Ubuntu #5: Muthi Mayhem

The case:

A 27 year old male is brought to the Ubuntu Hospital ED by EMS with a history of feeling unwell for two days. It is difficult to get further history from him, as he is extremely tachypnoeic and confused. His family relate to you that he has always been perfectly healthy until three days ago when he began to complain of vomiting and abdominal pain, and appeared breathless. He did not take any chronic medication. According to EMS, there were no medication bottles at home, nor was there any sign of illicit drug abuse.

His vitals are: BP 116/70 P 105 BPM, Sats 98% on RA, RR 40/min, Temperature 36.4 C, blood glucose is 6.4.

The monitors are placed and this is his ECG:

Lead II is being captured for ECG analysis. The T waves are tall and peaked, towering over the QRS complexes. The tall T waves are suspicious for hyperkalaemia.

The initial findings are:

He has no clear features of any particular toxidrome on examination. He appears significantly dehydrated. His lungs are clear and his cardiac exam is normal.

His blood gas shows: pH 6.9 , PO2 110 mm Hg, PCO2 11mm Hg, HCO3 2 mmol/L, BE -25, Na 125 mmol/L K 7.1 mmol/L Cl 95 mmol/L, Lactate 6. Urine dipstix shows 1+ protein.

His blood gas shows a severe metabolic acidosis with an elevated anion gap. Intravenous crystalloids are started and his hyperkalaemia is corrected. The Urea, Creatinine and electrolytes won’t be back for hours so you decide to do a renal ultrasound:

His kidneys are normal in size, measuring approximately 10.5 cm in length. The cortex of the kidney is normal in width.  There is no hydronephrosis. Of note, the kidneys are echogenic, meaning brighter than normal, signifying kidney disease) On ultrasound, usually the cortex of the kidney is darker than liver parenchyma. In this image they are extremely bright. Although the echogenicity of the kidney cannot always differentiate Acute Kidney Injury from Chronic Kidney Disease, the normal size of the kidneys with normal cortical thickness is highly suggestive of Acute Kidney Injury.

Transverse view of the right kidney. Note how bright the kidney appears. The renal pyramids appear prominent, but this is a normal variant.

The case progresses:

Despite fluids, he remains anuric. His pH rises to 7.11 on a subsequent gas. He begins to show signs of pulmonary oedema due to fluid overload, so he is intubated and ventilated while arrangement for transfer to ICU for haemodialysis is made. Blood results show: urea 85.7 mmol/L, creatinine 2057 umol/L.  His LFTS show a transaminitis ALT 1124, AST 549. Full blood count is normal. A standard urine drugs of abuse screen comes back negative, while serum paracetamol, valproate and salicylate levels are undetectable. His septic markers, malaria screen and blood cultures are negative. He is even HIV negative and his hepatitis studies are also negative. So, what’s the diagnosis?

You’re puzzled. The story just doesn’t add up for you. He was previously well until he acutely falls ill within 72 hours. Through an interpreter, you sit down with the family to get a better history. They tell you that he had visited a sangoma a few days prior and think he was given traditional medicine, known locally as “muthi”. He visited the sangoma as he thought he was a victim of bad luck, and was seeking divine protection. They don’t know what was in the muthi.

What is muthi?

Traditional healers, commonly called “sangomas” are common in South Africa. They believe they can discern a patient’s illness or problem by consulting with the patient’s ancestral spirits. They then may prepare traditional medicines made of herbs, minerals and animal extracts. How it is used often depends on the patient’s illness; children with diarrhoea may be given a traditional medicine enema or it may be applied to a rash. It is also applied in wounds, taken orally or inhaled. The majority of these medicines are not harmful, and may provide a placebo effect. However, these medicines are not researched, controlled or sterilised and sometimes contain toxic compounds, unknown to the patient.

