Kevin Chatham-Stephens

Severe Illness Associated with Reported Use of Synthetic Cannabinoids - Mississippi, April 2015.

On April 2, 2015, four patients were evaluated at the University of Mississippi Medical Center (UMMC) in Jackson, Mississippi, for agitated delirium after using synthetic cannabinoids. Over the next 3 days, 24 additional persons went to UMMC with illnesses suspected to be related to synthetic cannabinoid use; one patient died. UMMC notified the Mississippi State Department of Health, which issued a statewide alert via the Health Alert Network on April 5, requesting that health care providers report suspected cases of synthetic cannabinoid intoxication to the Mississippi Poison Control Center (MPCC). A suspected case was defined as the occurrence of at least two of the following symptoms: sweating, severe agitation, or psychosis in a person with known or suspected synthetic cannabinoid use. A second statewide alert was issued on April 13, instructing all Mississippi emergency departments to submit line lists of suspected patients to MPCC each day. By April 21, 16 days after the first alert was issued, MPCC had received reports of approximately 400 cases, including eight deaths possibly linked to synthetic cannabinoid use; in contrast, during April 2012–March 2015, the median number of telephone calls to MPCC regarding synthetic cannabinoid use was one per month (range = 0–11). The Mississippi State Department of Health, with the assistance of CDC, initiated an investigation to better characterize the outbreak, identify risk factors associated with severe illness, and prevent additional illnesses and deaths.

Notes from the Field: Botulism Outbreak from Drinking Prison-Made Illicit Alcohol in a Federal Correctional Facility — Mississippi, June 2016

Botulism Outbreak from Drinking Prison-Made Illicit Alcohol in a Federal Correctional Facility — Mississippi, June 2016 Lindsey McCrickard, DVM1,2; Mariel Marlow, PhD1,2; Julie L. Self, PhD1,2; Louise Francois-Watkins, MD2; Kevin Chatham-Stephens, MD2; Jannifer Anderson3; Sheryl Hand3; Kathryn Taylor, MD3; Jennifer Hanson3; Keiundria Patrick3; Carolina Luquez, PhD2; Janet Dykes, MS2; Suzanne R. Kalb, PhD4; Kaitlin Hoyt4; John R. Barr, PhD4; Todd Crawford, MSN5; Anthony Chambers, MD5; Brian Douthit5; Robert Cox, MD6; Matt Craig, MD6; John Spurzem, MD6; Joseph Doherty, MD6; Michael Allswede, DO7; Paul Byers, MD3; Thomas Dobbs, MD3

Hepatotoxicity associated with weight loss or sports dietary supplements, including OxyELITE Pro™ — United States, 2013

In September 2013, the Hawaii Department of Health (HDOH) was notified of seven adults who developed acute hepatitis after taking OxyELITE Pro™, a weight loss and sports dietary supplement. CDC assisted HDOH with their investigation, then conducted case-finding outside of Hawaii with FDA and the Department of Defense (DoD). We defined cases as acute hepatitis of unknown etiology that occurred from April 1, 2013, through December 5, 2013, following exposure to a weight loss or muscle-building dietary supplement, such as OxyELITE Pro™. We conducted case-finding through multiple sources, including data from poison centers (National Poison Data System [NPDS]) and FDA MedWatch. We identified 40 case-patients in 23 states and two military bases with acute hepatitis of unknown etiology and exposure to a weight loss or muscle building dietary supplement. Of 35 case-patients who reported their race, 15 (42.9%) reported white and 9 (25.7%) reported Asian. Commonly reported symptoms included jaundice, fatigue, and dark urine. Twenty-five (62.5%) case-patients reported taking OxyELITE Pro™. Of these 25 patients, 17 of 22 (77.3%) with available data were hospitalized and 1 received a liver transplant. NPDS and FDA MedWatch each captured seven (17.5%) case-patients. Improving the ability to search surveillance systems like NPDS and FDA MedWatch for individual and grouped dietary supplements, as well as coordinating case-finding with DoD, may benefit ongoing surveillance efforts and future outbreak responses involving adverse health effects from dietary supplements. This investigation highlights opportunities and challenges in using multiple sources to identify cases of suspected supplement associated adverse events. Published 2016. This article is a U.S. Government work and is in the public domain in the USA.

Exposure Calls to U. S. Poison Centers Involving Electronic Cigarettes and Conventional Cigarettes—September 2010–December 2014

IntroductionE-cigarette use is increasing, and the long-term impact on public health is unclear. We described the acute adverse health effects from e-cigarette exposures reported to U.S. poison centers.MethodsWe compared monthly counts and demographic, exposure, and health effects data of calls about e-cigarettes and conventional cigarettes made to poison centers from September 2010 through December 2014.ResultsMonthly e-cigarette calls increased from 1 in September 2010, peaked at 401 in April 2014, and declined to 295 in December 2014. Monthly conventional cigarette calls during the same period ranged from 302 to 514. E-cigarette calls were more likely than conventional cigarette calls to report adverse health effects, including vomiting, eye irritation, and nausea. Five e-cigarette calls reported major health effects, such as respiratory failure, and there were two deaths associated with e-cigarette calls.ConclusionE-cigarette calls to U.S. poison centers increased over the study period, and were more likely than conventional cigarettes to report adverse health effects. It is important for health care providers and the public to be aware of potential acute health effects from e-cigarettes. Developing strategies to monitor and prevent poisonings from these novel devices is critical.

