SEVERE COLCHICINE TOXICITY IN A SUICIDE ATTEMPT CAUSING MULTIORGAN FAILURE: A SURVIVAL STORY

Abstract

SESSION TITLE: A Look Into Poisoning and Drug OverdosesSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 12:25 pm - 01:25 pmINTRODUCTION: Colchicine, an anti-inflammatory agent, is commonly used in acute gout flares and familial Mediterranean fever. If taken in excess or in the setting of hepatic or renal impairment it can lead to fatal doses. This report demonstrates a case of severe colchicine toxicity complicated by multi-organ failure that was managed with supportive care.CASE PRESENTATION: 62-year-old male (64kg) presented after suicide attempt with colchicine. He had history of chronic hepatitis C, poly-substance use, bipolar and borderline personality disorder, depression, and prior suicide attempts. He ingested 90 pills of colchicine 0.6mg (0.84mg/kg) and presented 90 minutes later due to severe abdominal pain. He was normotensive on arrival but required intubation for airway compromise due to bouts of emesis. Screening for acetaminophen, ethanol, and salicylate levels were unrevealing. Activated charcoal and whole bowel irrigation were completed after consultation with poison control. Within 24 hours he went into biventricular failure and cardiogenic shock requiring multiple vasopressors. Over the next 6 days he went into multi-organ failure, labs significant for leukopenia (2.2k), anemia (11.2), thrombocytopenia (10k) secondary to bone marrow suppression, elevated ALT>3300, AST>6000 due to shock liver, and acute renal failure creatinine worsening from 0.77 to 5.27 mg/dL.DISCUSSION: Colchicine has a narrow therapeutic index. It involves enterohepatic circulation and renal excretion and is not dialyzable; leading to a greater potential for toxicity in scenarios of renal or hepatic impairment. Systemic toxicity is dose dependent and can occur at doses 0.5-0.8 mg/kg, doses >0.8 mg/kg as evidenced in this patient can lead to shock and multi-organ failure with a high mortality rate nearing 100%. There is no antidote for colchicine toxicity, management is based on early recognition with an attempt to increase elimination and decrease absorption coupled with supportive care. Shock is attributed to excess gastro-intestinal losses early in the course; this can be followed by cardiogenic shock due to severe ventricular dysfunction. The use of VA-ECMO has been successful in scenarios of profound hemodynamic collapse. Through appropriate fluid resuscitation followed by vasopressor support, our patient was able to have full recovery. More specifically, renal function returned to baseline without the need for hemodialysis, his transaminitis improved and pancytopenia resolved.CONCLUSIONS: This case highlights a patient with severe colchicine toxicity in multi-organ failure that was able to fully recover from supportive care measures alone. The need for early recognition and treatment is pivotal in this highly lethal drug toxicity. This is a warning sign for clinicians to be aware of the lethality of this drug at high doses and be cognizant of the number of pills prescribed, especially to patients with suicidal ideations/attempts.Reference #1: Long, Neil. "Colchicine Toxicity.” Life in the Fast Lane • LITFL, 19 July 2021, https://litfl.com/colchicine-toxicity/.Reference #2: Sharma, Nitika, and Charles Nnewihe. "1185.” Critical Care Medicine, vol. 41, 2013, https://doi.org/10.1097/01.ccm.0000440419.49895.53.Reference #3: Maxwell, M J. "Accidental Colchicine Overdose. A Case Report and Literature Review.” Emergency Medicine Journal, vol. 19, no. 3, 2002, pp. 265–266., https://doi.org/10.1136/emj.19.3.265.DISCLOSURES: No relevant relationships by Priyanka BattaNo relevant relationships by Kalpana ChinthaNo relevant relationships by Adam GreenNo relevant relationships by Hossam HannaNo relevant relationships by Prateek JunejaNo relevant relationships by Awab KhanNo relevant relationships by Anshul KumarNo relevant relationships by Thong NgoNo relevant relationships by Monali PatelNo relevant relationships