Ricin intoxication

 

Substance

蓖麻

 

Common name or Trade name

- contains Ricin 蓖麻毒素

-          Ricinus communis；

-          castor oil plant

-          本草綱目:李時珍曰︰仁甘辛有毒热，氣味颇近巴豆，亦能利人，故下水汽。其性善走，能開通諸竅經絡，故能治偏風、失音口噤、口目斜、頭風七竅諸病，不止于出有形之物而已。蓖麻油能拔病氣出外，故諸膏多用之。 此药外用屢奏奇勋，但内服不可輕率爾。或言捣膏以箸点于鹅馬六畜舌根下，即不能食，或点肛内，即下血死，其毒可知矣[1]。

-          Toxic substance: Ricin [2].

-          ricin-intoxicated patients worldwide described were found in Asia (38% cases), America (30%) and Europe (24%). Intoxication was mostly accidental (74%) [3].  

 

Involving system

-          Route: intravenous home-made castor bean extract, died 6 days after intoxication [4].

-          Route: oral ingestion of the beans. Injection of ricin is believed to be more lethal［5］．

-          Hepatotoxicity [6].

 

Presentation  

 

-          Ricin injection (738 µg of ricin A-chain (∼10.5 µg/kg) 3 ml Injection (IM). resulted in a near-fatal poisoning that evolved with septic shock-like syndrome, multiple organ dysfunction and necrotizing fasciitis [7].

-          Severe abdominal cramps and nausea after injection of a castor bean extract［5］.

-          A fulminant diarrhea developed, resulting in hypovolemic shock and cardiorespiratory collapse.

-          acute gastroenteritis-like disease as primary manifestations leading to severe fluid and electrolyte imbalance.

-          The mechanism of death was peripheral vascular collapse and progressing multiple organ failure (MOF) occurring 10h-72h after intoxication. [3].

 

 

Antidote and Treatment

 

-          No antidote.

-          Symptomatic treatment consisting mostly to rehydration with intravenous fluids and digestive decontamination performed with activated charcoal and/or gastric lavage [3]

This decontamination treatment administered early has been very effective [3] Prompt treatment with supportive care was necessary to limit morbidity and mortality.

-           

Disposition

-          if rapid deterioration of his hemodynamic function: transferred to ICU [5].　

-          Watch out if an outbreak of serious respiratory or gastrointestinal illness [3].

 

References

 

[1]. 中醫寶典. http://zhongyibaodian.com/bcgm/bima.html

 

[2].認識中藥蓖麻籽.香港中藥藥劑師協會https://www.cmpa.org.hk/%E8%AA%8D%E8%AD%98%E4%B8%AD%E8%97%A5%E8%93%96%E9%BA%BB%E5%AD%90/

 

[3]. Abbes M, Montana M, Curti C, Vanelle P. Ricin poisoning: A review on contamination source, diagnosis, treatment, prevention and reporting of ricin poisoning. Toxicon. 2021 May;195:86-92. doi: 10.1016/j.toxicon.2021.03.004. Epub 2021 Mar 9. PMID: 33711365.

 

[4]. Staňková M, Handlos P, Švidrnoch M, Maier V. Fatal intoxication by intravenous injection of castor bean (Ricinus communis L.) extract-a case study. Int J Legal Med. 2020 Nov;134(6):2133-2141. doi: 10.1007/s00414-020-02340-x. Epub 2020 Jun 17. PMID: 32548760.

 

[5]. Verougstraete N, Helsloot D, Deprez C, Heylen O, Casier I, Croes K. Lethal Injection of a Castor Bean Extract: Ricinine Quantification as a Marker for Ricin Exposure Using a Validated LC-MS/MS Method. J Anal Toxicol. 2019 Apr 1;43(3):e1-e5. doi: 10.1093/jat/bky100. PMID: 30590581.

 

[6]. Palatnick W, Tenenbein M. Hepatotoxicity from castor bean ingestion in a child. J Toxicol Clin Toxicol. 2000;38(1):67-9. doi: 10.1081/clt-100100920. PMID: 10696929.

 

[7]. Bucaretchi F, Borrasca-Fernandes CF, Prado CC, Lanaro R, Costa JL, Petroni OM, Giraldi T, Blotta MHSL, Justo-Junior AS, Sousa NL, Aragão FJL, De Capitani EM, Hyslop S. Near-fatal poisoning after ricin injection. Clin Toxicol (Phila). 2021 Feb;59(2):158-168. doi: 10.1080/15563650.2020.1771358. Epub 2020 Jun 1. PMID: 32475181.

edited by Yu-Jang Su   April 13, 2021.  

