Acute Iodine Toxicity From a Suspected Oral Methamphetamine IngestionMarilyn N. Bulloch PharmD, BCPS1,2 • Vijaya Sundar MD1

1) Department of Internal Medicine University of Alabama-School of Medicine CCHS 2) Harrison School of Pharmacy Auburn University

Introduction

Case Literature Review Conclusion

DisclosuresAll Authors: Nothing to disclose

Iodine is a naturally occurring element first discovered by a French chemist in the early nineteenth century1-3. It is available commercially as a tincture or as crystals1. Additionally, iodine is widely found in a variety of products including antiseptics, germicides, water treatment chemicals, radiological contrast media, and multiple pharmacologic compounds2-6. Dietary sources containing iodine are so common that the Recommended Daily Allowance of 150 mcg/day is optimized or exceeded in most western countries2, 4-5. Humans appear to have a high tolerance iodine exposure, particularly when ingestion is less than 2 mg/day, because iodine must be converted to iodide, a generally non-toxic substance, or bound to proteins, starches, or unsaturated fatty acids before it is absorbed from the intestine into the blood4,6-7. From there, most is cleared and excreted renally2,6.

In addition to its legitimate dietary, medicinal, and commercial purposes, iodine is used in the illegal production of methamphetamine. Iodine crystals are used to produce hydriodic acid which is then used to help reduce pseudoephedrine to d-methamphetamine1. Producers who are unable to obtain iodine crystals directly may produce them by mixing hydrogen peroxide with iodine tincture, which is more readily available for purchase than iodine crystals1. Utilization of the tincture also allows methamphetamine producers to bypass the Comprehensive Methamphetamine Control Act of 1996 which requires a detailed record of all iodine crystal sales exceeding 400 mg1. Methamphetamine can be used orally, intravenously, via inhalation, or snorted.

Discussion

Table 1: Laboratory Results During Hospital CourseLaboratory Parameter a Outside Hospital b Day 1 Day 2 Day 4 Normal Values c

pH ---c 7.328 --- --- 7.35-7.45

PCO2 --- 37.8 mmHg --- --- 35-45 mmHg

PO2 --- 70 mmHg --- --- 80-100 mmHg

HCO3 (ABG) --- 20 mmol/L --- --- 22-26 mmol/L

O2 Saturation --- 89-99% 97% 95% 94-100%

WBC 3.4 8.6 20.4 7.1 4.8-10.8 x 103

Hgb/Hct 12.9 g/dL / 37.4% 12.1 g/dL / 35.4% 12.1 g/dL / 35.1% 12.5 g/dL / 36.1% 14-18 g/dL / 42-52%

Bands --- 47% 37% 9% 0-9%

Sodium --- 139 mmol/L 138 mmol/L 138 mmol/L 136-145 mmol/L

Chloride --- 107 mmol/L 106 mmol/L 106 mmol/L 98-107 mmol/L

HCO3 (CBC) --- 25 mmol/L 25 mmol/L 29 mmol/L 22-28 mmol/L

SCr 1.6 mg/dL 1.4 mg/dL 1 mg/dL 0.7 mg/dL 0.6-1.3 mg/dL

Albumin 6.3 g/dL 2.9 g/dL 3.0 g/dL 3.2 g/dL 3.5-5 g/dL

AST 8 IU/L 330 IU/L 126 IU/L 29 IU/L 10-42 IU/L

ALT 270 IU/L 303 IU/L 212 IU/L 84 IU/L 10-40 IU/L

TSH --- 1.275 uIU/mL --- --- 0.35-5.5 uIU/mL

INR 1.4 --- 1.6 --- 1

a All other laboratory values not listed but measured were within normal limits. b Outside hospital within Druid County Health System. Normal laboratory values are the samec Normal values for Druid County Health System at time of patient admissiond Value not measured or not reported

• 22 year old Caucasian male• No significant past medical history• Patient had a history of methamphetamine abuse• Orally ingested a “spoonful” of unknown tan, gooey, pasty substance without smell or taste found inside a zip-lock bag on the side of the road• Patient suspected substance to be methamphetamine

Author No. of Patients Iodine Exposure Effects Treatment Results and Outcomes

Moore 1• Oral ingestion for suicide attempt• 120 mL tincture of iodine

• Not reported • Not reported • Death 55 minutes after ingestion

Moore 1 • Oral ingestion• 60 mL tincture of iodine

• Not reported • Not reported • Death 33 hours after ingestion

Moore 1 • Oral ingestion•120 mL tincture of iodine

• Not reported • Not reported• Recovery at day 4• Survived

Moore 327• Oral ingestion for suicide attempt• Iodine tincture, iodoform, Lugol’s solution