Traditional medicine poisoning

This is a case of poisoning by traditional medicine ingestion.  This can be easily missed if traditional medicines and visits to the traditional healer are not specifically enquired about. Patients and their families seldom volunteer this information for fear of being rebuked by healthcare staff. The diagnosis of traditional medicine poisoning may be difficult to make, due to its presentation mimicking so many other critical illnesses. A patient often falls ill with a particular illness, for example, pneumonia, takes traditional medicine to get better and then presents to a hospital critically ill, resulting in it being difficult to prove the traditional medicine’s causality over association. Traditional healers often prefer to keep the ingredients of their muthi secret, so it is difficult to know clinically what precise poisoning is present. Furthermore, hospital labs lack the equipment and assays necessary to detect the causative agents.

Multiple potentially toxic substances have been identified in commonly available traditional medicines. Heavy metals such as lead, mercury and and potassium dichromate are common constituents of traditional medicines. The herbs, plants and bark used in traditional medicine are often harmless, however there are some notable exceptions. Cape Aloe and “Impila” both contain hepatotoxic and nephrotoxic compounds, which have been extensively studied. Poisoning with traditional medicine containing these plants produces a syndrome of renal failure, hepatic dysfunction, and seizures, which commonly results in hypoglycaemia and severe metabolic acidosis.  Furthermore, cardiac glycosides present in plants indigenous to South Africa can result in a digoxin-like toxidrome.

Mortality in traditional medicine induced renal failure is high, being 34-41% in studies done in Johannesburg and 43% in a study done in children at Mthatha Hospital, in the Eastern Cape. Mortality is even higher if hepatic injury is also present, in HIV positive patients and in infants.

Studies done in Zimbabwe, Botswana, Uganda and South Africa have uniformly shown that although traditional medicine poisoning is less common than poisoning with conventional pharmaceutical drugs, death rates related to poisoning with traditional medicine are significantly higher. Traditional medicine poisoning may very well be underreported, due to it more commonly used in rural areas and the reluctance to inform medical staff about its use.

A Toxicologist’s goldmine 

South Africa has been described as a Toxicologist’s goldmine; poisoning is common, yet still much research needs to be done. African toxicology deserves more attention. It is imperative that Health care professionals working in Africa are aware of the use of traditional medicine, their potential toxicity and their potential to worsen or complicate a patient’s illness. Traditional medicine will continue to be used as it is a focal part of African culture. However if toxic compounds and plants are eradicated from their use through education and awareness, lives can potentially be saved.

References:
1. Renal relevant radiology: use of ultrasonography in patients with AKI. Faubel S, Patel NU, Lockhart ME, Cadpaphornchai MA. Clin J Am Soc Nephrol. 2014 Feb;9(2):382-94 http://www.ncbi.nlm.nih.gov/pubmed/24235286

2. Traditional healers and paediatric care. De Villiers FPR, Ledwaba MJP. South African Medical Journal 2003;93:664-665 http://www.ncbi.nlm.nih.gov/pubmed/?term=Traditional+healers+and+paediatric+care.+De+Villiers+FPR%2C+Ledwaba+MJP.

3. Metallic mercury use by South African traditional health practitioners: perceptions and practices Street RA, Kabera GM, Connolly C. Environmental Health 2015;14:1-7 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4537568/

4. The toxicity of Callilepis laureola, a South African traditional herbal medicine. Popat A, Shear NH, Malkiewicz I, Stewart MJ, Steenkamp V et al. Clinical Biochemistry 2001;34:229-236 http://www.ncbi.nlm.nih.gov/pubmed/?term=The+toxicity+of+Callilepis+laureola%2C+a+South+African+traditional+herbal+medicine.+Popat+A%2C

5. Characteristics of acute poisoning at two referral hospitals in Francistown and Gaborone, South African Family Practice, 50:3, 67-67c, DOI:10.1080/20786204.2008.10873722

6. Fatalities by poisoning in the Mthatha area of South Africa. Meel BL. SA Fam Pract 2007;49(7):17-18

7. Contribution of plants and traditional medicines to the disparities and similarities in acute poisoning incidents in Botswana, South Africa and Uganda. Malangu Afr J Tradit Complement Altern Med. (2014) 11(2):425-438 http://dx.doi.org/10.4314/ajtcam.v11i2.29 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202653/

