sensory and motor distal axonal

neuropathy (axonopathy), also has neuropathy (axonopathy), also has blue discoloration of hands and blue discoloration of hands and

feet, desquamation, and pulmonary feet, desquamation, and pulmonary irritationirritation


AcrylamideAcrylamide


Ginger Jake, NTE inhibitor, Ginger Jake, NTE inhibitor, sensory-motor neuropathy, sensory-motor neuropathy,

1960 Morocco disaster1960 Morocco disaster


Triorthocresyl phosphate Triorthocresyl phosphate (TOCP)(TOCP)


Minamata BayMinamata Bay


MethylmercuryMethylmercury


Bhopal disasterBhopal disaster


Methyl isocyanateMethyl isocyanate


Lung cancer, beer drinker with Lung cancer, beer drinker with cardiomyopathy, classic tetrad: cardiomyopathy, classic tetrad:

goiter, cardiomyopathy, goiter, cardiomyopathy, metabolic acidosis, metabolic acidosis,

polycythemia, inhibits oxidation polycythemia, inhibits oxidation of a-KG to succinyl CoA and of a-KG to succinyl CoA and

pyruvate to acetyl CoA pyruvate to acetyl CoA


CobaltCobalt


Pulmonary disease-anemia Pulmonary disease-anemia syndrome, strong respiratory syndrome, strong respiratory

sensitizer sensitizer


Trimellitic anhydrideTrimellitic anhydride


Uranium mining, lung cancer Uranium mining, lung cancer


RadonRadon


Firefighter with delayed Firefighter with delayed pulmonary edema (ARDS) pulmonary edema (ARDS)

and smell of freshly mowed and smell of freshly mowed hay hay


PhosgenePhosgene


Pest-control operator with Pest-control operator with fishy odor, respiratory fishy odor, respiratory

distress, refractory distress, refractory hypotension, delayed hypotension, delayed

pulmonary edema pulmonary edema


PhosphinePhosphine

(aka Phosfish)(aka Phosfish)


Sewage worker with rapid Sewage worker with rapid collapse, mucous membrane collapse, mucous membrane irritation, blackened jewelry, irritation, blackened jewelry,

sodium nitrite antidote sodium nitrite antidote


Hydrogen SulfideHydrogen Sulfide


Endoscopy technician with Endoscopy technician with mucous membrane irritation, mucous membrane irritation, pulmonary edema, leukemia, pulmonary edema, leukemia, sweet odor, convulsions, N/V sweet odor, convulsions, N/V


Ethylene OxideEthylene Oxide


Epping jaundice Epping jaundice


Methylenedianiline Methylenedianiline


Aromatic solvent, acute CNS Aromatic solvent, acute CNS depression, basal ganglia depression, basal ganglia

toxin, pneumonitis, toxin, pneumonitis, hypokalemia, RTA/renal hypokalemia, RTA/renal

failure, myopathy, failure, myopathy, leukoencephalopathyleukoencephalopathy


TolueneToluene


Fungicide with pungent odor, Fungicide with pungent odor, skin and respiratory skin and respiratory

sensitizer, photoallergic sensitizer, photoallergic dermatitis dermatitis


CaptafolCaptafol


1937 Sulfanilamide poisoning1937 Sulfanilamide poisoning


Diethylene glycolDiethylene glycol


Neonatal gasping syndrome Neonatal gasping syndrome


Benzyl alcoholBenzyl alcohol


1986 Lake Nyos disaster 1986 Lake Nyos disaster


Carbon dioxideCarbon dioxide


L-TryptophanL-Tryptophan


Eosinophilia myalgia syndromeEosinophilia myalgia syndrome


Koremlu poisoning Koremlu poisoning


ThalliumThallium


Hopewell epidemic, “Kepone Hopewell epidemic, “Kepone shakes”, Chesapeake Bay shakes”, Chesapeake Bay

contamination contamination


ChlordeconeChlordecone


Stalinon poisoning, vomiting, Stalinon poisoning, vomiting, transitory paralysis, transitory paralysis,

photophobia, white matter photophobia, white matter edemaedema


TriethyltinTriethyltin


Golfer with disulfiram reaction Golfer with disulfiram reaction at the 18th hole at the 18th hole


Thiuram herbicide Thiuram herbicide


Welder with early Parkinson’s Welder with early Parkinson’s Disease Disease


ManganeseManganese


Parakeet dies while family is Parakeet dies while family is cooking in the kitchen cooking in the kitchen


Polymer fume feverPolymer fume fever


Welder dies after ingesting Welder dies after ingesting soldering flux soldering flux


Zinc chlorideZinc chloride


Black henna, black hair dye, Black henna, black hair dye, angioedema, renal failure, angioedema, renal failure, and methemoglobinemia, and methemoglobinemia, leukemia/bladder cancer leukemia/bladder cancer


Para-phenylenediamines Para-phenylenediamines

(para- and ortho-PD)(para- and ortho-PD)


Fumigant worker, peanut Fumigant worker, peanut poisoning, fish odor poisoning, fish odor


Zinc phosphideZinc phosphide


Young male chimney sweeper Young male chimney sweeper with early testicular cancer with early testicular cancer


Polyaromatic hydrocarbons Polyaromatic hydrocarbons


Middle aged male stripping Middle aged male stripping paint that develops angina paint that develops angina

from delayed carbon from delayed carbon monoxide poisoning monoxide poisoning


Methylene chlorideMethylene chloride


Galvanized metal welder, Galvanized metal welder, “Monday morning fever”, “Monday morning fever”, “brass foundry workers “brass foundry workers

ague” ague”


Zinc Oxide Zinc Oxide

(Metal fume fever)(Metal fume fever)


Mill worker with allergic Mill worker with allergic contact dermatitis and contact dermatitis and

respiratory sensitization respiratory sensitization (occupational asthma) (occupational asthma)


Plicatic acid Plicatic acid

(Western red cedar) (Western red cedar)


Farmer’s lung Farmer’s lung


Thermophilic Thermophilic actinomycetesactinomycetes


Irritant gas, warning agent in Irritant gas, warning agent in methyl chloride, component methyl chloride, component

of papite (tear gas), of papite (tear gas), cyclophosphamide metabolite cyclophosphamide metabolite


AcroleinAcrolein


Urine metabolite of acrylamide Urine metabolite of acrylamide used for testing worker used for testing worker

exposure exposure


Carboxyethyl-cysteine Carboxyethyl-cysteine


Primary ingredient in bone Primary ingredient in bone cement, skin sensitizer, cement, skin sensitizer,

elevated urine mercapturic elevated urine mercapturic acid, pediatric burnsacid, pediatric burns


