2015 ACMT Annual Scientific Meeting VizQuiz Answers

1)B Patient is exposed to Arsenic at his workplace, a semiconductor factory. Arsine gas was liberated during the cleaning of a waste water tank.

2) D

3) E This is Ackee fruit (blighia sapida). The unripe fruit contains the toxins Hypoglycin A and B, which inhibit beta oxidation of fatty acids and causes hypoglycemia. Clinically the condition is popularly known as Jamaican Vomiting Sickness.

4) B Systemic loxoscelism is a syndrome characterized by a combination of constitutional symptoms (chills, malaise, weakness), physical findings suggestive of inflammation (fever, edema, arthralgias), and laboratory data remarkable for hemolytic anemia and/or coagulopathy. Systemic loxoscelism is rare, with only 1% of one series of brown recluse bites progressing to systemic symptoms. The development of systemic toxicity is not predicted by the extent of the cutaneous reaction.

5) D Lamotrigine is a well known cause of Stevens Johnson Syndrome.

6) B

7) C

8) B This patient ingested hydrofluoric acid and manifested progressive QT interval prolongation. Hydrofluoric acid causes QT interval prolongation by inducing hypomagnesemia and hypocalcemia. These events may place the patient at risk for polymorphic ventricular tachycardia or torsades de pointes.

9) D Betel nut quid, areca nut, tobacco and betel leaf are shown

10) E This patient’s electrocardiogram is consistent with digoxin toxicity and also reveals the digoxin effect in the lateral leads. Cardiac steroids decrease cardiac conduction velocity in addition to refractoriness and conduction through the atrioventricular node. This occurs via inhibition of sodium-potassium ATPase thereby leading to an increase in intracellular sodium content and preventing the antiporter from expelling calcium. Excessive elevation of the intracellular calcium content elevates the resting potential, producing myocardial sensitization and predisposes to dysrhythmias.

11) E Takotsubo cardiomyopathy triggered by the stressful event of malignant hyperthermia. This diagnosis was made due to the transient nature of the hypokinesis, the absence of CAD, ischemic looking EKG abnormalities, and a stressful trigger.

12) D The patient was intoxicated with methanol. He had presented in a delayed fashion to healthcare. His cranial computed tomography (CT) showed bilateral, symmetric, lentiform nucleus edema with associated hemorrhage. Methanol is metabolized to formaldehyde and formic acid by alcohol and aldehyde dehydrogenases, respectively. Formate is an inhibitor of cytochrome c of the electron transport chain. The lentiform nucleus is a highly metabolically active area of the brain. These CT findings can be seen in methanol poisoning as well as toxicity of carbon monoxide, cyanide and other inhibitors of aerobic respiration.

13) B

14) C

15) B This patient developed anticonvulsant hypersensitivity syndrome from concomitant use of valproic acid and lamotrigine. The patient had been prescribed valproic acid for behavior modification and had been taking it for >1 year. Approximately 2 weeks prior to presentation and one week prior to onset of symptoms lamotrigine was added to his medication regimen. Lamotrigine produces a reactive arene oxide metabolite that is thought to be the causative metabolite. Concurrent use of valproic acid and lamotrigine may increase the production of the toxic metabolite. Valproic acid competes with lamotrigine in the glucuronidation process. This patient developed altered mental status, elevated transaminases, acute lung injury and respiratory failure, acute kidney injury, and rhabdomyolysis.

16) D The primary toxins present in Amanita muscaria are ibotenic acid and muscimol, both of which cause neurotoxicity. Sedation secondary to muscimol is prominent in adults while children often manifest excitatory symptoms such as seizures due to the ibotenic acid.

17) A The plant is the white snakeroot plant which cause milk sickness. This is virtually unheard of in modern times.

18) A The plant is the grass pea which can cause neurolathyrism

19) B Rhodendron which contains grayanotoxin