 

Tetrodotoxin

 

Tetrodotoxin (TTX) 

Substance

- Till 2019, around 28 analogs of TTX are known, but only 12 were detected in marine organisms [1]. Potent marine neurotoxin with bacterial origin: ( Pseudoalteromonas tetraodonis), a marine bacterium normally associated with the production of tetrodotoxin in pufferfish[2]).

- in some puffer fish, gastropods(腹足動物), and bivalves(雙殼類)[1].

- heat-stable and acid-stable, nonprotein, alkaloid toxin 

Common name or Trade name

 河豚毒素

Involving system

- blocking voltage-activated sodium channels, terminating nerve conduction and muscle action potentials, leading to progressive paralysis and, in extreme cases, to death from respiratory failure [3].

Presentation [4, 5]

-  Peri-oral paraesthesia (65%--72%)

- weakness of both lower limbs (59—62%%).

- paraesthesia all over the body (49%--64%).

- headache (41%--47%),

- difficulty in respiration (38%)

- nausea and vomiting (22%), blurring of vision (19%)

- vertigo (16%)  

 

Antidote and Treatment

-       Palliative / supportive treatment

-       No antidote. no specific treatment [4]

Disposition 

-       Mortality rate: 12--22%. [4, 5, 6]

REFERENCES

1.     Tamele IJ, Silva M, Vasconcelos V. The Incidence of Tetrodotoxin and Its Analogs in the Indian Ocean and the Red Sea. Mar Drugs. 2019 Jan 5;17(1):28. doi: 10.3390/md17010028. PMID: 30621279; PMCID: PMC6357042.

2.     Lee RD, Jospin G, Lang JM, Eisen JA, Coil DA. Draft Genome Sequence of Pseudoalteromonas tetraodonis Strain UCD-SED8 (Phylum Gammaproteobacteria). Genome Announc. 2015 Nov 5;3(6):e01276-15. doi: 10.1128/genomeA.01276-15. PMID: 26543114; PMCID: PMC4645199.

3.     Cole JB, Heegaard WG, Deeds JR, McGrath SC, Handy SM; Centers for Disease Control and Prevention (CDC). Tetrodotoxin poisoning outbreak from imported dried puffer fish--Minneapolis, Minnesota, 2014. MMWR Morb Mortal Wkly Rep. 2015 Jan 2;63(51):1222-5. PMID: 25551594.

4.     Ahasan HA, Mamun AA, Karim SR, Bakar MA, Gazi EA, Bala CS. Paralytic complications of puffer fish (tetrodotoxin) poisoning. Singapore Med J. 2004 Feb;45(2):73-4. PMID: 14985845.

5.     Chowdhury FR, Nazmul Ahasan HA, Mamunur Rashid AK, Al Mamun A, Khaliduzzaman SM. Tetrodotoxin poisoning: a clinical analysis, role of neostigmine and short-term outcome of 53 cases. Singapore Med J. 2007 Sep;48(9):830-3. PMID: 17728964.

6.     Islam QT, Razzak MA, Islam MA, Bari MI, Basher A, Chowdhury FR, Sayeduzzaman AB, Ahasan HA, Faiz MA, Arakawa O, Yotsu-Yamashita M, Kuch U, Mebs D. Puffer fish poisoning in Bangladesh: clinical and toxicological results from large outbreaks in 2008. Trans R Soc Trop Med Hyg. 2011 Feb;105(2):74-80. doi: 10.1016/j.trstmh.2010.10.002. Epub 2010 Dec 3. PMID: 21129761.

edited by Yu-Jang Su  March 24, 2021. 

 

Paraquat poisoning

 

Substance

-  Paraquat.

Common name or Trade name

-   巴拉刈. 速草淨, 全草滅, 草蕪松 [1]

Involving system

-      Gastrointestinal – oral, transient liver toxicity, jaundice. [1]

- lung: pulmonary fibrosis [1]

- kidney: ATN, AKI [1]

- heart: hypotension, myocarditis, arrhythmia. [1]

- AMS- mental change. Seizure. Coma. [1]

Presentation 

-       Nausea, vomiting. [1]

-       Diarrhea [1]

-       Dyspnea [1]

-       Pneumoperitoneum, pneumomediastinum [2].

