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Purpose: The review is provoked because of lack of awareness of the medical practitioners in Bulgaria concerning of the ethnology, pathogenesis, clinical symptoms and treatment of the ciguatera fish poisoning (CFP). This can be a source of prolonged diagnostic delays, as some cases reporting in another country in Europe, for example Germany, Spain and UK. Varna is the sea town with many sailor crews returning from tropical and subtropical regions, or CFP can affect people who travel to the Pacific and Caribbean or ate exotic fish from supermarket. The information of this fish food-borne poisoning is part of student’s education in discipline “Marine medicine” in Medical University, Varna. Materials and methods: To present better information from different authors and last scientific data, we made review of published materials of 58 issues to construct definition, history, etiology, pathogenesis (toxins and mechanisms of action), clinical symptoms, treatment and prevention of the Ciguatera or ichtyosarcotoxicosis, a wide spread food-born poisoning. Results: Ciguatera poisoning is ichtyosarcotoxicosis, a wide-spread foodborne poisoning in people after consumption of flesh of different kinds of fishes in which toxins produced by poisonous microorganisms (Dinoflagellates) have accumulated. The poisoning develops by accumulating toxins higher up the food chain starting with toxin producing dinoflagellates (species: Gambierdiscus toxicus, Prorocentrum concavum, Pr. lima, Ostreoposis lenticularis, Ostr. Siamensis and others), continuing with the poisoned algae (species: Portieria, Halymenia, Turbinaria, Sargassum), and after that involving small crustacea and small fishes to greater fishes (vector fishes, genus Herbivores and Carnivores), in which the toxins have been stored in amount, great enough to cause foodborne poisoning in humans. This poisoning is widespread in tropical and subtropical regions, but because of its delayed toxic effects, lasting for months and years, there is a possibility that every medic can encounter its unusual symptoms, requiring specific treatment. The following toxins cause the poisoning: ciguatoxin, meitotoxin, ostreotoxin, domoic acid and some other unspecified toxins. They are lipid soluble, thermo stable and cannot be decomposed by culinary processing. These toxins have neurotoxic, cardiotoxic, hemolytic properties and cause diarrheic syndrome. Clinical presentation is characterized by average latent period of 12 hours after the consummation, vomiting and diarrhea next 24 hours and neurological symptoms that appear at the beginning of the poisoning with paresthesias along the body, changing feeling of hot and cold, strong myalgia. Disturbances in cardiac rhythm and conduction, strong dehydration or shock are possible in severe cases. Light cases pass over in several days, but, more often the poisoning has a chronic course – from 3-4 months to 1 year, with prevalence of neurologic symptoms: myalgia, paresthesias, skin itching with scratches, depression. The management is not specific and includes stomach lavage with activated charcoal, fluids replacement during the first 24 hours, corticosteroids, antiallergics, high doses of vitamins from group B (Vit. B1, Vit. B6, Vit. B12), mannitol IV, nootropic medicaments, antidepressants and other symptomatic medicaments. The prophylaxis is done by examining every fish with specific test for detecting ciguateratoxin.

Purpose: Poisoning with drugs occupies a leading position among the causes of acute intoxications. Etiological distribution of medicated poisoning in different countries, even if they are adjacent, is different. In the most studies it was reported that the highest incidence of poisoning is with benzodiazepines or other psychoactive drugs. A retrospective analysis of acute poisoning with benzodiazepines and other hypnotic drugs in the Varna region for 25 years period – from 1991 to 2015 was carried out. Material and Methods: The number of patients who received hospital treatment after poisoning with benzodiazepines is 1741, and those with other hypnotics is 293, representing respectively 26.37% and 4.44% of all drug intoxications. Results: The share of poisoning with benzodiazepines and hypnotics compared to all acute intoxications is 11.66%. They are more common in women – 1566 (77%). Men are 468 (23%), the ratio of men to women was 3.34:1. The largest number of intoxications is in the age group up to 24 years - 1123 (55.2%), and only 4.1% of patients over 60 years. Intentional suicide attempts are 1896 (93.2%). Death is registered in 8 (0.4%) patients.

Summary The aim of the study was to carry out a toxicological chemical analysis of methanol in detectable quantities in the blood of patients with acute alcohol intoxication. Blood samples from 85 patients with acute alcohol intoxication were analysed for the presence of methanol. All patients with acute methanol intoxication were excluded from the study. The methods of gas chromatography with vapor-phase analysis (head-space) and flame ionization detection (FID) were used. The limit of detection (LOD=0.015 g/L) and the limit of quantification (LOQ=0.025 g/L) of methanol in whole blood were evaluated. In 30% of the cases, methanol was found in the blood in detectable quantities. The levels of methanol were on the average 5 to 6 times lower than the toxic methanol level (0200 g/L) and they were not due to natural metabolic processes (ingestion of fruit, fruit juices or vegetables). No reliable statistically linear correlation between the concentration of ethanol and methanol was found. Methanol subintoxications are major factors in alcohol intoxications, in which the quantity of the alcohol ingested is not as important as its quality. Chronic methanol subintoxication of people who often consume alcohol of poor quality is discussed.

