Strychnine poisoning

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Strychnine poisoning can be fatal to humans and can be introduced to the body by inhalation, swallowing or absorption through eyes or mouth. It produces some of the most dramatic and painful symptoms of any known toxic reaction. For this reason, strychnine poisoning is often used in literature and film.

Diagnosis

History and Symptoms

Ten to twenty minutes after exposure, the body’s muscles begin to spasm, starting with the head and neck. The spasms then spread to every muscle in the body, with nearly continuous convulsions, and get worse at the slightest stimulus. The convulsions progress, increasing in intensity and frequency until the backbone arches continually. Death comes from asphyxiation caused by paralysis of the neural pathways that control breathing, or by exhaustion from the convulsions. The subject will die within 2–3 hours after exposure. At the point of death, the body “freezes” immediately, even in the middle of a convulsion, resulting in instantaneous rigor mortis.

Treatment

Medical Therapy

There is no specific antidote for strychnine. Treatment of strychnine poisoning involves an oral application of an activated charcoal infusion which serves to absorb any poison within the digestive tract that has not yet been absorbed into the blood. Anticonvulsants such as phenobarbital or diazepam are administered to control convulsions, along with muscle relaxants such as dantrolene to combat muscle rigidity.^[1] If the patient survives past 24 hours, recovery is probable.

The treatment for strychnine poisoning in the late 19th and early 20th centuries was to administer tannic acid which precipitates the strychnine as an insoluble tannate salt, and then to anaesthetise the patient with chloroform until the effects of the strychnine had worn off.

References

↑ Strychnine:

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Pathophysiology

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References

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Causes

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References

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Differentiating Strychnine Poisoning from other Diseases

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Overview

Differential Diagnosis

One the basis of stiffness and fever it can be differentiated from:

**Differential Diagnosis of Tetanus**
Disease	Diagnosis			Treatment
Disease	Symptoms	Signs	Laboratory Findings	Treatment
Tetanus^[1]^[2]	Tonic contraction of muscles between the spasmodic episodes Trismus or lockjaw Neck stiffness Swallowing difficulty Stiffening of the calf and pectoral muscle groups	Opisthotonos Leg extension with arm flexion Risus sardonicus respiratory distress	Not significant	Diazepam Magnesium Human TIG
Neuroleptic Malignant Syndrome ^[3]^[4]	History of intake of offending drugs e.g neuroleptics like: Fluphenazine Haloperidol Olanzapine Risperidone Autonomic instability Rigidity Disorientation Fever	Dysphagia Pallor Dyspnea Shuffling gait Agitation	Myoglobinemia Elevated LDH Elevated creatine kinase Hyperkalemia Elevated AST and ALT Hyperphosphatemia Elevated alkaline phosphatase Hyperuricemia	Supportive therapy Stop the offending agent Medical Therapy Dantrolene Amantadine Bromocriptine
