Wednesday, April 9, 2008


A high-class "escort" is rushed to your emergency room complaining of headache, nausea, anxiety, and a metallic taste in her mouth. Things sound fishy since she was scheduled to testify against an unnamed politician of some repute next week. On exam, you detect a bitter almond odor on her breath. Her skin is a cherry red color. The following labs are normal: fingerstick glucose, acetaminophen, salicylates, pregnancy (though that would have made this even more juicy), EKG, and cooximetry. There is an anion gap acidosis.

Challenge: What is the mechanism of action? What is the antidote?


So in researching this case, I found out a bunch of smells related to drug overdoses. I don't actually expect anyone to attempt this.
Challenge: What are the drug overdoses associated with the following smells?

1. Fruity or acetone-like
2. Garlic
3. Mothballs
4. Kerosene
5. Freshly mown hay
6. Rotten eggs
7. Wintergreen

Here's the "Word Box" (note, some odors have more than one related agents and some agents have more than one odor!)
phosgene, arsenic, selenium, naphthalene, ethanol, chloroform, methyl salicylate, isopropyl alcohol, organophosphates, parathion, hydrogen sulfide.


Alex said...

cyanide? or arsenic? not sure

1 - DKA
2 -
3 -
4 - naphthalene ?
5 -
6 - sulfides ?
7 - salicylates

Craig said...


This is a case of inhaled hydrogen cyanide (HCN). Cyanide poisoning is usually due to fire, industrial exposure, sodium nitroprusside treatment for hypertensive emergencies, and dietary intake. Cyanide avidly binds cytochrome oxidase, blocking oxidative phosphorylation. Since cells cannot use oxygen, they undergo anaerobic metabolism. This may be exacerbated by increased free radicals. Presentation depends on method of exposure; gas exposure is described here. The differential importantly includes carbon monoxide poisoning. Antidotes involve induction of methemoglobinemia, use of sulfur donors, and binding of cyanide with sodium thiosulfate and hydroxycobalamin (nitrates can also be used).

Acetone (fruity) – ethanol, isopropyl alcohol, chloroform, salicylates
Garlic – arsenic, organophosphates, phosphorus, thallium, selenium
Mothballs – naphthalene, paradichlorobenzene
Kerosene – organophosphates, parathion
Freshly mown hay – phosgene
Rotten eggs – hydrogen sulfide
Wintergreen – methyl salicylate

Source: UpToDate.
nice job!