{"id":54413,"date":"2023-12-31T11:14:47","date_gmt":"2023-12-31T11:14:47","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=54413"},"modified":"2024-01-05T06:25:56","modified_gmt":"2024-01-05T06:25:56","slug":"pharmaceutical-intervention-at-community-level-report-of-a-clinical-case-due-to-lychee-intoxication","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol16no4\/pharmaceutical-intervention-at-community-level-report-of-a-clinical-case-due-to-lychee-intoxication\/","title":{"rendered":"Pharmaceutical Intervention at Community Level: Report of a Clinical Case Due to Lychee Intoxication"},"content":{"rendered":"\n

Introduction<\/strong><\/p>\n\n\n\n

An intoxicated person may show a set of signs\nand symptoms as a consequence of the presence of an exogenous compound that, in\nsufficient quantity, may even cause damage to the organism. It is known that\nmany substances are potentially toxic depending on the dose, some of them only\nrequire a very small dose, but there are others that require a large amount to\nproduce adverse reactions. This can lead to a health problem, which may even\nneed to be addressed at the first level of healthcare. Under any scenario, the\ncommunity pharmacist’s job consists of working collaboratively with the doctor\nto ensure that the patient’s medication is safe, and to this end follows\ndifferent guidelines that allow better control over the patient’s medication,\nall with the aim of detecting drug-related problems (DRP) or interactions with\nfood, and avoiding negative outcomes associated with medication (NME).\nSuitably, patients attending primary care and community pharmacies should be\nincluded in the pharmacotherapeutic follow-up service, in order to achieve the\ncorrect use of the prescribed drugs, and when necessary, the pharmacist should\ncommunicate with the treating physician so that in the event that a DRP or NMR\nis detected, a correct dispensing of the drugs is pursued to ensure their\nproper use, in accordance with the principles of necessity, effectiveness and\nsafety. This case report presents the circumstances and toxicological findings\nattributed to the ingestion of lychee fruit in a minor, with a medical diagnosis\nof undifferentiated intoxication.<\/p>\n\n\n\n

Case Report<\/strong><\/p>\n\n\n\n

This clinical case presents a 3-year-old male\npatient with the following signs and symptoms: rash, diaphoresis, somnolence,\ndry mucous membranes, loss of concentration, exhaustion, fever, HR 87 per\nminute, and FR 23 per minute, in addition to loss of consciousness before\narriving at the office. Due to the signs and symptoms shown, the doctor made a\ndiagnosis of unidentified food poisoning, and empirical treatment was started\nwith Loratadine at a dose of 2 mg every 24 hours, for 5 days, pending\nlaboratory tests of serum glucose and C-reactive protein (CRP).  At the same time, the physician in charge\ntells the patient’s mother to go to the pharmacist so that a pharmaceutical\ncare plan can be drawn up.<\/p>\n\n\n\n

The mother goes to the pharmacist’s office the\nnext day after the medical consultation, and there, the methodology described\nby DADER1<\/sup> for the pharmaceutical care approach is applied. In the\ninterview conducted by the (community) pharmacist, when inquiring about the\npatient’s hygienic dietary habits, the patient’s mother refers that the child\nconsumed about \u00bc kg of lychees as the only food (approximately 12 pieces)\nthroughout the day. During the interview, it was established that in the\nprevious day’s diet no food out of the ordinary was found in the patient’s diet,\nso we proceeded to investigate whether there is evidence of any component of\nthe fruit that generates any sign or symptom such as those presented by the\npatient, finding reports of intoxications by this fruit in other countries2-4<\/sup>.  When the pharmacist and the treating\nphysician discuss the information found, a joint decision is taken to measure\nthe blood glucose concentration with a test strip, and it is colored in the\nrange of 60-80 mg\/dL. Based on this result, at that moment the pharmaceutical\nintervention is performed, conciliating with the physician about a potential\nfood poisoning due to excessive intake of lychees, recommending the use of\nCetirizine at a dose of 1.25 mg every 8 hours for 3 days (instead of\nloratadine), in addition to a gruel containing 5 g of cornstarch every 8 hours\nand 15 mg activated charcoal orally at that time. The patient is discharged and\nan appointment is made 5 days later for the pharmaceutical consultation,\nremembering the indication to perform the biochemical tests of serum glucose\nand CRP, data that will help in the follow-up of the patient’s treatment. At\nthe second appointment with the doctor, the mother comes with the results of\nthe biochemical laboratory tests, and it is found that the glucose levels have\nnormalized, as well as the other parameters requested: serum glucose of 75\nmg\/dL and CRP of 1.6 mg\/dL.<\/p>\n\n\n\n