8. Acute Renal Failure associated with the use of traditional folk remedies in South Africa. Luyckx VA, Steenkamp V, Stewart MJ. Renal Failure 2005; 1:35-43 http://www.ncbi.nlm.nih.gov/pubmed/15717633

9. Traditional medicine poisoning in Zimbabwe: clinical presentation and management in adults. Human & Experimental Toxicology 2002; 21:579- 586 http://www.ncbi.nlm.nih.gov/pubmed/?term=Traditional+medicine+poisoning+in+Zimbabwe%3A+clinical+presentation+and+management+in+adults

10. Underestimating the Toxicological Challenges Associated with the Use of Herbal Medicinal Products in Developing Countries. Neergheen-Bhujun, VS Biomed Research International 2013. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3791562/

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#badEM16: Almero Oosthuizen on Paraquat poisoning

Almero Oosthuizen treated the badEM16 crowd to an entertaining talk some common and some deadly poisonings other than organophosphates.

Take away points:

  • First aid first: remove contaminants from patient and protect yourself

  • Aggressive palliative care may be the only option for some patients: learn how to do it well.

Almero Oosthuizen is an Emergency Medicine Physician in Cape Town, South Africa with a passion for education, and an excellent sense of humor.

Twitter: @Almero

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Trauma in Pregnancy Part 3: Fear of radiation can lead to harm

Fear of radiation can lead to harm: A rational approach to diagnostic imaging following trauma in pregnancy

Imagine this patient presents to your emergency department:

A 25 year old female is brought in by paramedics with a history of being involved in a motor vehicle collision. She was an unrestrained passenger and reported abdominal pain on scene. Her initial vitals are: BP 110/70 mm Hg, HR 98 BPM, respiratory rate of 18 per minute, Sats of 98% on RA and GCS 15/15. She has a singleton pregnancy at 21 weeks gestation.

Your team begins to assess her. She appears to be haemodynamically stable currently, but has significant lower abdominal tenderness on palpation. An eFAST is negative, and the fetal heart beat is present.

She also has significant tenderness in the lower abdomen at any attempt on moving her hips. You suspect a pelvic fracture and order a pelvic X-ray. (If you have any concern about ordering a pelvic x-ray in this scenario, read on)

The pelvic X-ray shows: bilateral superior and inferior pubic rami fractures are present. The fetal rib cage is visible overlying the right iliac crest.

How would you manage this patient further?

You need to consider the pubic rami fractures and their potential associated organ injuries.

You also need to consider if further imaging is necessary? If so, what?

Pubic rami fractures are associated with bladder, urethra and vaginal injuries. In pregnancy, the bladder is displaced as the uterus enlarges and is at further risk of injury. A careful examination of the perineum needs to be done. A urethral catheter can be placed provided that no signs of urethral trauma are present. Urethral trauma in females is rare. Signs of urethral trauma include: blood at the urethral meatus and bruising of the perineum. Macroscopic haematuria indicates that bladder and upper urinary tract injuries may be present and further imaging, such as a CT cystogram,  needs to be done.

It’s important to remember that a tremendous force is required to cause a pelvic fracture. A pelvic fracture in pregnancy should always make you think of significant pelvic haemorrhage, as the pelvic veins are engorged. The pelvic cavity can also “hide” a significant amount of blood.

A CT of the abdomen and pelvis may be indicated in this instance as the risk of missed injury outweighs the risk to the fetus.

Diagnostic imaging in Pregnancy – is it safe?

 Diagnostic imaging in the pregnant patient is commonly thought to be dangerous, even amongst medical professionals. The myth that doing an X-ray in pregnancy is prohibited is surprisingly pervasive. Research from radiation disasters such as the Hiroshima and Nagasaki demonstrated that that there are significantly increased risks of fetal malformations, spontaneous abortions and cancer following extreme radiation exposure. So, should we be worried that we will subject our patients and their babies to the same risk by performing an X-ray or CT scan?