Methyl methacrylateMethyl methacrylate


Spain 1981: rapeseed oil Spain 1981: rapeseed oil contaminated with denatured contaminated with denatured

aniline. Diffuse pulmonary aniline. Diffuse pulmonary infiltrates on x-ray, infiltrates on x-ray,

methemoglobinemia methemoglobinemia


AnilineAniline


Airbag inflation, herbicide, Airbag inflation, herbicide, cytochrome aa3 inhibitor cytochrome aa3 inhibitor


Sodium azideSodium azide


Fumigant, fire extinguisher, Fumigant, fire extinguisher, lower extremity axonopathy, lower extremity axonopathy,

intoxication resembles intoxication resembles Wernicke’s encephalopathy, Wernicke’s encephalopathy,

inferior colliculi lesions, inferior colliculi lesions, NAC may worsen syndromeNAC may worsen syndrome


Methyl bromideMethyl bromide


Irritant gas with gasoline-like Irritant gas with gasoline-like odor, may cause hypotension odor, may cause hypotension

and bradycardia with and bradycardia with inhalation, associated with inhalation, associated with

lymphohematopoeitic cancerslymphohematopoeitic cancers


1,3 Butadiene1,3 Butadiene


Current pesticide/herbicide Current pesticide/herbicide but once in mouthwash and but once in mouthwash and

toothpaste, toothpaste, methemoglobinemia and GI methemoglobinemia and GI

distress after 3-6 hour distress after 3-6 hour latent periodlatent period


Sodium chlorateSodium chlorate


Hyperthyroid medication that Hyperthyroid medication that was linked to aplastic was linked to aplastic

anemia – now ground water anemia – now ground water contaminantcontaminant


PerchloratesPerchlorates


Tar smarts; pitch warts and Tar smarts; pitch warts and squamous cell carcinoma; squamous cell carcinoma;

chronic melanosis; UV chronic melanosis; UV phototoxicity; strong phototoxicity; strong

carcinogen of lung, bladder, carcinogen of lung, bladder, skin, scrotal, oral, stomachskin, scrotal, oral, stomach


Coal tar productsCoal tar products


Ammonia-like odor, rocket fuel Ammonia-like odor, rocket fuel and water treatment agent, and water treatment agent,

toxicity tetrad: SLE (skin toxicity tetrad: SLE (skin sensitizer), sensitizer),

methemoglobinemia, methemoglobinemia, seizures, hepatitisseizures, hepatitis


Hydrazine (diamines)Hydrazine (diamines)


Paint remover and solvent Paint remover and solvent with fishy or ammonia smell with fishy or ammonia smell that causes severe hepatitis that causes severe hepatitis with jaundice and eventual with jaundice and eventual

liver failureliver failure


Dimethylacetamide (DMAC)Dimethylacetamide (DMAC)


Solvent used in pharmaceutical Solvent used in pharmaceutical industry, acrylic fiber industry, acrylic fiber

production and recovery of COproduction and recovery of CO22 in gasses that may result in skin in gasses that may result in skin irritation, severe hepatotoxicity, irritation, severe hepatotoxicity,

and disulfiram reactions and disulfiram reactions


N,N Dimethylformamide N,N Dimethylformamide (DMF)(DMF)


Explosive/munitions production, Explosive/munitions production, spandex fibers, causes severe GI spandex fibers, causes severe GI distress and vomitus smells like distress and vomitus smells like bitter almonds, retrobulbar and bitter almonds, retrobulbar and

optic neuropathy, methb, optic neuropathy, methb, hepatitis, aplastic anemia; and hepatitis, aplastic anemia; and

yellowing of skin, hair, and eyesyellowing of skin, hair, and eyes


1,3 Dinitrobenzene1,3 Dinitrobenzene


Oily liquid used in explosives Oily liquid used in explosives and diisocyanate production, and diisocyanate production, possible weight loss product, possible weight loss product, uncoupler, retrobulbar and uncoupler, retrobulbar and optic neuropathy, methb, optic neuropathy, methb,

turns skin turns skin yellowyellow


2,4 Dinitrotoluene2,4 Dinitrotoluene


Sweet smelling irritant gas, Sweet smelling irritant gas, insect fumigant and heat insect fumigant and heat

stabilizer for plastic stabilizer for plastic production, delayed production, delayed pulmonary toxicitypulmonary toxicity


EpichlorohydrinEpichlorohydrin


Textile finishing agent and used in Textile finishing agent and used in the synthesis of malathion; the synthesis of malathion;

vapors result in corneal edema, vapors result in corneal edema, photophobia, and diplopia; photophobia, and diplopia; chronic use associated with chronic use associated with

occupational asthma, hemolytic occupational asthma, hemolytic anemia, and pulmonary anemia, and pulmonary

hemorrhagehemorrhage


Maleic anhydrideMaleic anhydride


Used as an odorant for natural Used as an odorant for natural gases, rotten cabbage odor, gases, rotten cabbage odor,

methemoglobin and methemoglobin and hemolytic anemiahemolytic anemia


MercaptansMercaptans


Abdominal pain, hemolytic Abdominal pain, hemolytic anemia, Paris green, anemia, Paris green,

hematuria, bronze skin hematuria, bronze skin


ArsineArsine


Metals that produce non-Metals that produce non-fibrogenic benign fibrogenic benign pneumoconiosis pneumoconiosis


Tin (Stannosis)Tin (Stannosis)

Barium (Baritosis)Barium (Baritosis)

Iron (siderosis)Iron (siderosis)

Calcium (Chalitosis)Calcium (Chalitosis)

MolybdenumMolybdenum


Vineyard sprayer’s lung Vineyard sprayer’s lung (interstitial pulmonary (interstitial pulmonary

fibrosis, histiocytic fibrosis, histiocytic granulomas, granulomas,

adenocarcinoma) [Portugal]adenocarcinoma) [Portugal]


CuSOCuSO44

(Bordeaux soln)(Bordeaux soln)


Hard metal pneumoconiosis, Hard metal pneumoconiosis, pulmonary eosinophilia pulmonary eosinophilia

portends poor prognosis portends poor prognosis


Tungsten-carbideTungsten-carbide


Diamond polishers lung Diamond polishers lung


CobaltCobalt


Patient on dialysis who Patient on dialysis who develops somnolence, develops somnolence,

perioral numbness, perioral numbness, abdominal pain, and abdominal pain, and

hyperamylasemiahyperamylasemia


MnSOMnSO44


Worker with osteosclerosis with Worker with osteosclerosis with accompanying nerve root accompanying nerve root

compression. Plain film xray compression. Plain film xray reveals ligament calcification reveals ligament calcification

and lesions resembling and lesions resembling osteoblastic metastasisosteoblastic metastasis


FluorisisFluorisis

Cryolite (NaAlFl)Cryolite (NaAlFl)


Acroosteolysis (bone resorption Acroosteolysis (bone resorption at distal phalanx)at distal phalanx)


