TOXIC/METABOLIC DISORDERS RITE REVIEW Toxin 1 A 44-yo man presented with a 5 year history of numbness, tingling pain in his extremities and pain in the epigastrium Toxin 1 A 44-yo man presented with a 5 year history of numbness, tingling pain in his extremities and pain in the epigastrium. He has worked for many years in a battery-recycling unit. On exam, he is slightly weak in the radial distribution bilaterally and he has a bluish discoloration to his gums. LEAD Nonspecific - Neuropathy (axonal, sensory and motor) - Abdominal pain Specific - Bluish discoloration of the gums - Microcytic anemia with basophilic stippling - Increased coproporphyrin levels - Radial motor nerves particularly affected LEAD Microcytic anemia, Basophilic Stippling LEAD Thickened Metaphyseal Lines (Lead Accumulation) Toxin 2 Based on a true story.. A Chinese man presents with 1-2 weeks of headache, abdominal pain, vertigo, lethargy, constipation, and numbness and tingling of the extremities. He has noticed some double vision and lack of visual acuity in the past few days. He has also noticed that his hair is beginning to come out quite easily. He notes that he recently requested a divorce from his wife and moved out, but she requested that he move back in to help care for the children last month, which he did. Toxin 2 Thallium levels are off the charts. Investigators learned subsequently that the patients wife had ordered four bottles of thallium from Bristol Myers Squib in the two months before her husbands hospitalization. Thallium Nonspecific GI Symptoms Small fiber neuropathy Cranial nerve and autonomic involvement Alopecia [was a depilatory] Specific Acts at Na+/K+ ATPase system Thallium Sources The poisoners poison, inheritance powder Used to be used as a depilatory Used to be used as a rodenticide, now banned bcs of accidental deaths. Foreign Cases Occupational Exposures ( electronics, lenses, semiconductors, alloys, gamma radiation detection equipment, imitation jewelry, artist's paints, low temperature thermometers, and green fireworks. ) Murderpedia.org (case of Tianle Li, 2011) Thallium What is the antidote? Thallium What is the antidote? PRUSSIAN BLUE Toxin 3 A 35-year-old man comes into clinic 3 months of insidious onset of numbness and tingling in his toes and fingertips, progressing slowly in the ensuing weeks to involve the feet and hands. For the past 2-3 weeks, he has had burning pain and has noted weakness in gripping tools. Further questioning reveals the patient has been a carpenter since completing high school 17 years ago. For the last 10 years, he has lived in a rural, wooded area in a home he built. On exam, skin has brown patches of hyperpigmentation, with scattered overlying pale spots in and around the axillae, groin, nipples, and neck. The palms and soles show multiple hyperkeratotic corn-like elevations 4 to 10 mm in diameter. Three irregularly shaped, sharply demarcated, erythematous, scaly plaques, measuring 2 to 3 cm, are noted on the patients torso. The remainder of the physical examination is normal. Arsenic Nonspecific Rash and GI upset Found in hair, bone, fingernails Specific Reacts with sulfhydryl groups of proteins to mess up oxidative metabolism of neuron Acute neuropathy Source Semiconductors, treated woods, pesticides/herbicides/insecticides Another inheritance powder Toxin 4 A 46 yo male CEO comes to clinic with diffuse pain. He feels like he is becoming gradually weaker and is feeling like his walk is becoming somewhat clumsier. He is also feeling more panicky, has difficulty sleeping, and was recently diagnosed with a new anxiety disorder. He has had several months of abdominal pain and nausea with a 16 pound unintentional weight loss in the past 3 months. Toxin 4 When you ask about general health practices, he says he is very health-conscious, eating fish at every meal for the past year or so. METHYL MERCURY Nonspecific: - Hallucinations, dementia, personality change - Ataxia - Choreathetosis - Distal paresthesias - Absorbed through the skin and GI tract Specific: - Cerebellar granular cell neuron degeneration - Depletes cellular selenium (essential micronutrient) - Constricted visual fields - Tx: penicillamine or dimercaptosuccinic acid. Toxin 5 A 30-year-old male welder presented with a two-year history of gait disturbance. A neurological assessment revealed features of parkinsonism which included hypophonia, hypomimia, mild bradykinesia and rigidity with no resting tremor, a reduction in arm swing. Toxin 5 Manganese Patients with biliary atresia are at risk Prolonged parenteral nutrition is a risk Can see in liver disease (hepatically cleared) Parkinsonism Dystonia T1 weighted hyperintensity in the globus pallidus Toxin 6 Nonspecific: Headache, vomiting Parkinsonism Specific CNS demyelination days to weeks after exposure A cherry-red color in the tissues, including the brain Necrosis of the bilateral globus pallidus Treatment is high flow hyperbaric oxygen Binds to hemoglobin with an affinity times that of oxygen Source Weird Als parents died from this Furnace Carbon Monoxide Nonspecific: Headache, vomiting Parkinsonism Specific CNS demyelination days to weeks after exposure A cherry-red color in the tissues, including the brain Necrosis of the bilateral globus pallidus Treatment is high flow hyperbaric oxygen Binds to hemoglobin with an affinity times that of oxygen Source Weird Als parents died from this Furnace, car with plugged up exhaust pipe Toxin 7 A 22-year-old man presented after waking the previous day with numbness below his knees. His symptoms progressed over a few days to paraesthesia in the fingers, and difficulty with walking and performing fine tasks with his hands On exam Flaccid tone with distal>proximal weakness Broad-based gait Positive Romberg. Sensation to light touch and pinprick was reduced below the knees, vibration sense was absent below the anterior superior iliac spines and joint position sense absent below the ankles. CBC, CMP, TSH, B12 nl. Toxin 7 Case Continued Thought to be AIDP, treated with IVIG He admitted to using whippits increasingly over the six weeks before presentation, now up to 120 g (15 whippits) per day. Although B12 was normal, methylmalonic acid levels were markedly raised at nmol/L (