81. Methemoglobinemia as a Complication of Topical Dapsone
Swartzentruber GS, Yanta JH, Pizon AF, Menke NB
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Background: Methemoglobinemia may result from a wide variety of oxidant stressors. Dapsone and its acetylated metabolite, dapsone hydroxylamine, are known oxidants and have been frequently reported as a cause of methemoglobinemia. Topical dapsone has not been previously reported as a cause of methemoglobinemia. We present a case of methemoglobinemia after using topical dapsone 5% gel for facial acne.
Hypothesis: Topical dapsone has the potential to cause methemoglobinemia.
Methods: This is a single patient chart review. A 19 year-old female without significant past medical history presented to the emergency department with blue lips and nail beds. Her home medications included citalopram, topical dapsone (Aczone®), and oral contraceptives. She awoke on the day of presentation and noted that her lips and fingers were blue. She complained of a mild headache and mild shortness of breath. Initial vital signs were normal except for an oxygen saturation of 82% on room air. Her dyspnea persisted despite treatment with 2 liters per minute of oxygen by nasal cannula. Oxygen saturation increased to 90% following treatment with oxygen. Chest radiograph and electrocardiogram were normal. Laboratory studies were within normal limits (Hgb 12.4 mg/dL) except for a methemoglobin (MetHgb) level of 20.3%. She was treated with a single intravenous bolus of 2 mg/kg methylene blue which resulted in complete resolution of her cyanosis and symptoms. A repeat MetHgb level 120 minutes after treatment was 1.9%. A urine gas chromatography/mass spectrometry qualitative drug screen demonstrated dapsone. Nine hours after treatment, her MetHgb level was 7.2%, she was asymptomatic, and was therefore discharged home.
Case Discussion: We hypothesize this patient’s methemoglobinemia was the result of systemic absorption of topical dapsone gel.
Conclusions: Topical dapsone gel may be absorbed systemically thereby causing oxidant stress and resulting in methemoglobinemia.
82. ST Elevation Myocardial Infarction Presenting as Complication of Crotalus horridus Envenomation
Swartzentruber GS1, Cibik LA2, Richardson WH3, Lloyd VJ3
1University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 2Baptist Medical Center, Jacksonville, FL, USA; 3Palmetto Health Richland, Columbia, SC, USA
Background: Myocardial infarction (MI) has been reported previously as a complication of snake envenomation. To our knowledge, ST-elevation MI (STEMI) has not been previously reported as a complication of North American crotaline envenomation.
Hypothesis: Rattlesnake envenomation can cause MI by a mechanism not yet clearly elucidated.
Methods: This is a single patient chart review. A 72 year-old male presented to the emergency department (ED) with chest pain shortly after being bitten by a juvenile canebrake rattlesnake (Crotalus horridus). EMS was called and enroute to the ED the patient developed chest pain and hypotension. His vital signs on arrival were T 97.4, HR 89, RR 28, BP 96/72, O2 saturation 100% on non-rebreather mask. Swelling was present over the left dorsal hand, a single puncture wound was noted on the second digit.
Results: The initial EKG demonstrated ST elevation in leads II, III, and aVF. Laboratory results included WBC 9.7, Hgb 13.2, Plt 524, PT/INR 12.3/0.9, PTT 28.9, fibrinogen 712, and troponin was elevated at 0.24. Hypotension resolved following a 1000cc bolus of 0.9% saline. Rectal aspirin 300mg, heparin, and 6 vials of crotaline Fab antivenom were administered in the emergency department. The patient was admitted for emergent cardiac catheterization and intubated for ongoing hypoxia. The circumflex artery revealed a 70%-80% mid-vessel stenosis with thrombus formation. There was additional thrombus formation just proximal to the branching point of the second obtuse marginal branch. After thrombectomy and stent implantation, there was no residual obstruction. The patient was extubated on hospital day #2. Fourteen vials of crotaline Fab antivenom were administered. He was discharged to home in good condition after 6 days in the hospital.
