Category Archives: Toxicology

Double Moffitt Pearls 11/3 & 11/6 – ALF, Toxic ingestions and Mesenteric Lymphadenopathy

Moffitt Pearls 11.3.17 – Saipan Case

Thank you to Amy for presenting a case from Saipan!! We learned about a middle-aged man presenting with encephalopathy and jaundice found to have acute liver injury and renal failure of unclear etiology. The leading thoughts were possibly leptospirosis vs biliary colic that self resolved. The patient was managed with IV abx and IVFs and improved over 2 weeks. We discussed the limitations of practicing in this setting and inability to transfer this patient to a center for transplant evaluation.

Key Pearls

  • EtoH Hepatitis: jaundice, anorexia, fever, and tender hepatomegaly. Labs: transaminases (typically less than 300 int. unit/mL), AST/ALT ratio > 2. Patients may also present with right upper-quadrant/epigastric pain, hepatic encephalopathy, and signs of malnutrition.
  • Acute liver failure is defined as the presence of coagulopathy (INR > 1.5), encephalopathy and no pre-existing liver disease. See more details below.
  • Leptospirosis has a broad range of manifestations, from subclinical illness or mild self-limited disease (approximately 90% of infections) to Weil’s syndrome (Weil’s disease), which is characterized by renal failure, jaundice, and hemorrhage and has a 5 to 15% mortality rate (1).
  • See this NEJM article where HH crushes the diagnosis in the first couple of sentences (it is related to this case)

Overview of Acute Liver Failure 

ALF = coaguapathy INR > 1.5, encephalopathy, and no signs of chronic liver disease

Key History: 

  • IVDU, travel, sexual, ingestions, Fmhx Wilson’s, (note: Hemochromatosis – no acute liver failure)

Physical Exam:  

  • Vitals, stigmata of liver disease, neuro exam, optho exam

Etiology of Acute Liver Failure

  • Ischemia*
  • Toxins* – Tylenol (most common cause in USA), Amanita
  • Acute viral hepatitis*
    • Professional: HAV, HBV, sometimes HCV, HEV
    • “Moonlighters”: HSV, CMV, VZV, parvovirus
  • Autoimmune Hepatitis
  • Acute Budd Chiari – esp if concomitant portal vein thrombosis
  • HELLP
  • Reactivation of HBV or HDV on chronic HBV
  • Wilsonian crisis – often with concomitant hemolytic anemia
  • Malignant infiltration – breast, small cell lung, lymphoma, melanoma, myeloma
  • HLH
  • Heat stroke 
  • Remember -> NOT causes of acute liver failure – ETOH, NAFLD, iron overload, alpha-1 def, PSC, PBC
  • * denotes are most likely to cause AST/ALT in the 1000s

 

Moffitt Pearls 11/6 – Toxic Ingestions

Thank you to Tim for presenting a fascinating case of a young woman 9 weeks post-partum presenting with a profound gap acidosis and osm gap initially c/f ethylene glycol vs methanol ingestion found to have severe starvation ketosis. We discussed the evaluation of possible ingestions and treatment for suspected Ethylenel Glycol ingestion with fomepizole (below).

Thank you HH for presenting a mini-case of a young engineer returning from India p/w abdominal pain, n/v and mild hepatocellular transaminitis (300s) found to have mesenteric lymphadenopathy 2/2 hepatitis E!!

Key Pearls

  • Per EM guidelines send Serum Osm, Salicylates, APAP and EtoH levels in any suspected ingestion.
  • Fomepizole is used in ethylene glycol and methanol toxic ingestion. It is a competitive inhibitor of alcohol dehydrogenase and prevents formation of glycolic acid which is responsible for both the acidosis and oxalate crystal formation. See this NEJM article for more info.
  • We learned the ddx for mesenteric lymphadenopathy include hepatitis E in addition to those listed below!!

Effect of Fomepizole on Metabolism of Eythlene Glycol and Methanol (Brent J. N Engl J Med 2009;360:2216-2223)Picture1

Differential Diagnosis for Mesenteric Lymphadenopathy

  1. Malignancy – almost any intraabdominal malignancy and metastatic process can cause mesenteric lymphadenopathy, however the following are more common:
    1. Lymphoma
    2. Carcionid Tumors
    3. Kaposi Sarcoma
    4. Carcinoma of pancreas, colon or small bowel
  2. Infection
    1. TB or MAC
    2. Salmonella and Yersinia
    3. T. Whippelii
    4. Viral Infections –EBV and Hepatitis E
  3. Inflammatory
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MOFFITT MORNING REPORT PEARLS 3/10/17: Wolfsbane and Activated Charcoal!