Introduction: Altered mental status caused by certain acute poisonings creates barriers for effective doctor-patient communication and compromises the process of informed consent (IC) for treatment. A categorization of toxicological patients with regard to communication capacity would be helpful for practical purposes. Aim : This article has the following aims: characterization of toxicology patients with mental status altered by poisoning according to the etiology of intoxication; discussion of the impact of cerebral toxic syndrome on the capacity for effective communication between the doctor and the patient and for IC. Materials and Methods : A retrospective study of the medical documentation of 2088 patients with acute intoxications, treated in the Clinic of Intensive Treatment of Acute Intoxications and Toxicoallergies at Naval Hospital, Varna during the 2010–2013 period: case files, IC forms, was conducted. The R program package, version 3.4.2 (2017-09-28), was used for statistics. Results : Toxic cerebral syndrome was found in 966 cases of acute intoxication, 46% of all patients, with especially high percentages in the medicament, alcohol, and narcotics intoxication groups. Regaining lucid mental state was observed within 1 hour in 21.9% of patients, and for the rest, it took from 2 hours to 7 days. Only 1211 patients, or 58%, signed the admission IC form themselves. Conclusion : Characterization of acute intoxications with regard to capacity for effective doctor-patient communication is necessary because of the great percentage of patients with cerebrotoxic syndrome. Good knowledge of the specificity of toxicology patients and good communication skills of physicians can help the proper process of informed decisions of the patient.

Purpose: Poisoning with drugs is a serious medical and social problem worldwide. Retrospective analysis of acute poisoning with narcotic drugs had been performed in Varna region for 25 years (1991-2015). Material and Methods: The number of patients received hospital treatment after poisonings with narcotic substances was 677, which represented 3.9% of all acute exogenous intoxications. Results: Narcotic poisonings were more common in men – 546 (80.6%), than in women – 131 (19.4 %). The ratio male/ female was 4.17:1. The largest number of intoxications were in the age group up to 24 years – 1123 (66%), and only 2.65% of patients were over 45 years. Death was registered in 6 (0.9%) patients.

Purpose: Methanol (CH3OH) is a monohydric alcohol, vastly used both in housekeeping and industry. Although the acute methanol intoxications are rare, they may include life-threatening symptoms, substantial lethality and negative consequences such as neurological disorders and vision damage. Aim of the work is to conduct a retrospective study on the acute methanol intoxications within Varna region for a 10-year period (2006-2015). Material/Methods: This study covers 39 patients of the Clinic for Intensive Treatment of Acute Intoxications and Toxicoallergies at Naval Hospital – Varna, all of which had their diagnosis confirmed, including gas chromatography methods. Results: Methanol intoxication prevalence showed male/female ratio close to 2.9:1. The major part of the cases concerned economically active population, the age group of 25-60 being the most affected. In all instances an oral methanol intake has been involved. Death occurred in 14 cases (35.9%)

A clinical case of a self-poisoning with a single ingestion of 40-45 mL of alleged metal mercury with suicid­al purpose by a 50-year-old man is described. On the following day he was admitted to the Toxicology Clinic with symptoms of nausea, strong abdominal colic, diarrhea, and feces with macroscopic admixture of mer­cury drops. At the inspection of the residue of the substance, an unusual black-grey color on its surface was noted. Later, mercurous oxide was proven by chemical analysis. No toxic symptoms of the central nervous system, respiratory system or kidneys were observed. X-rays of the abdomen were performed and tracked dynamically: the first one showed numerous round shadows with metal density along the whole colon, the second - after 5 days - showed reduced number of similar shadows only in the distant colon, and the third X-ray on the 9th day was normal. Mercury was discovered in the blood: 0.250 I¼mol L-1 on the fourth day after the ingestion and 0.120 I¼mol L-1 - on the tenth day. Some therapeutic problems of acute mercury intoxica­tion of present interest are discussed.

In recent years, phosphine and metal phosphides intoxications have been observed extremely rarely in clinical practice. Although rare, these intoxications have a severe clinical course, often with unclear clinical presentation at the beginning and possible lethal exit during the first hours or the next several days. Several tests for analysis of phosphide intoxication, based on the classical qualitative semimicroanalysis which do not require complex equipment, are presented and compared in this article. These tests contribute significantly to confirming the toxicology diagnosis and identifying the source. A rapid paper test (adopting the method of Chugh et al. ) has been developed for the purposes of the routine toxicology practice to serve the practicing doctor, as quick and exact diagnostic orientation in cases with unclear history and clinical presentation of the intoxication.