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Toxicology Rounds: Pruno, Cinnamon, and Hand Sanitizer Steal the Show at NACCT

Gussow, Leon MD

doi: 10.1097/01.EEM.0000424146.86715.a1
Toxicology Rounds

Dr. Gussowis 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.

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The annual North American Congress of Clinical Toxicology (NACCT) meeting always has a great collection of interesting cases. The 2012 conference in Las Vegas this fall was no exception. These cases describe severe toxicity from common items found around the home — or the jail cell.

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Prison Pruno

A prisoner at the Utah State Prison presented to the emergency department complaining of dysphagia, diplopia, dysarthria, increasing muscle weakness, and vomiting. His symptoms had started about two days earlier after he consumed a homemade prison wine called pruno. The medical staff suspected botulism based on his clinical presentation, and began to look for additional cases.

They identified eight cases of foodborne botulism. Five of the patients had Clostridium botulinum type A spores or toxin identified in samples of serum, stool, or gastric contents. C. botulinum was also detected in a damp sock that had been used to filter the fermented brew. Three patients required intubation for respiratory failure within 24 hours of admission to the hospital. All eight were treated with investigational heptavalent botulinum antitoxin (HBAT) obtained from the Centers for Disease Control and Prevention. Stays in the intensive care unit lasted up to 23 days. No patients died, but most reported residual symptoms 11 months later.

The batch of pruno involved in this outbreak was made by mixing oranges, grapefruit, canned fruit, water, and sugar with a baked potato that a prisoner had been hoarding for weeks. These ingredients were mixed in a sealed plastic bag and left to ferment for several days at room temperature in an anaerobic environment. Other inmates who consumed a second batch of pruno made using the same ingredients except the potato did not develop signs or symptoms of botulism, and it was assumed that the potato was the original source of botulism spores. Several previously reported cases of botulism outbreaks in prisoners and a recent series of four cases in Arizona were all associated with ingestion of pruno made with potatoes. It is well known that root vegetables can be contaminated with C. botulinum spores picked up from the soil.

Botulism should be suspected when a patient presents with cranial nerve palsies (blurred vision, diplopia, dysphagia, and dysarthria) followed by a symmetrical descending motor weakness. Gastrointestinal symptoms — nausea, vomiting, and abdominal pain — also occur and can lead to a mistaken diagnosis of gastroenteritis. Botulinum antitoxin will not reverse established symptoms, but it can slow or halt disease progression.

This fascinating case series was presented at NACCT by Benjamin Williams, MD, from the University of Utah. Additional details were reported in MMWR. (2012;61:782.)

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The Cinnamon Challenge

A 43-year-old woman called 911 when she became short of breath after attempting to complete the Cinnamon Challenge. This dare requires the subject to swallow a teaspoonful of cinnamon in less than 60 seconds without benefit of water or any other fluid to wash it down.

The patient was so dyspneic when EMS arrived that they intubated her for impending respiratory failure. A chest film at the hospital showed aspiration pneumonitis, and she was admitted to the intensive care unit. She developed refractory shock on the second hospital day, requiring three pressors, and hepatic injury with elevated transaminases and decreased cardiac function.

The patient's clinical status rapidly improved after several days. She was extubated on the third hospital day and was discharged home on the fifth day.

This case was presented as a poster by Shana Kusin, MD, et al, from the Oregon Poison Center and the Washington Poison Center. (“Cinnamania: 15 Seconds of Internet Fame, 3 Days in the ICU,” Clin Toxicol 2012;50:655; see FastLinks.) The cinnamon challenge has become an Internet meme. More than 50,000 videos on YouTube show individuals attempting this feat, including one featuring Gov. Pat Quinn of Illinois. (He cheats, washing the cinnamon down with bottled water. See FastLinks.)

Powdered cinnamon quickly dries the mouth and throat, eliminating secretions that would enable the powder to be swallowed comfortably. This irritates mucus membranes, causing coughing and gagging. Powdered cinnamon when inhaled can cause pneumonitis or pneumonia. The American Association of Poison Control Centers issued a statement warning against this dangerous practice in March. (See FastLinks.)

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Hand Sanitizer Intoxication

A 36-year-old man was seen in the emergency department for alcohol intoxication. He was alert but uncooperative, and his speech was slurred. Serum glucose was 131 mg/dL, and his breathalyzer ethanol level 278 mg/dL. His mental status had improved enough for him to be discharged after being observed for 4.5 hours.

Aaron Schneir, MD, and Richard Clark, MD, from the University of California-San Diego School of Medicine, reported, however, that the patient was found pulseless and apneic in the waiting room bathroom 30 minutes after discharge. (Clin Toxicol 2012;50:711.) Next to him was an empty 354 mL bottle of Purell alcohol-based hand sanitizer (62% ethanol) that he had taken from the ED treatment area. He was resuscitated and admitted to the intensive care unit. Serum alcohol level was 526 mg/dL. An MRI on the third hospital day showed evidence of hypoxic encephalopathy. Supportive care was withdrawn on the seventh hospital day, and the patient died.

The authors stated that this is the first report in the English-language medical literature of a fatality attributed to ingestion of alcohol-based hand sanitizer. One of the things I find striking is just how rapidly alcohol in the product was absorbed to produce a lethal level. This case is a reminder that alcoholic patients will sometimes ingest any intoxicant at hand as their ethanol level comes down. Two products frequently ingested in the medical setting are alcohol-based hand sanitizers and rubbing alcohol (isopropanol). The authors suggest that health care facilities consider steps to make these products less accessible to patients, but don't recommend any specific measures.

Click and Connect!Access the links in EMN by reading this issue on our website or in our iPad app, both available onwww.EM-News.com.

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© 2012 Lippincott Williams & Wilkins, Inc.