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Thieves Market. Eva Patton-Tackett MD Marshall University. Case. Pt is a 56 year old white female Presented with mental status changes to primary care physician Poor concentration for 2 weeks Tremor in the few days prior to presentation Slowness of motion for last few days.

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thieves market

Thieves Market

Eva Patton-Tackett MD

Marshall University

slide2
Case
  • Pt is a 56 year old white female
  • Presented with mental status changes to primary care physician
  • Poor concentration for 2 weeks
  • Tremor in the few days prior to presentation
  • Slowness of motion for last few days
slide3
Difficulty walking
  • Confusion
  • Pt was then admitted from her primary care physician’s office
history cont
History cont.
  • Pt has hx of depression
  • She was seen by her psychiatrist 2 weeks prior to presentation
  • Increased Cymbalta
  • Started Seroquel
  • Discontinued Ambien
  • Pt and family were unsure of the dosage changes
slide6
PMHx
  • Chronic collagenous colitis
    • Recently diagnosed
    • Recent hospitalization complicated by C. Diff sepsis
    • Prolonged ICU stay
  • Hypothyroidism
  • Hypoparathyroidism
pmhx cont
PMHx Cont.
  • GERD
  • Hypertension
  • Irritable bowel syndrome
  • Bipolar disorder/Depression
medications
Medications
  • Cymbalta ? dose
  • Seroquel ? Dose
  • Xanax 0.5 mg TID
  • Lexapro 20mg daily
  • Lamictal 25mg in the am and 100mg in the pm
  • Amlodipine 10mg daily
  • Toprol XL 50mg daily
medications cont
Medications cont
  • Synthroid 112mcg daily
  • Calcitriol 0.25mcg every other day
  • Calcium acetate
  • Mag oxide 400mg BID
  • Nexium 40mg daily
  • Tramadol 50mg Q8 hours prn
  • Asacol 800mg TID
  • Entocort 9mg every am
slide10
PSHx
  • TAHBSO
  • Thyroidectomy
social hx
Social Hx
  • No smoking
  • No ETOH
  • No illicit drugs
  • Married
  • Works at VAMC as a nurse
family hx
Family Hx
  • Breast CA in her mother
slide13
ROS
  • Chronic diarrhea
  • Chronic fatigue
  • Dizziness
  • Otherwise negative
slide14
PE
  • 136/83 71 16 98%RA
  • Negative except Neurological exam
  • Neuro
    • Thought blocking apparent with impairment of subtraction and multiplication on MSE
    • PERRL EOMI
    • Impaired balance with abnormal finger to nose on the left greater than right
neurological exam cont
Neurological exam cont.
  • Motor exam normal (strength was 5/5 Bilateral UE/LE proximal and distal)
  • Increased reflexes, up going toes
  • Rigidity diffuse
  • Myoclonic jerks and tremor on intention
  • Gait unsteady, but able to walk
  • Unable to do heel to toe
slide16
Labs
  • Na 141 K+ 4.3 Cl 104 Bicarb 27 BUN 22 Cr 1.3 Glucose 107
  • Ca 9.8
  • WBC 9.7 Hb15 Hct43 Plt 316
  • TSH 1.074
  • CT head wnl
labs cont
Labs cont
  • ESR 21
  • RPR neg
  • B12 769
  • Ammonia 24
  • UDS positive only for benzodiazepines
hospital course
Hospital Course
  • Pt was admitted
  • Her mental status did not improve
  • First Serotonin syndrome was considered
  • All psychotropic medications were held
  • Psychiatry was consulted
  • Neurology was consulted
psychiatry recommendations
Psychiatry Recommendations
  • Doctor agreed with stopping her medications for now
  • He also suspected that her mental status may be due to medication interactions
neurology recommendations
Neurology Recommendations
  • EEG
    • Showed generalized slowing
  • MRI
    • Mild atrophy
    • No acute changes
    • Chronic microvascular disease
lumbar puncture
Lumbar Puncture
  • WBC 5
  • RBC 3
  • Glucose 68
  • Protein 56
  • Culture negative
hospital course cont
Hospital Course cont.
  • Pt did not show improvement after psychiatric medications were held
  • She actually worsened
  • Increased delirium
  • Hallucinations
hospital course cont24
Hospital Course cont.
  • Non-communicative
  • Unable to walk
  • No strong evidence for serotonin syndrome
  • After discussion with the family pt was transferred to UVA
slide25
UVA
  • Initially suspected to have Creutzfeldt-Jacob Disease
  • Herbal and OTC medications were reviewed
  • Further testing and consultation revealed the diagnosis
otc medications
OTC Medications
  • Simethicone 160mg 3-4 times daily prn
  • Bismuth 524/30ml, 45ml TID
  • Remifemin
  • Estrovent PM
diagnosis
DIAGNOSIS
  • Bismuth toxicity was suspected
  • Serum bismuth 397
  • Urine bismuth 293
  • Both are grossly elevated
bismuth toxicity
Bismuth Toxicity
  • Pepto – Bismol is the most common OTC
  • Bismuth subsalicylate
  • Mental status changes
  • Nephrotoxicity
  • Salicylate toxicity
history
History
  • Bismuth has been used since the 1700s as salves or to settle upset stomach
  • Epidemic outbreak (>1000 cases) in France and Australia in 1973-1980
  • Now more uncommon
  • Incidence is increasing due to its benefit in treating H. pylori.
bismuth toxicity phases
Bismuth Toxicity Phases
  • Phase I – Prodromal phase associated with mood changes and cognitive abnormalities such as lack of concentration. This phase can last for weeks and progresses slowly.
phases cont
Phases cont.
  • Phase II – Physical finding start to appear with myoclonus and tremor. Delirium and/or dementia also start to appear. This phase usually occurs suddenly and progresses rapidly
differential dx
Differential Dx
  • Creutzfeldt – Jacob Disease
  • Heidenhein’s Disease (Occipital CJD)
  • Metabolic Encephalopathy
  • Drug induced encephalopathy
  • Encephalitis
  • Other heavy metal poisoning, such as, Mercury
  • Alzheimer’s Disease
diagnosis34
Diagnosis
  • Bismuth level > 5 ug/l
  • MRI normal
  • EEG – diffuse slowing is the most common, and it is unaffected by photoic stimulation or eye opening.
course of toxicity
Course of Toxicity
  • Toxicity is usually associated with chronic ingestion
  • Once disease is recognized and bismuth is withheld
  • Pt improves gradually of weeks to months.
  • Usually complete resolution is noted.
treatment
Treatment
  • Withdrawal of agent !
  • Symptomatic treatment while patient is improving
  • There have been very rare reports of fatality
patient outcome
Patient Outcome
  • She has completely recovered
  • She is at her usual base-line and is again working
references
References
  • Jungreis, Alexander and Schaumburg, Herbert. Encephalopathy from abuse of bismuth subsalicylate (Pepto-Bismol). Neurology 1993; 43:1265.
  • Von Bose, Michael and Zaudig, Michael. Encephalopathy Resemblin Creutzfeldt-Jakob Disease Following Oral, Prescribed Doses of Bismuth Nitrate. British Journal of Psychiatry 1991; 158:278-80.
  • Gordon, Mark et. al. Bismuth Subsalicylate Toxicity as a Cause of Prolonged Encephalopathy with Myoclonus. Movement Disorders 1995; 10, 2:220-2.
  • Summers, William. Bismuth Toxicity Masquerading as Alzheimer’s. 1998; 57-9.