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Updated April, 2023 by Jeremy Hardin, MD and Alicia Minns, MD

Original author Alicia Minns, MD

Introduction

Diethylene glycol (DEG) is a colorless, odorless, clear liquid with a sweet taste. It is a toxic alcohol that is also an excellent solvent for water-insoluble chemicals. DEG can be a component of antifreeze preparations, various cosmetics, liquid printer ink cartridges, lubricants, brake fluid, wallpaper strippers, and as a plasticizer. It has been implicated in multiple global health catastrophes in which it was substituted for the more expensive, safer medication diluents, with resultant mass deaths. The hallmarks of DEG toxicity are neurotoxicity and renal failure, with deaths still reported to occur despite aggressive treatment with hemodialysis.

Case Presentation

A 50-year-old female presented to a local emergency department with nausea and abdominal pain. She states that she had just drank multiple cartridges of printer ink in a suicide attempt. Her physical exam was notable for black discoloration of the mouth and tongue, and slurred speech. 24 hours after admission she developed coma, anuric renal failure, an anion gap metabolic acidosis, and bilateral cranial nerve VII paralysis. Hemodialysis was initiated,…

Updated April, 2023 by Nathan Friedman, MD

Original author Stephen Thornton, MD

Introduction

β-adrenergic antagonists (beta-blockers; BBs) are commonly used for treatment of hypertension, coronary artery disease, and tachydysrhythmias. β-adrenergic antagonists have also been used to treat congestive heart failure, glaucoma, migraine headaches, benign essential tremor, panic attacks, stage fright, and hyperthyroidism. There were approximately 10,000 exposures reported nationally to poison centers in 2015. Propranolol accounts for a disproportionate number of fatalities and severe morbidity, likely due to its increased toxicity compared to other BBs and its use in patients with anxiety and stress.

Case presentation

A 65-year-old woman presented to the emergency department 3 hours after an intentional ingestion of her propranolol. Her heart rate was 35 beats per minute and her blood pressure was 80/40 mm Hg. She was somnolent and confused. The patient received intravenous glucagon 1 mg with no improvement in her hemodynamics. A second dose of intravenous glucagon 5 mg was administered. The patient’s heart rate improved to 50 beats per minute and her blood pressure increased to 90/50 mm Hg.

Questions

1. What…

Updated April, 2023 by Justin Seltzer, MD
Original author Jean Lo, MD

Introduction

Neurologic symptoms following consumption of seafood are uncommon but well described, with tens of thousands of cases annually worldwide and likely many more that are unreported and/or misdiagnosed. Neurotoxic seafood poisoning most often occurs following consumption of fish and shellfish. However, seafood consumption distant from where the animal was initially caught may complicate identification of the culprit organism. Further, diagnosis can be difficult, especially given limited provider familiarity with clinical syndromes.

Case 1 presentation

A 30 year old male was brought to the emergency department 6 hours after eating sea bass. His symptoms included perioral numbness and tingling, a strange metallic taste, and reversal of temperature discrimination. He was also mildly hypotensive and bradycardic.
Questions

1. What is the likely causative agent?
2. Where are the likely sources?
3. What is the physiologic mechanism by which the agent exerts its effects?

Case 2 presentation

A 25 year old female was brought to the emergency department 24…

Updated April, 2023 by Jeremy Hardin, MD and Allyson Kreshak, MD

Original author Allyson Kreshak, MD

Introduction

Methemoglobin is the oxidized form (Fe3+) of hemoglobin. It is generated when hemoglobin in the ferrous state (Fe2+) loses an electron and is oxidized to the ferric (Fe3+) state. Ferric hemoglobin is unable to bind oxygen, and excessive methemoglobin causes a left shift of the hemoglobin-oxygen dissociation curve. Together these effects lead to cyanosis, tissue hypoxia, and functional anemia. Certain drugs and genetic abnormalities can induce excessive methemoglobin formation and potentially severe hypoxia and death. Methemoglobinemia should be considered in all patients with cyanosis and hypoxia that are unresponsive to supplemental oxygen.