Absolutely not. The fear of radiation has been blown out of proportion. The dose of radiation required in diagnostic imaging falls far below the dose required to induce fetal malformations and miscarriage, and falls exceedingly far below the levels present in radiation disasters such as Hiroshima. If a critically injured pregnant patient warrants a CT scan, even a “panscan”, she should get it. This represents a paradigm shift in many people’s minds, so let’s look at the evidence.

 

The dose of radiation absorbed is measured in milliGrays (mGy)  in most parts of the world, apart from North America where it’s measured in millirad (mRad). With doses of more than 100 mGy there is a small increase in risk of spontaneous abortion, organ malformation and mental retardation.

Below 50 mGy there is no risk for any of these adverse events. All guidelines on diagnostic imaging in pregnancy state that it safe to perform imaging if the cumulative dose falls below this cut-off.

This is stated in international radiology, gynaecology and trauma guidelines. There is no recognisable harm to the fetus or pregnancy below this 50 mGy cut-ff. Imaging should not be avoided if it is indicated to help guide management of the patient.

Of course, one should always practise ALARA, (as low as reasonably possible) and consider other diagnostic imaging such as ultrasound or MRI if the same amount of information can be gained from these tests. However, bear in mind that the sensitivity for the FAST in pregnancy is less than in the non-pregnant patient, and MRI is not a useful modality if your patient is critically injured, as it takes a long time to acquire.

Let’s look at what diagnostic imaging falls below 50 mGy:

A CT of the brain, cervical spine and chest all fall well below 50 mGy as the fetus is out of the field of view. The dose of radiation in these cases is minimal and barely adds to the baseline radiation that the fetus is already exposed to.

A CT of the abdomen and pelvis also falls well below 50mGy, provided that the scan is planned well. For example, instead of doing a pre, post and delayed contrast scan, do a single phase with IV contrast.Further dose attenuation can be done radiographers. It’s important to decide on an imaging protocol for pregnant patients in advance with your radiology department at your hospital.

Between 50-100 mGy the risk for adverse effects on the fetus is small, and uncertain. At present, 50 mGy is considered by most the as the maximum acceptable total dose for diagnostic imaging during pregnancy. There may be times when this dose may be reached, such as when CT cystogram needs to be done to visualise a bladder injury. This risk should be discussed with the patient, and the risk-benefit ratio for imaging and treatment considered by the relevant medical specialties involved.

What about the risk of childhood cancer?

 The risk of childhood cancer appears to have a different threshold of risk compared to congenital malformations. The baseline risk for an individual getting a childhood cancer is 0.2 – 0.3%. A 10 mGy fetal dose would increase this incidence by 0.05% to approximately 0.35%. This is a small but appreciable risk so we should limit excessive diagnostic imaging where possible, but without compromising the mother. Shielding the abdomen has not been shown to reduce radiation absorbed by the fetus, as it is the internal scattering of photons that the fetus is exposed to.

In summary:

Estimation of harm caused by imaging in pregnancy has been grossly exaggerated.
Diagnostic imaging should not be withheld from the pregnant trauma patient where the mechanism of injury is worrying. X-rays and CT of the brain, cervical spine and chest should be done when clinically indicated.
The ALARA principle should be followed when a CT of the abdomen and pelvis is ordered to minimize radiation where the fetus is directly exposed. This can be done by radiation reducing techniques if the CT is important to reduce maternal morbidity from missed diagnosis.

References:

Imaging of trauma in the pregnant patient: https://www.ncbi.nlm.nih.gov/pubmed/24819793

Imaging of trauma: Abdominal trauma and pregnancy. A radiologist’s guide to doing what’s right for mother and baby: http://www.ajronline.org/doi/abs/10.2214/AJR.12.9091

Radiation exposure and pregnancy: when should we be concerned? http://pubs.rsna.org/doi/full/10.1148/rg.274065149

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