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

3. Bromethalin Commonly used as a rodenticides Neurotoxin

4. 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

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

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

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

8. Day 2 - 4 Psychiatric Hospital Reported to be obtunded and catatonic Transferred to ER

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

10. CT Scan Hypodensities detected

11. Lumbar Puncture Clear cerebrospinal fluid (CSF) Elevated opening pressure

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

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

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

16. 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

17. “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”

18. CONCLUSION