By Alicia Minns, MD
Introduction
Cardioactive steroids or cardiac glycosides are naturally‐occurring compounds identified in various plant and animal species. Self-poisoning with plants is a major problem in certain parts of the world such as rural Asia, killing thousands of people each year. One of the most common poisons used for self-harm in much of South Asia are the seeds of the yellow oleander tree (Thevetia peruviana), and the rate of morbidity and mortality is high. There are multiple naturally occurring cardiac glycosides including Lily of the Valley (Convallaria majalis), Squill (Drimia maritima), Foxglove (Digitalis sp), Common Oleander (Nerium oleander), and the Cane Toad (Rhinella marina). There is structural diversity among these compounds and they are subclassified on the basis of the steroid moiety, whereby those with a five‐membered lactone ring are called cardenolides while those…
by Alicia Minns, MD
Introduction
Ciguatera is one of the more common causes of fish-related foodborne illness in the United States. It is caused by toxins that accumulate in the flesh of large predatory fish found in tropical oceans. The name ciguatera is derived from the Spanish name cigua for the sea snail Turbo pica found in the Caribbean Spanish Antilles. This neurotoxic syndrome has been recognized throughout history, with one of the earliest cases having probably been reported in the 4th century when Alexander the Great refused to allow his soldiers to eat fish. One of the earliest written records of suspected ciguatera poisoning is from the journal of Captain William Bligh, who described symptoms consistent with ciguatera in 1789 after eating mahi-mahi. In addition, it was also quite possibly ciguatera that was illustrated by Captain James Cook while sailing on the Resolution in the South Pacific in 1774.
Of reported cases, 75% (except in Hawaii) involve the barracuda, snapper, jack, or grouper. Hawaiian carriers of the toxin include parrot-beaked bottom feeders and surgeonfishes, particularly those inhabiting waters with high dinoflagellate populations, such as those with disturbed coral reefs. Ciguatera has also been…
Case presentation
A 39 year-old man was found slumped over at his home computer by his wife, who noted him to be diaphoretic and clammy with a weak pulse. She had last seen him normal 2 hours prior, at which point she had gone to bed. Unable to rouse him, she called 911. On arrival of paramedics, he was hypothermic to 36°C with a respiratory rate of 10. He was given an 0.4 mg of naloxone and had only a partial response within the next 5 minutes.
His presenting vital signs were as follows: blood pressure 104/73, pulse 77 beats per minute, respiratory rate 14 breaths per minute and oxygen saturation was 96% on room air. He was sedated initially but arousable to voice, and oriented with a nonfocal neurologic exam. Pupils were 3 mm and reactive. Naloxone 0.4 mg was again given with only a partial response.
Serum chemistry was normal except for Cr 1.43 mg/dL without a previous baseline. Liver function tests were normal. An electrocardiogram demonstrated normal sinus rhythm with normal intervals.
Over the next two hours, the patient gradually regained orientation and began to answer question. He related that due to his long-standing insomnia, he often takes 100-200 mg of diphenhydramine daily to sleep, as well as his usual 3 tablets of his prescription…
Introduction
On March 25, 2016 the Sacramento County Division of Public Health released a drug overdose health alert entitled Fentanyl-Contaminated Street Norco. This report was in response to 12 cases of poisoning from “street” Norco thought to contain fentanyl over the previous 48 hours. Legitimate Norco tablets contain a combination of acetaminophen and hydrocodone in various amounts. Hydrocodone is considered a semi-synthetic opioid in that it is synthesized by modification of an opiate (naturally occurring compounds isolated from the Papaver somniferum poppy plant such as morphine, codeine, heroin, and opium). Fentanyl is termed a synthetic opioid as it is not derived from naturally occurring sources like the aforementioned opiates. As described above, both hydrocodone and fentanyl are opioids meaning that they are agonists at various opioid receptors. Quantifying a true difference in potency can be challenging given the multiple variables that go into such a determination including receptor affinity, receptor activation, and lipophilicity. Studies have shown that fentanyl binds the mu opioid receptor with about 30 times the affinity of hydrocodone. Perhaps the best way to understand the difference in potency is through differences in therapeutic…
By Daniel Lasoff, MD and Binh Ly, MD
Introduction
Amnesic shellfish Poisoning (ASP) is a potentially deadly illness caused by the toxin domoic acid. Domoic acid is produced by the diatom pseudo-nitzschia, an algae species, and shellfish that eat this algae bioaccumulate domoic acid. In 1987, there was a major outbreak of amnesic shellfish poisoning from the consumption of contaminated mussels resulting in over a hundred human cases with several deaths. Today there is strict monitoring of the ocean and commercial shellfish producers to ensure the risk of amnesic shellfish poisoning is minimized, but recreational fishing may place consumers at risk on a much smaller scale. It is thought, that Alfred Hitchcock may had taken his inspiration for the film, The Birds, from an August 1961 newspaper report of thousands of crazed seabirds with suspected poisoning and were slamming into houses…
By Alicia Minns, MD
Introduction
Salvia divinorum is a rare member of the mint family (Labiatae), endemic to a small region of Oaxaca, Mexico. Shamans of the Mazatec Indians of Oaxaca have used the plant for centuries for religious purposes as well as in medicinal practices to treat diarrhea, headache, rheumatism, anemia, and a semi-magical disease known as panzón de Borrego, or a swollen belly, believed to be caused by an evil sorcerer. Similar to cannabis, S. divinorum can be also cultivated indoors or in any humid and semitropical environment. Recently, S. divinorum (usually referred to as salvia) has received increasing attention for its recreational use due to its unique psychedelic effects. It has gained popularity as a “legal high” due to its accessibility, legality in many areas, perception of relative safety, and lack of detectability upon routine drug screening. S. divinorum is frequently promoted as a safe and legal alternative to scheduled hallucinogenic drugs, such as cannabis, LSD, and mescaline.