• Not reported

•Gastric lavage• Oral starch solution administration

• No deaths due to iodine ingestion

Dyck et al. 1• Oral ingestion• Lugol’s solution

• Iodine level (6hrs post-ingestion) - 60 mg/dL• Pulse 120 bpm, BP 160/100 mmHg, RR 44 bpm, Temp 36.8°C• Bilateral inspiratory rales at lung bases• Developed primarily gastrointestinal symptoms• Thyroxine level – 12.8 mcg/dL (initial), 9.5 mcg/dL (day 12)

• Starch mucilage orally• Sodium thiosulfate orally• IV sodium bicarbonate infusion (total 510 mmol over first 2 days)

•Survived to discharge

Edwards et al. 1• Oral ingestion • Strong Iodine Solution 200 mL containing15%w/v iodine

•Pulse 100 bpm, BP 155/85 mmHg, RR 38 bpm, O2 sat 95% on high flow O2

•High anion gap metabolic acidosis• Rising SCr. – 2.4 mg/dL (24 h), 3.1 mg/dL (7 days), 1.2 mg/dL (25 days) •Became oliguric and then anuric• Rhabdomyolysis• Increased AST, CK, and LDH

• Received 4 L crystalloid• Inotropes• CVVHD

•Died 67 hours post-ingestion

• Iodine toxicity is a potential complication of methamphetamine abuse• This case report describes a case of oral methamphetamine ingestion but iodine toxicity may be considered with any route of methamphetamine ingestion

Initial Presentation • Symptoms – chills, fever, abdominal pain, nausea, vomiting, diarrhea• Physical Exam

• Vital signs – BP 112/56, Pulse 110 bpm, RR 24 bpm, Temp 99.8°F• Awake, alert and oriented, drowsy• Mild respiratory distress• Diminished breath sounds in lower lobes bilaterally

• CXR – Pulmonary infiltrate in right lower lobe with possible pneumonia• Chest CT – Small bilateral pleural effusions with consolidation in the bases of both lungs

Hospital CourseDay 1 – Patient placed on levofloxacinDay 2 – Symptoms resolve. WBC increaseDay 3 – Bromide, lithium, and iodine levels ordered Iodine 325 mcg/L (normal 40-92 mcg/L) Bromide and lithium levels within normal limitsDay 4 – Laboratory values within normal limits Discharged on Amoxicilln/clavulanate 875/125 mg BIDPost-discharge – Fail to appear at clinic visit; Lost to follow-up

To our knowledge, this is the first documented report of acute iodine toxicity that is suspected to be due to oral methamphetamine ingestion. We could not definitively determine the substance to be methamphetamine because it had been disposed of prior to the patient’s arrival at our institution. However, the patient’s substance abuse history and description of the product supports the hypothesis that the ingested product was methamphetamine. Furthermore, our patient’s clinical presentation was consistent with oral iodine ingestion which heightens the suspicion that the product was methamphetamine. This patient’s narrow anion gap motivated the order for serum halogen levels on day three which returned with an iodine level congruous with toxicity. The patient’s symptoms were also consistent with oral iodine ingestion. While free iodine is in contact with the gastrointestinal mucosa, even sub-lethal doses are known to be bothersome. Our patient presented in abdominal distress shortly after ingestion of the product. Iodine is extremely irritating to the gastrointestinal tract and often results in gastrointestinal corrosion, abdominal pain, and vomiting6-8. Subsequent hypovolemia and electrolyte imbalances are what is thought to be responsible for the systemic effects that have been reported in other patients including hypotension, tachyarrhthmias, cardiovascular collapse, liver dysfunction6. Our patient presented with tachycardia and hepatic dysfunction, which were resolving at discharge, as would be expected with declining iodine levels.

In cases of fatal ingestion, death occurs within forty-eight hours2, 5, 7. Once one of the most common sources of suicide attempts in the United States, iodine’s implication in lethal acute toxicity is rare, due in large part to the almost immediate emetic effect iodine induces, and has not been reported since the 1930s 6-7. However, methamphetamine use continues to rise and the National Drug Intelligence Center predicts that domestic production of the illicit substance will rise over the next few years10. While this case focuses on oral ingestion of methamphetamine, iodine toxicity could potentially occur with each of the other routes of methamphetamine abuse. Given the findings reported in this case, clinicians should be aware of the possibility of iodine toxicity in patients with a history of methamphetamine abuse.

References available on handout

Poster ID: 1253