Near fatal acute colchicine intoxication in a child. A case report

Long-term outcome after suicidal colchicine intoxication in a 14-year-old girl: case report and review of literature

BACKGROUND

Colchicine is used as an anti-inflammatory drug in the treatment of gout, familial Mediterranean fever, and Behçet disease. However, because of its potent inhibition of mitosis, adverse effects and symptoms of intoxication are frequent. Clinical manifestations of colchicine intoxication include abdominal cramps, diarrhea, and multiorgan failure including cardiovascular collapse with fatal outcome.

OBJECTIVE

We report here the case of a 14-year-old girl who ingested 12.5 mg (0.23 mg/kg body weight) colchicine in a suicide attempt.

CASE REPORT

Major complaints of this fully conscious patient at the time of presentation ∼2 hours after ingestion of colchicine were nausea and impaired vision. Apart from a colchicine serum concentration of 16.2 ng/mL, no abnormalities were seen in the physical examination and blood tests. Gastrointestinal decontamination by activated charcoal, repeated administrations of sodium sulfate (Glauber salt) and substitution of volume and electrolytes led to complete recovery.

Grapefruit-drug interactions

Grapefruit juice and grapefruit product consumption have potential health benefits; however, their intake is also associated with interactions with certain drugs, including calcium channel blockers, immunosuppressants and antihistamines. The primary mechanism through which interactions are mediated is mechanism-based intestinal cytochrome P450 3A4 inhibition by furanocoumarins resulting in increased bioavailability of administered medications that are substrates. Grapefruit products have also been associated with interactions with P-glycoprotein (P-gp) and uptake transporters (e.g. organic anion-transporting polypeptides [OATPs]). Polyphenolic compounds such as flavonoids have been proposed as the causative agents of the P-gp and OATP interactions. The mechanisms and magnitudes of the interactions can be influenced by the concentrations of furanocoumarins and flavonoids in the grapefruit product, the volume of juice consumed, and the inherent variability of specific enzymes and transporter components in humans. It is therefore challenging to predict the extent of grapefruit product-drug interactions and to compare available in vitro and in vivo data. The clinical significance of such interactions also depends on the disposition and toxicity profile of the drug being administered. The aim of this review is to outline the mechanisms of grapefruit-drug interactions and present a comprehensive summary of those agents affected and whether they are likely to be of clinical relevance.

Fruit juice inhibition of uptake transport: a new type of food-drug interaction

A new type of interaction in which fruit juices diminish oral drug bioavailability through inhibition of uptake transport is the focus of this review. The discovery was based on an opposite to anticipated finding when assessing the possibility of grapefruit juice increasing oral fexofenadine bioavailability in humans through inhibition of intestinal MDR1-mediated efflux transport. In follow-up investigations, grapefruit or orange juice at low concentrations potentially and selectively inhibited in vitro OATP1A2-mediated uptake compared with MDR1-caused efflux substrate transport. These juices at high volume dramatically depressed oral fexofenadine bioavailability. Grapefruit was the representative juice to characterize the interaction subsequently. A volume-effect relationship study using a normal juice amount halved average fexofenadine absorption. Individual variability and reproducibility data indicated the clinical interaction involved direct inhibition of intestinal OATP1A2. Naringin was a major causal component suggesting that other flavonoids in fruits and vegetables might also produce the effect. Duration of juice clinical inhibition of fexofenadine absorption lasted more than 2 h but less than 4 h indicating the interaction was avoidable with appropriate interval of time between juice and drug consumption. Grapefruit juice lowered the oral bioavailability of several medications transported by OATP1A2 (acebutolol, celiprolol, fexofenadine, talinolol, L-thyroxine) while orange juice did the same for others (atenolol, celiprolol, ciprofloxacin, fexofenadine). Juice clinical inhibition of OATP2B1 was unresolved while that of OATP1B1 seemed unlikely. The interaction between grapefruit juice and etoposide also seemed relevant. Knowledge of both affected uptake transporter and drug hydrophilicity assisted prediction of the clinical interaction with grapefruit or orange juice.

Colchicine Overdose—The Need for a Specific Antidote

Purpose

To report the case of a colchicine overdose to highlight current limitations in the treatment of this toxicologic emergency.