Clinical Features of Foodborne and Wound Botulism: A Systematic Review of the Literature, 1932–2015

Background Botulism is a rare, potentially fatal paralytic illness caused by neurotoxins. To inform the evaluation of patients with suspected botulism, we conducted a systematic review to describe the clinical features of botulism. Methods We searched Medline Ovid, Embase Dialog, Embase Ovid, Cumulative Index to Nursing and Allied Health Literature (CINAHL) EBSCO, Global Health Ovid, Cochrane Library, Scopus, and ClinicalTrials.gov for English language articles through May 2015. Information abstracted included demographics, signs and symptoms, laboratory results, and clinical outcome for foodborne and wound botulism patients confirmed by laboratory testing, epidemiologic link, or association with an outbreak. The review followed PRISMA guidelines and was registered with PROSPERO (CRD42015024784). Results We identified 402 patients from 233 articles published in English between 1932 and 2015. Most cases (n = 346 [86%]) were foodborne botulism and most (n = 263 [65%]) were associated with an outbreak. The median incubation period was 1 day, and the median time from illness onset to hospital admission was 2 days. Shortness of breath, dyspnea, or respiratory distress or failure at hospital admission was reported in 169 (42%) patients; 71 (42%) reported respiratory involvement without report of extremity weakness. Among 154 patients for whom the hospital day of intubation was reported, 134 (87%) were intubated on the first or second hospital day. Conclusions Botulism patients can experience a range of signs and symptoms. Respiratory involvement may occur early in the illness and can occur without preceding extremity weakness. Clinicians and public health departments preparing for and responding to botulism events should use this information to guide the evaluation of suspected botulism patients.

The Epidemiology of Foodborne Botulism Outbreaks: A Systematic Review

Background We performed a systematic review of foodborne botulism outbreaks to describe their clinical aspects and descriptive epidemiology in order to inform public health response strategies. Methods We searched seven databases for reports of foodborne botulism outbreaks published in English from database inception to May 2015. We summarized descriptive characteristics and analyzed differences in exposure and toxin types by geographic region. We performed logistic regression to assess correlations between exposure source, implicated food, and outbreak size. Results There were 197 outbreaks reported between 1920 and 2014. The median number of cases per outbreak was 3 (range 2-97). The majority of reported outbreaks (109; 55%) occurred in the United States. Toxin types A, B, E, and F were identified as the causative agent in 34%, 16%, 17%, and 1% of outbreaks, respectively. The median duration between exposure and symptom onset was approximately 1 day. The mean percentage of cases requiring mechanical ventilation per outbreak was 34%. Seventy percent of all outbreaks and 77% of small outbreaks (≤11 cases) originated from point source exposures, while commercial foods were significantly (odds ratio, 6.9; 95% confidence interval, 2.2-21.1) associated with large outbreaks (≥12 cases). Conclusions Toxin type A accounted for half of outbreaks, and these outbreaks had a higher proportion of patient ventilatory failure. Most outbreaks were due to point source exposures, while outbreaks due to commercial food were larger. For effective responses to foodborne botulism outbreaks, these findings demonstrate the need for timely outbreak investigation and hospital surge capacity.

Clinical Criteria to Trigger Suspicion for Botulism: An Evidence-Based Tool to Facilitate Timely Recognition of Suspected Cases During Sporadic Events and Outbreaks

Effective treatment for botulism requires early clinical recognition. Diagnosis of botulism, including during outbreaks, can be challenging. We assessed combinations of signs and symptoms among confirmed cases and identified sensitive clinical criteria to trigger suspicion. We produced a tool that may facilitate rapid identification of sporadic and outbreak-associated cases.

