Recent Case -- WWYD

[BADMD]

57 year old female is brought in by EMS. Last seen normal by the family last night. They recall her going to bed but this AM found her laying in the living room in a puddle of vomit. EMS brings her in c-collar/backboard. Medical history is significant for breast cancer in 1999. As far as the family knows, she is in remission.

She is poorly responsive and kind of nods when asked a question. She has foaming secretions at the mouth, is tachypnic at ~30 resp/min. She is intubated using RSI with etomidate and succinylcholine.

Post intubation VS: pulse 88, bp 106/72, temp 33C rectal, resp 29 (Succs has warn off and she needs minimal sedation. Sat is 95% on 50% and improves if she is suctioned every few minutes.

Pertinent PE findings:
No obvious head or other trauma. Pupils are 2 mm with intermittent upbeat nystagmus. She does not track with the eyes. Lung sounds have course rhonchi. Heart sounds are normal. Abdomen is soft with bowel sounds. She grimaces when the upper abdomen is palpated. She has bilateral tremors in the hands with occasional jerking movements of the arms and shoulders. Reflexes are brisk throughout with some weak but repetitive clonus. She seems to have decreased tone generally.

As you hold your nose from the diarrhea stench it is clear that she has been incontinent of stool and urine...likely more than once.

DDx and next steps?

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[EM2BE]

I am thinking tox screen, but then again I am in the detox unit this month so probably not thinking straight.

 

[BADMD]

I am thinking tox screen, but then again I am in the detox unit this month so probably not thinking straight.

Urine drug screen is negative for amphetamines, cocaine, barbiturates, benzodiazepines, ethanol, marijuana, methadone, opioids, phencyclidine and propoxyphene.

 

[njac]

labs?

 

[coldcoldworld]

Alright, I'll play......

Neuro findings and mental status obviously concerning for central source. Pt already bought a head CT. Relatively pinpoint pupils and vertical nystagmus are kind of concerning for a pontine bleed. Myoclonic jerks are also concerning and may be from bleed or may represent subacute status. Might consider loading with Dilantin or just using some Benzos for sedation to see if jerking resolves. Mets from CA also a concern. CT head showed???

Also, technically this lady has SIRS criteria with tachypnea and hypothermia. You said she had course rhonchi so concern for pneumonia. CXR showed??? Also send off a UA and UCx, blood cultures. Belly exam is also concerning. Would get a KUB at minimum but likely just zip through her abdomen and pelvis while you're in the scanner. Might even tap her if no other clear source to altered mentation and SIRS.

Also, not sure how long she's been down so consider adding on a total CK to check for rhabdo in addition to BMP, CBCD, belly labs.

Is she on any meds that might contribute to her current picture.

Its probably some zebra since you're posting it so I'm likely way off.

 

[hyperbaric]

As mentioned above, I like pontine bleed and the usual tox suspects. Would like to add ammonia level.

 

[BADMD]

labs?

Whatcha want?

I got a request for a CBC, BMP and a few others...

CBC was essentially normal. Lytes: Na 141, K 2.6, Cl 106, HCO3 19 (mmol/dL) BUN 14, Cr 0.6 Glu 355 (mg/dL). AST/ALT 14/17 IU/L. Lipase 67 units/dL. CPK 5000. NH3 35.

Dunno UA but was probably fine.

CXR shows good tube placement with diffuse interstitial markings. There are no infiltrates.

Head CT normal.

No AXR or Abd CT was performed.

 

[BADMD]

Its probably some zebra since you're posting it so I'm likely way off.

Zebra-esque. The diagnosis was made in the ED, by the EPs after about 7 hours.

These kinds of cases are like dumbbells for the brain. Gotta make those lobes do some heavy lifting.

 

[BADMD]

Is she on any meds that might contribute to her current picture.

No meds that we are aware of. I almost forgot the amylase was 312.

 

[Hard24Get]

Urine drug screen is negative for amphetamines, cocaine, barbiturates, benzodiazepines, ethanol, marijuana, methadone, opioids, phencyclidine and propoxyphene.

ok, but what about organophosphates (resp distress, secretions, diarrhea, urination, etc)? Does she garden, was she depressed/anyone out to get her? EKG? Creutzfeld-Jakob on the differential, I guess, look for any history and check LP, consider EEG. ABG pre/post intubation? Looks like she has a met acidosis with sl gap, would look at LA and ketones for possible DKA/HOC. Ca think of much else, would treat that potassium, and check and fix mg, phos, etc if necessary in the interim as well as hypothermia support. I'm surprised her BP is so good. Thanks for the lesson.

 

[BADMD]

ok, but what about organophosphates (resp distress, secretions, diarrhea, urination, etc)? Does she garden,

Organophosphates have been off the market for residential use, even by commercial pest companies, for several years. Some are still available for agricultural use. This patient was from the suburbs and is not a commercial farmer nor has she gone to a farm.

Dunno about suicidally. EEG was ordered, then later cancelled.

There was no pre intubation ABG. Post showed a 7.25/45. She was started on bicarb (for the CPK) and the ABG normalized after a few hours. Negative acetone. No lactate sent.

 

[lucky_deadman]

Diarrhea makes it less likely, but you gotta think about Antilcholinergic syndrome (Diphenhydramine is usually readily available).

Serotonin Syndrome is high on the differential.

?DKA

Also think of Na channel blockade (TCAs, Li, SSRI/SNRIs, etc.). Definitely want an EKG (intervals and description of analysis).

Still gotta think of Fentanyl being in the mix.

Can I get Acetaminophen and Salicylate levels?