Vinyl chlorideVinyl chloride


Most common medication Most common medication associated with associated with hypersensitivity hypersensitivity

pneumonitispneumonitis


NitrofurantoinNitrofurantoin


Middle aged adult with chronic Middle aged adult with chronic seizure disorder with xray seizure disorder with xray

demonstrating hilar demonstrating hilar lymphadenopathy. Biopsy lymphadenopathy. Biopsy

reveals drug-induced reveals drug-induced lymphoid hyperplasialymphoid hyperplasia


PhenytoinPhenytoin


Elderly male with hepatic Elderly male with hepatic angiocarcinoma and angiocarcinoma and

pneumococcal sepsis. pneumococcal sepsis. Abdominal xray reveals Abdominal xray reveals multiple opacities in the multiple opacities in the

liver and spleenliver and spleen


Thorotrast (thorium dioxide)Thorotrast (thorium dioxide)


Xenobiotic-induced aplastic Xenobiotic-induced aplastic anemia is most commonly anemia is most commonly

associated with destruction associated with destruction of these progenitor cellsof these progenitor cells


CD34+ progenitor cellsCD34+ progenitor cells


Lymphoma in a Dutch flower Lymphoma in a Dutch flower bulb worker using a bulb worker using a

nematode fumigant (also nematode fumigant (also seen in fireman)seen in fireman)


Dichloropropene (Telon) Dichloropropene (Telon)


Cola-colored infant with Cola-colored infant with MRCP, abnormal skull MRCP, abnormal skull

calcification, and calcification, and hypoplastic nailshypoplastic nails


PCBsPCBs

(remember (remember PPepsi-epsi-CColored olored BBabies) abies)


Metabolite of disulfiram and Metabolite of disulfiram and used in the treatment of used in the treatment of

nickel carbaryl and nickel carbaryl and platinoid poisoningplatinoid poisoning


Diethyldithiocarbamate (DDC)Diethyldithiocarbamate (DDC)


4-year-old boy on an 4-year-old boy on an antineoplastic drug that antineoplastic drug that develops fever, SIADH, develops fever, SIADH,

necrotic myocardial necrotic myocardial infarction, and loss of deep infarction, and loss of deep

tendon reflexestendon reflexes


VincristineVincristine


Antineoplastic producing hilar Antineoplastic producing hilar lymphadenopathylymphadenopathy


MethotrexateMethotrexate


Antineoplastic producing Antineoplastic producing nodular bronchiolitis nodular bronchiolitis

obliteransobliterans


BleomycinBleomycin


Antineoplastic associated with Antineoplastic associated with perforation of the GI tractperforation of the GI tract


Dru

g C

once

ntr

atio

n

Time (hrs)

Na

tura

l Lo

g (

ln)

Dru

g C

once

ntr

atio

nTime (hrs)


11stst Order Elimination Order Elimination


PaclitaxolPaclitaxol


Antineoplastic associated with Antineoplastic associated with hemolytic uremia syndromehemolytic uremia syndrome


MitomycinMitomycin


Metal that is radiolucent on Metal that is radiolucent on plain film xrayplain film xray


Copper Copper


Metal causing paresthesias Metal causing paresthesias (pins and needles), ataxia, (pins and needles), ataxia,

dysarthria, constricted dysarthria, constricted visual fields, deafnessvisual fields, deafness


Methyl mercuryMethyl mercury


““Pink disease”: mercury Pink disease”: mercury teething powders such as teething powders such as

calomelcalomel


MercuryMercury

calomel (HgCl) calomel (HgCl)


Riboflavin inhibition (Riboflavin inhibition ( FAD); FAD); Painful peripheral neuropathy; Painful peripheral neuropathy;

neuropathy spares CN I, V, neuropathy spares CN I, V, VIII; alopecia with sparing of VIII; alopecia with sparing of

axilla, facial hair, and inner 1/3 axilla, facial hair, and inner 1/3 of eyebrow; reverse sleep cycleof eyebrow; reverse sleep cycle


ThalliumThallium


Biological monitoringBiological monitoring

BenzeneBenzeneTolueneTolueneStyreneStyreneLeadLeadMethylmercuryMethylmercuryInorganic Inorganic mercurymercuryPolyaromatic Polyaromatic HCHC


Biological monitoringBiological monitoring

BenzeneBenzene Total urine phenol Total urine phenol TolueneToluene Urine hippuric Urine hippuric

acid acid StyreneStyrene Urine mandelic Urine mandelic

and and phenylglyoxylic phenylglyoxylic acid acid

LeadLead Blood ZPP/FEPBlood ZPP/FEPMethylmercuryMethylmercury Blood mercury Blood mercury Inorganic Inorganic mercurymercury

Urine mercuryUrine mercury

Polyaromatic HCPolyaromatic HC Urine 1-Urine 1-hydroxypyrene hydroxypyrene


Oily liquid used in cold Oily liquid used in cold sterilization, sensitizer and sterilization, sensitizer and

occupational asthmaoccupational asthma


GlutaraldehydeGlutaraldehyde


Used in plastics and rubber, Used in plastics and rubber, dental fillings and styrofoam. dental fillings and styrofoam. Causes flu-like symptoms and Causes flu-like symptoms and

drunkeness acutely, drunkeness acutely, peripheral neuropathy and peripheral neuropathy and

hearing loss chronicallyhearing loss chronically


StyreneStyrene

Styrene syndromeStyrene syndrome


Chemical associated with Chemical associated with highest incidence of lung highest incidence of lung

cancer in the worldcancer in the world


Polyaromatic HCPolyaromatic HC


Dentist with vitamin B12-like Dentist with vitamin B12-like deficiency, bone marrow deficiency, bone marrow

suppression, and pernicious suppression, and pernicious anemia. Histochemistry reveals anemia. Histochemistry reveals inactive cobalt and inhibition inactive cobalt and inhibition

of methionine synthetaseof methionine synthetase


Nitrous oxideNitrous oxide


Person exposed to a cloud of Person exposed to a cloud of “red smoke” with delayed “red smoke” with delayed

pulmonary edema and pulmonary edema and chemical burns with chemical burns with characteristic yellow characteristic yellow

discolorationdiscoloration


Nitric acidNitric acid


Pyrophoric material causing Pyrophoric material causing severe thermal and chemical severe thermal and chemical burns (submerge in CuSOburns (submerge in CuSO44) ) and exposure may lead to and exposure may lead to

hepatotoxicity and hepatotoxicity and hypocalcemia with increased hypocalcemia with increased

QT intervalQT interval


White phosphorusWhite phosphorus


““Rush” fire in San Francisco in Rush” fire in San Francisco in 1983 leading to a number of 1983 leading to a number of

firefighters with firefighters with methemoglobinemia methemoglobinemia


Isobutyl nitrateIsobutyl nitrate


1978 Jonestown mass suicide1978 Jonestown mass suicide


KCNKCN


Only organic phosphorus Only organic phosphorus pesticide that possesses a pesticide that possesses a significant vapor hazard significant vapor hazard

