[Predictive value of the product of plasma colchicine concentration and poisoning time for the prognosis of colchicine poisoning patients]

Objective: To investigate the predictive value of the product of first plasmacolchicine concentration and poisoning time for the prognosis of colchicine poisoning patients, and to provide a basis for early prognosis assessment. Methods: October 2021, patients with colchicine poisoning admitted in the First Affiliated Hospitol of Wenzhou Medical University from January 2017 to September 2021 were collected, including general information such as patient gender, age, oral colchicine dose, poisoning time, the first laboratory test index andplasma colchicine concentration after admission. The patients were divided into survival group and death group according to their prognosis. The differences in clinical indicators such as admission plasma colchicine concentration, blood routine, blood biochemistry, coagulation function, and blood gas analysis were compared between the two groups, and their predictive value for the prognosis of patients were analyzed. Results: A total of 23 patients with colchicine poisoning, aged 20-85 years, were included in this study, of which 15 cases (65.22%) survived and 8 cases (34.78%) died. The first plasma colchicine concentration at admision were 0.42-53.61 ng/ml. The plasma colchicine concentration and the concentration-time product were 10.08-2147.04 h·ng/ml.Compared with the survival group, the plasma colchicine concentration and the concentration-time product in the death group were significantly increased, and the differences were statistically significant (P<0.05). Univariate logistic regression analysis showed that first plasma concentration and poisoning time>132.48 h·ng/ml, high C-reactive protein, high D-dimer, high absolute value of BE were the risk factors for the prognosis of patients with colchicine poisoning (OR=12.000, 95%CI: 1.1181-128.836; OR=1.053, 95%CI: 1.009-1.098; OR=1.219, 95%CI: 1.039-1.429; OR=1.360, 95%CI: 1.1.044-1.773; P<0.05). High prothrombin time activity was protective factor affecting the prognosis of colchicine poisoning patients (OR=0.941, 95%CI: 0.892~0.993; P<0.05). ROC curve analysis showed that the areas under the curves of first plasma concentration and poisoning time, C-reactive protein, absolute value of BE, D-dimer for predicting the prognosis of patients with colchicine poisoning were 0.918, 0.888, 0.867, 0.837, respectively, and the areas under the curves of prothrombin time activityfor predicting the prognosis of patients with colchicine poisoning was 0.788 (P<0.05) . Conclusion: The product of the first plasma colchicine concentration at admission and poisoning time is closely related to the prognosis of patients with colchicine poisoning, it can be used as a predictor for early evaluation of the prognosis of poisoned patients.

[Accidental colchicine intoxication in a cross-breed dog]

A 2-year old cross-breed dog presented due to acute vomiting and progressive lethargy following ingestion of the owner's anti-gout medication (colchicine, 0.35 mg/kg) 1-3 hours prior to presentation.The dog developed signs of all 3 stages of colchicine poisoning (gastrointestinal phase, multi-organ phase, recovery phase) and the clinical course was complicated by the presence of multi-organ dysfunction syndrome (MODS) and numerous negative prognostic factors.This case report describes the clinical and laboratory effects of colchicine poisoning and represents the first successful treatment of an accidental colchicine ingestion in a dog in Europe.

Clinical outcomes after colchicine overdose: A case report

RATIONALE

Colchicine can inhibit cell division and intracellular transport in affected organs by fixing intracellular tubulin and preventing its polymerization into microtubules. A lethal dose of colchicine is considered to be 0.8 mg/kg. The wide distribution of colchicine through 70% of the body following an overdose makes it difficult to eliminate.

PATIENT CONCERNS

A 56-year-old man with a clear history of colchicine overdose was admitted to our hospital nearly 40 hours after taking 12 mg (0.17 mg/kg) of colchicine. He had a history of gout and chronic kidney disease. As the disease progressed, he showed most of the clinical manifestations and pathological features of colchicine overdose.

DIAGNOSES AND INTERVENTIONS

Colchicine overdose was clear, with symptoms of multiple organ failure including primary gastrointestinal failure, bone marrow hematopoietic inhibition, rhabdomyolysis, cardiac damage, hepatocyte damage. The patient developed secondary septic shock, renal failure, circulatory failure, and respiratory failure. We performed continuous renal replacement therapy and gastric lavage, and administered norepinephrine, frozen plasma, proton-pump inhibitors, adenosylmethionine, antibiotics, granulocyte colony stimulating factor, and total parenteral nutrition.

OUTCOMES

The patient rapidly developed complete hematopoietic function inhibition, gastrointestinal failure, and cardiac damage 32 hours after admission. Sustained severe infection and circulatory instability caused a progressive deterioration of respiratory function. Tracheal intubation was performed but the patient continued to deteriorate, and death occurred approximately 132 hours after admission.

LESSONS

Excessive colchicine levels cause continuous organ damage due to extensive tissue distribution, eventually leading to multiple organ failure. Colchicine metabolism is delayed in patients with liver or kidney dysfunction, and even a low dose of colchicine may result in poisoning in these individuals. Early diagnosis and reduction of colchicine levels is critical to improve prognosis, and colchicine poisoning should be considered in patients with poor liver or kidney function even when the ingested dose is low.