Viral Meningitis^[5]^[6]^[7]	Fever Irritability Lack of appetite Lethargy Disoriented High grade fever Severe headache Stiff neck Sensitivity to bright light Nausea Vomiting	Headache Photophobia Phonophopia Pharyngitis in case of enterovirus infeciton Orchitis (In mumps) Vesicular or macular skin rash Petichiae Nuchal rigidity Signs of meningeal irritation: Kernig’s sign Brudzinski’s sign Altered mental status Hypotonia	CSF / plasma glucose ratio (>0.6) Lactate (mmols/l) (<2.1) Lymphocytes > granulocytes	Supportive Analgesics for pain. Acetaminophen for fever. Anti-viral therapy: Acyclovir Pleconaril
Stiff man syndrome	Marked rigidity Spasms Intermittent Painful Absent during sleep	Diaphoresis Arterial hypertension Tachypnea Cyanosis Apnea, tachypnea Respiratory arrest Dilatation of the pupils Tachycardia	CSF has Elevated IgG Oligoclonal bands Positive anti-GAD antibodies Elevated creatine kinase Normal CBC & ESR	Benzodiazepines Baclofen Vigabatrin Valproic Acid, Neurontin Injected botulinum toxin Prednisone, plasmapheresis, IVIG ( some success)
Drug induced (Tardive dyskinesia)^[8]^[9]^[10]	History of intake of the offending drug for at least one month Neuroleptics (antipsychotics) Metoclopramide Eye deviation Head and neck jerky movements No tonic contraction of the muscles between the spasms	Dyskinesia of the tongue and lips Dyskinesia of the limbs Dyskinesia of the neck	It is a clinical diagnosis depending on Dyskinetic movements Hx of > 1 month of antipsychotic use Labs may be done to rule out other differentials	Stop the offending agent Benztropine Benzodiazepines Injection of botulinum toxin Valbenzine Tetrabenazine
Strychnine poisoning^[11]^[12]^[13]^[14]	Hx of up to date tetanus immunizations History of intentional or accidental intake Strychnos nux vomica seeds Rodenticide	Hypervigilance Anxiety Mydriasis Hypereflexia Clonus Facial and neck stiffness	Blood assay Tissue assay Urine assay	Initial stabilization High dose Benzodiazepines Intubation and airway securing
Hypocalcaemia^[15]^[16]	Muscle twitching and cramping Circumoral and extremity paresthesia or tingling Altered mental status Irritability Depression Psychosis Seizure	Tetany (carpopedal spasm) Latent tetany Trousseau sign of latent tetany Chvostek’s sign Hyperactive tendon reflexes	Decreased blood calcium levels	Two ampules of intravenous calcium gluconate 10% is given slowly in a period of 10 minutes, or If hypocalcemia is severe, calcium chloride is given instead Maintenance doses of both calcium and vitamin-D
Parkinson’s disease^[17]^[18]	Stiffness Inability to write Jerky movements at rest Constipation Sleeping difficulty Walking difficulty	Tremor Rigidity Bradykinesia Postural instability Shuffling gait	Clinical diagnosis Improvement with dopaminergic therapy confirms diagnosis	Symptomatic therapy Dopamine agonists Levodopa Amantadine MAO inhibitors COMT inhibitors Anticholinergics

