The Case of the Cardiac Casserole

1. The Case of the Cardiac Casserole Mary Wittler, MD Toxicology Fellow Carolinas Medical Center and The Carolinas Poison Center Charlotte, NC

2. A small town in the southern Appalachian mountains, in mid-April

3. A mother and daughter spent the afternoon in the woods hiking and foraging for “ramp,” a local delicacy similar to wild onion.

4. After an idyllic day in the woods, the women made a casserole from the ramps they had collected, adding some potatoes and canned salmon.

5. Unfortunately… The casserole tasted “terrible.” Thirty to forty-five minutes after eating the casserole, both women developed nausea, vomiting, and extreme weakness.

6. They arrived in the local emergency department one hour post ingestion.

7. Patient #1: Mother • HPI • 83 yo acutely ill, confused, female • “smothering sensation, heartburn, and vomiting” • PMH • Type II DM, HTN, Recent CVA • TAH for uterine CA • Medications • Metformin, doxazosin, metoprolol XL, ASA, hydralazine/hctz, diazepam, mirtazapine, glyburide

8. Mother’s PE VS: BP 126/60 HR 51 RR 16 T 97.1 GEN: confused and mumbling SKIN: clammy HEENT: conjugate reactive pupils, dry mm RESP: clear CV: no mrg ABD: nontender with nl BS EXT: central pulse > peripheral NEURO: nl reflexes, no fasciculations or focal findings MS: no hallucinations

9. Labs

10. Urinalysis • >50 wbc, 2-5 rbc, 2+ bacteria • 1+ protein; negative nitrites, glucose, ketones, and bilirubin

11. Studies • CXR: mild cardiomegaly only • Serum digoxin: undetectable by EMIT • Kodak VITROS 250 analyzer, Ortho-Clinical Diagnostics • Lower limit of detection is 0.4ng/ml

12. Mother’s EKG

13. Clinical Course • Developed bradycardia (HR 30), hypotension (SBP 60), and oxygen desaturation (90%) • Treatment • O2 2 L NC • Atropine 0.5 mg IV • NS 1L • Promethazine 12.5mg IV x 2 for nausea • Improvement in HR 72 and BP 146/61

14. Clinical Course • No decontamination • 3 hours after arrival, required additional atropine 1mg for recurrent bradycardia • Admitted to the ICU

15. Patient #2: Daughter • HPI • 60 yo acutely ill female • “nausea, vomiting, abdominal cramping, several loose stools, weakness” • PMH • Hypothyroidism • Medications • Levothyroxine, conjugated estrogen, ASA

16. Daughter’s PE VS: BP 74/51 HR 58 RR 22 T 97.0 GEN: alert and oriented SKIN: pale and diaphoretic HEENT: conjugate reactive pupils, dry mm RESP: mild expiratory wheezing CV: no mrg ABD: nontender with nl BS EXT: central pulse > peripheral NEURO: nl reflexes, no fasciculations or focal findings MS: no hallucinations

17. Labs

18. Studies • UA: normal • CXR: borderline cardiomegaly and mild vascular congestion • Serum digoxin: undetectable • EKG: normal

19. Clinical Course • Treatment • Atropine 0.5 mg IV • IVF NS 1L • Promethazine 12.5mg IV x 2 nausea • Nebulized albuterol • Improvement in HR 78 and BP 104/62 • AC decontamination

20. Clinical Course • No further vomiting • 3 hours after arrival, BP 81/43 and HR 60 • Dopamine started • Admitted to the ICU

21. Plant Information • Family produced uncooked “ramp” specimens • Phone description to PC: • white, bulb-like root • one inch wide blade-like leaves • “consistent with an iris or lily” • No pesticide odor on plant

22. Additional Information The area of forage was described as a wooded area “on the side of a mountain”