Unsuspected Colchicine Overdose in a Female Patient Presenting as an Acute Abdomen

We report a case of multi-system organ failure as a result of unsuspected colchicine overdose in a patient with known gout and bulimia nervosa. The patient had initially presented with mild gastrointestinal symptoms with rapid progression to fulminant hepatic failure and multiple organ dysfunction before the causative agent was identified. The patient survived with aggressive intensive care support and ongoing medical treatment. Physicians should be aware of the risk assessment based on the ingested dose, that the clinical presentation of colchicine in toxic doses may be nonspecific with high potential for severe morbidity or death and that survival may occur despite multiple organ failure requiring aggressive support.

A rare case report of heavy dose colchicine induced acute kidney injury

BACKGROUND

Colchicine is a natural alkaloid that is mainly used for the treatment of inflammatory diseases. Effective and toxic doses are very similar, but case reports of higher colchicine doses inducing acute toxicosis is rare.

CASE PRESENTATION

A 19-year-old woman was sent to the emergency room for taking 80 colchicine tablets (0.5 mg per tablet) 44 h previously. The main physical symptom was abdominal pain. Following ingestion, the patient suffered multi-system failure including renal, respiratory, circulatory, and digestive. Continuous renal replacement therapy (CRRT) and other treatment measures were used to remove metabolic wastes and poisons, and to treat other complications. Renal function was restored after a series of treatments.

CONCLUSION

We report a case of an acute kidney injury induced by an overdose of colchicine. CRRT and a series of related treatments were beneficial for the treatment of colchicine poisoning.

Activated charcoal significantly reduces the amount of colchicine released from Gloriosa superba in simulated gastric and intestinal media

BACKGROUND

Poisoning with Gloriosa superba, a plant containing colchicine, is common in Sri Lanka.

OBJECTIVES

This study was to estimate release of colchicine from 5 g of different parts of Gloriosa superba in simulated gastric and intestinal media, and examine the binding efficacy of activated charcoal (AC) to colchicine within this model.

METHODS

A USP dissolution apparatus-II was used to prepare samples for analysis of colchicine using HPLC.

RESULTS

Cumulative colchicine release from tuber in gastric media at 120 minutes was significantly higher (2883 μg/g) than in intestinal media (1015 μg/g) (p < .001). Mean ± SD cumulative colchicine concentration over 2 hours from tuber, leaves and trunk in gastric medium was 2883.15 ± 1295.63, 578.25 ± 366.26 and 345.60 ± 200.08 μg/g respectively and the release in intestinal media was 1014.75 ± 268.16, 347.40 ± 262.61 and 251.55 ± 285.72 μg/g respectively. Introduction of 50 g of AC into both media made colchicine undetectable (<0.1 μg/ml).

CONCLUSIONS

The tuber released the highest quantity of colchicine. The colchicine release and elapse time to achieve saturated, equilibrium dissolution mainly depends on physicochemical properties of plant part. Significant in vitro binding of colchicine to AC suggests that AC has a role in decontamination of patients presenting to hospital after ingestion of Gloriosa superba.

Four children with colchicine poisoning

Colchicine poisoning is a rare event. It is characterized by multiorgan involvement and by poor prognosis associated with overdose. In this article we present four children with colchicine poisoning to emphasize that colchicine poisoning has a large spectrum in childhood. The children's ages ranged between 1 year and 3.5 years. The ingested dosage of colchicine was between 0.37 and 1.72 mg/kg. Most of the findings of colchicine poisoning such as gastrointestinal symptoms, hepatotoxicity, cardiotoxicity, bone marrow suppression, hypocalcaemia and hair loss were diagnosed in our patients. Two children receiving 0.37 mg/kg and 1 mg/kg colchicine and admitted 13 and 19 hours after poisoning, respectively, died. Our findings suggest that in addition to amounts of the drug, mortality was also related to the duration between drug ingestion and admission to hospital.

Toxicokinetics of Colchicine in Humans: Analysis of Tissue, Plasma and Urine Data in Ten Cases

1 A specific and sensitive radioimmunoassay was used to study the toxicokinetics of colchicine in seven cases of acute human poisoning. Post-mortem tissue concentrations of colchicine were measured in three further cases.

Depending on the time of patient admission, two disposition processes could be observed. The first, in three patients, admitted early, showed a bi-exponential plasma colchicine decrease, with distribution half-lives of 30, 45 and 90 min. The second, in four patients, admitted late, showed a mono-exponential decrease. Plasma terminal half-lives ranged from 10.6 to 31.7 h for both groups.

2 Pharmacokinetic analysis of urine colchicine data was performed for two patients. The fraction of unchanged colchicine excreted in urine was about 30%, renal clearance was about 131 h-1 and three-fold less than total body clearance (391 h-1). The apparent volume of distribution was 211 kg-1.

3 Post-mortem tissue analysis showed an ubiquitous colchicine distribution. Colchicine accumulated at high concentrations in the bone marrow (more than 600 ng g-1), testicle (400 ng g-1), spleen (250 ng g-1), kidney (200 ng g-1), lung (200 ng g-1) and heart (95 ng g -1); it was also found in the brain (125 ng g-1).

4 This toxicokinetic study shows that after massive ingestion, the disposition parameters and kinetics of colchicine are not markedly modified from those occuring in healthy volunteers. The absorption process was not delayed and the distribution and elimination half-lives were in the range known to occur with therapeutic doses.

