Transcript Int J Med Toxicol 2003

The Case of the
Cardiac Casserole
Mary Wittler, MD
Toxicology Fellow
Carolinas Medical Center and
The Carolinas Poison Center
Charlotte, NC
A small town in the southern
Appalachian mountains, in mid-April
A mother and daughter spent the
afternoon in the woods hiking and
foraging for “ramp,” a local
delicacy similar to wild onion.
After an idyllic day in the woods,
the women made a casserole from
the ramps they had collected,
adding some potatoes and
canned salmon.
Unfortunately…
The casserole tasted
“terrible.” Thirty to fortyfive minutes after eating
the casserole, both women
developed nausea,
vomiting, and extreme
weakness.
They arrived in the local emergency
department one hour post ingestion.
Patient #1: Mother
• HPI
– 83 yo acutely ill, confused, female
– “smothering sensation, heartburn, and vomiting”
• PMH
– Type II DM, HTN, Recent CVA
– TAH for uterine CA
• Medications
– Metformin, doxazosin, metoprolol XL, ASA,
hydralazine/hctz, diazepam, mirtazapine, glyburide
Mother’s PE
VS:
GEN:
SKIN:
HEENT:
RESP:
CV:
ABD:
EXT:
NEURO:
MS:
BP 126/60 HR 51 RR 16 T 97.1
confused and mumbling
clammy
conjugate reactive pupils, dry mm
clear
no mrg
nontender with nl BS
central pulse > peripheral
nl reflexes, no fasciculations or focal findings
no hallucinations
Labs
Urinalysis
• >50 wbc, 2-5 rbc, 2+ bacteria
• 1+ protein; negative nitrites, glucose,
ketones, and bilirubin
Studies
• CXR: mild cardiomegaly only
• Serum digoxin: undetectable by EMIT
– Kodak VITROS 250 analyzer, Ortho-Clinical
Diagnostics
– Lower limit of detection is 0.4ng/ml
Mother’s EKG
Clinical Course
• Developed bradycardia (HR 30), hypotension
(SBP 60), and oxygen desaturation (90%)
• Treatment
–
–
–
–
O2 2 L NC
Atropine 0.5 mg IV
NS 1L
Promethazine 12.5mg IV x 2 for nausea
• Improvement in HR 72 and BP 146/61
Clinical Course
• No decontamination
• 3 hours after arrival, required additional
atropine 1mg for recurrent bradycardia
• Admitted to the ICU
Patient #2: Daughter
• HPI
– 60 yo acutely ill female
– “nausea, vomiting, abdominal cramping,
several loose stools, weakness”
• PMH
– Hypothyroidism
• Medications
– Levothyroxine, conjugated estrogen, ASA
Daughter’s PE
VS:
GEN:
SKIN:
HEENT:
RESP:
CV:
ABD:
EXT:
NEURO:
MS:
BP 74/51 HR 58 RR 22 T 97.0
alert and oriented
pale and diaphoretic
conjugate reactive pupils, dry mm
mild expiratory wheezing
no mrg
nontender with nl BS
central pulse > peripheral
nl reflexes, no fasciculations or focal findings
no hallucinations
Labs
Studies
• UA: normal
• CXR: borderline cardiomegaly and mild
vascular congestion
• Serum digoxin: undetectable
• EKG: normal
Clinical Course
• Treatment
–
–
–
–
Atropine 0.5 mg IV
IVF NS 1L
Promethazine 12.5mg IV x 2 nausea
Nebulized albuterol
• Improvement in HR 78 and BP 104/62
• AC decontamination
Clinical Course
• No further vomiting
• 3 hours after arrival, BP 81/43 and HR 60
– Dopamine started
• Admitted to the ICU
Plant Information
• Family produced uncooked “ramp”
specimens
• Phone description to PC:
– white, bulb-like root
– one inch wide blade-like leaves
– “consistent with an iris or lily”
– No pesticide odor on plant
Additional Information
The area of forage was described as a
wooded area “on the side of a mountain”