-       Seizure [1]

-       jaundice [1]

-       Coma [1]

-       Asystole. [1]

Antidote and Treatment

-       Decontamination: remove clothes, washing [1].

-       NG irrigation within 1 hour [1].

-       Fuller earth, 100—150 gm. Child: 2 gm/kg BW. Activated charcoal 25—100gm, child 25—50 gm [1].

-       Hemoperfusion within 2—4 hours [1].

-       Hemodialysis if renal failure [1].

-       No antidote.

Disposition 

-       MICU in confirmed poisoning cases with hemodynamic unstable.

-       25% to 44% of mortality rate in pregnant women [3].

REFERENCES

1.      急診醫學會AILS三版P.85—94.

 

2.      James N, Bakshi R, Rudresh SS, Kaushik K, Ghumaan KS, Pannu AK. Pneumoperitoneum from pneumomediastinum in paraquat poisoning. Trop Doct. 2020 Sep 30:49475520960872. doi: 10.1177/0049475520960872. Epub ahead of print. PMID: 32998627.

 

3.      Trakulsrichai S, Paisanrodjanarat B, Sriapha C, Tongpoo A, Udomsubpayakul U, Wananukul W. Clinical outcome of paraquat poisoning during pregnancy. Clin Toxicol (Phila). 2019 Aug;57(8):712-717. doi: 10.1080/15563650.2018.1549328. Epub 2019 Jan 28. PMID: 30689470.

edited by Yu-Jang Su  Feb 27, 2021. 

毛地黃中毒

 

Substance

-  Digitalis.  

- 強心配糖體之動植物:夾竹桃, 鈴蘭, 紅海蔥, 海檬果, 玉竹, 馬利筋, 萬年青, 側金盞花, 黑眶蟾蜍, 中華大蟾蜍  [1] 

Common name or Trade name

-  digoxin. 

Involving system

-       Inhibit Na, K ATPase, increased intracellular Ca. (By increasing in intracellular sodium concentration competes for calcium through this exchange mechanism leading to an increase in intracellular calcium concentration.)  

-       Increment heart contractility.

Presentation 

- mean age of patient: 76.1 ± 12.2 years old, comorbidities with CHF: 66.4%; atrial fibrillation: 54%. [2]

-  hyperkalemia. [1]

- GI: GI upset, nausea. Diarrhea, weakness, dehydration [1]. Abdomen pain. [2]

- Neuro: altered mental status, headache, lethargy, confusion, syncope, hallucination, coma, convulsion.

- CV: arrhythmia, AV block. Bradycardia. [1] ECG: scooping ST-T complex. [3]

- eye: colored floaters, major in yellow [4].

Antidote and Treatment

-       NG irrigation within 1 hr

-       Activated charcoal. (Carbomix 12.5 gm/ hr) [1]

-       Hemodynamic change, arrhythmia, and cardiac arrest: digoxin Fab-specific Abs.

-IVF + dopamine infusion for hypotension. [1]

-       50% Glucose + HRI for hyperkalemia. (3 amps 50%Glucose + HRI 8U)

-       No definite effect by hemoperfusion and hemodialysis.

Disposition 

-   ICU if hemodynamic unstable.

 

REFERENCES

[1]. 急性中毒救命術, 台灣急診醫學會. P.175—182.

[2]. Limon G, Ersoy G, Oray NC, Bayram B, Limon O. Retrospective evaluation of patients with elevated digoxin levels at an emergency department. Turk J Emerg Med. 2016 Mar 14;16(1):17-21. doi: 10.1016/j.tjem.2015.10.001. PMID: 27239633; PMCID: PMC4882205.

[3]. Castello LM, Negro S, Santi F, Zanotti I, Vidali M, Bagnati M, Bellomo G, Avanzi GC. Accidental digitoxin intoxication: an interplay between laboratory and clinical medicine. Biochem Med (Zagreb). 2012;22(3):380-4. doi: 10.11613/bm.2012.040. PMID: 23092069; PMCID: PMC3900044.

[4]. Shi L, Sun LD, Odel JG. Colored floaters as a manifestation of digoxin toxicity. Am J Ophthalmol Case Rep. 2018 Mar 2;10:233-235. doi: 10.1016/j.ajoc.2018.02.024. PMID: 29780940; PMCID: PMC5956671.

edited by Yu-Jang Su            Jan 29, 2021