Joseph Myers, MD
Infectious Disease Specialist
Akron Infectious Disease, Inc., United States
Disclosure information not submitted.
Rupesh Raina, MD
Nephrologist
Summa Health Systems-Akron City Hospital, United States
Disclosure information not submitted.
Title: Failure of Therapeutic Plasma Exchange in Adult Suicide by Subcutaneous Ricin Injection
Introduction: The Castor bean plant (Ricinus communis) produces brown seeds from which ricin, a toxic chemical that inhibits protein synthesis and inactivates eukaryotic ribosomes is derived. Ricin exposure has a high mortality rate with no antidote. We report a patient who successfully committed suicide by injection of ricin.
Description: A 37-year-old man with a history of bipolar disorder and previous suicide attempts presented to the ED 24 hours after injecting his left medial biceps with 4 cc of fluid obtained from supernatant left after mashing 400 castor beans. He presented with dyspnea, chest tightness, chills, myalgias, and back pain. On initial exam: VS: T 101.7⁰F, BP 127/51 mmHg, P 100/min, RR 20/min, SpO2 89%. Awake, alert, oriented. Erythema noted over the injection site without necrosis. Remainder of exam was unremarkable. WBC = 10.2K/µL, platelets = 161K/µL. Creatinine = 0.60 mg/dL, ALT = 98 U/L, AST = 156 U/L, CK = 1,198 U/L. CXR normal. Diagnosis was acute ricin poisoning. The next day, CXR showed pulmonary vascular congestion. Plasma exchange therapy (PLEX), indicated due to successful reported treatment in pediatric cases, was initiated with albumin 1:1, blood flow 120 mL/min, PLEX rate 2500mL/h, and volume of exchange 3.5 liters. Median time from ingestion to PLEX was around 96 hours. Repeated blood work highlighted declining serum liver enzymes after second PLEX therapy. He received a total of five PLEX treatments. On hospital day six, he developed acute hypoxic respiratory failure requiring endotracheal intubation. Infectious workup was negative. The patient developed worsening respiratory failure then multi-organ system failure. On hospital day 10, family requested no further aggressive treatment and the patient was transferred to hospice care where he died 12 days after ricin injection.
Discussion: We report failure of plasma exchange in a man who subcutaneously injected castor bean extract. There are few published reports of suicide by ricin injection with no antidotes for ricin or empiric treatments. PLEX has been used to successfully treat children with oral ricin poisoning, however, there is no published data in adults who subcutaneously injected ricin. Improvement of serum biomarkers in our case suggest that PLEX may be effective as an early intervention in treatment of ricin toxicity.