(high vapor pressure)(high vapor pressure)


DichlorvosDichlorvos


Patient presenting after Patient presenting after herbicide ingestion with herbicide ingestion with

myotonia, myoclonus, myotonia, myoclonus, hematuria/rhabdo, and hematuria/rhabdo, and cardiac disturbancescardiac disturbances


Chlorphenoxy herbicideChlorphenoxy herbicide


Fetal syndrome – 10-30%, 25% Fetal syndrome – 10-30%, 25% risk of spontaneous risk of spontaneous

abortion, abortion, microcephaly/hydrocephaly, microcephaly/hydrocephaly, congenital heart disorders, congenital heart disorders,

microtia, cleft lip/palatemicrotia, cleft lip/palate


Fetal isoretinoinFetal isoretinoin


Microcephaly, developmental Microcephaly, developmental delay, telecanthus, short delay, telecanthus, short

nose and flat nasal bridge, nose and flat nasal bridge, anteverted nares, long anteverted nares, long

shallow filtrum, thin upper shallow filtrum, thin upper lip, nail displasialip, nail displasia


Fetal hydantoinFetal hydantoin


Microcephaly, small palpebral Microcephaly, small palpebral fissure length, thin upper lip, fissure length, thin upper lip,

smooth philtrum, flatted smooth philtrum, flatted cheeks and short nose. Risk of cheeks and short nose. Risk of brain injury increases as eyes brain injury increases as eyes

get smaller, philtrum gets get smaller, philtrum gets flatter, and lip gets thinnerflatter, and lip gets thinner


Fetal alcoholFetal alcohol


Small nose and markedly depressed Small nose and markedly depressed nasal bridge; brachydactyl; nasal bridge; brachydactyl;

hypoplasia of all distal hypoplasia of all distal phalanges; severe shortening of phalanges; severe shortening of lower extremities; Epiphyseal lower extremities; Epiphyseal stippling of the sacrum, spine, stippling of the sacrum, spine, proximal humeri, and femursproximal humeri, and femurs


Fetal warfarinFetal warfarin


(Parrot fish and tidal xanthid (Parrot fish and tidal xanthid crabs) Inhibits Na/K ATPase, crabs) Inhibits Na/K ATPase,

N/V/D, paresthesias, N/V/D, paresthesias, hypocalcemic tetany, CV hypocalcemic tetany, CV collapse (2nd most potent collapse (2nd most potent

toxin on planet earth) toxin on planet earth)


PalytoxinPalytoxin


(Paralytic shellfish poisoing, (Paralytic shellfish poisoing, gonyautoxins) Na channel gonyautoxins) Na channel blocker, oysters/red tides, blocker, oysters/red tides, N/V, paresthesias, throat N/V, paresthesias, throat

pain, descending paralysis pain, descending paralysis


SaxitoxinSaxitoxin


(Neurotoxin shellfish poisoing) (Neurotoxin shellfish poisoing) Na channel opener; Na channel opener;

paresthesias; temperature paresthesias; temperature reversal; N/V/D uncommon; reversal; N/V/D uncommon; tide aerosolized toxin causes tide aerosolized toxin causes

conjunctivitis, rhinitis, conjunctivitis, rhinitis, bronchitisbronchitis


BrevetoxinBrevetoxin


(Diarrhetic shellfish poisoing) (Diarrhetic shellfish poisoing) Inhibits protein phosphates Inhibits protein phosphates disrupting cell metabolism, disrupting cell metabolism,

benign gastric tumors, benign gastric tumors, N/V/D predominateN/V/D predominate


Okadaic acidOkadaic acid


(Amnestic shellfish poisoing) CNS (Amnestic shellfish poisoing) CNS glutamate receptor stimulation glutamate receptor stimulation

causing Na channel upregulation causing Na channel upregulation and Na/Ca influx g neuronal cell and Na/Ca influx g neuronal cell

lysis; toxicity resembles lysis; toxicity resembles Alzheimer’s-like dementia, N/V/D, Alzheimer’s-like dementia, N/V/D, headaches, ataxia, seizures; assoc. headaches, ataxia, seizures; assoc.

with eating blue muscleswith eating blue muscles


DomoicDomoic acidacid

(think Dumb-oic acid)(think Dumb-oic acid)


(Also maitotoxin) Na and Ca channel (Also maitotoxin) Na and Ca channel openers; metallic taste; openers; metallic taste;

paresthesias; glove and stocking paresthesias; glove and stocking numbness; palmer pruritis; numbness; palmer pruritis;

hot/cold reversal; sensation of hot/cold reversal; sensation of loose teeth; treat with mannitol loose teeth; treat with mannitol

and gapapentin; symptoms and gapapentin; symptoms worsen with alcoholworsen with alcohol


CiguatoxinCiguatoxin


Bacteria-catalyzed Bacteria-catalyzed decarboxylation of decarboxylation of

decomposing finfish decomposing finfish muscle, “sunburn-like” muscle, “sunburn-like” rash, urticaria, pruritis, rash, urticaria, pruritis,

bronchospasmbronchospasm


ScombroidScombroid

(Histamine poisoning)(Histamine poisoning)


Sodium channel blocker, Sodium channel blocker, perioral paresthesias, numbness, perioral paresthesias, numbness,

tremor, ataxia, tremor, ataxia, dysarthria/dysphagia, dysarthria/dysphagia,

respiratory paralysis, death (5th respiratory paralysis, death (5th most potent toxin on planet most potent toxin on planet

earth)earth)


TetrodotoxinTetrodotoxin


Japanese vinyl sandal maker Japanese vinyl sandal maker with peripheral with peripheral

sensorimotor neuropathy. sensorimotor neuropathy. Nerve biopsy reveals axonal Nerve biopsy reveals axonal

swelling. swelling.


HexaneHexane


Cicuta spp. Most fatal plant Cicuta spp. Most fatal plant species in North America species in North America

(30-70% fatality rate). (30-70% fatality rate).


Water HemlockWater Hemlock

Water Gate Candidate Scandal Water Gate Candidate Scandal (Water hemlock, GABA, (Water hemlock, GABA,

Cicutoxin, Seizures)Cicutoxin, Seizures)


The only form of poisoning The only form of poisoning caused by bacterial caused by bacterial

contamination.contamination.