References

↑ Woldeamanuel YW, Andemeskel AT, Kyei K, Woldeamanuel MW, Woldeamanuel W (2016). “Case fatality of adult tetanus in Africa: Systematic review and meta-analysis”. J Neurol Sci. 368: 292–9. doi:10.1016/j.jns.2016.07.025. PMID 27538652.
↑ Thwaites CL, Loan HT (2015). “Eradication of tetanus”. Br Med Bull. 116: 69–77. doi:10.1093/bmb/ldv044. PMC 4674006. PMID 26598719.
↑ Hosseini S, Elyasi F (2017). “Olanzapine-Induced Neuroleptic Malignant Syndrome”. Iran J Med Sci. 42 (3): 306–309. PMC 5429500. PMID 28533580.
↑ Leenhardt F, Perier D, Pinzani V, Giraud I, Villiet M, Castet-Nicolas A; et al. (2017). “Pharmacist intervention to detect drug adverse events on admission to the emergency department: Two case reports of neuroleptic malignant syndrome”. J Clin Pharm Ther. doi:10.1111/jcpt.12531. PMID 28488314.
↑ Chow E, Troy SB (2014). “The differential diagnosis of hypoglycorrhachia in adult patients”. Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.
↑ Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). “Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice”. PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.
↑ Tyler KL (2004). “Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaret’s”. Herpes. 11 Suppl 2: 57A–64A. PMID 15319091.
↑ Deng ZD, Li DY, Zhang CC, Pan YX, Zhang J, Jin H; et al. (2017). “Long-term follow-up of bilateral subthalamic deep brain stimulation for refractory tardive dystonia”. Parkinsonism Relat Disord. doi:10.1016/j.parkreldis.2017.05.010. PMID 28552340.
↑ “Valbenazine (Ingrezza) for tardive dyskinesia”. Med Lett Drugs Ther. 59 (1521): 83–84. 2017. PMID 28520698.
↑ Voelker R (2017). “Tardive Dyskinesia Drug Approved”. JAMA. 317 (19): 1942. doi:10.1001/jama.2017.5537. PMID 28510661.
↑ Charlotte Duverneuil, Geoffroy Lorin de la Grandmaison, Philippe de Mazancourt & Jean-Claude Alvarez (2004). “Liquid chromatography/photodiode array detection for determination of strychnine in blood: a fatal case report”. Forensic science international. 141 (1): 17–21. doi:10.1016/j.forsciint.2003.12.010. PMID 15066709. Unknown parameter |month= ignored (help)
↑ B. A. Smith (1990). “Strychnine poisoning”. The Journal of emergency medicine. 8 (3): 321–325. PMID 2197324. Unknown parameter |month= ignored (help)
↑ B. J. Maron, J. R. Krupp & B. Tune (1971). “Strychnine poisoning successfully treated with diazepam”. The Journal of pediatrics. 78 (4): 697–699. PMID 5547830. Unknown parameter |month= ignored (help)
↑ B. Oberpaur, A. Donoso, C. Claveria, C. Valverde & M. Azocar (1999). “Strychnine poisoning: an uncommon intoxication in children”. Pediatric emergency care. 15 (4): 264–265. PMID 10460082. Unknown parameter |month= ignored (help)
↑ Chhabra P, Rana SS, Sharma V, Sharma R, Bhasin DK (2016). “Hypocalcemic tetany: a simple bedside marker of poor outcome in acute pancreatitis”. Ann Gastroenterol. 29 (2): 214–20. doi:10.20524/aog.2016.0015. PMC 4805743. PMID 27065735.
↑ Desai M, Kolla PK, Reddy PL (2013). “Calcium unresponsive hypocalcemic tetany: gitelman syndrome with hypocalcemia”. Case Rep Med. 2013: 197374. doi:10.1155/2013/197374. PMC 3792521. PMID 24171002.
↑ Olanow CW, Watts RL, Koller WC (2001). “An algorithm (decision tree) for the management of Parkinson’s disease (2001): treatment guidelines”. Neurology. 56 (11 Suppl 5): S1–S88. PMID 11402154.
↑ Connolly BS, Lang AE (2014). “Pharmacological treatment of Parkinson disease: a review”. JAMA. 311 (16): 1670–83. doi:10.1001/jama.2014.3654. PMID 24756517.

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Epidemiology and Demographics

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References

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Risk Factors

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References

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Natural History, Complications and Prognosis

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References

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Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | Other Imaging Findings | Other Diagnostic Studies

Treatment

Medical Therapy | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case #1

External Links

http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/213700.htm

Template:Poisoning and toxicity

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[1] Strychnine:

[pmid27538652-1] Woldeamanuel YW, Andemeskel AT, Kyei K, Woldeamanuel MW, Woldeamanuel W (2016). “Case fatality of adult tetanus in Africa: Systematic review and meta-analysis”. J Neurol Sci. 368: 292–9. doi:10.1016/j.jns.2016.07.025. PMID 27538652.

[pmid26598719-2] Thwaites CL, Loan HT (2015). “Eradication of tetanus”. Br Med Bull. 116: 69–77. doi:10.1093/bmb/ldv044. PMC 4674006. PMID 26598719.

[pmid28533580-3] Hosseini S, Elyasi F (2017). “Olanzapine-Induced Neuroleptic Malignant Syndrome”. Iran J Med Sci. 42 (3): 306–309. PMC 5429500. PMID 28533580.

[pmid28488314-4] Leenhardt F, Perier D, Pinzani V, Giraud I, Villiet M, Castet-Nicolas A; et al. (2017). “Pharmacist intervention to detect drug adverse events on admission to the emergency department: Two case reports of neuroleptic malignant syndrome”. J Clin Pharm Ther. doi:10.1111/jcpt.12531. PMID 28488314.

[pmid24326618-5] Chow E, Troy SB (2014). “The differential diagnosis of hypoglycorrhachia in adult patients”. Am J Med Sci. 348 (3): 186–90. doi:10.1097/MAJ.0000000000000217. PMC 4065645. PMID 24326618.

