Focus

Bromethalin ingestion has the

potential to result in fatal human

poisoning

Bromethalin

• Commonly used as a rodenticides

• Neurotoxin

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

Case Report

• 21-year old male ingested No Pest ®

• Died 7 days later

Day 1

• Transported to ER

• Experienced an episode of emesis

Treated with

o Promethazine

o Thiamine

o Folic Acid

oDiphenhydramine

• Normal vital signs

• Urine drug screen

– Positive for barbiturates

• Deemed “Medically Cleared”

• Provisional diagnosis of major

depression with psychosis

• Transferred to Psychiatric Hospital

Day 2 - 4

• Psychiatric Hospital

• Reported to be obtunded and

catatonic

• Transferred to ER

Day 4

• Upon Admission

– Unresponsive to verbal and painful

stimuli

– Anisocoric pupils

• Flaccid extremities

• Intubated and placed on a ventilator

CT Scan

• Hypodensities detected

Lumbar Puncture

• Clear cerebrospinal fluid (CSF)

• Elevated opening pressure

CSF Studies• Elevated proteins

• Normal cell counts

• Negative for:

– Antisyphilis Anitbodies

– Venereal Disease

– Bacterial Cultures

– Herpes Simplex Virus 1 and 2

– West Nile Virus

Autopsy

• Brain:

Ischemia

Spongy and vacuolated white matter

• Lungs:

Consolidation

Acute Bronchoalveolar Pneumonia

Post-mortem Toxicology

• Screened For:• Volatile Solvents

(Alcohol)• Benzodiazepines

• Cyanide • Cocaine Groups

• Salicylates • Phencyclidine

• Barbiturates • Opiates

• Basic Drugs • Acetaminophen

• Stimulants

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

“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”

CONCLUSION