Adult intestinal colonization botulism mimicking brain death

A 43-year-old woman, with a history of mild intellectual disability and no recent travel nor known toxic exposures, presented to another medical facility after awaking with nausea, lethargy, and unsteadiness. In the emergency room, she developed dysphagia, dysarthria, and hypercapnic respiratory failure requiring intubation. Laboratory studies showed a mild leukocytosis. Computed tomography of the head showed no acute abnormality. Lumbar puncture (LP) showed 2 white blood cells/mm and protein 29 mg/dl. Over several days, she developed sluggish pupils, impaired extraocular movements, and quadriparesis. On day 8, nerve conduction studies (NCS) showed normal sural sensory responses and absent motor responses. She received a 5-day course of intravenous immunoglobulin for treatment of suspected Guillain–Barr e syndrome (GBS), but her weakness worsened. She was transferred to our neuroscience intensive care unit on day 10. On admission, she was unresponsive to voice or painful stimuli, and pupils were fixed and dilated. Corneal, oculocephalic, cough, and gag reflexes were absent. Muscle tone was reduced with absent tendon reflexes and mute plantar responses. Her abdomen was distended with minimal bowel sounds. She demonstrated lability in blood pressure and heart rate. Laboratory studies showed normal creatine kinase. Electroencephalogram (EEG) showed low to medium voltage activity, no definite posterior basic rhythm, but intact sleep architecture. Transcranial Doppler studies (TCDs) demonstrated normal cerebral blood flow. Magnetic resonance imaging of the brain showed no acute abnormalities. On day 11, electrodiagnostic testing was repeated. NCS showed normal sensory nerve action potentials (SNAPs) and absent compound muscle action potentials (CMAPs) with stimulation of facial, musculocutaneous, median, ulnar, peroneal, and tibial nerves. CMAPs were unrecordable with 50-HZ repetitive stimulation. Needle electromyography (EMG) showed silence at rest. The patient was unable to generate volitional motor unit potentials. Repeat LP on day 12 showed 1 white blood cell/mm, protein 16 mg/dl, and negative West Nile virus (WNV) RNA and antibodies. Serum and stool botulism testing and ganglioside antibody testing for GM1, GD1 subtypes, myelin-associated glycoprotein, and sulfated glucuronyl paragloboside were sent. Plasma exchange was initiated for suspected GBS. On day 21, mouse bioassay, using serum collected 9 days earlier, was preliminarily positive for botulinum toxin. Endopeptidase–mass spectrometry (Endopep-MS) on serum from day 10 later confirmed botulinum toxin type A. Heptavalent botulinum antitoxin was administered on day 23 and, 10 days later, pupil reactivity and gut motility began to improve. By this time, ganglioside antibody testing returned negative and stool cultures grew Clostridium botulinum type A. Repeat serum and stool samples were collected on day 35. Because of delayed clinical improvement and concern for adult intestinal colonization, a second dose of antitoxin was administered on day 36. Follow-up nerve conduction studies were unchanged; however, EMG showed fibrillation potentials and positive sharp waves, consistent with an acute, ongoing process given silence on the previous EMG. Again, no volitional motor unit potentials were recruited. By day 38, slight muscle movements were observed. C. botulinum type A was identified by enzyme-linked immunoassay and polymerase chain reaction in stool, suggesting persistent gastrointestinal colonization. Botulinum toxin was not detected in serum drawn on day 36. A 14-day course of oral vancomycin was initiated. Upon discharge to a ventilator care facility on day 59, extraocular movements were improving but she was still quadraparetic. She eventually achieved independence from the ventilator during daytime hours, but died from an unwitnessed cardiopulmonary arrest 8 months after onset. This is a rare presentation of an adult with intestinal C. botulinum colonization who, on arrival to our institution, had a neurological examination indistinguishable from brain death. According to American Academy of Neurology guidelines, an irreversible cause of coma must be established for brain death diagnosis, which was lacking. Furthermore, EEG and TCDs were inconsistent with brain death. NCS demonstrated a profound motor VC 2017 Wiley Periodicals, Inc.

Severe illness associated with reported use of synthetic cannabinoids: a public health investigation (Mississippi, 2015)

Abstract Study objectives: In April 2015, a multistate outbreak of illness linked to synthetic cannabinoid (SC) use was unprecedented in magnitude and severity. We identified Mississippi cases in near-real time, collected information on cases to characterize the outbreak, and identified the causative SC. Methods: A case was defined as any patient of a Mississippi healthcare facility who was suspected of SC use and presenting with ≥2 of the following symptoms: sweating, severe agitation, or psychosis during April 2–May 3, 2015. Clinicians reported cases to the Mississippi Poison Control Center (MPCC). We used MPCC data to identify cases at the University of Mississippi Medical Center (UMMC) to characterize in further detail, including demographics and clinical findings. Biologic samples were tested for known and unknown SCs by liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF/MS). Results: Clinicians reported 721 cases (11 deaths) statewide; 119 (17%) were UMMC patients with detailed data for further analysis. Twelve (10%) were admitted to an intensive care unit and 2 (2%) died. Aggression (32%), hypertension (33%), and tachycardia (42%) were common. SCs were identified in serum from 39/56 patients (70%); 33/39 patients (85%) tested positive for MAB-CHMINACA (N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide) or its metabolites. Compared to all patients tested for SCs, those positive for MAB-CHMINACA were more likely to have altered mental status on examination (OR = 3.3, p = .05). Conclusion: SC use can cause severe health effects. MAB-CHMINACA was the most commonly detected SC in this outbreak. As new SCs are created, new strategies to optimize surveillance and patient care are needed to address this evolving public health threat.