Tox in The Land: Common Historical Poisons

Poison is in everything, and nothing is without poison. The dosage makes it either a poison or a remedy. - Paracelsus

 
 

Case Presentation

40 y/o M presents to the ED complaining of vomiting, abdominal pain, diarrhea, hematemesis, hematuria.

Arsenic Poisoning

  • MOA: Binds sulfhydryl groups of critical enzymes, disrupts oxidative phosphorylation, and blocks cardiac potassium channels.

    • Encephalopathy

    • Peripheral neuropathy, Weakness

    • QT prolongation, Arrythmias

    • Alopecia, Melanosis, Hyperkeratosis, Hyperpigmentation, Mees’ lines

    • Metallic/Garlic taste, N/V/D, ABD pain

    • Hemolysis, Hematemesis, Hematuria

    • Multisystem organ failure


Evaluation

  • Urine arsenic, Whole blood arsenic levels, CBC, CMP, ECG, CXR


Treatment

  • Supportive care

  • Chelation therapy

    • Dimercaprol

    • DMSA

  • Plasmapheresis, HD

Arsenic Facts

  • Found naturally throughout the environment, including foods. It's also used in certain common products, including pesticides and pressure-treated wood.

  • White arsenic, which is arsenic oxide, is a water-soluble, tasteless solid easily added to drinks.

  • Arsenic and its compounds were a popular poison in the Middle Ages because it was easy to obtain and the symptoms of arsenic poisoning resembled cholera.

  • In the 1600s it became known as “inheritance powder”.

  • In the 1800s arsenic compounds became widely available – as weed-killers, flypapers, rat poisons, etc.

  • Arsenic became commonly used in domestic murders and it is estimated to have been used in a third of all criminal cases of poisoning throughout the nineteenth century.

Arsenic History

  • Gustaf Adolph Evangelical Church in New Sweden, Maine.

  • In April 2003, 16 members of the church in the small farming community became severely ill after consuming coffee brewed in an urn. Walter Reid Morrill, age 78, died from the side effects, and 15 other parishioners were extremely ill.

  • Just five days after the incident congregation member Daniel Bondesoncommitted suicide by shooting himself with a rifle. He allegedly left a suicide note that read like a confession to the mass poisoning.

  • The contents of Bondeson's note have never been made public, and the case is still considered unsolved.

  • Famous people who have died from arsenic poisoning:

    • Napoleon Bonaparte

    • George III of England

    • Simon Bolivar

Case Presentation

37 y/o F presents to the ED with altered mental status, tachycardic, dilated pupils, flushed, dry skin.


Anticholinergic Toxidrome

  • MOA: Competitively blocks the effects of acetylcholine at muscarinic cholinergic receptors on smooth muscle, cardiac muscle, secretory gland cells, and in peripheral autonomic ganglia and the central nervous system.

  • CNS effects:

    • Most often causes agitated delirium (hallucinations, incoherent speech, carphologia).

    • More severe cases may present with seizure and/or coma.

    • CNS effects may persist after peripheral features have resolved.

    • Pupillary dilation, causing blurry vision and photophobia.

    • Tachycardia

    • Hyperthermia with dry, flushed skin (Toxicology handshake - no sweat in the armpits).

    • Urinary retention

    • Ileus

Mad as a hatter, blind as a bat, red as a beet, hot as a hare, dry as a bone, full as a flask

Evaluation

  • POC Glucose, CBC, CMP, CPK, ECG, CXR

Treatment

  • Supportive care

  • Benzodiazepines

  • Physostigmine

  • Foley

https://en.wikipedia.org/wiki/Atropa_belladonna#/media/File:Atropa_belladonna_L._longipedicellate_flower.jpg

Atropine Facts

  • Atropa belladonna gets its name from the Italian words bella donna for "beautiful lady“

  • The plant was a popular cosmetic in the Middle Ages with the juice of the berries being used as a blush and diluting extracts from the plant in water made eye drops to dilate the pupils.

  • AKA deadly nightshade bush

  • Juice from the plant or its berries was used to tip arrows with poison.

  • In small doses this chemical causes hallucinations and was used for this purpose as long ago as ancient Greece.

  • In larger doses it was reputed to be one of the favorite poisons of would-be murderers in Medieval Europe and the juice of only a few berries was fatal.

