Decay
Want to know what poison causes septic shock? What famous scientist died after exposure? And what medical treatment requires a doctor’s note to get through airport security after receiving it?
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 Decay.
Want to know what poison causes septic shock? What famous scientist died after exposure? And what medical treatment requires a doctor’s note to get through airport security after receiving it? Listen to find out!
Today's episode starts in a hotel room. You've agreed to help a friend who started a concierge medicine business catering to patients who need a doctor while staying in fancy hotels in New York City. He’s a former colleague, who after suffering moral injury ie burnout, started the business. You agree to cover a few shifts on your days off to help him get it off the ground.
Your pager goes off, directing you to a fancy hotel on Central Park South. A hotel staffer opens the door to a suite with a view looking out over the whole of Central Park. You turn your attention away from the breathtaking view to the woman lying on the couch. Her face is pale and drawn, her movements are lethargic.
You push several used teacups and wine glasses out of the way and sit down on the edge of the coffee table to talk to her. She’s had diarrhea and vomiting since this morning. She has mild abdominal pain, mostly cramping during the vomiting or diarrhea. She denies hematemesis, ie vomiting blood and denies bloody or black stools. And no fever or urinary complaints.
She says she's 46 years old, doesn't have any medical problems and doesn't take any medicines. She's a moderate drinker, but denies tobacco and drugs. You check her vital signs noting a bit of a rapid heart rate at 110 beats per minute. Her other vitals are normal. Other than the wan appearance, her physical exam is also unremarkable.
Given she’s here in a hotel, you ask about her travel history. She excuses herself to run to the bathroom. You consider traveler’s diarrhea. Returning, she reports she lives in London, traveling frequently for her job as a journalist. She flew into New York yesterday and hadn’t been elsewhere for a few weeks, ruling out traveler’s diarrhea.
She asks if she could have food poisoning. You tell her that along with a basic stomach virus, it’s always a possibility. You give her a dose of ondansetron, ie Zofran, for nausea. You tell her the rapid heart rate is due to dehydration and tell her she can drink to rehydrate, or you can place an IV and give her IV fluids. Since both work equally well, and she feels better with the nausea medicine, she declines the IV. You prescribe ondansetron and tell her she can take over-the-counter anti-diarrhea medicines, like loperamide as needed.
You give her instructions to go to the emergency department, or seek other medical care, if she gets worse. She laughs and says she certainly didn't come to the United States to visit the emergency department and is sure she'll recover in a day or two though the illness is wreaking havoc with her work schedule.
You update your friend, in case she requires further medical care. He’ll have someone check on her tomorrow. Two days later you're working in the emergency department. Your resident presents the case of the patient in room five, a person with vomiting and diarrhea, concluding they likely have gastroenteritis, the medical word for a basic stomach virus.
You enter room 5, recognizing your patient from the hotel room. Quite frankly, she looks horrible. Before she was pale, now her skin has a sickly gray-green cast. She tells you the symptoms have gotten worse. The diarrhea has increased, to the point of incontinence of the liquid stool. Her abdominal pain is severe. She continues to be afebrile and nothing else about the history has changed. She took the ondansetron and loperamide, as you advised, without relief. She says she didn’t want to come to the emergency department under any circumstances, but is so weak she can’t walk. The hotel staff was helping her walk the few steps from the bed to the bathroom.
Her temperature 98.5 F or 36.9 C. Her heart rate is 130 beates per minute, faster than before, her blood pressure is 90/60, low. Her RR 18 and pox 100% on room air. You examine her, noting diffuse abdominal tenderness. Otherwise, her exam remains unremarkable. Your resident ordered basic lab work, IV fluids and nausea medicine. You tell her you’ll also check a CT scan of her abdomen as a precaution, though you don’t expect to find much.
You leave the room feeling unsettled. Is this food poisoning or a basic stomach virus? Definitely possible, but why is she so ill appearing? And worse despite your previous and very reasonable medical care? Norovirus, is a consideration, the diarrheal illness causing outbreaks on cruise ships and schools, it makes patients feel terrible. The treatment is supportive care, as we are doing. We can’t check for this in the ED, but you tell your resident to add on c.diff and stool studies checking for common bacterial and parasitic infections, things we can test for. C. Diff infection you can get from the hospital or from antibiotic use. We don't typically send other stools studies from the ED as the results take days to week to come back, but given that our patient doesn't look well, it's a good idea to expand the work up.
An hour later, you review her lab results. Her creatinine, the kidney function, is elevated, likely due to dehydration. Her liver function tests are moderately elevated, the etiology isn’t clear, but it’s not uncommon with viral infections.
The unexpected result is her CBC, the blood count. Her red blood cells and platelets are low, but not dramatically so. Her white blood cell count on the other hand, it is low, dangerously low. Question #1. Which of the following can cause a low white blood cell count?
Malaria
Lupus
Chemotherapy
Sepsis
All of the above.
