Anasemon Saad, PharmD
New York University Langone Medical Center
New York, NY
Disclosure information not submitted.
Jessica Cheung, PA-C
Physician Assistant, Pediatric Critical Care Medicine
NYU Langone Health, United States
Disclosure information not submitted.
Ami Shah, MD, MSHS
Attending Physician, Pediatric Critical Care Medicine
NYU Langone Health, United States
Disclosure information not submitted.
Ariel Daube, MD
Attending
Hassenfeld Children's Hospital at NYU Langone
New York, New York
Disclosure information not submitted.
Michelle Korn, DO
Attending Physician, Pediatric Critical Care Medicine
NYU Langone Health, United States
Disclosure information not submitted.
Title: Use of ECMO and Whole Blood Exchange Transfusion for Severe Colchicine Toxicity
Introduction: Colchicine is a plant-derived alkaloid that exerts its effect by inhibiting microtubule polymerization. Due to its narrow therapeutic index, acute colchicine toxicity is considered a medical emergency, and is associated with high mortality rates. Treatment is limited to supportive care with scarce reports of extracorporeal membrane oxygenation (ECMO) and whole blood exchange transfusion as treatment modalities.
Description: A 13 year old (55kg) previously healthy male ingested 7 mg (0.13 mg/kg) of colchicine with the intent “to get high.” He presented to the emergency department 36 hours after ingestion with vomiting, diarrhea, and fatigue. He was found to have tachycardia, elevated troponin, and an ejection fraction of 30%. He rapidly deteriorated, requiring intubation and vasoactive support shortly after admission. On hospital day (HD) 2 he suffered a three minute bradycardic arrest and was emergently cannulated onto veno-arterial ECMO due to the known risk of progressive cardiac depression and arrhythmia associated with colchicine toxicity. Renal function progressively worsened and continuous renal replacement therapy (CRRT) was started in tandem with the ECMO circuit. Filgastrim was started empirically due to the myelosuppressive effects of colchicine. On HD 4 the patient had a transient period of improvement in hyperlactatemia, followed by progressive decline in cardiac, renal, and liver function. Whole blood exchange was trialed on HD 6, but was aborted after 15% of planned volume exchange due to significant inflammatory response. He required continued fluid resuscitation due to worsening capillary leak and vasoplegia. Methylene blue was tried without improvement. On HD 8 the patient developed abdominal compartment syndrome. Decision was made by the parents to withdraw care. The patient died nine days following ingestion.
Discussion: Colchicine ingestion is a rare, but highly lethal toxicity that can lead to cardiovascular collapse. The early clinical presentation of colchicine poisoning includes nausea, vomiting, and diarrhea with multi-organ injury occurring within 24 hours post-ingestion. A high level of clinical suspicion is needed and immediate transfer to an ECMO-trained pediatric intensive care unit is warranted. Further studies are needed in researching the type and timing of interventions.