ScombroidScombroid

(Histamine poisoning)(Histamine poisoning)


St. Anthony’s Fire, ergotismSt. Anthony’s Fire, ergotism


Claviceps purpureaClaviceps purpurea


Structural similarity to the Structural similarity to the herbicide Endothall, also herbicide Endothall, also

know as Spanish Fly, know as Spanish Fly, produced by the blister produced by the blister

beetlebeetle


CantharidinCantharidin


Profound hypoglycemia, Profound hypoglycemia, hepatitis with hepatitis with

hyperbilrubinemia, hyperbilrubinemia, acidemia and aciduria acidemia and aciduria

without ketosiswithout ketosis


Ackee (hypoglycin)Ackee (hypoglycin)


The maximum concentration of The maximum concentration of a chemical to which workers a chemical to which workers may be exposed continuously may be exposed continuously for up to 15 minutes without for up to 15 minutes without

danger to health or work danger to health or work efficiency and safetyefficiency and safety


STELSTEL

(Short-term exposure limit)(Short-term exposure limit)


Sulfonylurea known to cause Sulfonylurea known to cause SIADH and disulfiram SIADH and disulfiram

reactionsreactions


ChlorpropramideChlorpropramide


Side chain on cephalosporin Side chain on cephalosporin (ie, cefazolin) antibiotics (ie, cefazolin) antibiotics

linked to disulfiram linked to disulfiram reactionsreactions


n-methyltetrathioln-methyltetrathiol


Antidysrhythmic with Antidysrhythmic with antimuscarinic properties antimuscarinic properties and causes hypoglycemiaand causes hypoglycemia


DisopyramideDisopyramide


Intoxicants that produce Intoxicants that produce metaphyseal bands on plain-metaphyseal bands on plain-

film x-rayfilm x-ray


Lead (lead lines)Lead (lead lines)

Yellow phosphorusYellow phosphorus

BismuthBismuth

Hyervitaminosis DHyervitaminosis D


5 most common medications 5 most common medications linked to lupus-like syndromelinked to lupus-like syndrome


CHIMPCHIMPChlorpropramideChlorpropramide

HydralazineHydralazineINHINH

MethyldopaMethyldopaProcainamideProcainamide


Idiopathic intracranial Idiopathic intracranial hypertension (pseudotumor hypertension (pseudotumor

cerebri)cerebri)


Vitamin AVitamin A


Dru

g C

once

ntr

atio

n

Time (hrs) Time (hrs)

Na

tura

l Lo

g (

ln)

Dru

g C

once

ntr

atio

n


Zero order eliminationZero order elimination


Chan SuChan Su


Chinese herbal remedy with Chinese herbal remedy with bufadenalide cardiac steroidbufadenalide cardiac steroid


Plant that is a CYP3A4 inducerPlant that is a CYP3A4 inducer


St. John’s WartSt. John’s Wart

((Hypericum perforatumHypericum perforatum) )


Pulegone Pulegone methofuran methofuran hepatitishepatitis

P450


Pennyroyal Pennyroyal

((Mentha pelugiumMentha pelugium))


Aspiration pneumonitis, CNS Aspiration pneumonitis, CNS depression, patient’s urine depression, patient’s urine

smells like violetssmells like violets


Turpentine (pine oil)Turpentine (pine oil)


Essential oil, CNS depression, Essential oil, CNS depression, mild hepatitis, hemorrhagic mild hepatitis, hemorrhagic

pulmonary edemapulmonary edema


Oil of Cloves (Eugenol) Oil of Cloves (Eugenol)

((Euginia aromaticaEuginia aromatica))


Most common cause of Most common cause of medication-induced contact medication-induced contact

dermatitisdermatitis


NeomycinNeomycin


Endocardial and mitral valve Endocardial and mitral valve fibrosis, pulmonary fibrosis, pulmonary

hypertensionhypertension


FenfluramineFenfluramine


Disinfectant associated with Disinfectant associated with neonatal vacuolar neonatal vacuolar

encephalopathy and cerebral encephalopathy and cerebral edemaedema


HexachlorapheneHexachloraphene


Disinfectant ingestion causing Disinfectant ingestion causing metabolic acidemia due to metabolic acidemia due to

decreased renal clearence of decreased renal clearence of HH+ + (patients have a normal (patients have a normal

lactate)lactate)


Providone iodineProvidone iodine


Disinfectant, hypopigmented Disinfectant, hypopigmented skin, tardive dyskinesia-like skin, tardive dyskinesia-like

syndrome, bradycardia, syndrome, bradycardia, hypotension, PEG hypotension, PEG decontaminationdecontamination


PhenolPhenol


““Rose eye” discoloration of Rose eye” discoloration of eyelids, conjunctivitis, eyelids, conjunctivitis, refractory hypotension, refractory hypotension, reddish discoloration of reddish discoloration of

viscera post-mortemviscera post-mortem


Acute selenium toxicity Acute selenium toxicity

(Selenious acid)(Selenious acid)


Peanut meal worker who Peanut meal worker who develops liver cancer develops liver cancer

(hepatoma)(hepatoma)


AflatoxinAflatoxin


Biomarker for benzene Biomarker for benzene exposureexposure


Urine phenolUrine phenol


HIV medication associated HIV medication associated with severe (death) with severe (death)

hypersensivity reactionshypersensivity reactions


AbacavirAbacavir


The two P450 isozymes linked The two P450 isozymes linked to the development of cancerto the development of cancer


CYP1A2CYP1A2

CYP2E1CYP2E1


Enzyme linked to aromatic Enzyme linked to aromatic anticonvulsant anticonvulsant

hypersensitivity syndromehypersensitivity syndrome


Epoxide hydrolaseEpoxide hydrolase


The only medication-induced The only medication-induced seizure that will likely seizure that will likely respond to phenytoinrespond to phenytoin


AminopyridineAminopyridine


The only local anesthetic that The only local anesthetic that causes vasoconstrictioncauses vasoconstriction


CocaineCocaine


Most cardiotoxic amide local Most cardiotoxic amide local anesthetic (may cause anesthetic (may cause

cardiotoxicity before CNS cardiotoxicity before CNS toxicity)toxicity)


BupivacaineBupivacaine


Most extensively metabolized Most extensively metabolized anesthetic, hepatitis, anesthetic, hepatitis,

malignant hyperthermia, malignant hyperthermia, acute lung injury from abuse acute lung injury from abuse

(PO/IV)(PO/IV)


HalothaneHalothane


The only IARC Group 4 drugThe only IARC Group 4 drug

IARC Group 4: Probably not IARC Group 4: Probably not carcinogenic to humanscarcinogenic to humans


Caprolactam Caprolactam


Patient with ventricular Patient with ventricular ectopy, blindness, N/V, ectopy, blindness, N/V,

diaphoresis, tinnitus, after diaphoresis, tinnitus, after drinking tonic water with drinking tonic water with

Cinchona succirubraCinchona succirubra extract extract


QuinineQuinine


Biventricular ventricular Biventricular ventricular tachycardiatachycardia


Cardiac steroids (#1)Cardiac steroids (#1)

