A 32-year-old man who worked as a farmer awakened his wife at 5 a.m. one morning and announced that their barn was on fire. The two of them rushed to the barn to remove valuable equipment before it was destroyed by the fire. As they fought the fire and waited for assistance from the local fire fighters, the farmer vomited and experienced several convulsions. His wife tried in vain to help him and reported later that when she touched her husband he only went into additional convulsions. He eventually became cyanotic and then unconscious. The fire company found him with no pulse and they successfully provided cardiopulmonary resuscitation. On arrival at the hospital he seemed much better, without cyanosis, with good vascular perfusion, and with sinus tachycardia. He did, however, continue to seize but this was controlled with diazepam administration, induction of paralysis, and mechanical ventilation. Arterial blood gases showed a severe metabolic acidosis with pH of 6.6 and pCO2 of 7.91 kPa.
On the basis of his exposure to a fire immediately before symptoms started, the initial diagnosis was carbon monoxide poisoning. Seizures were the most significant feature of his presentation and they can be found in CO poisoning. Seizures would not usually be such a major aspect of the illness, however. Quite soon the laboratory reported a carboxyhemoglobin result of 2% and this was regarded as proof that the patient's symptoms were not related to CO. Alcohol could be ruled out because the seizures were not preceded by stuporous, alcoholic-type behavior. An important clue to this patient's problem was the report from his wife that a mere touch from her sent him into further seizures. This response is characteristic of strychnine. The suspicion of strychnine was reinforced by the fact that strychnine is found as an insecticide on many farms. Additional studies on this patient revealed a creatine kinase of 1500 U/L and urinary crystals. The urinary crystal finding suggested the possibility of ethylene glycol poisoning. Gas chromatography showed no alcohols, however, and X-ray diffraction revealed that the crystals were not calcium oxalate, the kind that arises from ethylene glycol exposure.
Thin layer chromatography finally revealed that the patient had strychnine in his urine. GC/MS confirmed this finding with major ions at 334, 162, and 120, all characteristic of the electron impact spectrum of strychnine.
The patient was continuously dialysed and mechanically ventilated but he died on the 6th day of hospitalization. Examination of the patient's social history suggested suicide since he often complained of marital conflict and financial worries.
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