Bad Seed
Want to know how homemade jewelry can poison you? Why some people remain unaffected after exposure to this lethal toxin? How it was used to assassinate dissidents from Eastern Europe?
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Will our patient survive this podcast? It’s up to you and the choices you make. Our episode today is called the Bad Seed. Want to know how homemade jewelry can poison you? Why some people remain unaffected after exposure to this lethal toxin? How it was used to assassinate dissidents from Eastern Europe?
Today's episode starts in the emergency department. Medics arrive with a 52-year-old-man patient vomiting up blood. They picked him up in a hotel room, he was weak and unable to get out of bed.
The man is very pale and ill appearing. He says he began vomiting yesterday. Today he started having streaks of blood mixed with vomit then called EMS after vomiting up approximately 1 cup of red blood. He’s having diarrhea, also since yesterday, along with crampy abdominal pain. He denies blood in his stool or black stools.
The monitor shows the following vital signs blood pressure 85/45, heart rate 120 beats per minute, respiratory rate of 20, and oxygen saturation 98% on room air. The nurse pops a thermometer into his mouth and says he’s afebrile, no fever.
The first question I ask myself about every single patient is sick or not sick? What do you think? Yes, definitely sick. He needs aggressive resuscitation to treat his low blood pressure and rapid heart rate before they get worse. You tell the nurse you want 2 IVs and 2 liters of IV fluids, infused as quickly as possible. We need labs, including a blood count and coagulation studies. You cross-match him for several units of blood, the pale skin suggests he’s headed for a blood transfusion.
While giving the orders, you do a quick, but focused, physical exam. He's awake, alert and oriented with normal pupils. His skin, under his eyes and tongue are pale. Other than the rapid heart rate, heart and lungs are normal. He has no abdominal tenderness. The rest of his exam is normal.
Putting together these initial findings, we have a critically ill patient who appears to be in hypovolemic shock. The low blood pressure is the result of volume loss from vomiting, diarrhea and bleeding. The rapid heart rate is his body’s attempt to compensate for the loss and the low blood pressure by speeding up the heart so it pumps more. His pale skin suggests significant anemia, due to blood loss.
He responds to the fluids. His blood pressure is up 95/53 and his heart rate is down to 110. Moving in the right direction, but by no means are we out of the woods.
His lab results come back, showing a hemoglobin, the blood count, of 8 g/dL. This is low, normal is between 12-16. Typically, we don’t do a blood transfusion unless it’s below 7g/dL. But he doesn’t look well and we’re concerned he’s actively bleeding, so there is an argument to be made for transfusion. I’d definitely cross match several units and consent him to be ready in case things take a turn for the worse. Unexpectedly, his lab results show an elevated white blood cell count and lactate, suggesting infection or sepsis. It’s not impossible to see these changes in a sick patient due to a stress response, but it's certainly not typical with a GI bleed.
The next step is to call the gastroenterologist for an emergent consult. The patient needs an endoscopy, a camera into is esophagus and stomach, to look for the source of the bleeding and to intervene if possible. When you call, they will ask about specific toxins associated with GI bleeding. Which toxins? That’s question #1.
What two substances are commonly associated with gastrointestinal bleeding?
a. Aspirin
b. acetaminophen
c. alcohol
d. Marijuana
Answer a and c. Aspirin and anti-inflammatories like ibuprofen (brand Motrin or Advil) are common causes of gastrointestinal bleeding, as is chronic alcohol use. Acetaminophen doesn’t cause bleeding. Marijuana typically doesn’t, though with enough vomiting from cannabis hyperemesis, you can get GI tract irritation and some bleeding. The GI doctors always ask about anti-inflammatories and alcohol because, I’m sure you know, they’re risk factors for problems like esophagitis, gastritis and stomach ulcers.
Alcohol especially worries emergency medicine and GI. With severe alcohol use disorders and resulting cirrhosis of the liver, patients can develop gastric varices, swelling of the blood vessels in the stomach. If these rupture the result is catastrophic hemorrhage. I do mean catastrophic. You ask the patient about alcohol. He says no, also he doesn’t take aspirin or other anti-inflammatories. No anticoagulants, i.e. blood thinners, another common cause of bleeding. He denies medicines, over-the-counter meds, supplements and illicit drugs.
You stand at the back of the room while the gastroenterologist does the endoscopy, watching the projection the TV screen. She passes the scope down the narrow tube of the esophagus and into the larger area of the stomach. She points out a red, irritated area as gastritis. A small amount of blood oozes from one side.