[ACCIDENTAL POISONING WITH A PLANT COLCHICUM AUTUMNALE: REPORT OF TWO CASES]

Colchicine poisonings are serious and highly fatal conditions that occur as a result of food poisoning from plants that contain this alkaloid or overdose with drug containing colchicine. The leaves of edible wild garlic because of their similarity are often replaced with highly poisonous leaves of autumn crocus, causing poisoning. Described are two cases of food poisoning with Colchicum autumnale, who had similar symptoms in the initial stage, but different clinical course and outcome. Signs of poisoning require early identification and intensive supportive therapy, which increases the chances of survival.

Extracorporeal life support in the treatment of colchicine poisoning

CONTEXT

Ingestions of Colchicum autumnale may lead to severe poisoning. It begins with gastrointestinal symptoms and leukocytosis, followed by multi-organ failure with shock and a possible late recovery phase. Mortality is highly dependent on the ingested dose. We report a case of accidental C. autumnale poisoning with refractory cardiogenic shock and eventual survival after extracorporeal life support (ECLS).

CASE DETAILS

A 68-year-old woman was admitted to the intensive care unit (ICU) on day 3 after ingestion of C. autumnale in a meal. She first suffered from nausea and vomiting leading to severe dehydration. She then developed multi-organ failure and refractory cardiogenic shock, with a mean arterial pressure nadir of 50 mmHg despite high doses of catecholamines and a left ventricular ejection fraction at 5-10%. Venous-arterial ECLS was therefore started at an initial rate of 3.5 L/min and 3,800 rev/min. Her symptoms also included pancytopenia on day 4 with diffuse bleeding requiring iterative blood product transfusion. Platelet and leukocyte count nadirs were 13 × 10(9)/L (normal range: 150-400 × 10(9)/L) and 0.77 × 10(9)/L (normal range: 4.2-10.7 × 10(9)/L), respectively. ECLS allowed good cardiac contractility recovery within a few days, with complications including bleeding made controllable. Indeed, because of hemostasis disorders, the patient presented hemoptysis and hematuria. She was treated with tranexamic acid and transfused with blood products. She received 15 erythrocyte concentrates, 13 platelet concentrates, and 7 fresh frozen plasma. ECLS was removed by day 10, with subsequent weaning from mechanical ventilation as well as from hemodialysis in the following days.

DISCUSSION

This patient survives after the use of ECLS in Colchicum poisoning, with controllable complications. Thus, ECLS might be indicated to overcome the potentially refractory cardiogenic shock phase.

[A potentially fatal intoxication with colchicine]

BACKGROUND

Approximately ten times a year the Dutch National Poisons Information Centre (NVIC) is consulted regarding a colchicine intoxication or overdose.

CASE DESCRIPTION

An 18-year old woman was admitted to the intensive care unit after a suicide attempt with a potentially lethal dosage of colchicine tablets (0.5 mg/kg body weight). After a few hours the patient developed abdominal pain and vomited. Over subsequent days she developed anaemia, thrombocytopenia and a paralytic ileus. Treatment mainly comprised intensive supportive care, including sedation, ventilation and repeated administration of activated charcoal. After a week she gradually began to recover and was able to leave IC 10 days after ingestion.

CONCLUSION

Early recognition and treatment of colchicine intoxication is crucial to preventing a fatal outcome. Complete recovery is possible if extensive supportive treatment is given.

Colchicine poisoning: a case report and review of literature

Colchicine, a natural pseudo-alkaloid found in plants such as the Colchicum autumnale and Gloriosa superba has tremendous medicinal properties, but if misused by an unqualified person can result in fatal consequences. We report a case of colchicine poisoning in an adult man as a result of consumption of the herb G. superba by a 50-year-old man and review the literature.

Survival case of colchicine intoxication following ingestion of a lethal dose

INTRODUCTION

There have been few reports of cases where the ingestion of colchicine was utilized as a method of suicide and accordingly, its effect on the human body is not fully understood. It has been reported that all individuals who ingested more than 0.8 mg/kg of colchicine died of shock within 72 hours.

CASE REPORT

A 46-year-old man was sent to the hospital after ingesting a lethal amount of colchicine (total dose, 71 mg; body weight, about 70 kg) in a suicide attempt. On admission, his vital signs were stable and physical examination was unremarkable. Laboratory findings were normal. He was admitted to the intensive care unit, and severe diarrhea and vomiting commenced approximately 4 hours after ingestion, accompanied by electrolyte disturbance, coagulopathy and renal dysfunction. Bone marrow suppression, bradycardia, alopecia and myoneuropathy also occurred, these findings being the typical symptoms of colchicine poisoning. The symptoms were almost resolved after about 1 week and he was discharged on the 19th day of admission.

CONCLUSION

Immediate and precise care for colchicine poisoning successfully saved the patient's life.

