Focus Bromethalin ingestion has the potential to result in fatal human poisoning

Bromethalin Commonly used as a rodenticides Neurotoxin

Mechanism of Action Uncoupling of oxidative phosphorylation – Causes depletion of cellular ATP Disrupts the function of the Na/K pump Leads to cerebral edema and elevated cerebrospinal fluid (CSF) pressure

Case Report 21-year old male ingested No Pest ® Died 7 days later

Day 1 Transported to ER Experienced an episode of emesis  Treated with o Promethazine o Thiamine o Folic Acid o Diphenhydramine

Normal vital signs Urine drug screen – Positive for barbiturates Deemed “Medically Cleared” Provisional diagnosis of major depression with psychosis Transferred to Psychiatric Hospital

Day Psychiatric Hospital Reported to be obtunded and catatonic Transferred to ER

Day 4 Upon Admission – Unresponsive to verbal and painful stimuli – Anisocoric pupils Flaccid extremities Intubated and placed on a ventilator

CT Scan Hypodensities detected

Lumbar Puncture Clear cerebrospinal fluid (CSF) Elevated opening pressure

CSF Studies Elevated proteins Normal cell counts Negative for: – Antisyphilis Anitbodies – Venereal Disease – Bacterial Cultures – Herpes Simplex Virus 1 and 2 – West Nile Virus

Autopsy Brain:  Ischemia  Spongy and vacuolated white matter Lungs:  Consolidation  Acute Bronchoalveolar Pneumonia

Post-mortem Toxicology Screened For: Volatile Solvents (Alcohol) Benzodiazepines Cyanide Cocaine Groups Salicylates Phencyclidine Barbiturates Opiates Basic Drugs Acetaminophen Stimulants

Subsequent Studies Mammalian Studies – Similar symptoms Anisocoria Paresis Cerebral Edema Abdominal Distension Progressive CNS Depression Vacuolization of White Matter Elevated CSF Pressure Decreased Posturing Decreased Conscious Proprioception Death

“The diagnosis is made based on a history of exposure to a potentially toxic dose, clinical signs, histologic presence of white matter vacuolization, and detection of bromethalin in tissue, when possible”

CONCLUSION