The patient is critically ill, with signs and symptoms of shock. But if this is hemorrhagic shock due to blood loss, where’s the blood? The patient goes up to the ICU and you move on to the full waiting room, now backed up thanks to the time you spent resuscitating him. Finally, you make it to the end of your shift, exhausted. You’re ready to go home, but have at least million charts to complete first.
As you are clicking though the interminable notes, one of the nurses says to you, “Hey Doc, look at this,” showing you her phone. It’s a news report about a Hazmat response at a nearby hotel. “Isn’t that the hotel the medics picked our patient up from?” she says.
Found down in a hotel room is actually a fairly common call to poison centers. I don’t know about you, but I use hotel rooms for things like vacations and conferences. It seems many people use them for things like ingesting drugs, meeting sex workers, meeting unsavory characters in general, and overdosing. Was our patient doing something in this hotel room? Or did he simply have a medical emergency while there? Your phone rings. It's the intensivist. He has some toxicology questions after talking to law enforcement about the patient you just admitted with the GI bleed. Well, this doesn't sound good.
Do these things ever occur at the beginning of a shift? No. You still have half a million charts to go. There's apparently a rule akin to Murphy's Law that curveballs only occur at the end of the shift.
You tell him you’ll be up shortly to ask the patient some more questions. He says that isn’t possible because he’s just intubated the patient. The man became increasingly hypotensive and tachycardic despite aggressive blood and fluid resuscitation and is now on a ventilator and pressers, strong medicines to increase his blood pressure.
You tell the intensivist you’ll re-evaluate the patient, even if you can’t talk to him. In the elevator on the way up, you generate a differential diagnosis of toxins causing gastrointestinal bleeding and diarrhea, none of which stand out to you as likely causes of this problem.
Instead, you think about the Hazmat response. It could be a false alarm, but then that would make for a pretty boring podcast. Heavy metals cause vomiting and diarrhea. Do you need a hazmat suit for arsenic or thallium? No. Elemental mercury yes, actually, for liquid mercury as the vapors are inhaled. Do his symptoms fit with mercury toxicity? No, he’d have an altered mental status, tremor and subacute symptoms.
Hazmat responses are used for chemicals and weapons of mass destruction. How about a Novichok poison? Hazmat definitely required. Remember this is the Russian “new guy” poison where two non-toxic precursors are combined into something toxic, often an organophosphate. Listen to the New Guy episode for more. While I love this idea, and yes to vomiting and diarrhea, the vital signs exclude organophosphate toxicity. Remember the Killer Bees? He doesn’t have bradycardia. His heart rate is fast rather then slow, he also doesn’t have bronchospasm or bronchorrhea.
Is this hydrogen sulfide, a knockdown gas? No. It’s not carbon monoxide, to be this sick, he’d probably be unconscious. People have committed suicide by combining detergents to make toxic chlorine gas, but the rest of the hotel would be sick too.
Weapons of mass destruction include sarin or VX gas, organophosphates, which we’ve already said don’t fit with his presentation. Other agents used in the past are classified as a vesicants or blister agents because they cause blistering of the skin and mucous membranes like sulfur mustard from World War I. Cyanide can be a gas, because he’s so sick cyanide is a consideration, but in fact he’d already be dead if exposed to cyanide. Ultrapotent opioid gases, fentanyl derivates were used in the Moscow Theater attack, but again don’t fit.
The elevator door opens to an ICU swarming with people. Law enforcement, not doctors and nurses. You see the local police department, the state police, someone with an FBI jacket, another person with a badge saying homeland security. What is going on here?
The patient is in an isolation room, the kind designed for tuberculosis, Ebola and covid in the early days of the pandemic. Meanwhile you and your staff spent several hours at his bedside in standard paper surgical masks. You’re not sick and either are your nurses, so you don’t waste any more time thinking about this.
The ICU attending is being harassed by people from several different agencies all questioning him at the same time. He looks up and sees you with a look of relief. Before he can tell anyone you're the toxicologist, you grab his arm, tell law enforcement you're having a multidisciplinary meeting, pull him into the nearest conference room, and lock the door behind you. You can’t allow this circus to distract you from the patient and his care, though easier said than done.
You ask the intensivist for an update. After the patient left the ED, he deteriorated becoming more hypotensive with an increasingly rapid heart rate. The low blood pressure caused a deterioration in his mental status, so he was intubated. Afterwards, an NG tube was passed into the stomach, standard care to prevent aspiration, minimal blood was noted. He is having copious diarrhea, but not rice water stools like those of a prior patient with arsenic poisoning. He's developing renal failure, despite resuscitation with IV fluids. He now has multisystem organ failure. This update takes about a minute.