Discussion: Complex hematologic abnormalities such as platelet aggregation are well described following crotaline envenomation including recognized species-dependent effects. In this patient with moderate coronary atherosclerosis, thrombus formation could be a complication of the hemotoxic venom effect of Crotalus horridus. With the common use of anticoagulation and platelet-inhibiting medications in the setting of STEMI, management of STEMI in conjunction with crotaline envenomation presents unique challenges.
Conclusions: STEMI is a rare but potential life-threatening complication of North American crotaline envenomation.
83. Inverse Takotsubo Cardiomyopathy after Methamphetamine Use
Tran A1, Grimaldi L2,3, Shah A4, Menon S2, Levine M1,5
1Banner Good Samartian Medical Center, Phoenix, AZ, USA; 2Phoenix Children's Hospital, Phoenix, AZ, USA; 3University of Arizona, College of Medicine, Phoenix, AZ, USA; 4Arizona Pediatric Cardiology Consultants, Phoenix, AZ, USA; 5University of Southern California, Los Angeles, CA, USA
Background: Takotsubo cardiomyopathy (TC) is a reversible cause of heart failure caused by high adrenergic outflow. It is characterized by apical ballooning with hypokinesis. In inverse TC, the heart's apex is either normal or hyperdynamic with a hypokinetic base. There are several case reports of drug-induced TC, although very few cases of drug-induced inverse TC are described.
Hypothesis: Methamphetamine use is associated with inverse TC.
Methods: This is a case report of a 17 year-old man with history of heroin, marijuana, and amphetamine abuse who complained of 3 days of worsening nausea, vomiting, and acute onset of chest pain after using marijuana and methamphetamine.
Results:Patient was afebrile with a heart rate 143 bpm, respiratory rate 50 bpm, blood pressure 109/64, and oxygen saturation of 77% on room air. Exam revealed bilateral rales. No murmurs or peripheral edema was noted. CXR showed pulmonary edema with normal cardiac silhouette. Echocardiography revealed a dilated left ventricle, severely diminished motion in the basal and mid-wall segments, normal apical contraction, and a left ventricular ejection fraction (LVEF) of 29%. Troponin I was 4.68 ng/mL (<0.05 ng/mL). Pro-BNP was 18,701 pg/mL (
Discussion: The lack of upper respiratory symptoms, along with the temporal association between stimulant use and symptom onset, and the rapid improvement all suggest drug-induced etiologies, as opposed to a viral etiology. Very few cases have been reported on methamphetamine or amphetamine induced TC. Methamphetamine abusers may be at higher risk of developing cardiomyopathies compared to age-matched nonusers. Many of the reported cardiomyopathies are transient, as with TC and inverse TC. Mural thrombus is a known complication. LVEF and wall motion abnormalities should improve within 3-5 days and should return to baseline function within days to weeks.
Conclusion: Methamphetamine use may lead to inverse Takotsubo cardiomyopathy.
84. ACMT International Member Survey, Summer 2013
Vohra R1, Gosselin S2, Wong A3, Kopec K4, Gunja N5, On behalf of the ACMT International Committee
1UCSF Fresno Medical Center, Fresno, CA, USA; 2Centre Antipoison du Quebéc, Montreal, QC, Canada; 3Victorian Poisons Information Centre, Victoria, Australia; 4Duke University, Durham, NC, USA; 5University of Sydney, NSW, Australia
Introduction: The ACMT's International Committee was formed in 2008 to unite a diverse, geographically diffuse group of medical toxicology educators and researchers.
Research Question: How do international ACMT members self-evaluate their interested, goals, and priorities, and how can their responses guide strategic planning for this globally distributed network of toxicologists with diverse skills and needs?
Methods: A 9-question online survey was created in summer 2013 with input from International Committee members and ACMT leadership. We requested all international ACMT members provide feedback about their current responsibilities, projects, short- and long-term goals, and how ACMT and the International Committee could serve their professional and educational needs.