[pmid22880096-6] Leen WG, Willemsen MA, Wevers RA, Verbeek MM (2012). “Cerebrospinal fluid glucose and lactate: age-specific reference values and implications for clinical practice”. PLoS One. 7 (8): e42745. doi:10.1371/journal.pone.0042745. PMC 3412827. PMID 22880096.

[pmid15319091-7] Tyler KL (2004). “Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaret’s”. Herpes. 11 Suppl 2: 57A–64A. PMID 15319091.

[pmid28552340-8] Deng ZD, Li DY, Zhang CC, Pan YX, Zhang J, Jin H; et al. (2017). “Long-term follow-up of bilateral subthalamic deep brain stimulation for refractory tardive dystonia”. Parkinsonism Relat Disord. doi:10.1016/j.parkreldis.2017.05.010. PMID 28552340.

[pmid28520698-9] “Valbenazine (Ingrezza) for tardive dyskinesia”. Med Lett Drugs Ther. 59 (1521): 83–84. 2017. PMID 28520698.

[pmid28510661-10] Voelker R (2017). “Tardive Dyskinesia Drug Approved”. JAMA. 317 (19): 1942. doi:10.1001/jama.2017.5537. PMID 28510661.

[11] Charlotte Duverneuil, Geoffroy Lorin de la Grandmaison, Philippe de Mazancourt & Jean-Claude Alvarez (2004). “Liquid chromatography/photodiode array detection for determination of strychnine in blood: a fatal case report”. Forensic science international. 141 (1): 17–21. doi:10.1016/j.forsciint.2003.12.010. PMID 15066709. Unknown parameter |month= ignored (help)

[12] B. A. Smith (1990). “Strychnine poisoning”. The Journal of emergency medicine. 8 (3): 321–325. PMID 2197324. Unknown parameter |month= ignored (help)

[13] B. J. Maron, J. R. Krupp & B. Tune (1971). “Strychnine poisoning successfully treated with diazepam”. The Journal of pediatrics. 78 (4): 697–699. PMID 5547830. Unknown parameter |month= ignored (help)

[14] B. Oberpaur, A. Donoso, C. Claveria, C. Valverde & M. Azocar (1999). “Strychnine poisoning: an uncommon intoxication in children”. Pediatric emergency care. 15 (4): 264–265. PMID 10460082. Unknown parameter |month= ignored (help)

[pmid27065735-15] Chhabra P, Rana SS, Sharma V, Sharma R, Bhasin DK (2016). “Hypocalcemic tetany: a simple bedside marker of poor outcome in acute pancreatitis”. Ann Gastroenterol. 29 (2): 214–20. doi:10.20524/aog.2016.0015. PMC 4805743. PMID 27065735.

[pmid24171002-16] Desai M, Kolla PK, Reddy PL (2013). “Calcium unresponsive hypocalcemic tetany: gitelman syndrome with hypocalcemia”. Case Rep Med. 2013: 197374. doi:10.1155/2013/197374. PMC 3792521. PMID 24171002.

[pmid11402154-17] Olanow CW, Watts RL, Koller WC (2001). “An algorithm (decision tree) for the management of Parkinson’s disease (2001): treatment guidelines”. Neurology. 56 (11 Suppl 5): S1–S88. PMID 11402154.

[pmid24756517-18] Connolly BS, Lang AE (2014). “Pharmacological treatment of Parkinson disease: a review”. JAMA. 311 (16): 1670–83. doi:10.1001/jama.2014.3654. PMID 24756517.

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Strychnine poisoning

Overview

Overview

Diagnosis

History and Symptoms

Treatment

Medical Therapy

References

Pathophysiology

References

Causes

References

Differentiating Strychnine Poisoning from other Diseases

Overview

Differential Diagnosis

References

Epidemiology and Demographics

References

Risk Factors

References

Natural History, Complications and Prognosis

References

Diagnosis

Treatment

Case Studies

External Links

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