  • The symptoms it produces would be easily mistaken for one of the many fevers which afflicted people in those days.


Atropine History

  • Legend has it, Macbeth used deadly nightshade to poison Danes invading Scotland in 1040.

  • There's evidence that the serial killer Locusta may have used nightshade to kill the Roman emperor Claudius

  • It is rumored that the Roman empress Livia Drusilla used the juice of Atropa belladonna berries to murder her husband, the emperor Augustus

  • There are few confirmed cases of accidental deaths from deadly nightshade, but there are common plants related to Belladonna that can make you sick.

Case Presentation

35 y/o M presents to the emergency department complaining of headache, N/V, and SOB.

https://link.springer.com/chapter/10.1007/978-3-030-22445-5_11

Cyanide Poisoning

  • MOA: Poisons the mitochondrial electron transport chain within cells specifically binding to complex IV of cytochrome oxidase and prevents cells from using oxygen.

  • People exposed to a small amount of cyanide may have the following signs and symptoms within minutes:

    • Dizziness

    • Headache

    • Nausea and vomiting

    • Tachypnea

    • Tachycardia

    • Restlessness

    • Weakness

    • Exposure to a large amount of cyanide may cause:

    • Convulsions

    • Loss of consciousness

    • Hypotension

    • Respiratory failure leading to death

    • Bradycardia

Evaluation

  • CBC, CMP, Lactate, ECG, CXR

Treatment

  • Supportive care

  • Hydroxocobalamin

  • Sodium nitrite

  • Sodium thiosulfate

Cyanide Facts

  • Cyanide can be distilled from the kernels of certain nuts such as almonds and the leaves of some laurels bushes.

  • Cyanide is a rapidly acting, potentially deadly chemical that can exist in various forms.

  • Cyanide sometimes is described as having a “bitter almond” smell, but it does not always give off an odor, and not everyone can detect this odor.

  • Breathing cyanide gas causes the most harm but swallowing cyanide can be toxic as well.

  • Cyanide gas is less dense than air; so, it will rise.

  • Cyanide is more harmful to the heart and brain than to other organs because the heart and brain use a lot of oxygen.

  • The industrial chemical sodium cyanide is widely used, especially in mining, and has been involved in attempted mass murders.

  • Some popular examples of cyanide being used include the mass suicide at Jonestown and Heaven’s gate.

https://mallenbaker.net/article/clear-reflection/johnson-johnson-and-tylenol-crisis-management-case-study

Cyanide History

  • It was used to contaminate Tylenol capsules in the US in the 1980s and killed several people in the Chicago area.

  • Cyanide can cause death within minutes. It is the fastest acting of all poisons and for this reason it is the poison of suicide pills of the type carried by secret agents.

  • Stella Nickell in the early 1980s.

    • In June, 1986, a few years after the infamous unsolved Tylenol poisonings in Chicago, Bruce Nickell arrived at his Auburn, Washington home. He'd left work early with a headache. Four Excedrin later, Bruce collapsed. He died in the hospital. Physicians cited his emphysema. Less than a week later, Susan Snow took some of the same headache medicine and collapsed on her bathroom floor. Examination determined Susan had died from cyanide poisoning. There were fears of another Tylenol-like event but within weeks suspicion turned to Bruce's wife, Stella Nickell.

    • By December of 1987 Nickell was under indictment for product tampering -- police believed she sought the payouts from her husband's life insurance and had orchestrated the product poisoning that ended up killing Susan Snow as a cover-up. Nickell was convicted on all charges against her and sentenced to 90 years in prison.

Case Presentation

25 y/o M presents to the ED complaining of muscle pain, rigidity, fever, and jaw pain.

https://en.wikipedia.org/wiki/Strychnine#/media/File:Opisthotonus_in_a_patient_suffering_from_tetanus_-_Painting_by_Sir_Charles_Bell_-_1809.jpg

Strychnine Poisoning

  • MOA: Competitive antagonist of the inhibitory neurotransmitter glycine at the ventral horn motor neurons in the spinal cord. Increases motor neuronal excitability leading to increased muscular activity.