AconitineAconitine

Halogenated hydrocarbsonsHalogenated hydrocarbsons


Patient with an aortic Patient with an aortic dissection and renal failure dissection and renal failure

that develops altered mental that develops altered mental status, seizures, and no status, seizures, and no

metabolic acidosismetabolic acidosis


Thiocyanate toxicityThiocyanate toxicity


Opioid linked to serotonin Opioid linked to serotonin syndrome, seizures, MPTP, syndrome, seizures, MPTP, and may not result in miosis and may not result in miosis

in overdosein overdose


MeperidineMeperidine


Grey baby syndromeGrey baby syndrome


ChloramphenicalChloramphenical


NSAID linked to aplastic NSAID linked to aplastic anemiaanemia


PhenylbutazonePhenylbutazone


Patient with HIV with sulfa Patient with HIV with sulfa allergy who develops allergy who develops

hemolysis and hemolysis and methemoglobinemiamethemoglobinemia


DapsoneDapsone


Patient undergoing elective Patient undergoing elective endoscopy that develops endoscopy that develops

methemoglobinemia during methemoglobinemia during pre-oppre-op


Benzocaine Benzocaine

(Hurricane spray)(Hurricane spray)


Most frequently reported Most frequently reported antineoplastic overdoseantineoplastic overdose


VincristineVincristine


Free radical induced Free radical induced cardiomyopathy with cardiomyopathy with

irreversible heart failureirreversible heart failure


DoxorubicinDoxorubicin


Alkylating agent causing Alkylating agent causing hemorrhagic cystitis and hemorrhagic cystitis and

MESNA antidoteMESNA antidote


CyclophosphamideCyclophosphamide


Alkylating agent causing Alkylating agent causing pulmonary fibrosis and skin pulmonary fibrosis and skin

hyperpigmentation (tan hyperpigmentation (tan appearance)appearance)


BusulfanBusulfan

““Busulfan tan”Busulfan tan”


6 intoxicants for which urine 6 intoxicants for which urine alkalination (ion trapping) alkalination (ion trapping) enhances drug eliminationenhances drug elimination


SalicylatesSalicylatesPhenobarbitalPhenobarbitalMethotrexateMethotrexate

ChlropropramideChlropropramideChlrophenoxy herbicidesChlrophenoxy herbicides

FluorideFluoride


Scleritis and uveitis in a Scleritis and uveitis in a patient being treated for patient being treated for

hypercalcemiahypercalcemia


BisphosphanateBisphosphanate

(ie, pamidronate)(ie, pamidronate)


Peliosis hepatisPeliosis hepatis


Alkalated anabolic steroidsAlkalated anabolic steroids


MorphineMorphine


CocaineCocaine


PhosgenePhosgene


SarinSarin


DigoxinDigoxin


DioxinDioxin

(2,3,7,8 TCDD)(2,3,7,8 TCDD)


Succimer (DMSA)Succimer (DMSA)


AcetylcysteineAcetylcysteine


D-penicillamineD-penicillamine


Methylene blueMethylene blue


EDTAEDTA

Ethylenediaminetetraacetic Ethylenediaminetetraacetic AcidAcid


DeferoxamineDeferoxamine


PralidoximePralidoxime


Alpha-amanitinAlpha-amanitin


AspirinAspirin


AcetaminophenAcetaminophen

ParacetamolParacetamol


FlumazenilFlumazenil


TetrodotoxinTetrodotoxin


PhysostigminePhysostigmine


PyridoxinePyridoxine


DMPSDMPS


Lactrodectus mactansLactrodectus mactans


Black widowBlack widow

Painful bitePainful bite

Calcium channel openerCalcium channel opener

Increase release ACh, NEIncrease release ACh, NE


Loxosceles reclusaLoxosceles reclusa


Brown recluseBrown recluse

Painless bitePainless bite

Sphingomyelinase DSphingomyelinase D

HyoluranidaseHyoluranidase

Local wound ulcer (red, white, Local wound ulcer (red, white, blue)blue)


Tegenaria agrestisTegenaria agrestis


Hobo spiderHobo spider

Painless bitePainless bite

Local ulcerLocal ulcer


Chironex fleckeriChironex fleckeri


Box jellyfishBox jellyfish

Most lethal cnidariaMost lethal cnidaria

Rapid death in minutesRapid death in minutes

Acetic acid/AntivenomAcetic acid/Antivenom


Carukia barnesiCarukia barnesi


Irukandji jellyfishIrukandji jellyfish

Irukandji SyndromeIrukandji Syndrome

HypertensionHypertension


Physalia physallisPhysalia physallis


Portugese Portugese man-of-war/Bluebottleman-of-war/Bluebottle

Painful linear weltsPainful linear welts

Acetic acidAcetic acid


Acanthaster planciAcanthaster planci


Crown-of-thornsCrown-of-thorns

Pain, paralysisPain, paralysis

Hot water immersionHot water immersion


Pterosis sppPterosis spp


LionfishLionfish

Pain, possible blistersPain, possible blisters

Hot water immersionHot water immersion


Synanceja verrucosa Synanceja verrucosa

Synanceja horridaSynanceja horrida


StonefishStonefish

Cytotoxic, hemolytic, myotoxicCytotoxic, hemolytic, myotoxic

Severe pain, hypotension, Severe pain, hypotension, hemolysishemolysis

Hot water, antivenomHot water, antivenom


Dasyatis spp.Dasyatis spp.


StingrayStingray

Local painLocal pain

Vibrio infectionsVibrio infections

Hot water, antibioticsHot water, antibiotics


Atrax robustusAtrax robustus


Funnel web spiderFunnel web spider

Massive release of ACh, NE, epiMassive release of ACh, NE, epi

Rabbit IgG antivenomRabbit IgG antivenom

Death historically in peds < age Death historically in peds < age 44


Solenopsis invectaSolenopsis invecta


Fire antFire ant

Glucosaminidase, piperidinesGlucosaminidase, piperidines

Wheals, clear vesiclesWheals, clear vesicles

Local careLocal care


Centruroides exilicaudaCentruroides exilicauda


Bark scorpionBark scorpion

Sodium channel openerSodium channel opener

Pain, paresthesias, palsiesPain, paresthesias, palsies


Bufo alvariusBufo alvarius


Colorado River ToadColorado River Toad

Bufadienolide cardiac steroidBufadienolide cardiac steroid

Bufotenin tryptaminesBufotenin tryptamines

Chan Su HerbalChan Su Herbal

Dig fab fragmentsDig fab fragments


Bodybuilder presenting with Bodybuilder presenting with tachycardia, wide pulse tachycardia, wide pulse pressure, hypokalemiapressure, hypokalemia


ClenbuterolClenbuterol


Silo Filler’s DiseaseSilo Filler’s Disease


Nitric oxides (NO, NONitric oxides (NO, NO22))


