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Pet Poison Helpline ©20173600 American Blvd. W., #725 B loomington , MN 55431www.petpo isonhe lp l ine .com

Outdoor Toxins:Don’t let these poisons ruin your

summertime fun

Ahna Brutlag, DVM, MS, DABT, DABVTAssociate Director of Veterinary Services & Sr. ToxicologistPet Poison Helplineabrutlag@petpoisonhelpline.com&Adjunct Assistant ProfessorDept. Veterinary Biomedical SciencesCollege of Vet. Med., University of Minnesota

June 13, 2017

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• 24/7 animal poison control center

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• Educational center– Free webinars (archived)

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Email us for info!

Whole Pet with Wellness® from Nationwide

Carol McConnell, DVM, MBA

Chief Veterinary Officer

June, 2017

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Jennifer & Kimberly with Hank

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Andrew & Elizabeth with Olive

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Speaker IntroductionAhna G. Brutlag, DVM,

MS, DABT, DABVT

Associate Director of Veterinary Services

&

Senior Veterinary Toxicologist

Pet Poison Helpline

Minneapolis, Minnesota

&Adjunct Assistant Professor

College of Veterinary Medicine University of Minnesota

“Sherman” & Ahna

Today’s Lecture

• Case-based approach

• Recognize signs of selected toxins

• Understand approach to management/treatment

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CASE 1“Patrick”

History

• 13-week-old Boxer puppy, ~ 5 kg

• Pine Grove, CA

• Presented with acute hepatic and renal failure within 24 hours of being fed Wellness Well Bites Beef and Turkey Recipe soft and chewy treats.

• Treatment was instituted but the dog died of “multiple organ failure”.

Ingredients: Beef, Turkey, Ground Brown Rice, Oatmeal, Vegetable Glycerin, Guar Gum, Cane Molasses, Carrots, Salt, Natural Smoke Flavor, Garlic, Blueberries, Flaxseed, Sweet Potatoes, Apples, Phosphoric Acid (a natural acidifier), Sorbic Acid (a preservative), and Mixed Tocopherols (a natural preservative).

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Gross Postmortem

• Moderate autolysis

• Generalized pallor and yellow tinge to body organs and fat

• Slightly firm liver, pale and yellow-tinged

• Stomach, intestines, mesentery – diffusely edematous

• Melena

• Pulmonary edema

• Heart – diffusely and severely pale

Histopathology

• Massive acute hepatic necrosis

• Marked intestinal crypt necrosis/cryptitis

• Severe, bilateral acute tubular necrosis

• Pulmonary edema

• Segmental acute neuronal necrosis

Differentials

• ?

• ?

• ?

• ?

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Differentials

• Infectious disease– Salmonella

– Canine distemper virus

• Toxins– Fungus from pet treats?

– Ricin/abrin (castor bean/rosary pea)

– Blue-green algae (cyanobacteria)

– Gyromitrin (mushroom)

– Acetaminophen

– Iron, zinc

Tests

• Salmonella PCR and confirmation culture: lung, liver, spleen, mesenteric lymph node and feces

• Fecal examination: no parasite eggs detected

• Canine distemper virus IHC: negative

• Toxicology– Microcystins on stomach contents

– α-amanitin on kidney

Diagnosis

Amanitin mushroom intoxication!

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A. phalloides

A. ocreata

Wide distribution in the U.S.

Death cap or death angel

Western N. American destroying angel

Hepatoxic Amanitas

• Common locations (A. phalloides)

– San Francisco Bay, Pacific NW, NE US

– Oak, birch, white pine in wet/warm years

Hepatoxic mushrooms

• Cyclopeptides

• Amanita spp., Lepiota spp., Galerina spp.

• Toxin = amanitins

• Not destroyed in stomach, by cooking or freezing

• 1 mushroom can be fatal!

• MOA: Inhibit RNA polymerase & apoptosis– Hepatocytes, intestinal mucosa, renal tubules

• Oral LD50 (dog) = 0.5 mg/kg– Oral LD50 (human) = 0.1 mg/kg

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Amanitin, signs

• CLINICAL SIGNS– Phase 1: GI phase – Vomiting, severe abdominal pain, bloody diarrhea.

– Phase 2: Quiet phase – 24 hours to few days

– Phase 3: Hepatic phase - Characterized by increases in all liver enzymes, coagulopathy, encephalopathy, coma and death. Severe hypoglycemia in 50% of dogs.

– Phase 4: Renal phase – Animals that survive hepatic phase usually die of renal disease (proximal and distal necrosis). Death in 3-5 days after ingestion.

• TESTING

– Antemortem: Urine, serum, vomit, gavage fluid

– Post-mortem: Kidney, liver

Amanitin treatment

• No antidote

• Decontaminate ASAP

• Monitor labs closely x 2-3 days

• IV fluids

• GI support

• Hepatoprotectants– Silibinin 50 mg/kg IV @ 5 & 24 hrs

• Other– Penicillin G 1,000 mg/kg IV

• OATP1B3 substrate

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Mushroom ID Tips

• Many thousand species, <100 toxic in N. America

• To identify

– Collect in paper bag (not plastic), wrap in wax paper

– Label “Do not eat!”