[Case of colchicine intoxication caused by tubers of Gloriosa superba]

Gloriosa superba is one of the poisonous plants growing in Japan. It contains potent alkaloid such as colchicine which binds to tubulin and prevents it from forming microtubules that are part of the cytoskeleton in human cells. Ingestion of Gloriosa superba tubers causes severe and potentially fatal toxic effects. We report here a case of colchicine intoxication caused by tubers of Gloriosa superba. A 58-year-old male ingested about 25 g of Gloriosa superba tubers by mistake. He believed that it was wild yam. He developed abdominal pain, vomiting and diarrhea 30 minutes after the ingestion of the plant. Forty five hours later he was taken to the emergency department. Unfortunately he died due to progressive multiple organ failure about one hour after the admission. It was two days after Gloriosa superba ingestion. The clinical features and the aspect of the poisonous plants should be acquainted with people.

[Fatal colchicine poisoning--case report and review of literature]

Colchicine is a natural pseudo-alkaloid found in plants such as the autumn crocus (Colchicum autumnale) and glory lily (Gloriosa superba), which is used to treat gout and some other rheumatological disease. Colchicine binds to tubuline and prevents its polymerization into microtubules. It is thus able to impair those cellular functions that involve microtubules, eg. it arrests mitosis in metaphase. Tissues with high mitotic activity are preferentially affected. We report suicidal colchicine poisoning leading to death after 61 hours. Clinical course was typical for colchicine action. We observed severe diarrhea, cardiovascular shock, ARDS, multiorgan system failure and DIC. Postmortem toxicological studies confirm colchicine poisoning.

Deaths from intravenous colchicine resulting from a compounding pharmacy error--Oregon and Washington, 2007

Colchicine for injection has been available in the United States since the 1950s. Although not approved by the Food and Drug Administration (FDA), intravenous (IV) cholchicine has been an accepted treatment for acute gout symptoms. Several additional IV uses have been studied, including treatment of familial Mediterranean fever, pericarditis, primary biliary cirrhosis, amyloidosis, and Behçet's syndrome. More recently, outpatient use of IV administration for chronic back pain has been advocated by alternative medicine providers but is not an accepted practice. Colchicine has well-known toxicities that limit its safe therapeutic use. IV doses that exceed the standard single-use therapeutic dose of 2--4 mg per episode of gout have resulted in life-threatening toxicity. In March 2007, two persons from Washington and Oregon died after receiving IV colchicine for back pain from an alternative medicine clinic in Oregon. This report describes the investigation, which determined that a measuring error by a Texas compounding pharmacy resulted in a fatal colchicine concentration that was eight times greater than the recognized standard level. A subsequent review of medical records revealed that a third death from colchicine toxicity in a patient treated at the Oregon clinic also occurred in March and likely was associated with the same compounding error. These deaths highlight the potential risk from use of IV colchicine for back pain and the possibly fatal consequences of measuring errors in compounding pharmacy products.

Acute colchicine intoxication in a child: a case report

Colchicine poisoning is an uncommon, but potentially life-threatening, toxicologic emergency. The clinical features associated with overdose and the options for treatment are discussed. Colchicine poisoning typically shows 3 phases: initially, gastrointestinal symptoms predominate; in the second phase, multiorgan failure may occur, possibly leading to death. If the patient survives, the third phase of recovery follows, during which the patient often presents with hair loss. Early fatality is due to cardiovascular collapse and respiratory failure; however, pancytopenia and overwhelming septicemia can occur later. All patients suspected of having colchicine intoxication because of its unpredictable outcome should be managed according to the principles of intensive care, irrespective of the actual degree of poisoning. In those patients who survive the initial phase of poisoning, filgrastim (granulocyte colony-stimulating factor) offers an effective method of treating pancytopenia and preventing overwhelming septicemia. Daily monitoring of the patients' hematological status is strongly recommended. We are reporting a case of previously healthy girl who developed a multisystem organ failure after colchicine intoxication. The patient recovered completely and had no residual outcome.

Determination of colchicine residues in sheep serum and milk using high-performance liquid chromatography combined with electrospray ionization ion trap tandem mass spectrometry

Colchicine is a naturally occurring alkaloid used in human and veterinary medicine. It shows genotoxicity in in vitro and in vivo systems even at low concentrations. Therefore, no ADI has been established, and colchicine has been included in Annex IV of Council Regulation (EEC) No. 2377/90. No abuse of this drug in intensive livestock farming has yet been reported. However, there may be a natural route of entry for this compound into the food chain when Colchicum autumnale is consumed by animals kept outdoors. To address this concern, we developed and validated a highly sensitive and selective quantitative LC-ESI-MS-MS method for the detection of colchicine in sheep serum and milk. For sample pretreatment, all samples were liquid-liquid extracted with phosphate buffer (pH 8.0) and dichloromethane. LC separation was carried out on an RP C18 column employing a 0.5% formic acid/acetonitrile gradient system. The recoveries in both matrixes at a concentration range from 0.0005 to 1 mg/L were >80% with RSDs of <10%. The applicability of the method was demonstrated in serum and the corresponding milk samples from Albanian sheep. After exposure to C. autumnale, the animals showed clinical signs of intoxication. Significant concentrations (up to 1 mg/L) of the drug were found in serum as well as in milk samples.

