1
|
Doyle WN, Dumas K, Arnold JK. A Case of Brodifacoum-Induced Epiglottitis. Cureus 2023; 15:e47286. [PMID: 38021700 PMCID: PMC10656136 DOI: 10.7759/cureus.47286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
This case report presents a 33-year-old woman who presented to the emergency department with abdominal pain and gingival and vaginal bleeding. She admitted to using synthetic cannabinoids, and contamination with brodifacoum was suspected, for which qualitative testing was positive. The patient was discharged with an improved international normalized ratio (INR) seven days later with oral vitamin K. Fourteen days after discharge, she re-presented with widespread ecchymosis, leg swelling, and intermittent gingival and vaginal bleeding. Her INR was again elevated. She was controlled with oral vitamin K therapy, stabilized, and discharged three days later. Twenty-eight days following the second discharge, the patient re-presented with oral swelling, right eye ecchymosis, and vaginal bleeding after abstaining from vitamin K therapy for two weeks. A bedside nasopharyngolaryngoscopy showed the base of the tongue, epiglottis, aryepiglottic (AE) folds, arytenoids, and false vocal folds were all edematous with ecchymosis. Due to the diffuse epiglottic and supraglottic edema, the patient was intubated to avoid further decompensation. After receiving IV and oral vitamin K, she was extubated two days later. Her INR fully normalized, and she was then discharged on day 4. Our case of epiglottitis could demonstrate thermal injury associated with smoking synthetic cannabinoids, but given diffuse ecchymosis and severe coagulopathy, hematoma associated with brodifacoum poisoning was considered the most likely etiology. The patient's coagulopathy was rapidly reversed, empiric antibiotic coverage was provided, and she rapidly improved. Brodifacoum exposure has been known to cause increased bleeding, as seen in this case. However, it should also be considered that exposure can lead to epiglottitis. If a similar patient is presented in the future, it is important to consider that coagulopathy may be caused by the adulteration of drugs of abuse, specifically brodifacoum with synthetic cannabinoids.
Collapse
Affiliation(s)
- William N Doyle
- Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Kenneth Dumas
- Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Justin K Arnold
- Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| |
Collapse
|
6
|
Brucki SMD, Adoni T, Almeida CMO, Andrade DCD, Anghinah R, Barbosa LM, Bazan R, Carvalho AADS, Carvalho W, Christo PP, Coletta MD, Conforto AB, Correa-Neto Y, Engelhardt E, França Junior MC, Franco C, VON Glehn F, Gomes HR, Houly CGDB, Kaup AO, Kowacs F, Kanashiro A, Lopes VG, Maia D, Manreza M, Martinez ARM, Martinez SCG, Nader SN, Neves LDO, Okamoto IH, Oliveira RAAD, Peixoto FDM, Pereira CB, Saba RA, Sampaio LPDB, Schilling LP, Silva MTT, Silva ER, Smid J, Soares CN, Sobreira-Neto M, Sousa NADC, Souza LCD, Teive HAG, Terra VC, Vale M, Vieira VMG, Zanoteli E, Prado G. Cannabinoids in Neurology - Position paper from Scientific Departments from Brazilian Academy of Neurology. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:354-369. [PMID: 34133518 DOI: 10.1590/0004-282x-anp-2020-0432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 01/02/2023]
Abstract
Cannabinoids comprehend endocannabinoids, phytocannabinoids, and synthetic cannabinoids, with actions both in the central and peripherical nervous systems. A considerable amount of publications have been made in recent years, although cannabis has been known for over a thousand years. Scientific Departments from the Brazilian Academy of Neurology described evidence for medical use in their areas. Literature is constantly changing, and possible new evidence can emerge in the next days or months. Prescription of these substances must be discussed with patients and their families, with knowledge about adverse events and their efficacy.