Answer: E all of the above. One of the main features of malarial infection is fever which she doesn’t have. She didn’t suddenly develop lupus. This could defininatvly be sepsis, and while we don’t have a source of bacterial infection, I’d cover with broad spectrum antibiotics. In fact, the way the CBC looks, I’d think she’s getting chemo, except she isn’t. Chemotherapy suppresses the immune system, causing neutropenia, a wbc count so low patients can’t fight off infections and the reason neutropenic fever is a true emergency.
These results raise more questions than they answer. They won’t be answered in the ED. She needs admission for continued IV antibiotics until the source of this problem is found. Her CAT scan comes back negative, as expected. The c.diff is also negative. The hospitalist meets you at your desk to hear about the admission. You point to her name on the screen. He inhales a surprised breath saying, “Do you think she’s been poisoned?”
“What?” you ask.
He points to her name saying, “You don't know who she is? The journalist, and Russian dissident. She’s published several scathing articles detailing crime and corruption in the current regime.” He laughs and shrugs, “Well probably not that interesting. Just another boring case of diarrhea. We’ll admit her, see how she does.”
The charge nurse calls you into another room and the busy shift continues for another few hours. Finishing up the charts at the end of your shift, you have time to consider the information from the hospitalist. Could she be poisoned? Anything is possible, but common things being common it's not at the top of the list. Not to mention, we've discussed in the past, the differential diagnosis for vomiting and diarrhea is just about any substance on the planet, medicinal, poisonous or otherwise. You open her chart, scan over it again and make a mental note to follow her hospital course over the next few days.
Two days later, you go to see her upstairs. She’s in an isolation room in the ICU. Clumps of long blonde hair are all over her pillow. Her scalp is visible in places. Question #2. What is the medical term for this problem.
Madarosis
Alopecia
Hypertrichosis
Answer: B. Alopecia is the term for hair loss. Madarosis is loss of the eyelashes or eyebrows and hypertrichosis is too much hair growth.
She talks to you and answers your questions, reporting the diarrhea continues unabated, but is sapped of the sparkle and humor she displayed in the hotel room.
And that's not the only thing getting worse. Her liver and kidney function are worsening. It’s doubtful dehydration is the cause because copious amounts of IV fluids haven’t improved her creatinine. Her white blood cell count is now officially low enough that she’s neutropenic. In fact, she looks like an end stage cancer patient getting chemo. Hair loss, weight loose, intractable vomiting, and diarrhea. With an immune system that can't function.
Maybe the hospitalist is right. You don’t need me to tell you this is way too much for a stomach virus. Either she has an undiagnosed, rare disease, which the hospitalist can’t find. Or in fact, she is being poisoned.
You return to a computer to comb through her chart. Her red blood cell count and platelets are now very low too. This is bone marrow suppression. If you remember, your bone marrow makes the cells that circulate in your bloodstream, red blood cells, white blood cells and platelets. Various diseases and toxins can cause problems with each cell line, but when all the cell lines are down, this is bone marrow suppression.
Chemo as I mentioned is a big culprit, bone marrow cancer can cause it, in other words, leukemia, or lymphoma. Also rare hereditary diseases, tho not very likely in her case. Thank goodness we have oncologists; I could never do their very difficult jobs. But this is a toxicology, not an oncology podcast, so let's get right to toxins causing bone marrow suppression. At this point, it’s really the key feature of her illness.
As I said, chemotherapy drugs would be 1 thru 100 on any list, but no chemo here. Drugs for autoimmune diseases like lupus and rheumatoid arthritis can suppress the bone marrow. For example, quinidine and gold. Yep, gold salts are medicine. The classic drug is chloramphenicol, an antibiotic we rarely use thanks to this disastrous side effect. Another classic is clozapine, the antipsychotic, again rarely used for this reason. Antihelminths, or deworming agents, like albendazole can cause it. These drugs are rarely used in the US. We do occasionally see cocaine contained with levamisole, a veterinary deworming agent. Occasionally, antiepileptics like carbamazepine, though this is pretty rare. Drugs to treat hyperthyroidism and tuberculosis. Again, our patient doesn’t take any drugs and isn’t using supplements.
Where does this leave us? One possible cause comes to mind. Question 3. Time to pick your poison. This could be:
Radiation
Pesticides
Microplastics
Tobacco
The answer is A. radiation. How would she be exposed to radiation did I hear you ask? Excellent question. We use radiation as a medicine, there's a whole specialty of radiation oncology for cancer patients. This definitely has local effects, but rarely systemic bone marrow suppression. We use radioactive isotopes in nuclear stress tests for heart disease. Thyroid disease can be treated with implantation of radioactive pellets. In fact, if these patient’s travel, they require a special doctors note, because they will set off radiation detectors in airports and other places like the super bowel. It doesn’t make patients sick, even though the radioisotope used in cardiac stress tests is radioactive thallium!
She hasn’t had any procedures, still I 100% want to check for radiation. How? Unlike most toxicology testing, it's simple. Most hospitals have Geiger counters. One because hospitals contain radioactive isotopes as I mentioned and two, after 9/11 many hospitals wanted one on hand for emergency purposes.