Results: There were thirty-two responses from 12 countries. The primary employment areas of respondents were: bedside or inpatient consultation services (81%), poison control centers, medical education, research, and public health agencies. The most common areas of interest within toxicology included pharmaceutical drug toxicity (65%), pesticides, agrochemicals, emerging illicit drugs, and snakebites. Topics desired for continuing education included heavy metals, medico-legal issues, emerging drugs, addiction medicine, industrial and occupational toxicology, radiation safety, and grant-writing/ research funding opportunities. Funding remains a common barrier to international members’ goals (31%). Accreditation of international members as Fellows of ACMT is highly valued in countries which lack other official medical toxicology recognition. When asked how ACMT could better serve their needs, members requested more online continuing education aimed at skill transfer to local specialists in emergency medicine and toxicology, and facilitating research collaborations within the worldwide toxicology community. Finally, over 20 international conferences and scientific meetings were suggested for possible ACMT-sponsored symposia, where members could work with regional medical communities to explore ways that medical toxicologists can help address the global epidemic of poisonings worldwide.
Conclusions: Online education, collaborative research, international conference participation, and grant provision were the most commonly expressed themes from the survey responses. Although limited by the small sample size, this survey experience provides valuable insight for restructuring the International Committee and formulating its strategic plan.
85. Is It PrimeTime for FaceTime? VideoTelephone App Use In Toxicology Consultations
Vohra R, Mittendorf G
UCSF Fresno Medical Center, Fresno, CA, USA
Introduction: Poison control centers pioneered the use of telephones for remote medical direction over 50 years ago, but newer telemedicine technologies have recently emerged. We present 3 clinical cases where video-telephone calls using Apple Inc’s “FaceTime” application facilitated toxicology consultation in an emergency department.
Research Question: Is FaceTime a useful adjunct for medical toxicology consultations?
Case Reports: A.) Aspirin toxicity was suspected in a 55 year old man with a prior medical history of tuberculosis who presented with respiratory distress. FaceTime was used to confirm the patient’s salicylism toxidrome (diaphoresis, tinnitus, confusion, and respiratory distress) as well as radiographs demonstrating TB scars and pulmonary edema. These visual details prompted a recommendation for emergency hemodialysis, even though lab results were pending. A salicylate level of 96 mg/dL was resulted just as hemodialysis was begun. B.) 42 year old man with anxiety, chest pain, and headaches admitted to taking amyl nitrate “poppers” just prior to arrival. FaceTime confirmed the presence of perioral and nailbed cyanosis, and oxygen saturation of 88 % despite oxygen supplementation. Empiric therapy with methylene blue supplementation was recommended, the patient’s labs revealed methemoglobin level of 24% and an elevated troponin (0.56 ng/dL). C.) A 6 year old developmentally delayed girl swallowed dilute bleach from a mislabeled bottle. After choking and gagging initially, she returned to her baseline state, which included mutism and a predilection to drooling. FaceTime consultation with a toxicologist assured the emergency clinician and the patient’s parents that the child was safe for discharge following an oral fluids trial.
Discussion: Non-recorded video-phone technology represents an innovation for potentially enhancing valuable interactions between toxicologists, health professionals, and patients and relatives. Select physical examination findings, ECGs, and radiographs are types of data which can be transmitted effectively over FaceTime.
Conclusion: By facilitating real-time diagnosis, bedside education, and visual feedback among practitioners and consultants, videophone calls can enhance toxicology consultation and clinical outreach in an era of declining telephone call volumes to poison centers nationwide. A larger set of clinical experiences is needed to explore the place of these types of technologies in the changing landscape of medical toxicology.
86. Serotonin Syndrome Precipitated by Methylene Blue Administration for Treatment of Methemoglobinemia
Weis JJ1, Swartzentruber GS1, King AM2, Menke NB1
1University of Pittsburgh Medical Center, Pittsburgh PA, USA; 2Wayne State University, Detroit Medical Center, Detroit, MI, USA
Background: Methylene blue is a phenothiazine derivative used clinically as an antidote for methemoglobinemia, as a surgical dye, and as a vasopressor in refractory vasodilatory shock. Both methylene blue and its primary metabolite, azure B, are inhibitors of monoamine oxidase A.
Hypothesis: Methylene blue has sufficient inhibition of monoamine oxidase A to precipitate serotonin syndrome (SS), even at low doses.