Basal ganglia toxinsBasal ganglia toxins



COCO

ManganeseManganese

MethanolMethanol


Remediation level for home Remediation level for home radonradon


11 pc/L11 pc/L


Three agents associated with Three agents associated with perinatal deathperinatal death


ACE inhibitorsACE inhibitors

Cigarette smokingCigarette smoking

LeadLead


Most common hydrocarbon Most common hydrocarbon used in dry cleaningused in dry cleaning


PERCPERC

PerchloroethylenePerchloroethylene


Cement worker with contact Cement worker with contact dermatitisdermatitis


Chromium (CrChromium (CrVIVI))


OSHA PEL for benzeneOSHA PEL for benzene


1 ppm1 ppm


OSHA PEL for carbon OSHA PEL for carbon monoxidemonoxide


50 ppm50 ppm


Azo dye and rubber Azo dye and rubber manufacturing, HCN lab manufacturing, HCN lab

detection agent, detection agent, methemoglobinemia, methemoglobinemia,

associated with bladder associated with bladder cancer (IARC 1)cancer (IARC 1)


BenzidineBenzidine


Patient etching glass or wheel Patient etching glass or wheel cleaning with delayed pain cleaning with delayed pain out of proportion to exam, out of proportion to exam,

hypocalcemia, hyperkalemiahypocalcemia, hyperkalemia


Hydrofluoric acidHydrofluoric acid


Vitamin BVitamin B66 (pyridoxine) (pyridoxine) antidoteantidote


IsoniazidIsoniazid

Gyromitra esculentaGyromitra esculenta

HydrazinesHydrazines

Ethylene glycolEthylene glycol


The factor by which exposure The factor by which exposure is reduced by use of a is reduced by use of a

respiratorrespirator


Protection factorProtection factor

Ambient/protection factor = Ambient/protection factor = exposureexposure


Study design comparing an Study design comparing an exposed group to an exposed group to an

unexposed group either unexposed group either retro- or prospectively with retro- or prospectively with

results expressed as Relative results expressed as Relative RiskRisk


Cohort studyCohort study


Study design comparing an Study design comparing an exposed group to an exposed group to an

unexposed group at one point unexposed group at one point in time. Provides prevalence in time. Provides prevalence data, results expressed as data, results expressed as

Relative RiskRelative Risk


Study design comparing Study design comparing individuals with a specific individuals with a specific

condition to those that do not condition to those that do not have the condition and compare have the condition and compare

exposures or risk factors. exposures or risk factors. Results expressed as Odds RatioResults expressed as Odds Ratio


Case-control studyCase-control study


Cross-sectional studyCross-sectional study


Federal agency responsible for Federal agency responsible for conducting research and conducting research and

making recommendations for making recommendations for the prevention of work-the prevention of work-

related injury and illness. related injury and illness. Has no legal authority.Has no legal authority.


NIOSHNIOSH


The main federal agency The main federal agency charged with the charged with the

enforcement of safety and enforcement of safety and health legislation. health legislation.


OSHAOSHA


Enacted by Congress in1980 and Enacted by Congress in1980 and created a tax on the chemical and created a tax on the chemical and petroleum industries and provided petroleum industries and provided broad Federal authority to respond broad Federal authority to respond directly to releases or threatened directly to releases or threatened releases of hazardous substances releases of hazardous substances

that may endanger public health or that may endanger public health or the environment the environment


CERCLACERCLA

Comprehensive Environmental Comprehensive Environmental Response, Compensation, Response, Compensation,

and Liability Act and Liability Act

(aka Superfund)(aka Superfund)


Federal public health agency Federal public health agency charged with the charged with the

responsibility of evaluating responsibility of evaluating the human health effects of the human health effects of

exposure to hazardous exposure to hazardous substances. substances.


ATSDRATSDR


Characteristics of substances Characteristics of substances partitioning into breast milkpartitioning into breast milk


Low molecular weightLow molecular weight

Non-polar (breast milk is high Non-polar (breast milk is high in fats)in fats)

Low protein bindingLow protein binding


What are ther isks for What are ther isks for quinolone-induced quinolone-induced

tendinopathy? tendinopathy?


Age > 60 years Age > 60 years Non-obeseNon-obeseSteroid useSteroid use

Female,Female, Renal failureRenal failure

Diabetes Diabetes


What is the normal urinary What is the normal urinary ratio of testosterone to ratio of testosterone to

epitestosteroneepitestosterone


Less than 6 to 1Less than 6 to 1


Hepatic zone were CYP2E1 is Hepatic zone were CYP2E1 is primarily present and acitveprimarily present and acitve


Zone 3Zone 3

Centrilobular necrosisCentrilobular necrosis


The primary toxicity The primary toxicity associated with associated with methoxyfluranemethoxyflurane


NephrotoxicityNephrotoxicity


Describe their mechanisms Describe their mechanisms of actionof action

Tetrodotoxin Tetrodotoxin SaxitoxinSaxitoxin

BrevetoxinBrevetoxinDomoic acid Domoic acid Okadoic acid Okadoic acid



Tetrodotoxin: Blocks voltage-gated Na Tetrodotoxin: Blocks voltage-gated Na channelschannels

Saxitoxin: Blocks voltage-sensitive Na channelSaxitoxin: Blocks voltage-sensitive Na channelBrevetoxin: Stimulates voltage-sensitive Na Brevetoxin: Stimulates voltage-sensitive Na

channelchannelDomoic acid: Glutamate agonist, analog of Domoic acid: Glutamate agonist, analog of

glutamic and kainic acidsglutamic and kainic acidsOkadoic acid: Posphatase a1 and a2 inhibitorOkadoic acid: Posphatase a1 and a2 inhibitorCiguatoxin: lowers the threshold for opening Ciguatoxin: lowers the threshold for opening

voltage-gated Na channels voltage-gated Na channels


Fixed amount eliminated per timeFixed amount eliminated per timeNon-linear, no half-lifeNon-linear, no half-life

Elimination saturated, capacity limitedElimination saturated, capacity limitedConcentration rises with doseConcentration rises with dose

Curve on semi-log paperCurve on semi-log paperMichaelis-Menten when concentration Michaelis-Menten when concentration

is highis high


Zero order kineticsZero order kinetics


Clearance is constant over concentrationClearance is constant over concentrationElimination is not saturatedElimination is not saturated

Percentage eliminated per time is Percentage eliminated per time is constantconstant

Linear on semi-log paperLinear on semi-log paperHalf life is time for a 50% reductionHalf life is time for a 50% reduction

Michaelis-Menten when concentration is Michaelis-Menten when concentration is low low


First order kineticsFirst order kinetics


HORDeHORDe - Hydrolysis, - Hydrolysis, Oxidation, Reduction, Oxidation, Reduction,