Case Presentation

A 30-year-old male presented to the emergency department with cyanosis and altered mental status. According to his partner he had been taking shots of alcohol when he accidentally drank “poppers” and rapidly developed lightheadedness, cyanosis, and confusion. Initial vital signs were notable for heart rate 140 beats per minute, blood pressure 80/30 mm Hg, respiratory rate 24, and a pulse oximeter reading of 82% on room air. He was markedly cyanotic,…

Updated February, 2023 by Nate Friedman, MD & Alicia Minns, MD

Original author Alicia Minns, MD

Introduction

Synthetic cannabinoid (SC) compounds, also referred to as synthetic cannabinoid receptor agonists (SCRAs), were originally developed to study the pharmacology of cannabinoid receptors. In recent years, however, they have emerged as drugs of abuse. Synthetic cannabinoids first emerged in Europe in 2005, and then appeared in the United States in 2009, where they were marketed initially as “K2” and “Spice” and inhaled via a pipe or rolled into a cigarette. The poorly labeled contents have been found to include a mixture of psychoactively inert herbs and aromatic extracts sprayed with SC compounds and are packaged with labels stating “not for human consumption” or “incense.” Despite federal and state regulations prohibiting the sale and distribution, illicit use continues. Many SCs are more potent than delta-9-tetrahydrocannabinol (THC), the active ingredient in marijuana, and are more likely to be associated with sympathomimetic effects (tachycardia, hypertension) and hallucinations. There is also an increase in the occurrence of seizures as well as reports of unanticipated acute kidney injury.

As of February 2023, the US Drug…

Updated February, 2023 by Jeremy Hardin, MD and Binh Ly, MD

Original author Binh Ly, MD

Introduction

Acute cyanide poisoning is rare and often life-threatening if untreated. Cyanide is widely used across multiple industries including metallurgy, photography, plastic manufacturing, fumigation, jewelry polishing, cosmetics, and chemical synthesis. It is also found naturally within certain pitted fruits and is a by-product of combustion. Accidental occupational or environmental exposure as well as intentional poisoning are possible, and rapid recognition and treatment with the appropriate antidote is essential to prevent mortality.

Case Presentation

A 6 year old male with a past medical history of autism presents to the Emergency Department after being found by his parents unresponsive next to an open bottle of pills. His initial vital signs were temperature 36.9 degrees Celsius rectally, blood pressure 72/48 mmHg, heart rate 150 beats/minute, RR 26 breaths/minute, and oxygen saturation 100% on facemask with oxygen flow rate of 15 liters/min. On examination he was unconscious but did withdraw to painful stimuli in all extremities. There was no evidence of trauma, and his pupils were equal and reactive to light and…

Updated January, 2023 by Nathan A Friedman, MD & Alicia Minns, MD

Original author Alicia Minns, MD

Introduction

In the early 2000s, a dramatic surge of case reports of use and complications from Krokodil (also known as Crocodile, Krok, or Croc) emerged. Krokodil use was first reported in Siberia in 2002 and has mostly been described in European countries. The drug made its way into the United States with a few cases reported in the late 2000s, although reports in the medical literature have largely tapered off since the mid 2010s. No confirmed cases have been reported in the U.S. since at least 2014. During a period of media attention, it was dubbed the “drug that eats junkies,” and “Russia’s deadly designer drug.” It is characterized as the “flesh eating” or “flesh rotting” drug. The main active ingredient of Krokodil is desomorphine, a more potent and synthetic derivative of morphine. It can be manufactured at home from codeine and easily obtained additives and is significantly cheaper than heroin. Its use results in severe damage to the vasculature, muscles, and bones, and in multiorgan failure with a mean survival time of 2 years after its first use. Use of this drug spread across Eastern Europe because of its low cost and higher addictive potential.…

by Christie Sun and Binh Ly, MD

Introduction

Botulism is a potentially fatal neurological disease, resulting from botulinum neurotoxin produced by Clostridium botulinum and other Clostridium species. Outbreaks have been reported worldwide and while the fatality rate has improved, serious morbidity and mortality may still occur. The majority of adult cases are food borne, but there are also other forms related to inhalational exposure, wound inoculation, iatrogenic injections, and gastrointestinal (GI) colonization typically affecting infants.

Case presentation

A 38-year-old male presents to the Emergency Department with nausea, vomiting and abdominal pain in the setting of blurred vision and difficulty swallowing over the last 12 hours. He has no medical problems and was feeling well earlier today while at a potluck. Vital signs on arrival to the Emergency Department are as follows: temperature 98.7 degrees Fahrenheit, heart rate 61, blood pressure 105/63, respiratory rate 18, oxygen saturation 95% on room air. His exam reveals an alert male who and oriented. His neurological exam is notable for dilated pupils which are sluggishly reactive to light. There is mild ptosis on exam and sensation is normal, however deep tendon reflexes…