Colchicine overdose: the devil is in the detail

Colchicine, a highly poisonous alkaloid, is a commonly used treatment for gout, Bechet's disease, and familial Mediterranean fever. Despite the knowledge of its side effects, the near universally fatal consequence of a significant overdose is commonly under-appreciated. In this report, we present a case series of 9 patients over the past 15 years (from within the Auckland region of New Zealand) that have presented with a colchicine overdose. Surprisingly, a significant number were accidental overdoses and all cases, apart from one, resulted in death. We question the current knowledge base about the toxicity of this drug amongst prescribers, patients, and their families and its use in the treatment of acute gout. Given its extremely narrow therapeutic index, should the manner in which medical practitioners prescribe this drug be reassessed?

Liquid chromatography-tandem mass spectrometry for the determination of colchicine in postmortem body fluids. Case report of two fatalities and review of the literature

Poisoning by colchicine may occur following ingestion of this alkaloid used for the treatment of acute gouty arthritis. The authors report two fatalities and describe a liquid chromatography-electrospray ionization-tandem mass spectrometry (LC-ESI-MS-MS) triple-quadrupole method for the determination of colchicine in autopsy samples. One milliliter of heart blood, femoral blood, urine, bile, gastric, and vitreous each were extracted with saturated NH4Cl at pH 9.6 and dichloromethane/5% isopropanol. Separation was achieved on a C18-Xterra column with a mobile phase consisting of 2 mM ammonium formate buffer (pH 3)/acetonitrile in a gradient mode. Four product ions of the protonated molecule were monitored. The method was fully validated in whole blood (1 mL) and was linear in the range of 0.5-50 ng/mL (r2>0.99). The limit of detection was 0.1 ng/mL (50 times S/N), and the limit of quantitation was 0.5 ng/mL with RSDs<11.8% intraday (n=6), <18.7% interday (n=18), and accuracy<3% (n=18). Case #1: a 33-year-old nurse committed suicide by the ingestion of 80 colchicine 1-mg tablets. She died 61 h later after resuscitation procedures. Colchicine was found in heart blood at 5.2 ng/mL, femoral blood at 17.4 ng/mL, urine at 19.4 ng/mL, bile at 42.8 ng/mL, gastric at 348 ng/mL, and vitreous at 3 ng/mL. Case #2: a 57-year-old man with gout was found dead at home. Colchicine was found in heart blood at 22.8 ng/mL, femoral blood at 21.9 ng/mL, lung blood at 45.2 ng/mL, urine at 148.5 ng/mL, bile at 1818.5 ng/mL, gastric at 219.8 ng/mL, and vitreous at 0.5 ng/mL. These results were consistent with death. Because of its good sensitivity, this LC-ESI-MS-MS triple-quadrupole method is suitable for the determination of colchicine not only in fatalities but also for pharmacokinetic studies.

Acute colchicine intoxication during clarithromycin administration in patients with chronic renal failure

Colchicine is an effective antiinflammatory medication. It should be used with great caution, however, in patients requiring dialysis. Coadministration of colchicine and macrolides may impair colchicine elimination, resulting in excess drug exposure and toxicity. We report 2 renal failure cases of colchicine intoxication occurring with the administration of clarithromycin.

A Novel LC-ESI-MS-MS Method for Sensitive Quantification of Colchicine in Human Plasma: Application to Two Case Reports

A novel method based upon liquid chromatography coupled to ion trap mass spectrometry (MS) detection with electrospray ionization interface has been developed for the identification and quantification of colchicine in plasma or whole blood. Colchicine was isolated from plasma using a liquid-liquid extraction with dichloromethane at pH 8.0 and embutramide as an internal standard, with satisfactory extraction recoveries. Solutes were separated on a 3-microm C18 Uptisphere (Interchim) column (150 x 2.0-mm i.d.) using acetonitrile/2 mM NH4COOH pH 3.8 buffer (50:50, v/v) as the mobile phase with a flow-rate of 200 microL/min. Data were collected either in full-scan MS mode at m/z 100-450 or in full-scan MS-MS mode, selecting the ion m/z 400.1 for colchicine and m/z 294.1 for embutramide. The most intense daughter ion of colchicine (m/z 358.1) and embutramide (m/z 207.9) were used for quantification. Retention times were 2.40 and 4.25 min for colchicine and embutramide, respectively. Calibration curves were linear in the 0.50-50 ng/mL range. The limits of detection and quantification were 0.05 ng/mL and 0.50 ng/mL, respectively. The intra- and interassay precisions were < 14%, and the intra- and interassay accuracies were in the 97-105.8% range at either 2 or 20 ng/mL. A fatal case of colchicine self-poisoning with a lethal blood concentration of 60 ng/mL and nonfatal case with a plasma sample collected very late (at least 36 h after the ingestion) are presented. The described method enables the unambiguous identification and quantification of colchicine with a very good sensitivity, using only 1 mL of sample.

Colchicine intoxication diagnosed in a skin biopsy: a case report

Colchicine toxicity is a rare, but well-described clinical entity. The histopathologic findings in various organ systems have been delineated in colchicine intoxication; however, skin findings have only been described in rare cases. We present a case of colchicine toxicity diagnosed on skin biopsy in a patient presenting with mental status changes. Her cutaneous manifestation consisted of a diffuse, blanchable, violaceous, morbilliform rash involving the trunk and proximal extremities. The histopathologic findings included metaphase-arrested keratinocytes with underlying basal vacuolization. These features, considered in the setting of multiorgan dysfunction and a known exposure of colchicine, led to the diagnosis.

