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Thieves Market

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

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  1. Thieves Market Eva Patton-Tackett MD Marshall University

  2. 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

  3. Difficulty walking • Confusion • Pt was then admitted from her primary care physician’s office

  4. Discussion

  5. 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

  6. PMHx • Chronic collagenous colitis • Recently diagnosed • Recent hospitalization complicated by C. Diff sepsis • Prolonged ICU stay • Hypothyroidism • Hypoparathyroidism

  7. PMHx Cont. • GERD • Hypertension • Irritable bowel syndrome • Bipolar disorder/Depression

  8. 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

  9. 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

  10. PSHx • TAHBSO • Thyroidectomy

  11. Social Hx • No smoking • No ETOH • No illicit drugs • Married • Works at VAMC as a nurse

  12. Family Hx • Breast CA in her mother

  13. ROS • Chronic diarrhea • Chronic fatigue • Dizziness • Otherwise negative

  14. 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

  15. 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

  16. 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

  17. Labs cont • ESR 21 • RPR neg • B12 769 • Ammonia 24 • UDS positive only for benzodiazepines

  18. Differential Diagnosis

  19. 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

  20. Psychiatry Recommendations • Doctor agreed with stopping her medications for now • He also suspected that her mental status may be due to medication interactions

  21. Neurology Recommendations • EEG • Showed generalized slowing • MRI • Mild atrophy • No acute changes • Chronic microvascular disease

  22. Lumbar Puncture • WBC 5 • RBC 3 • Glucose 68 • Protein 56 • Culture negative

  23. Hospital Course cont. • Pt did not show improvement after psychiatric medications were held • She actually worsened • Increased delirium • Hallucinations

  24. Hospital Course cont. • Non-communicative • Unable to walk • No strong evidence for serotonin syndrome • After discussion with the family pt was transferred to UVA

  25. UVA • Initially suspected to have Creutzfeldt-Jacob Disease • Herbal and OTC medications were reviewed • Further testing and consultation revealed the diagnosis

  26. Discussion

  27. OTC Medications • Simethicone 160mg 3-4 times daily prn • Bismuth 524/30ml, 45ml TID • Remifemin • Estrovent PM

  28. DIAGNOSIS • Bismuth toxicity was suspected • Serum bismuth 397 • Urine bismuth 293 • Both are grossly elevated

  29. Bismuth Toxicity • Pepto – Bismol is the most common OTC • Bismuth subsalicylate • Mental status changes • Nephrotoxicity • Salicylate toxicity

  30. 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.

  31. 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.

  32. 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

  33. 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

  34. 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.

  35. 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.

  36. Treatment • Withdrawal of agent ! • Symptomatic treatment while patient is improving • There have been very rare reports of fatality

  37. Patient Outcome • She has completely recovered • She is at her usual base-line and is again working

  38. Questions

  39. 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.

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