Methods: This is a single patient chart review. A 38 year-old female with a past medical history of depression, carcinoid syndrome, and dermatographia presented to the emergency department with palpitations and fatigue. She reported a recent history of lethargy, anxiety, and lightheadedness. She was taking dapsone for 12 months and had started paroxetine a few weeks prior. Initial vital signs were T 98.6, HR 146, BP 169/104, RR 22, SatO2 90%. Her SatO2 did not improve with 100%. Her workup was unremarkable (Hgb 13 mg/dL) except for a methemoglobin (MetHgb) level of 20.8%. She was given a dose of methylene blue 1 mg/kg which was repeated after she failed to improve. During transfer, she became diaphoretic, myoclonic, agitated, and intermittently confused. Her MetHgb level had decreased to 2.6% after treatment but rebounded to 9.0% on hospital day 2. Vital signs on arrival were T 98.6, HR 133, RR 16, BP 153/83, SatO2 95%. She was awake, alert, anxious, and profusely diaphoretic. She was slow to respond to questions and had mild trismus. She had repetitive flexion and extension of her left lower extremity which was difficult for her to control. She had concurrent rigid lower extremities and sustained clonus at the knees and ankles. She was diagnosed with SS by a medical toxicologist. She was treated with intravenous lorazepam for these symptoms. Her symptoms resolved within 24 hours and her vital signs normalized. A urine gas chromatography/mass spectrometry demonstrated paroxetine, dapsone, and methylene blue.
Discussion: We report a case of serotonin syndrome in the setting of low-dose administration of methylene blue for the treatment of symptomatic methemoglobinemia.
Conclusions: Concurrent use of methylene blue with serotonergic xenobiotics at doses as low as 2 mg/kg can precipitate serotonin syndrome.
87. Stress-Induced Cardiomyopathy Resulting from Abstinent Opioid Withdrawal
Wieferich KJ, Raja AJ, Yanta JH, Menke NB
University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Background: Stress-induced cardiomyopathy is a transient non-ischemic cardiomyopathy, usually caused by an acute physical or emotional stressor that presents with findings concerning for acute coronary syndrome despite lack of angiographic coronary artery disease. Rare case reports have described this phenomenon in the setting of iatrogenic opioid withdrawal. In our case, stress-induced cardiomyopathy occurred after discontinuation of opioid medications.
Hypothesis: Abstinent opioid withdrawal can induce stress-induced cardiomyopathy.
Methods and Results: This is a single patient chart review. The patient is a 37-year-old male with a history of oxycodone, heroin, and fentanyl abuse who presented to the Emergency Department with a chief complaint of opioid withdrawal symptoms five days after last using oxycodone. He denied recent opioid or other drug use. On presentation, he was agitated, nauseated, tachypneic, diaphoretic, and complained of diffuse abdominal pain. Initial vital signs were temperature 36.8 C, blood pressure 147/98, pulse 88, respiratory rate 32, and saturating 98% on room air. Urine drug screen was positive for opiates only. 4 mg of lorazepam and 4 mg of midazolam were administered in attempt to control his agitation. Due to uncontrolled agitation, the patient was intubated. Further evaluation revealed diffuse ST segment depression on EKG with elevated serum troponin (initial 14 ng/mL, peak 44 ng/mL). A previous EKG from one-year prior was normal. Cardiology was consulted and the patient started on aspirin, clopidogrel, and heparin. The patient underwent coronary angiography that revealed normal coronaries and left ventriculography demonstrated diffuse left ventricular hypokinesis with apical sparing and an ejection fraction of 15%. He was diagnosed with non-ischemic cardiomyopathy and started on aspirin, lisinopril, hydrochlorothiazide, and carvedilol. The patient left against medical advice on hospital day three, therefore no follow up was obtainable.
Discussion: We believe that the patient developed stress-induced cardiomyopathy from opioid withdrawal secondary to abstinence. He was found to have: new ST changes on EKG, troponin elevation with no evidence of coronary artery disease, and diffuse LV hypokinesis, this presentation is consistent with the Mayo diagnostic criteria for stress cardiomyopathy.
Conclusion: Severe non-ischemic cardiomyopathy may occur as a complication of opioid withdrawal due to abstinence.