Serum Osmolality/Lactate/Acetone (gotta think Toxic Alcohols as well)

 

[Hard24Get]

Organophosphates have been off the market for residential use, even by commercial pest companies, for several years. Some are still available for agricultural use. This patient was from the suburbs and is not a commercial farmer nor has she gone to a farm.

Dunno about suicidally. EEG was ordered, then later cancelled.

There was no pre intubation ABG. Post showed a 7.25/45. She was started on bicarb (for the CPK) and the ABG normalized after a few hours. Negative acetone. No lactate sent.

Dammit, then why do we still study that crap in med school? Anyway, I meant cholinergics in general, but obviously not the answer. I guess there was no LP or it ruled out meningitis or encephalitis since you didn't mention the result. Too sudden for Huntingtons, etc. I dunno, still sounds like a toxidrome with a neg head CT, looking forward to getting schooled.

 

[deleted109597]

Organophosphates have been off the market for residential use, even by commercial pest companies, for several years. Some are still available for agricultural use. This patient was from the suburbs and is not a commercial farmer nor has she gone to a farm.

You can buy lots of things with malathion in it. Even up to 96%.

 

[deleted109597]

I'm going with mets to the brain.

 

[nymbarra]

I agree w/ h24g, it sounds a lot like a cholinergic toxidrome. Saw a case of serotonin syndrome once as a med student...does not seem like this is the case, although could be mixed.

(Just thinking aloud) CPK explained by the clonic movements, amylase by salivation (and not likely a pancreatitis since lipase is wnl), no evidence of brain, liver, or kidney involvement by labs/imaging.

Interesting that she's got a metabolic acidosis picture and yet her K is so low...especially just one day presentation...

What meds is she on? Any autoimmune disease? Any CT of the chest or imaging of her belly?

You're in a cold place, right? I guess hypothermia could induce some of the vagal symptoms along with acid secretion leading to GI ulcer..any J/osbourne waves on ekg?

 

[TysonCook]

I'm going with cholinergic tox, or pontine bleed. Head CT, LP, and I didn't see it but also would think of CO.

Did she have a med list at this point?

 

[ERMudPhud]

I'll shoot at a zebra

The only real abnormality we have so far other than her acidosis and K is "interstitial markings" on CXR. Could be fluid overload but I don't think she's been resuscitated that much. That makes me think of lymphangitic spread of her breast CA to her lungs which often gives an interstitial pattern on CXR. If she has that she could have leptomeningeal involvement as well. That could give her hydrocephalus, encephalopathy, and seizures.

Any obvious breast masses and what does the CT show?

I'd still keep looking for tox stuff and CNS infections but that is my Zebra

 

[BADMD]

Hard24get was on target. This is cholinergic intoxication.

After about 7 hours, a urine GC/MS came back from the reference lab (talk about fast turn around) and was positive for carbaryl. This is when I got involved with the case.

Carbaryl is a carbamate insecticide. While they are similar to organophosphates, animal studies with them, specifically with carbaryl, have shown worse outcomes when treatment includes pralidoxime. While malathion can be obtained, its availability, especially when compared to carbaryl is much much smaller (I haven't actually been able to find any at my near by Home Depots or my local ACE hardware). Malathion also has low acute toxicity, except when drunk in large quantities.

The docs seeing this patient were fooled into thinking this was a new onset seizure with a prolong post ictal phase. Early placement of a foley and an NG tube masked two of the largest symptoms. The tremor and fasciculations were thought to be seizures. The chest xray findings were likely related bronchial secretions and improved by the next day. The hypokalemia was likely related to a large amount of vomit that was left at the scene and then worsened with NG suction. Why she wasn't hypochloremic, I don't know. It may have been related bicarb related GI loses balancing out, however she only had two large episodes of diarrhea. The CPK elevations are from muscle movement. The abdominal tenderness was originally thought to be from pancreatitis (which can be associated with carbaryl and OPs), however was more likely related to repeated retching.

The differential should go beyond OPs, as they are fairly rare. Consider carbamates, both medical and insecticidal, but also keep in mind Alzheimer's meds, such as donepazil.

The family and the patient denied suicidal ingestion, however I still have a difficult time believing that she could have been exposed to enough carbaryl though careless use to have life threatening cholinergic toxicity.

 

[BADMD]

Oh yes, can't forget massive doses of atropine. While this patient cleaned up with about 4 mg, patients severely poisoned with OP insecticides average 75 mg before the bronchial secretions dry up.

 

[Hard24Get]

Holy crap, great case! I had no idea about cholinergic syndrome from insecticides (and you totally had me fooled I was way off base)! Thanks, I love these posts - fun & educational.

 

[EM2BE]

Holy crap, great case! I had no idea about cholinergic syndrome from insecticides (and you totally had me fooled I was way off base)! Thanks, I love these posts - fun & educational.

I agree.

 

[njac]

I <3 tox.

good case.

 

[nymbarra]

Good case

Thanks!

 

[dchristismi]

Nice case, thanks.

When I was in med school, my puppy got into some carbamate, (don't ask - I guess I'm a bad doggy mom) and had a mild cholinergic presentation. Well, she mostly drooled and peed a lot. Drooled, and drooled, and drooled. Two different e-vets said they would give her charcoal; since I had the bottle of malathion, I just watched her. Wore off after several hours. Malathion doesn't taste very good, I guess. But yes, it's widely available. I knew what she'd gotten into because I could smell it - it's a very distinctive smell.

Did the patient have the odor? I admit to having a crappy sense of smell, but I think I'd notice it if I was intubating someone. And now I'm wondering how long it would last. I mean, you'd have to drink more than a swig or two to get that altered, wouldn't you?