[Poisoning by the autumn crocus plant]

Confirmed cases of poisoning resulting from the ingestion of Colchicum autumnale in mistake for Allium ursinum were analysed retrospectively. The study included 32 patients between 27 and 90 years. The severity of the intoxication was graded on the basis of the poisoning severity score (PSS). All the patients developed diarrhea and/or vomiting after a latency period of between 2 and 24 h. All those patients with a latency of > 9 h suffered only mild poisoning. If the leaves were boiled before being eaten, 64% of the patients suffered moderate, severe or fatal poisoning; when the leaves were eaten raw, only 33%. It is presumed that heating may promote the liberation of colchicines from the plant. Eight of the nine patients with severe or fatal poisoning were older than 65 years. A possible cause of the more serious course in the elderly may be a decrease in renal clearance. In addition, a diminished sense of smell may allow the absence of the typical garlic smell and taste of Allium ursinum to go unrecognised.

Troponin for prediction of cardiovascular collapse in acute colchicine overdose

The use of colchicine, a treatment for acute gout and familial Mediterranean fever, is limited by its toxicity. A relatively low dose of colchicine may be fatal. After a colchicine overdose, monitoring should include 6-12 hourly serum troponin measurements. A rising troponin level predicts cardiovascular collapse and is an indication for more intensive management.

Two Probable Cases of Serious Drug Interaction Between Clarithromycin and Colchicine

Although colchicine is a commonly used medication in patients with gouty arthritis and various multisystem disorders, its safety margin in therapeutic use is not well understood. This report describes two fatal cases of agranulocytosis presumed to result from a drug interaction involving colchicine and clarithromycin.

Mitotic arrest and toxicity in Biomphalaria glabrata (Mollusca: Pulmonata) exposed to colchicine

Continuous exposure of Biomphalaria glabrata snails to 0.1% colchicine resulted in a significant increase, relative to non-exposed snails, in the number of arrested mitotic figures in the amebocyte-producing organ (APO) as soon as 4 h, with peak numbers after 12 h of exposure. The number of circulating hemocytes was significantly elevated at 24 h. However, by 72 h both the number of mitotic figures in the APO and the concentration of circulating hemocytes in the hemolymph had returned to control levels. Hemocytes appeared to possess normal morphology throughout this exposure, including the formation of long filopodia with supporting rodlike structures that have been reported to contain microtubules. Snail survival decreased as a function of exposure time. Significantly fewer snails, relative to controls, survived a 48-h exposure, and only 1 out of 30 snails recovered from a 72-h exposure to 0.1% colchicine. Colchicine-exposed snails displayed intoxicated behavior, even upon removal from the colchicine solution, although no histopathology was evident in the CNS of snails exposed for 72 h.

Fatal colchicine poisoning by accidental ingestion of meadow saffron-case report

A 62-year-old male died of colchicine poisoning after accidental ingestion of Colchicum autumnale (meadow saffron). He ate a salad of plant with green leaves regarded as wild garlic (Allium ursinum). A few hours later he developed symptoms of gastroenteritis and was admitted to hospital. In spite of gastric lavage, activated charcoal and supportive measures, multi-organ system failure developed over the next two days. Laboratory analysis showed highly elevated blood concentrations of hepatic enzymes, creatine kinase, lactate dehydrogenase and blood urea nitrogen, as well as leukocytopenia and thrombocytopenia. Mechanical ventilation, dopamine, noradrenaline, crystalloid solutions and fresh frozen plasma were applied but despite treatment the patient died five days after the ingestion. Post-mortem examination revealed hepatic centrilobular necrosis, nephrotoxic acute tubular necrosis, petechial bleeding in fatty tissue, blunt and shortened intestinal villi and cerebral toxic edema. Botanical identification of incriminated plant gave Colchicum autumnale which confirmed colchicine poisoning. Although the accidental ingestion of Colchicum autumnale is rare and to our knowledge only five such cases have been described in detail, this is the second fatal case in Croatia described in the last 3 years.

Colchicine-related death presenting as an unknown case of multiple organ failure

A 45-year-old man presented to the emergency department (ED) with acute renal and hepatic failure as well as hypotension and metabolic acidosis. Despite aggressive intensive care, he had continued hypotension, leukocytosis, fever, renal and hepatic failure, and lactic acidosis. On hospital day 3, pancytopenia was noted. Bone marrow biopsy showed marked aplasia without a specific etiology being elucidated. He received granulocyte colony-stimulating factor and antibiotics, but died on hospital day 12 after a cardiac arrest. The patient repeatedly denied intentional drug ingestion. Due to his clinical course, the poison center recommended obtaining a colchicine level. The plasma colchicine level, 72 h after admission, was 6.1 ng/mL (GC/MS). This level exceeds acute levels reported in some cases of prior fatalities. This case is novel in that the patient's multiple organ dysfunction remained unexplained for several days before occult colchicine toxicity was implicated as the probable cause by the colchicine level. Also, there was a paucity of gastrointestinal symptoms on presentation, the opposite of what is expected in colchicine toxicity.

