An Unidentified Poisoning

Department of Clinical Toxicology and Pharmacology

Hunter Area Health Service

43 yo woman

• Last seen at 4pm

• Found by sons at 6.30pm

• Drowsy, confused speech

• Teary and smelling of alcohol

• Unable to confirm nature of tablets

• Behcet’s Disease

NMMH ED

• T 34.9, HR 80 reg, BP 130/84, Sats 99% R/A• pH 7.52

pCO219.8

pO2 138.4 BSL 4.8

HCO3 16.2

BE -6.0

SaO2 99.2

• Should she have gut decontamination?

• Became agitated

• Physically restrained

• Orogastric tube - patient removed

• Nasogastric tube - polyethylene glycol

• NaHCO3

• Multiple dose Activated Charcoal

• Family friend later finds an empty bottle of sulfasalazine and another nearly empty bottle of unknown tablets (90 missing).

• Date of prescription unknown for both

• Normal FBC

• Normal coags

• Na 130 Normal LFTs

K 3.2

urea 2.4

creatinine 71

Anion Gap 16

• Salicylate level <0.1

• Paracetamol <7

• Blood Alcohol 0.22

NMMH ICU

• Uncooperative, disoriented

• Pupils mid-size and reactive

• Normal tone, normal reflexes

• HS normal, chest clear

• Active bowel sounds

• UO 100mls/hr

Overnight

• Nauseated

• Vomiting

• T 38.0°C

At 12 hours

• T 38°C• Examination NAD• ECG SR, normal axis, no acute changes• Hb 140, WCC 19.1, Plt 196• PT 14, APTT 28• UEC normal• alb 42, bili 8, GGT 19, ALP 237, ALT 30,

AST 124, LD 958, CK 326

At 12 hours

• R/A pH 7.42

pCO2 33.9

pO2 81.5

HCO3 21.4

BE -2.4

SaO2 99.0

At 18 hours

• T 38.1°C triple antibiotics

• Cramping abdominal pain

• RUQ tenderness

• Scanty bowel sounds

• Poor urine output

• U/A large blood, large protein

Day 2

• PT 23, APTT 59, TT 24

• urea 7.2, creatinine 136

• alb 35, LD 4123, CK 1286 (troponin 4.6)

• Hb 125, WCC 24.7 (myelo 7.4, metamyelo 7.9, bands 3.0, n. 4.4), Plt 118

• fibrinogen 0.7

• XDP >1.6

Day 3

• Belly pain settled

• Ileus

• Dyspnoeic

• Myalgic

• UO ~50mls/hr

• HS normal, JVP 1cm, mild sacral oedema, scanty bibasal crackles

Day 3

• CXR - small bilateral pleural effusions, no interstitial fluid

• 4L O2 pH 7.30

pCO228.1

pO2 90.8

HCO3 14.1

BE -10.8

SaO2 96 %

Day 3

• Hb 100, WCC 5.6 (n. 5.3), Plt 38

• urea 13.3, creatinine 147

• alb 30, LD 5387, CK 7500

Day 4

• Myalgia resolving

(CK peaks at 42 415 on D5)

• Hb 86, WCC 3.0, Plt 12

• Albumin trough at 24

• Platelet transfusion

• Consideration of G-CSF

Day 5

• DIC resolving

• WCC 4.0 (n. 0.6) G-CSF

Day 6 -8

• New systolic murmur and gallop

• Pitting oedema to mid-thorax (alb 28)

• Echo - mod. severe LV systolic dysfunction

- abnormal diastolic function

- moderate TR

- pulmonary hypertesion

Days 9-10

• V/Q Scan - low to moderate probability of PE (20-40%)

• CT Scan - NAD

• ACEI and diuretic 6kg wt loss

Days 11-21

• Alopecia

• Warfarinisation

• Mobilisation

There’s a disease going around IstanbulWhich I mean to describe here in fullIt affects, just between us,The eyes, mouth and penisOf Hassam, Hasium and Abdul

They have terrible ulcers and soresThey thought they had bought from the whoresIt has since been decidedTheir doctor confidedThat Behcet’s Disease is the cause

They all have a leucocytosisAnd Hassam developed a ptosisHasium spends all dayEating charcoal and clayAnd Abdul developed psychosis

There is trouble as well with their eyesFor their retinal vessels leak dyesThey have large joint arthritisAnd thrombophlebitisAnd their gangrenous feet attract flies

Case report: colchicine antibodies

• Baud FJ et al. Treatment of severe colchicine overdose with colchicine-specific Fab fragments. N Engl J Med 1995;;332:642-645.

0.1

1

10

100

36 40 44 48 52

Time after overdose

Plas

ma

Col

chic

ine

(ng

/mL)

0

1

2

3

4

5

6

7

8

9

10

Car

diac

out

put (

L/m

in/m

2)

Free colchicine

Total colchicine

Cardiac output

Colchicine Fab