Collapse
Affiliation(s)
- Sonia Maria Dozzi Brucki
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.,Hospital Santa Marcelina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Tarso Adoni
- Hospital Sírio-Libanês, Núcleo de Neurociências, São Paulo SP, Brazil.,Hospital Heliópolis, Departamento de Neurologia, São Paulo SP, Brazil
| | - Carlos Mauricio Oliveira Almeida
- Universidade Estadual do Amazonas, Departamento de Neurologia, Manaus AM, Brazil.,Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | - Daniel Ciampi de Andrade
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Renato Anghinah
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Luciana Mendonça Barbosa
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Rodrigo Bazan
- Universidade Estadual Paulista "Júlio de Mesquita Filho", Faculdade de Ciências Médicas e Biológicas de Botucatu, Hospital das Clínicas, Departamento de Neurologia, Psicologia e Psiquiatria, Botucatu SP, Brazil
| | | | - William Carvalho
- Hospital Geral de Goiânia Dr Alberto Rassi, Departamento de Neurologia, Goiânia GO, Brazil
| | - Paulo Pereira Christo
- Santa Casa de Belo Horizonte, Departamento de Neurologia, Belo Horizonte MG, Brazil.,Universidade Federal de Minas Gerais, Hospital das Clínicas, Departamento de Neurologia, Belo Horizonte MG, Brazil
| | - Marcus Della Coletta
- Universidade do Estado do Amazonas, Escola Superior de Ciências da Saúde, Manaus AM, Brazil
| | - Adriana Bastos Conforto
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Eliasz Engelhardt
- Universidade Federal do Rio de Janeiro, Instituto de Neurologia Deolindo Couto, Departamento de Neurologia, Rio de Janeiro RJ, Brazil
| | | | | | - Felipe VON Glehn
- Universidade Estadual de Campinas, Instituto de Biologia, Genética, Imunologia e Bioagentes, Campinas SP, Brazil
| | - Helio Rodrigues Gomes
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | | | - Fernando Kowacs
- Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Clínica Médica, Porto Alegre RS, Brazil.,Hospital Moinhos de Vento, Serviço de Neurologia e Neurocirurgia, Porto Alegre RS, Brazil
| | | | - Victor Gonçalves Lopes
- Hospital Federal dos Servidores do Estado, Departamento de Neurologia, São Paulo SP, Brazil
| | - Débora Maia
- Universidade Federal de Minas Gerais, Hospital das Clínicas, Departamento de Neurologia, Belo Horizonte MG, Brazil
| | - Maria Manreza
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | | | - Saulo Nardy Nader
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | | | - Rogério Adas Ayres de Oliveira
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Fabiano de Melo Peixoto
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Cristiana Borges Pereira
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Roberta Arb Saba
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil.,Hospital do Servidor Público Estadual, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Lucas Porcello Schilling
- Pontifícia Universidade Católica do Rio Grande do Sul, São Lucas Hospital, Instituto do Cérebro, Porto Alegre RS, Brazil
| | | | - Emanuelle Roberta Silva
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.,Hospital Sírio-Libanês, Núcleo de Neurociências, São Paulo SP, Brazil
| | - Jerusa Smid
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | | | - Manoel Sobreira-Neto
- Universidade Federal do Ceará, Faculdade de Medicina, Departamento de Medicina Clínica, Fortaleza CE, Brazil
| | | | - Leonardo Cruz de Souza
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Grupo de Pesquisa em Neurologia Cognitiva e do Comportamento, Belo Horizonte MG, Brazil
| | | | | | - Matheus Vale
- Faculdade de Medicina do ABC, Departamento de Neurologia, Santo André SP, Brazil
| | | | - Edmar Zanoteli
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina, Departamento de Neurologia, São Paulo SP, Brazil.,Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia, São Paulo SP, Brazil
| | - Gilmar Prado
- Universidade Federal de São Paulo, Departamento de Neurologia, São Paulo SP, Brazil
| |
Collapse
|
7
|
van Breemen RB, Hafner JW, Nosal DG, Feinstein DL, Rubinstein I. Unmet clinical laboratory need in patients hospitalized for acute poisoning from long-acting anticoagulant rodenticides. TOXICOLOGY COMMUNICATIONS 2021; 5:93-96. [PMID: 34458660 PMCID: PMC8388241 DOI: 10.1080/24734306.2021.1925444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The importance of real-time, quantitative toxicology data available for physicians treating poisoned patients was illustrated during the 2018 outbreak in Illinois of severe coagulopathy caused by inhaling illicit synthetic cannabinoids products contaminated with commercially-available brodifacoum, difenacoum, and bromadiolone, three potent, long-acting anticoagulant rodenticides (LAARs). Identification and quantification of these life-threatening toxins in blood samples of hospitalized patients required toxicology testing with liquid chromatography-tandem mass spectrometry (LC-MS/MS) that was not available in clinical laboratories of hospitals at the time of the outbreak. This highly-sensitive, quantitative assay can provide critical information to guide patient care during and after hospitalization, including identification of offending LAARs, estimates of the ingested dose, and dosage and discontinuation of oral vitamin K1 therapy after hospital discharge once plasma LAARs concentrations decreased to a safe level (<10 ng/mL). Accordingly, we propose an action plan to enable treating physicians to quantify plasma concentrations of several LAARs simultaneously in poisoned patients. It involves rapid (<15 min), sensitive, and validated LC-MS/MS methods developed, tested and validated in our laboratory. This will allow treating physicians to request quantitative plasma LAARs testing, report test results in the patient's hospital discharge summary, and recommend regular monitoring of plasma LAARs concentrations in the outpatient setting.
