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Emergency Medicine News:
doi: 10.1097/01.EEM.0000440694.51764.ae
Toxicology Rounds

Toxicology Rounds: Tales from the Kitchen's Dark Side

Gussow, Leon MD

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Dr. Gussow is a voluntary attending physician at the John H. Stroger Hospital of Cook County in Chicago (formerly Cook County Hospital), an assistant professor of emergency medicine at Rush Medical College, and a consultant to the Illinois Poison Center. He is also the editor of his own blog, The Poison Review.

Just when you thought it was safe to go into the kitchen along comes the annual North American Congress of Clinical Toxicology to make you think takeout instead. The NACCT poster sessions always present a fascinating variety of clinical cases and studies, and these unusual ones focused on poisons you don't hear about every day.

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Take the seemingly innocuous lupini bean, for instance. It usually keeps a low profile as a pickled snack, and oddly enough, as a green manure, but in this case managed to drive one 35-year-old man to the ED complaining of decreased visual acuity, palpitations, dry mouth, and urinary hesitancy. His vital signs revealed mild tachycardia (94 bpm) and hypertension (152/93 mm Hg), but his pupils were dilated, his mental status was normal, and the remainder of his physical examination was unremarkable aside from dry mucous membranes.

The patient reported consuming half a cup of lupini beans for breakfast 90 minutes before symptoms began, according to Cullen and Minns from the California Poison Control System who presented the case. He had purchased the raw beans at an organic food store, following the package instructions to soak them in water overnight and then simmer them for three hours.

His symptoms gradually resolved, and his heart rate decreased to 65 bpm after being observed for five hours in the ED. He was discharged home in good condition.

“Many lupins are grown for their flowers, but the seeds of certain species, although bitter and toxic when fresh, can be treated to make them edible,” according to Alan Davidson in The Oxford Companion to Food. Not all species of lupin are poisonous, but those that are derive their toxicity and bitterness from quinolizidine alkaloids, anticholinergic compounds that must be removed by a tedious process involving repeated boiling, soaking, and draining over many days.

Anticholinergic toxicity from ingesting poorly prepared lupini beans is quite rare in the United States. This patient presented with typical signs and symptoms of anticholinergic syndrome: mydriasis, blurred vision, tachycardia, dry mucous membranes, and urinary retention. Confusion, absent in this case, can also be a symptom. Treatment generally involves supportive care and observation and sometimes benzodiazepines for anxiety. I am not aware of any reported cases with neurological manifestations (seizures or severe agitation) serious enough to justify the antidote physostigmine.

Yet another reason to stay out of the kitchen, according to Iwanicki and Heard at the Rocky Mountain Poison Center, can be found in the case of a 53-year-old woman who came to the ED with persistent hiccups, upper extremity paresthesias, agitation, and complaints of “fuzzy thinking.” Her vital signs and physical exam were unremarkable except for frequent hiccupping. Laboratory results included BUN 19 mg/dL, serum creatinine 1.1 mg/dL, and potassium 4.4 mEq/L.

The patient reported that she had been drinking several quarts of star fruit juice daily. Her symptoms resolved completely after treatment with fluids and benzodiazepines.

The star fruit (AKA carambola), a waxy yellow-green tart fruit native to Southeast Asia and the South Pacific, is used in cooking and to make juices, jams, and sherbets. It has also been administered medicinally as a diuretic and to treat bleeding and hemorrhoids. Star fruit appears to contain an excitatory neurotoxin. It may be oxalic acid, although this component has not been definitively identified.

Many previous reports have appeared in the medical literature of patients with chronic or acute renal failure who have developed neurotoxicity after eating star fruit or drinking its juice. A prominent feature in many of these cases is intractable hiccupping. Other symptoms include confusion, agitation, muscle weakness, paresthesias, vomiting, insomnia, and seizures sometimes progressing to status epilepticus. The clinical presentation can mimic stroke, and symptoms resolve in many cases with hemodialysis.

This appears to be the first reported case of star fruit-associated neurotoxicity in a patient with normal renal function. The authors noted that the inability to obtain serum neurotoxin levels is a limitation and the connection is not ironclad, but I find a patient developing classic symptoms of poisoning after drinking a large amount of star fruit juice to be quite convincing.

NACCT gave us two good reasons to avoid the kitchen, but bars and coffee shops where water pipes are the big draw aren't any better. The water pipe — also called a hookah, nargileh, or shisha — has gained considerable popularity, especially around college and university campuses. A recent survey of students in North Carolina found that more than 40 percent had tried a water pipe at least once.

Molasses-soaked flavored tobacco is heated in the water pipe by burning coals. The smoke or vapor is then bubbled through water before being inhaled. Many believe that water pipes are safe, but they quite clearly are not. Users are exposed to a double dose of carbon monoxide from the tobacco and the burning charcoal. The cooled, humidified smoke is less harsh than a cigarette's, making it possible to inhale a much greater volume per unit of time. Contrary to popular belief, the water does not filter out appreciable amounts of carbon monoxide or other toxic components.

Bentur et al studied 62 volunteers who participated in a 30-minute session of group water pipe smoking, and found their carboxyhemoglobin levels were as high as 40 percent. The authors concluded that their results support efforts to restrict establishments that allow water pipe smoking.

Two NACCT posters also reported on patients exposed to nicotine-containing liquid from electronic cigarettes. The first by Cantrell from the California Poison Control System found no serious toxicity among 35 cases of e-cigarette smoking. The second poster by Ordonez et al summarized 79 e-cigarette exposures reported to the Texas Poison Center Network from January 2009 to March 2013. Most cases involved ingestion, with a small number involving dermal, ocular, or inhalation exposure. Common symptoms included nausea and vomiting, headache and dizziness, and throat or eye irritation. No severe sequelae were reported.

Most if not all of these cases seemed to involve exposure to nicotine liquid from a single e-cigarette or cartridge. Refill containers of that solution are available in volumes up to 30 ml containing as much as 540 mg of nicotine. This is far greater than the estimated minimal lethal pediatric dose of 1 mg/kg, and could present a problem even in adult intentional suicidal ingestions.

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* Visit Dr. Gussow's blog at www.thepoisonreview.com.

* Follow Dr. Gussow on Twitter.com/poisonreview.

* Read all of Dr. Gussow's past columns at http://bit.ly/GussowToxRounds.

* Comments about this article? Write to EMN at emn@lww.com.

© 2013 by Lippincott Williams & Wilkins

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