You make some phone calls to locate the Geiger counter. Nobody seems to know where it is but several people promise to look for it. In the meantime, let's talk about radiation poisoning.
Question #4. Who discovered radiation poisoning?
Marie Curie
Albert Einstein
Nicola Tesla
Max Plank
Answer: A. Marie Curie essentially discovered it in the late 1800s along with her discovery of x-rays. That said, understanding of its effects developed after her exposure in the 1900s and it wasn’t until 1946 that acute radiation syndrome was first described by the US Army medical corps treating victims of the Hiroshima and Nagasaki nuclear bombs. Four stages of radiation poisoning are described. First, nausea and vomiting, beginning anywhere from hours to days after exposure. Second, there may be a latent stage where the patient appears to improve. Followed by stage 3, severe illness and stage 4 is recovery. The stages take hours to weeks depending on the dose of exposure.
The third stage is the bulk of what we think of as radiation poisoning and consists of a number of different problems, comprising what are called sub-syndromes. To briefly summarize, patients can have cerebrovascular problems, including weakness, seizures, and coma. Pneumonitis and lung injury. The skin can blister and desquamate, meaning peel off. Hair and nail loss can occur.
G.I. symptoms including vomiting, diarrhea and abdominal pain are very prominent. Why? Gastrointestinal cells are the most rapidly dividing in the body and therefore show the effects of radiation most quickly. In fact, the whole mucosal lining can slough off, allowing bacteria into the body, causing secondary infections and sepsis.
Bringing us back to the immune system, the most impacted by radiation exposure. The white blood cells are most affected, but complete bone marrow suppression isn’t uncommon. If the patient develops infection from loss of the GI mucosal or skin barriers, they have no immune system to fight off sepsis and overwhelming infection.
Question #5. What lab test is the best predictor of radiation exposure?
Red blood cell count
Platelet count
Liver function tests
White blood cell count
Answer: D the white blood cell count. There’s something called the Andrew’s nomogram, I love this graph because it’s a case where a picture is worth a thousand words. It’s a graphic depiction of a dose response curve, predicting severity of poisoning. The higher the dose of radiation the patient is exposed to, the more quickly their white blood cell levels drop. Using that graph, if our patient is indeed suffering, radiation poisoning, she is in a severe category of injury, given how quickly her white cell count dropped after the onset of symptoms.
Acute radiation syndrome describes the clinical effects on the patient. But what is the radiation doing? It has both direct and indirect effects. It directly damages DNA. Acutely, this can kill the cell. Indirectly, it causes formation of free radicals from water for example, which also damages cells.
All these are complications related to acute radiation exposure. As I’m sure you know, exposure is a risk factor for cancer. This is a chronic effect. Scarily enough, radiation is considered a universal carcinogen, meaning it can cause almost any type of cancer. Why? Because radiation causes breaks in DNA.
Back to our patient. A man in the engineering department finds the Geiger counter and brings it to the ICU.
You scan the patient.
Nothing. Not even a blip. You check a YouTube video to make sure you’re using the thing right. It’s not rocket science. Turn it on, wave it around, listen for the clicking sounds. You do this several times. No clicking. None.
You heave a sigh of relief. If the patient had radiation poisoning, she’d have contaminated the hospital room, the other patients, the staff and you. But wait if it’s not radiation what is it? Why do her symptoms fit best with radiation poisoning if there’s no radiation?
This type of dilemma is one we physicians spend a lot of time thinking about. We don’t want to make an anchoring error, continuing to pursue a diagnosis despite a lack of supporting evidence. On the other hand, we don’t want to drop a diagnosis that fits, just because we don’t have a positive result. It’s been called the zebra retreat, backing away from a rare diagnosis, just because it’s rare. A good clinician can navigate these two uncertainties and plot a course down the middle. Easier said than done, I can tell you.
Thinking about this path and our patient. Both the hospitalist and the hematologist agree, her symptoms fit with radiation poisoning. On one hand, the patient has no exposure history. She wasn't making a dirty bomb, she doesn't work in a factory with radioisotopes, and she certainly hasn't been mining uranium. The Geiger counter says no radiation.
On the other hand, she's a Russian dissident, living abroad, criticizing the current regime. If you've listened to this podcast or paid attention to anything in the news, you don't need me to tell you that's a dangerous job. So what do we do?
And, are you about to get sick? You were in her hotel room, touched her tea cups and wine glasses and sat on the coffee table.
Hate to leave you on a cliffhanger, but we've run out of time today and you're gonna have to listen to the next episode to find out.
The last question in today’s podcast. Question #6. What caused Marie Curies death? Likely due to her life-time radiation exposure.
Thyroid cancer
Neutropenia and sepsis
Aplastic anemia
Hemorrhage
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.
Thanks so much for your attention. It helps if you subscribe, leave reviews and/or tell your friends. Transcripts are available on the website at pickpoison.com.
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.