Accidental Intravenous Colchicine Poisoning

Colchicine is a commonly used drug for the treatment of gout and other indications. Toxicity from intentional oral overdoses of colchicine has been reported. Two cases are reported here in which colchicine was given by intravenous injection, and patients presented with multiorgan toxicity. The authors tested plasma and urine colchicine levels in these patients and found them significantly elevated. Testing of the vial from which the colchicine injections were given showed that the vial was mislabeled and contained 10-fold greater concentration of drug than the labeling indicated. These patients thus received a bolus dose of 20 mg of intravenous colchicine rather than the intended 2-mg dose. An intravenous dose of this magnitude has not previously been reported.

Colchicine poisoning: case report of two suicides

Colchicine overdose is uncommon but potentially life threatening because of the high toxicity of the drug. Poisoning by colchicine may occur following ingestion of medication used in acute attacks of gout and inflammatory diseases. We describe two cases involving suicide by the ingestion of medications marketed in France. In case 1, only heart blood was taken after body external examination. In case 2 an autopsy was performed and heart blood, urine, gastric contents and bile were taken for toxicological analysis. Colchicine was assayed in biological specimens by an HPLC-DAD method, after extraction by dichloromethane at pH 8, adding prazepam as internal standard (IS). Analyses were performed on a Symetry C-8 column. Mobile phase was a gradient of acetonitrile/pH 3.8 phosphate buffer. Colchicine is eluted at 13.1 min and the method is linear for blood, urine and bile over the range 4-1000 ng/mL. LOQ is 4 ng/mL. The concentrations of colchicine detected are: case 1: heart blood 13 ng/mL; case 2: heart blood 66 ng/mL, urine 500 ng/mL, gastric content 12 ng/mL, bile 5632 ng/mL. Our findings are in the range of lethal concentrations previously described, but there is no correlation with the amount of ingested drug. Even after massive overdose, it could be impossible to detect colchicine in blood, and as there is a widespread enterohepatic recirculation before excretion in bile and feces, bile is the target sample to analyse. We conclude in both cases that the cause of death was suicide with colchicine. It appears very important to perform an autopsy in order to obtain bile, urine, heart blood and femoral blood.

Accidental Poisoning with Autumn Crocus

We describe a case of a 43-yr-old female with severe multiorgan injury after accidental poisoning with Colchicum autumnale, which was mistaken for wild garlic (Allium ursinum). Both plants grow on damp meadows and can be confused in the spring when both plants have leaves but no blossoms. The autumn crocus contains colchicine, which inhibits cellular division. Treatment consisted of supportive care, antibiotic therapy, and granulocyte-directed growth factor. The patient was discharged from the hospital after three weeks. Three years after recovery from the acute poisoning, the patient continued to complain of muscle weakness and intermittent episodes of hair loss.

Acute poisoning with autumn crocus (Colchicum autumnale L.)

INTRODUCTION

Colchicum autumnale, commonly known as the autumn crocus or meadow saffron, contains the antimitotic colchicine, which binds to tubulin and prevents it forming microtubules that are part of the cytoskeleton in all cells.

CASE REPORT

A 71-year-old woman ate a plant she thought to be wild garlic (Allium ursinum). Ten hours later she arrived at the emergency department complaining of nausea, vomiting and watery diarrhea. Ingestion of a poisonous plant was suspected and she was treated with gastric lavage, oral activated charcoal and an infusion of normal saline. Toxicology analysis with gas chromatography and mass spectrometry revealed colchicine in the patient's gastric lavage, blood (5 microg/l) and urine (30 microg/l). She developed arrhythmias, liver failure, pancreatitis, ileus, and bone marrow suppression with pancytopenia. Alopecia began in the third week. Treatment was supportive only. Five months later she had no clinical or laboratory signs of poisoning.

DISCUSSION

The patient mistakenly ingested autumn crocus instead of wild garlic because of their great similarity. Colchicine primarily blocks mitosis in tissues with rapid cell turnover; this results in gastroenterocolitis in the first phase of colchicine poisoning, bone marrow hypoplasia with pancytopenia in the second and alopecia in the third, all of which were present in our patient. Colchicine toxicity in tissues without rapid cell turnover caused arrhythmias, acute liver failure and pancreatitis.

CONCLUSION

Colchicine poisoning can result in gastroenterocolitis followed by multi-organ dysfunction syndrome. In unexplained gastroenterocolitis after ingestion of wild plants as a salad or spice, especially when wild garlic is mentioned, we should always consider autumn crocus. Diagnosis could be confirmed only by toxicology analyses. Management of colchicine poisoning is restricted to supportive therapy.

Accidental colchicine poisoning in a dog

A 14-month-old toy poodle-cross was presented, after ingesting the owner's colchicine medication, with severe gastrointestinal disturbances and in shock. Despite aggressive medical management, the patient was euthanized approximately 24 hours after the ingestion. The clinical features, treatment, and necropsy findings of colchicine poisoning are discussed.

[Suicidal attempt with colchicine]

Colchicine is an alkaloid that has been successfully used for a long time in the treatment of acute gout episodes. It's efficacy lies in its inhibition of inflammation cell migration and in the action of specific cytokines, as well as of the production of lactic acid and deposition of uric acid in affected tissues. Colchicine toxicity is rare but may entail highly negative consequences for health unless a rapid gastric decontamination with stomach lavage and active carbon is carried out, and adequate support measures are taken as wellas appropriate hydration and electrolyte replacement. We present the case of a patient who was admitted to hospital after ingesting colchicine with suicidal intention. Colchicine inhibits cell division, which explains its distinct toxicity stages. The lack of proportion existing between ingested dose and clinical impact may result from concomitant treatment with other drugs or from peculiarities in its metabolism.