  • People exposed to low doses may have the following signs and symptoms within the first hour of exposure:

    • Agitation

    • Apprehension or fear

    • Ability to be easily startled

    • Restlessness

    • Painful muscle spasms

    • Uncontrollable arching of the neck and back

    • Rigid arms and legs

    • Jaw tightness

    • Muscle pain and soreness

    • Difficulty breathing

    • Fever

    • Kidney and liver injury

    • Dark urine

  • People exposed to high doses may experience the following signs and symptoms within the first 15 minutes of exposure:

    • Respiratory failure

    • Brain death

Evaluation

  • CBC, CMP, CPK, Lactate, ECG, CXR

Treatment

  • Supportive care

  • Benzodiazepines

  • Airway control, paralysis if needed

https://en.wikipedia.org/wiki/File:Jane_Stanford.jpg

Strychnine Facts

  • Strychnine is a white, odorless, bitter crystalline powder.

  • Can be extracted from the seeds of the nux vomica tree, which grows in Southeast Asia

  • It was reputed to be a tonic and prescribed in small doses by doctors to aid convalescence.

  • It was widely used to poison rats and other animals and as such was easily obtained

  • Strychnine is a strong poison; only a small amount is needed to produce severe effects in people.

  • Jane Stanford

    • In 1905, university co-founder Jane Stanford escaped poisoning when she thought her mineral water tasted off and she immediately vomited it out.

    • Testing found that it had been poisoned with strychnine.

    • One month later in Hawaii, she drank a bicarbonate soda after suffering from an upset stomach. Soon she felt sick and believed she had been poisoned again. The poison caused her to lose control of her body completely and spasm until she died.

    • An autopsy revealed that the cause was strychnine.

    • While a lot of theories have surrounded her death, the killer remains a mystery. 

Case Presentation

63 y/o M presents to the ED complaining of difficulty walking, leg pain, frequent falls, and hair loss.

Thallium Poisoning

  • MOA: Interferes with glycolysis, Krebs cycle, and oxidative phosphorylation. Binds sulfhydryl groups on the mitochondrial membrane interrupting the Na/K ATPase. Biochemically like K and is thus treated like potassium in the body.

  • Ingestion of toxic amounts of thallium might cause:

    • Abdominal pain

    • Nausea

    • Vomiting

    • Diarrhea

  • After a substantial, acute exposure or chronic exposure to limited amounts of thallium symptoms may include:

    • Severely painful ascending neuropathy

    • Ataxia

    • Seizures

    • Alopecia

    • Neurocognitive deficits

Evaluation

  • Blood thallium concentration, CBC, CMP, EKG, CXR, ABD XR.

Treatment

  • Supportive care

  • Consider activated charcoal

  • Prussian Blue

https://en.wikibooks.org/wiki/Wikijunior:The_Elements/Thallium#/media/File:Science123nkhf.jpg

Thallium Facts

  • Pure thallium is a bluish-white metal that is found in trace amounts in the earth's crust.

  • In its pure form, thallium is odorless and tasteless and can also be found combined with other substances such as bromine, chlorine, fluorine, and iodine. When combined it appears colorless-to-white or yellow.

  • It has not been produced in the United States since 1984. Currently, all the thallium is obtained from imports and from thallium reserves.

  • Thallium is used mostly in manufacturing electronic devices, primarily for the semiconductor industry. It also has limited use in the manufacture of special glass and for certain medical procedures.

  • This element was only discovered in the 1860s

  • In some countries it has been available as rat poison but has been more widely used as an agent of assassination.

  • Thallium sulfate is water-soluble and tasteless, and they take several days for the symptoms to appear and even then, these are generally attributed to other illnesses.

  • This poison was used by Saddam Hussein’s secret police and by the Russian KGB.

Thallium History

1995 Beijing, China

  • Zhu Ling is the best-known victim of thallium poisoning. Ling, a university student in China, started losing her hair, suffering blurred vision, and having horrible stomach pains before falling into a coma.

  • Her friends shared the symptoms on the internet, where the public replied with suspicions of thallium poisoning which was later confirmed by doctors.

  • Though she lived, she suffered significant neurological damage.

  • The poisoner was never convicted, but her roommate Sun Wei, who comes from a prominent and well-connected family, is still considered the prime suspect. 

POST BY: DR. NATE WILLIAMS (R4)

FACULTY EDITING BY: DR. LAUREN PORTER

ToxLauren McCaffertytox, toxicology, medtox, poisoning, poison, cyanide, arsenic, atropine, anticholinergic, strychnine