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An Unidentified Poisoning

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.

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An Unidentified Poisoning

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  1. An Unidentified Poisoning Department of Clinical Toxicology and Pharmacology Hunter Area Health Service

  2. 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

  3. NMMH ED • T 34.9, HR 80 reg, BP 130/84, Sats 99% R/A • pH 7.52 pCO2 19.8 pO2 138.4 BSL 4.8 HCO3 16.2 BE -6.0 SaO2 99.2

  4. Should she have gut decontamination?

  5. Became agitated • Physically restrained • Orogastric tube - patient removed • Nasogastric tube - polyethylene glycol • NaHCO3 • Multiple dose Activated Charcoal

  6. 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

  7. Normal FBC • Normal coags • Na 130 Normal LFTs K 3.2 urea 2.4 creatinine 71 Anion Gap 16

  8. Salicylate level <0.1 • Paracetamol <7 • Blood Alcohol 0.22

  9. NMMH ICU • Uncooperative, disoriented • Pupils mid-size and reactive • Normal tone, normal reflexes • HS normal, chest clear • Active bowel sounds • UO 100mls/hr

  10. Overnight • Nauseated • Vomiting • T 38.0°C

  11. 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

  12. At 12 hours • R/A pH 7.42 pCO2 33.9 pO2 81.5 HCO3 21.4 BE -2.4 SaO2 99.0

  13. 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

  14. 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

  15. Day 3 • Belly pain settled • Ileus • Dyspnoeic • Myalgic • UO ~50mls/hr • HS normal, JVP 1cm, mild sacral oedema, scanty bibasal crackles

  16. Day 3 • CXR - small bilateral pleural effusions, no interstitial fluid • 4L O2 pH 7.30 pCO2 28.1 pO2 90.8 HCO3 14.1 BE -10.8 SaO2 96 %

  17. Day 3 • Hb 100, WCC 5.6 (n. 5.3), Plt 38 • urea 13.3, creatinine 147 • alb 30, LD 5387, CK 7500

  18. 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

  19. Day 5 • DIC resolving • WCC 4.0 (n. 0.6)  G-CSF

  20. 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

  21. Days 9-10 • V/Q Scan - low to moderate probability of PE (20-40%) • CT Scan - NAD • ACEI and diuretic 6kg wt loss

  22. Days 11-21 • Alopecia • Warfarinisation • Mobilisation

  23. 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

  24. 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

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

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

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

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