Dealkylation Dealkylation


Phase I MetabolismPhase I Metabolism


Conjugation of polar groupsConjugation of polar groupsIncrease hydrophilicityIncrease hydrophilicity

GAS MAGGAS MAG - Glucuronidation, - Glucuronidation, acetylation, sulfation, acetylation, sulfation,

methylation, addition of methylation, addition of amino acids and glutathione amino acids and glutathione


Phase II MetabolismPhase II Metabolism


Intoxicants associated with Intoxicants associated with peripheral neuropathyperipheral neuropathy


AcrylamideAcrylamide

Bromide (Methyl)Bromide (Methyl)


StyreneStyrene

TrichloroethyleneTrichloroethylene


Occupational intoxicants Occupational intoxicants associate with asthma associate with asthma

(pulmonary sensitizers)(pulmonary sensitizers)


Maleic AnhydrideMaleic Anhydride

Trimellitic Anhydride: “Trimellitic Flu” Trimellitic Anhydride: “Trimellitic Flu”

Ethylenediamine Ethylenediamine

Toluene diisocyante/isocyanates: Toluene diisocyante/isocyanates: (#1)(#1)

Diethylhexyl Phthalate (DEHP)Diethylhexyl Phthalate (DEHP)


Rodenticide producing nausea, Rodenticide producing nausea, vomiting, bradycardia, and vomiting, bradycardia, and

hyperkalemiahyperkalemia


Red squill (digoxin-like Red squill (digoxin-like syndrome)syndrome)


Rodenticide producing CNS Rodenticide producing CNS excitation, irritability, excitation, irritability,

seizures, coma, seizures, coma,

ventricular dysrhythmiasventricular dysrhythmias


SMFA (Compound 1080)SMFA (Compound 1080)

TetramineTetramine


Rodenticide producing Rodenticide producing oropharyngeal and skin oropharyngeal and skin

burns, smoking burns, smoking

vomitus and stools, garlic vomitus and stools, garlic odor, GI and hepatic injuryodor, GI and hepatic injury


Yellow phophorusYellow phophorus


Rodenticide producing Rodenticide producing tremors, myoclonus, tremors, myoclonus, depressed mental depressed mental

statusstatus


BromethalinBromethalin


This compound was used in hospital This compound was used in hospital laundry. Toxicity resulted in 9 neonates laundry. Toxicity resulted in 9 neonates

ill, 2 deaths. ill, 2 deaths. Presented with: fever, sweating, renal Presented with: fever, sweating, renal

failure and acidosis. This agent was failure and acidosis. This agent was also used in also used in

various ways including in treating wood various ways including in treating wood to function as preservative. to function as preservative.

It uncouples oxidative phosph.It uncouples oxidative phosph.


PentachlorophenolPentachlorophenol

Disaster occurred in 1967Disaster occurred in 1967


What chemical(s) is associated What chemical(s) is associated with causing choracne?with causing choracne?


Usually due to chlorinated aromatic Usually due to chlorinated aromatic hydrocarbons. Also associated with hydrocarbons. Also associated with

general chlorine exposure. general chlorine exposure. Pentachlorophenol is classically Pentachlorophenol is classically

associated with this (Still used as associated with this (Still used as wood preservative today i.e telephone wood preservative today i.e telephone

poles; formerly as fungicide; not poles; formerly as fungicide; not permitted for home use) permitted for home use)


Hairdresser hand dermatitisHairdresser hand dermatitis


p-phenylenediaminep-phenylenediamine

Permanent hair color dye with Permanent hair color dye with p-phenylenediamine (PPD)p-phenylenediamine (PPD)

oxidized by H2O2 → Aminesoxidized by H2O2 → Amines

Fingertips #1 spotFingertips #1 spot


International treaty completed in International treaty completed in 1987 by 24 nations to control 1987 by 24 nations to control

the depletion of the ozone the depletion of the ozone layer. Targeted to decrease the layer. Targeted to decrease the use of CFCs and halons used in use of CFCs and halons used in

fire extinguishers i.e. Halon fire extinguishers i.e. Halon 1211 and 13011211 and 1301


Montreal ProtocolMontreal Protocol


Shoemaker’s Shoemaker’s

PolyneuropathyPolyneuropathy


Shoemaker’s Shoemaker’s PolyneuropathyPolyneuropathy

Due to use of N-hexane. Another term is Due to use of N-hexane. Another term is “Hexacarbon neuropathy.” Same “Hexacarbon neuropathy.” Same

associated with Methy-N-Butyl Ketone. All associated with Methy-N-Butyl Ketone. All of which → methylethyl ketone; all of mhich of which → methylethyl ketone; all of mhich

are metabolized to 2,5-butanedione (the are metabolized to 2,5-butanedione (the actual problem child). Had a classic mass actual problem child). Had a classic mass problem in Italy with this. Don’t confuse problem in Italy with this. Don’t confuse

with the other big HC used in this with the other big HC used in this industry; benzene. These folks also industry; benzene. These folks also

developed the problems associated with developed the problems associated with benzene: AML benzene: AML


Toluene toxicities (4 major)Toluene toxicities (4 major)


Toluene toxicitiesToluene toxicities

Distal RTA Distal RTA

Metabolic acidosis (due to Hippuric Metabolic acidosis (due to Hippuric acid metabolite and RTA) acid metabolite and RTA)

Hypokalemia and associated Hypokalemia and associated symptoms symptoms

Leukoencephalopathy (chronic use)Leukoencephalopathy (chronic use)


The only hydrocarbon The only hydrocarbon exposure associate with a exposure associate with a change in cardiovascular change in cardiovascular

mortality mortality



Associated with accelerated Associated with accelerated atherosclerotic CAD atherosclerotic CAD

(Don’t forget the peripheral (Don’t forget the peripheral neuropathy) neuropathy)


Cement eczemaCement eczema


Refers to the dermatitis Refers to the dermatitis associated with exposure to associated with exposure to

chromium 6+chromium 6+

Type IV hypersensitivity Type IV hypersensitivity reactionreaction


Wolf-Chaikoff EffectWolf-Chaikoff Effect


Wolf-Chaikoff EffectWolf-Chaikoff Effect

The reaction where chronic iodine The reaction where chronic iodine exposure lead to ↓ thyroid hormone exposure lead to ↓ thyroid hormone production. The inhibition of organic production. The inhibition of organic binding of iodide in the thyroid gland binding of iodide in the thyroid gland

by excess iodide → ↓ thyroid synthesis. by excess iodide → ↓ thyroid synthesis. Compare with the Jodbasedow Compare with the Jodbasedow

reaction (The reaction where chronic reaction (The reaction where chronic iodine exposure causes increased iodine exposure causes increased

thyroid hormone production)thyroid hormone production)

1 med tox board review: buzzwords for the boards gp daubert 2014

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