Summary

A 23-year-old man was admitted to the intensive care unit (ICU) after attempting suicide via polypharmacy ingestion, which included 80 to 100 colchicine 0.6 mg tablets (approximately 0.9 mg/kg of body weight). He was taken to the emergency department where gastric decontamination was initiated. Because attempts to obtain a colchicine-specific antibody fragment (Fab) were unsuccessful, only supportive therapies were provided throughout his hospitalization. Over the course of several days, the patient experienced the 3 separate evolutionary phases of colchicine toxicity ultimately leading to multiple organ failure and hemodynamic collapse, and death.

Conclusion

Acute colchicine intoxication is a rare, but potentially life-threatening event. Although 1 case report demonstrated the successful use of a colchicine-specific Fab fragment in the management of acute colchicine overdose, there is presently no commercially-available antidote for colchicine toxicity. Prompt recognition of the overdose, aggressive gastrointestinal decontamination, and supportive therapies directed at the multi-organ failure remain the standard of care.

[Familial Mediterranean fever: MEFV gene mutations and treatment]

Familial Mediterranean fever (FMF) is an autosomal recessive disease which predominantly affects certain ethnic groups mainly Sephardic Jews, Turks, Arabs and Armenians. FMF has been rarely reported in Japan. Characteristic symptoms include self-limited recurrent attacks of fever with serositis such as peritonitis, pleuritis, and arthritis. The most serious complications of FMF are secondary AA amyloidosis and subsequent chronic renal failure. FMF is caused by mutations in MEFV gene which encodes a protein called pyrin. Pyrin regulates processing of IL-1beta, NF-kappaB activation and apoptosis. Dysregulated function of pyrin results in excessive production of proinflammatory cytokine thereby evoking inflammatory attacks. The mainstay of treatment is colchicine which is effective for both relieving symptoms and preventing secondary amyloidosis.

Colchicine use in children and adolescents with familial Mediterranean fever: literature review and consensus statement

The daily application of colchicine is the standard therapy for prophylaxis of attacks and amyloid deposition in familial Mediterranean fever. However, because of many issues (eg, dosage, time of introduction, etc), no standardized treatment recommendations have been established. In this work we review the available literature on colchicine use with respect to its indication, efficacy, mode of application, and safety in children and adolescents with familial Mediterranean fever. On the basis of this analysis, a consensus statement on the application of colchicine in children and adolescents with familial Mediterranean fever was developed by caregivers from Germany, Austria, and Turkey.

Toxic epidermal necrolysis-like reaction secondary to colchicine overdose

Colchicine is a microtubule-inhibiting drug used to treat gout, familial Mediterranean fever and many other skin diseases. Intoxication with colchicine affects multiple organs, often fatally. Cutaneous sequelae of colchicine toxicity are rare. We describe the clinical and histological features of a toxic epidermal necrolysis-like exanthem in a patient who lethally overdosed on colchicine.

[Colchicine in dermatology]

<zakljucak> Kolhicin je stari lek cija je primena, kao monoterapija ili u kombinaciji sa drugim lekovima, aktuelna i u savremenoj medicini. Najznacajnija mu je primena za lecenje i profilaksu perzistentne palmoplantarne pustuloze i oralnih aftoznih ulceracija, lecenje Svitovog sindroma, Beh?etove bolesti, sklerodermije i fibromatoze penisa.

Late diagnosis of severe colchicine intoxication

A 4-year-old Turkish girl was referred to our hospital with the findings of encephalopathy and pancytopenia. She had a history of severe abdominal cramps and gastrointestinal bleeding. A confused state, muscle pain and weakness, erythema-bullous and erythema-nodosum-like skin lesions, and alopecia were observed at her hospitalization. All of these symptoms resolved on follow-up. On laboratory investigation severe thrombocytopenia and leukopenia, mild anemia, a moderate increase in aspartate aminotransferase and alanine aminotransferase levels were detected. After reevaluating her medical history, it was learned that she had accidentally taken 1.3 to 1.5 mg/kg of colchicine 3 to 4 days before her first hospitalization. The possibility of misdiagnosis of colchicine intoxication should be borne in mind, and pediatricians must be aware of its toxic effects, especially in areas where patients with familial Mediterranean fever are present.