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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this article&#44; we describe the case of a female adolescent aged 13 years that visited the emergency department and had consumed duloxetine &#40;600 mg&#41; and extended-release morphine &#40;300 mg&#41; 17 h prior with suicidal intent&#46; At home&#44; she developed abdominal pain&#44; vomiting&#44; headache and somnolence and inability to urinate&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the past year&#44; the patient had experienced symptoms of an eating disorder&#44; suicidal ideation and gender dysphoria&#44; and had consumed alcohol and tobacco&#44; and had received no medical or psychological care of any kind&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On arrival to hospital&#44; her vital signs were in the normal range&#44; and the salient findings of the physical examination were mild bradypsychia&#44; pupillary miosis and discomfort on palpation of the hypogastric region&#46; After 2 h in the emergency department&#44; she exhibited obtundation&#44; with a reduced response to physical stimuli&#44; associated with bradypnea &#40;8 breaths per minute&#41; and shallow breathing&#44; accompanied by a decrease in oxygen saturation &#40;80&#37;&#41;&#46; Opioid-induced respiratory depression was suspected&#44; leading to administration of supplemental oxygen and naloxone &#40;0&#46;01 mg&#47;kg&#41;&#44; which achieved immediate recovery of baseline mental status and resolution of the acute urinary retention&#46; Four hours after the initial episode&#44; the patient required naloxone again for management of respiratory depression&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The baseline electrocardiogram and blood gas analysis were normal&#46; The complete blood count and chemistry panel &#40;18 h post-exposure&#41; revealed leucocytosis &#40;18 000 &#215; 10<span class="elsevierStyleSup">9</span> cells&#47;L&#44; 89&#46;5&#37; neutrophils&#41;&#44; preserved renal and liver function&#44; serum levels of glucose of 97 mg&#47;dL&#44; creatine kinase of 130 U&#47;L and&#44; most importantly&#44; elevation of amylase &#40;476 U&#47;L&#59; normal range&#44; 25&#8211;101 U&#47;L&#41; and troponin I &#40;593&#46;3 ng&#47;L &#91;99th percentile&#93;&#59; normal range&#44; &#60;16 ng&#47;L&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The level of paracetamol was below 2&#46;5 &#956;g&#47;mL&#44; and the basic urine drug test was positive for opiates&#44; a finding confirmed in the expanded toxicological screen &#40;blood and urine&#41;&#44; with detection of morphine and tramadol through gas chromatography-mass spectrometry&#46; After this result&#44; the patient acknowledged consumption of tramadol&#46; Duloxetine was not detected &#40;liquid chromatography- tandem mass spectrometry&#41;&#46; During her stay&#44; the patient underwent serial blood tests that exhibited progressive normalization of the abnormalities described above&#44; and only the troponin I levels remained elevated until day 6&#44; while all the electrocardiograms remained normal &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The patient did not experience further clinical worsening and remained under observation in the emergency department for 24 h&#44; after which she was admitted to the child and adolescent inpatient psychiatric unit&#44; where she did not experience complications&#44; and subsequently evaluated with an ultrasound examination in the paediatric cardiology department&#44; the results of which were normal&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Tramadol is an opioid used for analgesia on account of the effects that result from the selective binding of its metabolite&#44; O-desmethyltramadol&#44; to &#956; opioid receptors&#46; In addition&#44; it inhibits the reuptake of norepinephrine and serotonin&#44; which augments the potential adverse effects in the case of an overdose &#40;opioid syndrome&#44; serotonin syndrome and&#47;or risk of seizures&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and can be cardiotoxic at high doses&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Tramadol poisoning is rare in paediatrics&#59; in this patient&#44; we found a peak level of 681 ng&#47;mL &#40;therapeutic range&#44; 100&#8722;300 ng&#47;mL&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> similar to the levels found in previous reports of paediatric poisoning in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The half-life of tramadol in the patient was 8&#46;8 h&#44; higher than the one described following administration of therapeutic doses &#40;6 h&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Usually&#44; opioid overdose causes respiratory depression&#44; with a risk of severe hypoxaemia and cardiac arrest&#44; although direct cardiotoxicity is