Colchicine poisoning resulting from accidental ingestion of meadow saffron (Colchicum autumnale)

A rare case of colchicine poisoning resulting from accidental ingestion of meadow saffron (Colchicun Autumnale) is reported. The plant can frequently be found in the woods of the Northern Hemisphere (1), also in Japan. A 48-year-old male was admitted to hospital complaining of vomiting, nausea and diarrhea following ingestion of the plant and died in four days. The most striking histological findings were metaphasic mitotic figures in the mucosa of the large intestine and the liver. Colchicine was detected in the bile with high-performance liquid chromatography/sonicspray ionization mass spectrometry (HPLC/SSI-MS).

[Colchicine poisoning by accidental ingestion of the bulbs of Sandersonia aurantiaca: report of a case]

We report a case of colchicine poisoning in an 82-year-old woman. She had suffered from senile dementia and in her confused state ingested two bulbs of Sandersonia aurantiaca (Christmas-bells, Chinese lantern lily). She was admitted complaining of gastrointestinal symptoms, mainly severe watery diarrhea. The duration of her diarrhea was approximately 40 hours. On the 3rd day after ingestion, leukopenia and thrombocytopenia occurred. Although 50 micrograms of granulocyte-colony stimulating factor was administered from the 5th day to the 8th day, her white blood cell count did not increase and revealed nadir (100/microliter) on the 7th day. Her platelet count also revealed nadir on the 7th day. She died of respiratory failure in the early morning of the 9th day. The bulb of Sandersonia was found to contain colchicine at a concentration of 4.7 mg/g, and her serum level of colchicine was 6.3 ng/ml on the 6th day. Colchicine is an alkaroid extractable from the plants like Colchicum autumnale (meadow saffron, autumn crocus), and Gloriosa supra tuber. These plants belong to the lily family. Sandersonia aurantiaca also belongs to the lily family and we found that its bulb contained colchicine. To our knowledge, this is the first report of colchicine poisoning by Sandersonia aurantiaca.

Application of LC-MS analysis to a colchicine fatality

A 73-year-old man developed nausea, vomiting, and diarrhea 20-30 min after receiving a 1.0 mg intravenous dose of colchicine for the treatment of severe pain due to gouty arthritis in his physician's office. He was hospitalized 8 h later, and his condition deteriorated as he developed renal and respiratory failure. He subsequently died 10 h later, or a total of 18 h after he received the original 1 mg colchicine injection. The patient received a prescription for oral 0.6 mg colchicine tablets 8 days previously and consumed eight tablets during that period, an average of 0.6 mg/day (42 of 50 tablets remained at the time of death). Colchicine concentrations were measured by liquid chromatography-mass spectrometry in selected ion monitoring mode using positive ionization. Chromatography was performed using an Eclipse XDB C8 analytical column (30 mm x 2.1-mm i.d., 3-microm particle size) and a programmed mobile phase consisting of 50 mM pH 4 ammonium acetate buffer and acetonitrile. Colchicine concentrations were as follows: 50 microg/L in cardiac blood, 10 microg/L in vitreous humor, 575 microg/kg in liver, 12,000 microg/L in bile, and 4.4 microg in 60 g received gastric contents (estimated total gastric contents 100 g). The cause of death was ruled to be "acute colchicine toxicity" and the manner of death "accidental."

Deaths associated with inappropriate intravenous colchicine administration

Intravenous (IV) colchicine is occasionally prescribed for the treatment of acute gouty arthritis. The Food and Drug Administration (FDA) recently received a report of death in a patient that was associated with inappropriate IV dosing of colchicine. This report prompted further investigation of other deaths associated with IV colchicine use in the FDA Adverse Event Reporting System (AERS) and the medical literature. A total of 20 deaths were identified. Eight patients were females, 11 were males, and the gender was unknown in 1. In all cases, the recommended maximum cumulative dose of 2 to 4 mg during a course of therapy was exceeded. Dose reductions are recommended in patients with renal or hepatic disease and in the elderly. All reported adverse events were associated with colchicine toxicity, including thrombocytopenia, leukopenia, pancytopenia, agranulocytosis, aplastic anemia, acute renal failure, and disseminated intravascular coagulopathy. Death occurred within 1 to 40 days after drug administration. Therapeutic guidelines exist for use of IV colchicine and these guidelines should be followed to prevent serious toxicities and death.

Accidental colchicine overdose. A case report and literature review

Colchicine overdose is uncommon but potentially life threatening. It is a safe drug when used according to established therapeutic guidelines but causes serious systemic effects if ingested in doses that exceed the recommendations. Overdose must therefore be recognised early and treated appropriately to optimise the outcome. A fatal case of colchicine overdose caused by inappropriate self medication is reported and to the best of the authors' knowledge, there has been no report of fatal accidental overdose in the United Kingdom. The pharmacology of colchicine, the clinical features associated with overdose, and the options for treatment are discussed.