The conversation about hazmat and law enforcement, far longer because it doesn't really make any sense. Apparently after the patient left the hotel room, housekeeping staff entered because the room hadn’t been cleaned for a week. The housekeeper found chemistry equipment along with guns. The front desk called the police, who called the Hazmat response team after finding a white powder in the room.
When you mention white powder, anthrax immediately comes to mind. Remember the letters at the post office and sent to politicians containing anthrax spores? This is classified as a biological weapon, as are some naturally occurring toxins. Time to pick your poison. Question 2. Which of the following biological weapons is poisoning our patient?
A. botulism
B. ricin
C. anthrax
D. mycotoxins
The answer is B. ricin. Botulism causes flaccid paralysis so that doesn’t fit. Mycotoxins causing vomiting and diarrhea, along with GI bleeding. However, they also cause bleeding from other areas like the nose and the gums. They also cause inflammation of the skin with vesicles and bullae, which again our patient doesn’t have. Anthrax causes several different diseases depending on the route of exposure. Inhalation of the spores causes fever and pneumonia, cutaneous anthrax causes ulcers and a rash. Leaving us with ricin.
What are the symptoms of ricin toxicity? You start with general malaise and fatigue along with vomiting and diarrhea. You can get GI bleeding. This is followed by multisystem organ failure and death. Pretty much describing our patient. Is our patient having a GI bleed? Yes, but it’s not a life-threatening amount of bleeding and it’s not what’s making him so sick. The vitals signs and worsening clinical status are from ricin poisoning itself.
You leave the intensivist in the conference room with a computer so he can focus on the rest of his patients. You ask the two police officers on either side of the patient’s door if they have any photos of the scene from the hotel room. One nods yes and pulls out his phone. The hotel room is a standard arrangement with two double beds, a desk and cheap shag carpeting. The floor and every available surface are cluttered with food wrappers and trash. One photo shows a close up of beakers, flasks and test tubes. You zoom in looking for clues, but don't see much.
You ask if he saw any beans. He looks surprised, flips through another few photos then zooms into a countertop near the chemistry equipment. At first glance, it looks like a collection of beetles, but they are in fact beans. Ricin is a naturally occurring toxin. Question 3. Where does it come from?
A. Fava beans
B. Castor beans
C. Calabar beans
D. Lima beans
Answer: B. Castor beans. Fava beans are poisonous only to a small subset of patients with an enzyme deficiency called G6PD. Eating the beans causes a hemolytic crisis, I.E the red blood cells break down, but most people can eat them with no problem whatsoever. Calabar beans are the source of physostigmine, an antidote for anticholinergic toxicity. The bean is also famous as a trial bean in African witchcraft trials. Cool, but not the cause of our patient's symptoms. Lima beans are one of the world’s worst tasting foods, but they are safe to eat, a source of great disappointment to me in childhood.
Ricin comes from castor beans. While we call them beans, they are really seeds from the Ricinus communis plant. It'll take time for confirmatory toxicology testing, specimens usually go through the local health department and might go to the CDC, but I'd be pretty confident that we've made the diagnosis based on the patient's symptoms and finding the beans in his hotel.
How does ricin work? It is extremely potent because it affects ribosomes, organelles present in every single cell in your body. What do they do? Essentially, they turn RNA into amino acids which in turn become proteins. If you poison ribosomes, you stop the cells from making proteins and the cell dies. It's estimated a single ricin molecule can inactivate 1,500 ribosomes per minute.
Symptoms are related to route of exposure. Ingestion is common, more on this in a minute. Like with colchicine, you see gastrointestinal effects first because these are the most rapidly dividing cells in the body. As with our patient, you see nausea, vomiting and diarrhea followed by complete multisystem organ failure as the ribosomes in the rest of the body fail.
Weaponization of ricin, reportedly accomplished by both the US and the Soviet Union in the past, would result in inhalational exposure. In this case symptoms would start with cough and shortness of breath, followed by a pulmonary edema and pneumonia. People have injected ricin - a lot more on this in a few minutes- resulting in pain and blistering with necrosis at the site followed again by a multisystem organ failure and death.
Let’s get back to our patient. Now that we know what's happened what should we do? Give an antidote? No, there is no antidote. Unfortunately, the treatment is supportive care, which our patient is getting. IV fluids, blood transfusion if necessary and ICU care is the best we can do for him. While the police continue their investigation and the ICU treatment, let's talk more about exposure.