not a common manifestation&#46; Evidence from some animal models has shown an association of chronic consumption of tramadol with myocardial inflammatory illness&#44; and a published paediatric case report described coronary disease due to vasospasm following fentanyl poisoning&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Acute hypoxaemia results in an increase in cell membrane permeability due to ischaemic injury&#44; and this in turn results in leakage of intracellular salivary or pancreatic amylase&#46; Chronic hypoxaemia causes lactic acidosis&#46; Both mechanisms can lead to hyperamylasaemia&#44; and one such case has been described following tramadol poisoning&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is also important to remember that morphine and codeine can make the sphincter of Oddi spasm&#46; Given the absence of manifestations of acute pancreatitis&#44; we assume that the 2 episodes of respiratory depression were what caused hyperamylasaemia in this patient&#44; with a persistently elevated level of 187 U&#47;L 16 h after admission&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Serotonin syndrome is a potentially fatal condition caused by increased serotonergic activity in the nervous system&#46; The symptoms include altered mental status&#44; autonomic instability and neuromuscular hyperactivity and nonspecific abnormalities in laboratory tests&#46; The ingestion of multiple drugs that block the reuptake of serotonin can cause this syndrome&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Opioid poisoning should be suspected in paediatric patients with troponin elevation and no electrocardiographic evidence of cardiac arrest or ischaemia and no signs of pancreatitis&#46; The complex synergy of tramadol and morphine poisoning justified the anomalous laboratory findings in this case&#46;</p></span>"
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Scientific Letter
High-sensitivity troponin I elevation and hyperamylasemia in a pediatric case with tramadol and morphine overdose
Elevación de troponina I ultrasensible e hiperamilasemia en una intoxicación pediátrica con tramadol y morfina
Silvia González Lagoa, María José Pérez Garcíaa, Isabel Gomilab,c, Jordi Puiguriguerc,d, Bernardino Barcelóc,e,f,
Corresponding author
bernardino.barcelo@ssib.es

Corresponding author.
a Servicio de Urgencias de Pediatría, Hospital Universitari Son Espases, Palma de Mallorca, Spain
b Servicio de Análisis Clínicos, Hospital Universitari Son Llàtzer, Palma de Mallorca, Spain
c Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma de Mallorca, Spain
d Servicio de Urgencias, Unidad de Toxicología Clínica, Hospital Universitario Son Espases, Palma de Mallorca, Spain
e Servicio de Análisis Clínicos, Unidad de Toxicología Clínica, Hospital Universitari Son Espases, Palma de Mallorca, Spain
f Departamento de Medicina, Facultad de Medicina, Universidad de las Islas Baleares, Palma de Mallorca, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In this article&#44; we describe the case of a female adolescent aged 13 years that visited the emergency department and had consumed duloxetine &#40;600 mg&#41; and extended-release morphine &#40;300 mg&#41; 17 h prior with suicidal intent&#46; At home&#44; she developed abdominal pain&#44; vomiting&#44; headache and somnolence and inability to urinate&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the past year&#44; the patient had experienced symptoms of an eating disorder&#44; suicidal ideation and gender dysphoria&#44; and had consumed alcohol and tobacco&#44; and had received no medical or psychological care of any kind&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On arrival to hospital&#44; her vital signs were in the normal range&#44; and the salient findings of the physical examination were mild bradypsychia&#44; pupillary miosis and discomfort on palpation of the hypogastric region&#46; After 2 h in the emergency department&#44; she exhibited obtundation&#44; with a reduced response to physical stimuli&#44; associated with bradypnea &#40;8 breaths per minute&#41; and shallow breathing&#44; accompanied by a decrease in oxygen saturation &#40;80&#37;&#41;&#46; Opioid-induced respiratory depression was suspected&#44; leading to administration of supplemental oxygen and naloxone &#40;0&#46;01 mg&#47;kg&#41;&#44; which achieved immediate recovery of baseline mental status and resolution of the acute urinary retention&#46; Four hours after the initial episode&#44; the patient required naloxone again for management of respiratory depression&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The baseline electrocardiogram and blood gas analysis were normal&#46; The complete blood count and chemistry panel &#40;18 h post-exposure&#41; revealed leucocytosis &#40;18 000 &#215; 10<span class="elsevierStyleSup">9</span> cells&#47;L&#44; 