Acute Iodine Toxicity From a Suspected Oral Methamphetamine Ingestion Marilyn N. Bulloch PharmD, BCPS 1,2 Vijaya Sundar MD 1 1) Department of Internal Medicine University of Alabama-School of Medicine CCHS 2) Harrison School of Pharmacy Auburn University Introduction Case Literature ReviewConclusion Disclosures All Authors: Nothing to disclose Iodine is a naturally occurring element first discovered by a French chemist in the early nineteenth century 1-3. It is available commercially as a tincture or as crystals 1. Additionally, iodine is widely found in a variety of products including antiseptics, germicides, water treatment chemicals, radiological contrast media, and multiple pharmacologic compounds 2-6. Dietary sources containing iodine are so common that the Recommended Daily Allowance of 150 mcg/day is optimized or exceeded in most western countries 2, 4-5. Humans appear to have a high tolerance iodine exposure, particularly when ingestion is less than 2 mg/day, because iodine must be converted to iodide, a generally non-toxic substance, or bound to proteins, starches, or unsaturated fatty acids before it is absorbed from the intestine into the blood 4,6-7. From there, most is cleared and excreted renally 2,6. In addition to its legitimate dietary, medicinal, and commercial purposes, iodine is used in the illegal production of methamphetamine. Iodine crystals are used to produce hydriodic acid which is then used to help reduce pseudoephedrine to d- methamphetamine 1. Producers who are unable to obtain iodine crystals directly may produce them by mixing hydrogen peroxide with iodine tincture, which is more readily available for purchase than iodine crystals 1. Utilization of the tincture also allows methamphetamine producers to bypass the Comprehensive Methamphetamine Control Act of 1996 which requires a detailed record of all iodine crystal sales exceeding 400 mg 1. Methamphetamine can be used orally, intravenously, via inhalation, or snorted. Discussion Table 1: Laboratory Results During Hospital Course Laboratory Parameter a Outside Hospital b Day 1Day 2Day 4Normal Values c pH--- c PCO mmHg mmHg PO mmHg mmHg HCO3 (ABG)---20 mmol/L mmol/L O 2 Saturation %97%95%94-100% WBC x 10 3 Hgb/Hct12.9 g/dL / 37.4%12.1 g/dL / 35.4%12.1 g/dL / 35.1%12.5 g/dL / 36.1%14-18 g/dL / 42-52% Bands---47%37%9%0-9% Sodium mmol/L138 mmol/L mmol/L Chloride mmol/L106 mmol/L mmol/L HCO3 (CBC)---25 mmol/L 29 mmol/L22-28 mmol/L SCr1.6 mg/dL1.4 mg/dL1 mg/dL0.7 mg/dL mg/dL Albumin6.3 g/dL2.9 g/dL3.0 g/dL3.2 g/dL3.5-5 g/dL AST8 IU/L330 IU/L126 IU/L29 IU/L10-42 IU/L ALT270 IU/L303 IU/L212 IU/L84 IU/L10-40 IU/L TSH uIU/mL uIU/mL INR a All other laboratory values not listed but measured were within normal limits. b Outside hospital within Druid County Health System. Normal laboratory values are the same c Normal values for Druid County Health System at time of patient admission d Value not measured or not reported 22 year old Caucasian male No significant past medical history Patient had a history of methamphetamine abuse Orally ingested a “spoonful” of unknown tan, gooey, pasty substance without smell or taste found inside a zip-lock bag on the side of the road Patient suspected substance to be methamphetamine AuthorNo. of PatientsIodine ExposureEffectsTreatmentResults and Outcomes Moore1 Oral ingestion for suicide attempt 120 mL tincture of iodine Not reported Death 55 minutes after ingestion Moore1 Oral ingestion 60 mL tincture of iodine Not reported Death 33 hours after ingestion Moore1 Oral ingestion 120 mL tincture of iodine Not reported Recovery at day 4 Survived Moore327 Oral ingestion for suicide attempt Iodine tincture, iodoform, Lugol’s solution Not reported Gastric lavage Oral starch solution administration No deaths due to iodine ingestion Dyck et al.1 Oral ingestion Lugol’s solution Iodine level (6hrs post-ingestion) - 60 mg/dL Pulse 120 bpm, BP 160/100 mmHg, RR 44 bpm, Temp 36.8°C Bilateral inspiratory rales at lung bases Developed primarily gastrointestinal symptoms Thyroxine level – 12.8 mcg/dL (initial), 9.5 mcg/dL (day 12) Starch mucilage orally Sodium thiosulfate orally IV sodium bicarbonate infusion (total 510 mmol over first 2 days) Survived to discharge Edwards et al.1 Oral ingestion Strong Iodine Solution 200 mL containing15%w/v iodine Pulse 100 bpm, BP 155/85 mmHg, RR 38 bpm, O2 sat 95% on high flow O 2 High anion gap metabolic acidosis Rising SCr. – 2.4 mg/dL (24 h), 3.1 mg/dL (7 days), 1.2 mg/dL (25 days) Became oliguric and then anuric Rhabdomyolysis Increased AST, CK, and LDH Received 4 L crystalloid Inotropes CVVHD Died 67 hours post-ingestion Iodine toxicity is a potential complication of methamphetamine abuse This case report describes a case of oral methamphetamine ingestion but iodine toxicity may be considered with any route of methamphetamine ingestion Initial Presentation Symptoms – chills, fever, abdominal pain, nausea, vomiting, diarrhea Physical Exam Vital signs – BP 112/56, Pulse 110 bpm, RR 24 bpm, Temp 99.8°F Awake, alert and oriented, drowsy Mild respiratory distress Diminished breath sounds in lower lobes bilaterally CXR – Pulmonary infiltrate in right lower lobe with possible pneumonia Chest CT – Small bilateral pleural effusions with consolidation in the bases of both lungs Hospital Course Day 1 – Patient placed on levofloxacin Day 2 – Symptoms resolve. WBC increase Day 3 – Bromide, lithium, and iodine levels ordered Iodine 325 mcg/L (normal mcg/L) Bromide and lithium levels within normal limits Day 4 – Laboratory values within normal limits Discharged on Amoxicilln/clavulanate 875/125 mg BID Post-discharge – Fail to appear at clinic visit; Lost to follow-up To our knowledge, this is the first documented report of acute iodine toxicity that is suspected to be due to oral methamphetamine ingestion. We could not definitively determine the substance to be methamphetamine because it had been disposed of prior to the patient’s arrival at our institution. However, the patient’s substance abuse history and description of the product supports the hypothesis that the ingested product was methamphetamine. Furthermore, our patient’s clinical presentation was consistent with oral iodine ingestion which heightens the suspicion that the product was methamphetamine. This patient’s narrow anion gap motivated the order for serum halogen levels on day three which returned with an iodine level congruous with toxicity. The patient’s symptoms were also consistent with oral iodine ingestion. While free iodine is in contact with the gastrointestinal mucosa, even sub-lethal doses are known to be bothersome. Our patient presented in abdominal distress shortly after ingestion of the product. Iodine is extremely irritating to the gastrointestinal tract and often results in gastrointestinal corrosion, abdominal pain, and vomiting 6-8. Subsequent hypovolemia and electrolyte imbalances are what is thought to be responsible for the systemic effects that have been reported in other patients including hypotension, tachyarrhthmias, cardiovascular collapse, liver dysfunction 6. Our patient presented with tachycardia and hepatic dysfunction, which were resolving at discharge, as would be expected with declining iodine levels. In cases of fatal ingestion, death occurs within forty-eight hours 2, 5, 7. Once one of the most common sources of suicide attempts in the United States, iodine’s implication in lethal acute toxicity is rare, due in large part to the almost immediate emetic effect iodine induces, and has not been reported since the 1930s 6-7. However, methamphetamine use continues to rise and the National Drug Intelligence Center predicts that domestic production of the illicit substance will rise over the next few years 10. While this case focuses on oral ingestion of methamphetamine, iodine toxicity could potentially occur with each of the other routes of methamphetamine abuse. Given the findings reported in this case, clinicians should be aware of the possibility of iodine toxicity in patients with a history of methamphetamine abuse. References available on handout Poster ID: 1253