88. Successful Physostigmine Treatment of Delirium Induced by Clozapine Adulterated Street Drugs
Wiegand TJ, Ahari S, O'Geen R
University of Rochester Medical Center, Rochester, NY, USA
Background: Physostigmine is used for the treatment of antimuscarinic toxicity. Our consult service regularly uses this antidote to treat coma and delirium from certain atypical antipsychotics (e.g. quetiapine, olanzapine). Clozapine is an atypical antipsychotic with mixed muscarinic agonist/antagonist effects.
Hypothesis: Physostigmine treatment may help resolve antimuscarinic effects and CNS depression in clozapine overdose.
Methods: This is a single patient chart review. A 37 year-old male with polysubstance abuse was found unconscious beside a bag of pink powder. EMS found the patient obtunded with respiratory failure. A total of 1.5 mg naloxone was administered with no improvements. On presentation the patient was comatose and required emergent intubation due to respiratory failure and need for airway stabilization. Vitals included HR of 120 beats/minute, BP 122/78 mmHg, RR 10 breaths/minute and O2 saturation of 93% via non-rebreather. Foley catheter placement yielded 2 liters of urine. The patient did not require sedation for intubation. Initially, copious secretions required oropharyngeal suctioning. Miosis was also present along with hypoactive bowels and relaxed neuromuscular tone. EKG showed sinus tachycardia and QTc of 490 ms. Urine drug screen was positive for benzodiazepines and comprehensive screen confirmed methadone and clozapine (which the patient wasn’t prescribed). Within 12 hours the patient awoke and was extubated however paroxysms of agitated delirium interspersed with somnolence required restraints be used. Miosis, tachycardia, absent bowel sounds and dry skin were still present and a fever had developed (38 C). At this point he had a very dry mouth as well.
Results: Toxicology administered 2 mg of physostigmine resulting in dramatic lucidity with marked improvement in level of consciousness, heart rate and normal salivation. Restraints were removed and he admitted to buying a powder he was told contained heroin and benzodiazepines (no heroin was present) but suspected to have contained only clozapine. He required no further antidote and was subsequently discharged.
Discussion: There are only two previous publications from the 1970’s describing physostigmine treatment of clozapine toxicity in overdose.
Conclusions: Physostigmine may reverse CNS depression and significant antimuscarinic effects and improve overall patient care in clozapine overdose.
Previously Presented and Previously Published Research: Poster Presentations
89. Darracq MA, Rentmeester L, Cullen J, Cantrell FL. “Orbeez”: The magic absorbing bead – risk of pediatric bowel obstruction? Clin Toxicol 51(7):588.
90. Darracq MA, Devgun J, Chen X, Cantrell FL. FUNGUS AMONGUS: Testing the public’s ability to identify mushrooms. Clin Toxicol 2013; 51(7):650.
91. Ordonez J, Forrester MB, Kleinschmidt K. Electronic cigarette exposures reported to poison centers. Clin Toxicol 2013; 51(7):685.
92. Ordonez J, Morrester MB, Kleinschmidt K. Comparison of diphenhydramine and Datura abuse. Clin Toxicol 2013; 51(7):702-3.
93. Finkelstein Y, Hollands S, Sivilotti ML, Hutson JR, Mamdani MM, Macdonald E, Juurlink DN. Long-term outcomes following deliberate self poisoning: A 10-year longitudinal population-based study. Clin Toxicol 2013; 51(7):576.
94. Thornton S, Akpunonu P, Luu S, Brudevole J, Lee P, Cantrell FL. Prevalence and characteristics of hypofibrinogenemia after North American rattlesnake envenomation reported to a statewide poison control system. Clin Toxicol 2013; 51(7):620.
95. Arroyo-Plasencia AM, Schwarz ES, Velez LI, Hail SJ, Kao LW, Kleinschmidt KC, Young A. Physostigmine. Clin Toxicol 2013; 51(7):690-1.
96. Dissanayake V, Senanayake MP, Perera RP. Made to deliver: a comparison of lead contamination in imported and non-imported spices. Clin Toxicol 2013; 51(7):641.
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