Thanks to Nick for discussing the case of a young man with no known medical history who presented with altered mental status and ventricular tachycardia after ingestion of a Chinese herb product called aconitum (aka wolfsbane or monkshood)! Thankfully he did well with supportive care. Pearls below:

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Top Pearls:

  1. In a recent survey, 17.7% of U.S. adults used natural products in the past year.
  2. Aconitum (aka wolfsbane or monkshood) is a highly toxic plant product used in herbal medicine that can lead to fatal cardiac arrhythmias.
  3. Activated charcoal does not have strong evidence to support its use but is recommended for most toxic ingestions if given within one hour following the ingestion.

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For those who want more info:

Commonly used natural products: In the 2012 National Health Interview Survey, 17.7% of U.S. adults used natural products in the previous year. Here are the 10 most common natural products used by U.S. adults:

Fish oil (7.8%)

Glucosamine or chondroitin (2.6%)

Probiotics or prebiotics (1.6%)

Melatonin (1.3%)

Coenzyme Q-10 (1.3%)

Echinacea (0.9%)

Cranberry (0.8%)

Garlic (0.8%)

Ginseng (0.7%)

Ginkgo biloba (0.7%)

It’s important to keep in mind not only direct toxic effects of natural products, but also their interactions with medications (e.g. St. John’s wort and warfarin, ginkgo biloba and warfarin/NSAIDs, grapefruit and calcium channel blockers).

Check out the Natural Medicines Comprehensive Database (http://naturaldatabase.therapeuticresearch.com) for scientific and clinical information on safety and efficacy of natural products. Seriously, check it out. It has a lot of good info.

The NIH also has resources on herbs and supplements:

https://nccih.nih.gov/health/herbsataglance.htm

https://medlineplus.gov/druginfo/herb_All.html

https://ods.od.nih.gov/factsheets/list-all/

 

Aconitum/Aconite: aka wolfsbane or monkshood.

  • Plant product widely used in Chinese and Indian herbal medicine.
  • All parts of the plant contain high levels of toxin, especially the root.
  • Processing into tincture of aconite reduces toxicity by 90%, but still associated with morbidity and mortality even with small ingestions.
  • Mechanism: Binds and maintains sodium channels in the open position.
  • Cardiotoxicity includes ventricular arrhythmias (VT, Torsades, VF), bradycardia, hypotension, and asystole.
  • Other toxicities include neurologic (paresthesias, weakness, altered mental status) and GI (vomiting and diarrhea).
  • Safety and Efficacy: From the Nature Medicines Comprehensive Database (above), this product is “unsafe” when used in any fashion, and there is “insufficient reliable evidence” for its efficacy. It has no known interactions with medications or other herbs/supplements.

 

Activated charcoal:

  • Absorbent powder made from superheated organic material.
  • Surface area is covered with functional groups that adsorb chemicals within minutes of contact, preventing GI absorption.
  • Most useful within 1 hour of ingestion, while toxin remains in the stomach.
  • Contraindications include depressed mental status with poor airway protection, late presentation, need for endoscopy if ingestion is caustic (impairs visualization), and intestinal obstruction. Intubation for the purpose of giving activated charcoal is not recommended.
  • The usual adult dose is a single dose of 50 g.
  • It is administered by mixing with water to form a gritty slurry.
  • Unsurprisingly, this is not palatable, so flavoring with juice or thickening with sorbitol may be helpful if needed.
  • Safety: The main complication is aspiration, but this occurs in <1% of poisonings, and the data are not clear whether it is the charcoal or the toxic ingestion that increases aspiration risk.
  • Efficacy: There are no clear RCTs showing clinical benefit to activated charcoal.
  • Despite this, it is recommended in most ingestions, with exceptions being heavy metals (e.g. iron, lead, mercury), inorganic ions (lithium, potassium, iodide), corrosive acids/alkali, hydrocarbons, and alcohols.
  • Gastric lavage and ipecac are no longer recommended for ingestions.

 

Evernote: https://www.evernote.com/shard/s272/sh/8e6c0c43-b0b9-4cdc-a8da-a9281ec0b75b/a5490f6f7c4ab38fe8caa9b422285c5c

 

Have a great day everyone!

SamMy