There are really two extremes here on either end of the spectrum. A very common presentation is a child or occasionally an adult who eats a castor bean or a jequirity pea. Jequirity peas, also called rosary peas, are beautiful red seeds often used rosaries and jewelry making. They contain a toxin called abrin, similar to ricin. Most often these patients are asymptomatic, or have some vomiting and diarrhea, but not multisystem organ failure. Death, while possible hasn’t been reported due to castor beans in the US since 1935. Why? How can a patient ingest a bean with a toxin as lethal as ricin and be asymptomatic?
Great question with a really interesting answer. Ricin, or abrin, is contained inside the bean. Beans have a fibrous outer coating, often times dried into a hard outer shell. Basically, if a person swallows the bean whole it usually passes out, still whole, from the other end of the digestive tract. So there’s no exposure to the ricin inside the bean. If a bean is bitten or chewed, this is when you get ricin release. On the one hand, I’ve just said you only need a tiny amount for significant toxicity. But ricin isn’t absorbed well from the GI tract, so most patients after these accidental exposures are fine.
Inhalation also seems to be at two extremes. This is a very feared method, though interestingly, or maybe I should say fortunately, there’s little human data. Workers in a castor oil plant developed mild symptoms after inhaling castor bean dust, but were fine after removal from the source. Animal data shows rapid necrotizing pneumonia, and death. Thus, the fear of its use as a weapon of mass destruction.
Powdered ricin has been used in an astonishingly large number of events. Ricin can be extracted from the beans into a powdered form. These incidents, of course, generate massive news coverage, law enforcement response, and fear amongst the general public. However, the outcome has been more malicious fear-mongering than real terrorism as the feared complication of mass murder and assassination of political figures have fortunately not occurred. Public figures receiving ricin in the mail haven’t gotten sick. I think this is because the powdered form really doesn’t become aerosolized as much as the villains would like. Ricin or ingredients to make it, have been found in the homes of people planning to poison judges, FBI agents and their own spouses. It’s been mailed to the White House and the Senate and found in possession of terrorists. One woman planned to mail ricin to the White House and frame her husband for the crime.
Injection of ricin is frequently lethal as demonstrated by intent of both suicide and assassination, bringing us to one of the most famous poisoning cases ever, the assassination of Georgi Markov a Bulgarian dissident living in the UK with a ricin pellet fired from a spring loaded umbrella.
At the Spy Museum in Washington DC, I was excited to see an exhibit about this including a replica of the umbrella. Markov defected to the west and lived in London, working for the BBC and Radio Free Europe. In September 1978, standing on the Waterloo Bridge awaiting the bus, he felt a prick in his thigh. A man behind him apologized, picked up an umbrella and rushed off into a taxi. Shortly thereafter, Markov became ill with a fever, was admitted to the hospital the next day and died 4 days later of presumed septicemia. That might have been the end of the story, except for the pathologist. On postmortem exam of the wound in the thigh, he noticed a tiny metal pellet. It's never been 100% confirmed, but is widely accepted the umbrella was a gun with a ricin containing pellet. One month prior, another Bulgarian dissident in Paris was ill with a fever after a blow to the back. After Markov’s death he was re-examined, with a pellet in his subcutaneous fat layer, likely saving his life as none of the ricin was systemically absorbed.
Wait a minute. What about castor oil did I hear you say? It has been used as medicine for hundreds of years. Question 4. Castor oil is poisonous.
A. True
B. False
Answer: False. If properly extracted from the bean, castor oil has no ricin in it.
Back to our patient. Thanks to aggressive care in the ICU, he survives. Upon discharge from the hospital, he’s arrested. He’s convicted of having a possession of a biological toxin and sentenced to several years in prison. The police believe, but can’t prove, he intended to use the ricin to mail to local politicians. You never find out how he was exposed, but it’s likely given the state of his room, it contaminated his food and he unintentionally ingested the purified ricin he’d extracted from the beans, absorbing enough to become ill, but not enough to kill him.
This is a fictional case, as are all our cases, to protect the innocent. But it is based on real poisonings that have occurred periodically. As always with the podcast I'm leaving out significant details in case anyone with nefarious intent is listening.
The last question is today's pop culture consult. Ricin played a role in which TV show?
A. Breaking Bad
B. Narcos
C. The wire
D. The Sopranos
Follow the Twitter and Instagram feeds both @pickpoison1 and you’ll see the answer when I post it. Remember, never try anything on this podcast at home or anywhere else.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Thank you. Until next time, take care and stay safe.