89&#46;5&#37; neutrophils&#41;&#44; preserved renal and liver function&#44; serum levels of glucose of 97 mg&#47;dL&#44; creatine kinase of 130 U&#47;L and&#44; most importantly&#44; elevation of amylase &#40;476 U&#47;L&#59; normal range&#44; 25&#8211;101 U&#47;L&#41; and troponin I &#40;593&#46;3 ng&#47;L &#91;99th percentile&#93;&#59; normal range&#44; &#60;16 ng&#47;L&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The level of paracetamol was below 2&#46;5 &#956;g&#47;mL&#44; and the basic urine drug test was positive for opiates&#44; a finding confirmed in the expanded toxicological screen &#40;blood and urine&#41;&#44; with detection of morphine and tramadol through gas chromatography-mass spectrometry&#46; After this result&#44; the patient acknowledged consumption of tramadol&#46; Duloxetine was not detected &#40;liquid chromatography- tandem mass spectrometry&#41;&#46; During her stay&#44; the patient underwent serial blood tests that exhibited progressive normalization of the abnormalities described above&#44; and only the troponin I levels remained elevated until day 6&#44; while all the electrocardiograms remained normal &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The patient did not experience further clinical worsening and remained under observation in the emergency department for 24 h&#44; after which she was admitted to the child and adolescent inpatient psychiatric unit&#44; where she did not experience complications&#44; and subsequently evaluated with an ultrasound examination in the paediatric cardiology department&#44; the results of which were normal&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Tramadol is an opioid used for analgesia on account of the effects that result from the selective binding of its metabolite&#44; O-desmethyltramadol&#44; to &#956; opioid receptors&#46; In addition&#44; it inhibits the reuptake of norepinephrine and serotonin&#44; which augments the potential adverse effects in the case of an overdose &#40;opioid syndrome&#44; serotonin syndrome and&#47;or risk of seizures&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and can be cardiotoxic at high doses&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Tramadol poisoning is rare in paediatrics&#59; in this patient&#44; we found a peak level of 681 ng&#47;mL &#40;therapeutic range&#44; 100&#8722;300 ng&#47;mL&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> similar to the levels found in previous reports of paediatric poisoning in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The half-life of tramadol in the patient was 8&#46;8 h&#44; higher than the one described following administration of therapeutic doses &#40;6 h&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Usually&#44; opioid overdose causes respiratory depression&#44; with a risk of severe hypoxaemia and cardiac arrest&#44; although direct cardiotoxicity is not a common manifestation&#46; Evidence from some animal models has shown an association of chronic consumption of tramadol with myocardial inflammatory illness&#44; and a published paediatric case report described coronary disease due to vasospasm following fentanyl poisoning&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Acute hypoxaemia results in an increase in cell membrane permeability due to ischaemic injury&#44; and this in turn results in leakage of intracellular salivary or pancreatic amylase&#46; Chronic hypoxaemia causes lactic acidosis&#46; Both mechanisms can lead to hyperamylasaemia&#44; and one such case has been described following tramadol poisoning&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is also important to remember that morphine and codeine can make the sphincter of Oddi spasm&#46; Given the absence of manifestations of acute pancreatitis&#44; we assume that the 2 episodes of respiratory depression were what caused hyperamylasaemia in this patient&#44; with a persistently elevated level of 187 U&#47;L 16 h after admission&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Serotonin syndrome is a potentially fatal condition caused by increased serotonergic activity in the nervous system&#46; The symptoms include altered mental status&#44; autonomic instability and neuromuscular hyperactivity and nonspecific abnormalities in laboratory tests&#46; The ingestion of multiple drugs that block the reuptake of serotonin can cause this syndrome&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Opioid poisoning should be suspected in paediatric patients with troponin elevation and no electrocardiographic evidence of cardiac arrest or ischaemia and no signs of pancreatitis&#46; The complex synergy of tramadol and morphine poisoning justified the anomalous laboratory findings in this case&#46;</p></span>"
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ISSN: 23412879
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