Salvinorin A, the active component of salvia, is unique for several reasons, which include: 1) it is the first plant-derived molecule with selectivity for kappa-opioid receptors, 2) it is structurally unrelated to any known opioid receptor agonist, and…
By Charles W. O’Connell, MD
Introduction
Metformin is a first-line agent for type 2 diabetes mellitus often used as monotherapy or in combination with oral diabetic medications. It is a member of the biguanide class and its main intended effect is expressed by the inhibition of hepatic gluconeogenesis. In addition, metformin increases insulin sensitivity, enhances peripheral glucose utilization and decreases glucose uptake in the gastrointestinal tract. Phenformin, a previously used biguanide, as withdrawn from the market in the 1970’s due its association with numerous cases of lactic acidosis. Metformin is currently used extensively in the management of diabetes and is the most commonly prescribed biguanide worldwide. The therapeutic dosage of metformin ranges from 850 mg to a maximum of 3000 mg daily and is typically divided into twice daily dosing. It is primarily used in the treatment of diabetes but has been used in other conditions associated with insulin resistance such as polycystic ovarian syndrome. MALA is a rare but well reported event that occurs with both therapeutic use and overdose states.
Case presentation
A 22-year-old female presents to the Emergency Department after being found alongside a suicide note by her family. She was…
By Alicia Minns, MD
Introduction
Over the last decade, there has been an explosion of novel psychoactive substances. Among these, are the “2C” compounds; the name referring to the chemical structure consisting of two carbon atoms between the phenyl and amine moieties. Synthetic designer hallucinogens gained popularity after the 1991 publication of Alexander Shulgin’s book, PIHKAL, A Chemical Love Story. PIHKAL, an acronym for “Phenethylamines I Have Known and Loved,” details the synthesis of over 200 mind-altering compounds including the “2C” series of hallucinogenic phenethylamines. There are numerous analogs of the 2C compounds and multiple cases have been reported detailing potentially fatal intoxications. Over the last 5 years, a new group of 2C compounds have emerged on the market, the N-methoxybenzyl-substituted phenethylamines (NBOMe). The three most frequently reported drugs in this series are 25I-NBOMe, 25C-NBOMe, and 25I-NBOMe, however several other drugs in this class have been reported in the scientific literature, especially by neurobiological research studies, as well as on internet web pages. Initially synthesized for research purposes, these drugs are potent serotonin 5HT2A receptor agonists, which confer hallucinogenic properties and are thought to…
by Alicia Minns, MD
Introduction
Scombroid poisoning, or histamine fish poisoning, is a type of food poisoning that is similar to symptoms of seafood allergies. The term “scombroid” derives from the type of fish (i.e. Scombridae) first implicated, such as tuna and mackerel. The first report of scombroid poisoning was published in 1830. It involved five sailors who consumed bonito fish, a member of the Scombridae family. Scombroid is associated with ingestion of dark-meat fish, such as tuna, bluefish, mahi-mahi, amber jack and mackerel. These fish contain high levels of free histidine in their muscle tissues. Scombroid results from consumption of fish containing high level of histamine, which accumulates when bacteria metabolize the amino acid histidine in the fish muscle. The enzyme histidine decarboxylase in certain bacteria such as Proteus, Klebsiella, Aerobacter and Escherichia coli…
Introduction
In 2003 the Drug Enforcement Agency first detected levamisole in cocaine bricks. In 2008 officials in Alberta, Canada identified a cluster of unexplained cases of agranulocytosis related to cocaine contaminated with levamisole. Levamisole is a veterinary pharmaceutical used primarily to treat worm infestations in livestock. It can be easily purchased worldwide in various forms (tablets, gels, solutions, pastes and powders). Levamisole, the levo enantiomer of tetramisole, was originally developed as an antihelminthic agent. Levamisole is approved by the United States Food and Drug Administration as adjuvant chemotherapy, with 5-fluorouricil, for the treatment of colon cancer. Because it has immunostimulant and immunomodulatory properties, levamisole has also been used for treatment of various autoimmune disorders (rheumatoid arthritis, juvenile rheumatoid arthritis, and nephrotic syndrome) and cancers (breast and lung). Levamisole is thought to increase T-cell activation and proliferation, neutrophil mobility, adherence, and chemotaxis. It is also thought to increase the formation of antibodies to various antigens. Unfortunately, it also acts as a hapten and triggers an immune reaction causing the opsonization and destruction of white blood cells.