Discussion<\/strong><\/p>\n\n\n\n

Although lychee intake is relatively common,\nthere is a limited amount of data on acute toxicity or hospital admissions that\nmay occur after consumption of this fruit, mainly in the Latin American region.\nStudies reported in other countries indicate that the reason for the deaths is\ndue to two substances, Hypoglycine A and Methylcyclopropylglycine, which\ninhibit gluconeogenesis, that is, the metabolic pathway by which new glucose is\nproduced in the liver4-6<\/sup>. Hypoglycine and methylcyclopropylglycine\nintoxication has been reported as a health problem worldwide since 1976, and\nfor at least a century, there are reports of the disease known as Jamaica\nFever, which is characterized by exactly the same symptoms from eating a fruit\ncalled Ackee, from the same family as lychees, horse chestnut and others of the\nspecies; Likewise, the general state of health of the patient plays an\nimportant role, since consuming these two substances on an empty stomach, and\nnot eating anything else afterwards, facilitates intoxication due to a lack of\nglycogen, an energy reserve polysaccharide that is transformed into glucose\nwhen needed. On the other hand, the clinical diagnosis of patients intoxicated\nby the ingestion of fruits can be difficult to establish5-8<\/sup>.<\/p>\n\n\n\n

In the clinical case described here, with the\nfirst treatment prescribed by the physician to treat intoxication caused by\nlychee consumption, the patient presented little response to treatment with\nloratadine, because the prescribed dose was at subtherapeutic doses; although\nloratadine and cetirizine belong to the second-generation selective antagonists,\nhistamine H1 receptors, the difference between these two drugs lies in the time\nof onset of their pharmacological effect, since that of cetirizine is 1-2\nhours, compared to that of loratadine (4-6 hours)9<\/sup> so the drug that\nacts in the shortest time is recommended. Once the DADER methodology was\napplied, it was established that the DRP detected was due to the\nineffectiveness of the first prescribed drug, which, as a consequence, led to\nan RNM, based on the poor response to intoxication after treatment. After\nadministration of cetirizine, six hours after reconsidering the dosage, the\npatient’s signs and symptoms of intoxication improved considerably.<\/p>\n\n\n\n

Conclusion<\/strong><\/p>\n\n\n\n

The DADER method consists of a series of\nquestions that help identify DRP; at the community pharmacy level, it helps to\nevaluate the pharmacological history. In this clinical case, this method was\napplied as a substantial tool for the pharmacist to establish the\nappropriateness of the prescription. The pharmacist’s intervention at the\ncommunity level is fundamental to evaluate and resolve the cause of medication\nineffectiveness, since it guides and supports the medical staff regarding a\npossible dose adjustment or type of medication, and to improve the patient’s\npharmacotherapy. Pharmacists have the responsibility to meet the patient’s\nmedication-related needs. With the case described here and the appropriate\npharmaceutical intervention, it was possible to detect, prevent and resolve the\nDRP and NMR. This type of action implies a continuous, systematized and\ndocumented commitment, collaborating with the patient and the rest of the\nhealth care team to achieve concrete results that improve the quality of life\nof patients. In Mexico there are no studies or guides that indicate the\nmanagement of lychee poisoning; However, in countries like India, the\nconsumption of this fruit is monitored, mainly in the case of the paediatric\npopulation, due to the hypoglycemic effects that this fruit can cause. It is\nimportant to reinforce the presence of professional pharmacists at the\ncommunity level, something that has yet to be achieved in Mexico.<\/p>\n\n\n\n

Acknowledgments<\/strong><\/p>\n\n\n\n

 The\ncorresponding author would like to thank to Miss Michelle Guadarrama, for\nproviding required support in the translation of the manuscript.<\/p>\n\n\n\n

Conflict of interest<\/strong><\/p>\n\n\n\n

The authors declared no conflict of interest.<\/p>\n\n\n\n

Funding sources<\/strong><\/p>\n\n\n\n

The author did not receive funding to conduct\nthis work<\/p>\n\n\n\n

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