Collapse
Affiliation(s)
| | - John W. Hafner
- Department of Emergency Medicine, University of Illinois, Peoria, IL, USA
| | - Daniel G. Nosal
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Douglas L. Feinstein
- Department of Anesthesiology, University of Illinois, Chicago, IL, USA
- Jesse Brown VA Medical Center, Chicago, IL, USA
| | - Israel Rubinstein
- Jesse Brown VA Medical Center, Chicago, IL, USA
- Department of Medicine, University of Illinois, Chicago, IL, USA
| |
Collapse
|
8
|
Feinstein DL, Nosal DG, Ramanathan S, Zhou J, Chen L, Hershow RC, van Breemen RB, Wright E, Hafner JW, Rubinstein I. Effects of vitamin K1 treatment on plasma concentrations of long-acting anticoagulant rodenticide enantiomers following inhalation of contaminated synthetic cannabinoids. Clin Toxicol (Phila) 2020; 58:716-724. [PMID: 31736367 PMCID: PMC7583456 DOI: 10.1080/15563650.2019.1687903] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/21/2019] [Accepted: 10/25/2019] [Indexed: 12/30/2022]
Abstract
Background: An outbreak of synthetic cannabinoid (SC)-associated coagulopathy and bleeding in Illinois, USA was determined to be due to inhalation of SC contaminated with brodifacoum (BDF), difenacoum (DiF), and bromadiolone (BDL), highly potent long-acting anticoagulant rodenticides (LAARs). Treatment with high-dose vitamin K1 (VK1) prevented mortality; however, plasma LAAR levels were not measured risking recurrence of coagulopathy and bleeding due to premature discontinuation. The goal of this study was to determine if plasma LAAR levels were reduced following standard of care treatment to normalize coagulopathy.Methods: Blood samples were collected from a cohort of 32 patients, and ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis used to quantify plasma LAAR levels including enantiomers.Results: BDF was detected in 31 samples; 30 also contained DiF and 18 contained BDL. Initial plasma levels were 581 ± 87, 11.0 ± 1.9, and 14.9 ± 5.9 ng/mL for BDF, DiF, and BDL, respectively (mean ± SE). At discharge plasma, BDF levels remained elevated at 453 ± 68 ng/mL. Plasma half-lives for BDF, DiF, and BDL were 7.5 ± 1.3, 7.2 ± 1.9, and 1.8 ± 0.3 days, respectively. The half-life for trans-BDF enantiomers (5.7 ± 0.8 days) was shorter than for cis-enantiomers (7.6 ± 1.9 days). BDF half-lives were shorter, and coagulopathy normalized faster in patients receiving intravenous VK1 as compared to oral VK1. Patients prescribed VK1 at discharge had fewer re-admittances.Conclusions: These results demonstrate that plasma LAAR levels at discharge were elevated in poisoned patients despite normal coagulation, and that the route of VK1 administration affected LAAR pharmacokinetics and INR normalization. We propose plasma LAAR levels and coagulation be monitored concomitantly during follow-up of patients with LAAR poisoning. KEY POINTSIn patients treated with high-dose vitamin K1 for LAAR poisoning, plasma levels remained 40-fold above safe levels upon discharge from hospital.LAAR half-lives, normalization of coagulopathy, and readmittances were reduced by treatment with intravenous vitamin K1.
Collapse
Affiliation(s)
- Douglas L Feinstein
- Jesse Brown VA Medical Center, Chicago, IL, USA
- Department of Anesthesiology, University of Illinois, Chicago, IL, USA
| | - Daniel G Nosal
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Swetha Ramanathan
- Division of Epidemiology and Biostatistics, University of Illinois, Chicago, IL, USA
| | - Jifang Zhou
- College of Pharmacy, University of Illinois, Chicago, IL, USA
| | - Luying Chen
- Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Ronald C Hershow
- Division of Epidemiology and Biostatistics, University of Illinois, Chicago, IL, USA
| | | | - Erik Wright
- Department of Emergency Medicine, University of Illinois, Peoria, IL, USA
| | - John W Hafner
- Department of Emergency Medicine, University of Illinois, Peoria, IL, USA
| | - Israel Rubinstein
- Jesse Brown VA Medical Center, Chicago, IL, USA
- Department of Medicine, University of Illinois, Chicago, IL, USA
| |
Collapse
|