by Akash RayNo relevant relationships by Hiral Shukla SESSION TITLE: A Look Into Poisoning and Drug Overdoses SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Colchicine, an anti-inflammatory agent, is commonly used in acute gout flares and familial Mediterranean fever. If taken in excess or in the setting of hepatic or renal impairment it can lead to fatal doses. This report demonstrates a case of severe colchicine toxicity complicated by multi-organ failure that was managed with supportive care. CASE PRESENTATION: 62-year-old male (64kg) presented after suicide attempt with colchicine. He had history of chronic hepatitis C, poly-substance use, bipolar and borderline personality disorder, depression, and prior suicide attempts. He ingested 90 pills of colchicine 0.6mg (0.84mg/kg) and presented 90 minutes later due to severe abdominal pain. He was normotensive on arrival but required intubation for airway compromise due to bouts of emesis. Screening for acetaminophen, ethanol, and salicylate levels were unrevealing. Activated charcoal and whole bowel irrigation were completed after consultation with poison control. Within 24 hours he went into biventricular failure and cardiogenic shock requiring multiple vasopressors. Over the next 6 days he went into multi-organ failure, labs significant for leukopenia (2.2k), anemia (11.2), thrombocytopenia (10k) secondary to bone marrow suppression, elevated ALT>3300, AST>6000 due to shock liver, and acute renal failure creatinine worsening from 0.77 to 5.27 mg/dL. DISCUSSION: Colchicine has a narrow therapeutic index. It involves enterohepatic circulation and renal excretion and is not dialyzable; leading to a greater potential for toxicity in scenarios of renal or hepatic impairment. Systemic toxicity is dose dependent and can occur at doses 0.5-0.8 mg/kg, doses >0.8 mg/kg as evidenced in this patient can lead to shock and multi-organ failure with a high mortality rate nearing 100%. There is no antidote for colchicine toxicity, management is based on early recognition with an attempt to increase elimination and decrease absorption coupled with supportive care. Shock is attributed to excess gastro-intestinal losses early in the course; this can be followed by cardiogenic shock due to severe ventricular dysfunction. The use of VA-ECMO has been successful in scenarios of profound hemodynamic collapse. Through appropriate fluid resuscitation followed by vasopressor support, our patient was able to have full recovery. More specifically, renal function returned to baseline without the need for hemodialysis, his transaminitis improved and pancytopenia resolved. CONCLUSIONS: This case highlights a patient with severe colchicine toxicity in multi-organ failure that was able to fully recover from supportive care measures alone. The need for early recognition and treatment is pivotal in this highly lethal drug toxicity. This is a warning sign for clinicians to be aware of the lethality of this drug at high doses and be cognizant of the number of pills prescribed, especially to patients with suicidal ideations/attempts. Reference #1: Long, Neil. "Colchicine Toxicity.” Life in the Fast Lane • LITFL, 19 July 2021, https://litfl.com/colchicine-toxicity/. Reference #2: Sharma, Nitika, and Charles Nnewihe. "1185.” Critical Care Medicine, vol. 41, 2013, https://doi.org/10.1097/01.ccm.0000440419.49895.53. Reference #3: Maxwell, M J. "Accidental Colchicine Overdose. A Case Report and Literature Review.” Emergency Medicine Journal, vol. 19, no. 3, 2002, pp. 265–266., https://doi.org/10.1136/emj.19.3.265. DISCLOSURES: No relevant relationships by Priyanka Batta No relevant relationships by Kalpana Chintha No relevant relationships by Adam Green No relevant relationships by Hossam Hanna No relevant relationships by Prateek Juneja No relevant relationships by Awab Khan No relevant relationships by Anshul Kumar No relevant relationships by Thong Ngo No relevant relationships by Monali Patel No relevant relationships by Akash Ray No relevant relationships by Hiral Shukla