– Photo surrounding environment

– Take to mycologist

More toxic mushrooms

• Neurotoxic– Hallucinogenic mushrooms (“magic mushrooms”)

• E.g., Psilocybe, Panaeolus, Conocybe and Gymnopilus

• Ataxia, vocalization, nystagmus, aggression, hyperthermia

– Isoxazoles: Contain ibotenic acid & muscimol• E.g., Amanita pantherina& Amanita muscaria

• Ataxia, sedation, muscle spasms, seizures

• Muscarinic (muscarine containing)– E.g., Inocybe spp., Clitocybe spp., Amanita muscaria

– SLUDGE, bradycardia, miosis

• False morel – Gyromitra spp. & Helvella spp.

– Vomiting, abdominal pain, diarrhea, seizures

• Nephrotoxic– E.g., Cortinaria spp, Amanita smithiana

Ode to mushroom fanatics

There are bold

mushroom hunters

and there are old

mushroom hunters,

but there are no old,

bold mushroom hunters.

Chuck Barrows, New Mexico

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FRANK’S FOLLYCase 2

• “Frank”

• 6 yo, 18 kg, intact male, pit bull, healthy

• UTD on vaccines

• Heartworm/flea/tick preventative 2 weeks prior

• In North Carolina

• 6am: lip licking, tremoring, erythematous, ataxic

What toxin could cause Frank’s

signs?

A. Bromethalin rodenticide

B. Grapes or raisins

C. Moldy food

D. Pyrethroid insecticide

E. Xylitol

Audience Poll

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Frank’s case

• More history…– Insecticide applied to ant hill

day prior

– Bifenthrin, 0.2%

• 12 pm: Arrives at hospital– PE: Very mild tremors

– Labs WNL

• Discharged same day

Bifenthrin

• Pyrethroid insecticide

• 1,000 canine cases @ PPH

• Common sources @ PPH:– Ortho Bug-G-Gone granules, 0.115%

– Ortho Home Defense Insect Killer for Lawns/Landscape, 0.3%

– Talstar products (many varieties)

– Eliminator Ant, Flea and Tick Killer granules, 0.1%

– Menards Premium Lawn & Landscape Insect Control granules, 0.115 %

– Eliminator Fire Ant Killer Plus Granules II, 0.1%

– Over N' Out Ant Poison (granules), 0.2 %

Bifenthrin, clinical signs

• Onset: 30 min-few hours, rarely delayed 6-12 hrs

• CNS & GI

– Ataxia, weakness, tremors (generalized), seizures, mydriasis (rare)

– Hypersalivation, nausea, vomiting, diarrhea (rare)

• Very limited data in literature

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Bifenthrin, treatment

• Treat them like a cat vs pyrethroid– Methocarbamol IV

– Anti-convulsants (if needed)

– Monitor temp/lytes

– IVF for perfusion and temp control

• GI decontamination only if stable/appropriate timing

• Diagnostic testing @ D-Lab (e.g., UC Davis)

SDS/MSDS Confusion

• May have VERY limited info regarding health effects

“ROSIE”

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“Rosie”

• 4 yo, 6 kg, FS Jack Russell terrier

• PMH: Corneal transplant with

ophthalmic tacrolimus and gentamicin

• Early September in East Hampton, NY

• Found on beach (river estuary) near carcass

• Laterally recumbent, non-responsive, and shaking.

• Large amount of sand in her mouth/throat.

• Multiple seizures en route to hospital

Rosie, presentation to ER

• Valium and charcoal @ rDVM

• PE @ ER: – HR 136 bpm

– RR 160/min

– T 102.3 F

– MM pink, moist, CRT <2 sec, petechiae on gums

– Absent menace & PLRs, miotic pupils OU

– Nonresponsive

– BP = 58 mmHg systolic

– Pulse ox = 85%, on O2 = 95%

Rosie, Labs @ ER

• PCV/TP 58% / 6.6

• CBC: WBC 5000, plts 149K

• Blood gas– Respiratory acidosis (pCO2 54.8 [35-45 mmHg], pH 7.15 [7.33-7.45]) &

Na 152.4 (139-151 mmol/L)

• Chem: – BUN 36 (9-29 mg/dL), creat 1.4 (0.4-1.4 mg/dl), glucose 14 (75-125

mg/dl), ALT 269 (0-120 U/L), GGT 30 (0-14 U/L)

• Coag: PT 19 sec (12-17), PTT WNL

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Rosie, Labs @ ER

• PCV/TP 58% / 6.6

• CBC: WBC 5000, plts 149K

• Blood gas– Respiratory acidosis (pCO2 54.8 [35-45 mmHg], pH 7.15 [7.33-7.45]) &

Na 152.4 (139-151 mmol/L)

• Chem: – BUN 36 (9-29 mg/dL), creat 1.4 (0.4-1.4 mg/dl), glucose 14 (75-125

mg/dl), ALT 269 (0-120 U/L), GGT 30 (0-14 U/L)

• Coag: PT 19 sec (12-17), PTT WNL

Rosie, Labs @ ER

• PCV/TP 58% / 6.6

• CBC: WBC 5000, plts 149K

• Blood gas– Respiratory acidosis (pCO2 54.8 [35-45 mmHg], pH 7.15 [7.33-7.45]) &

Na 152.4 (139-151 mmol/L)

• Chem: – BUN 36 (9-29 mg/dL), creat 1.4 (0.4-1.4 mg/dl), glucose 14 (75-125

mg/dl), ALT 269 (0-120 U/L), GGT 30 (0-14 U/L)

• Coag: PT 19 sec (12-17), PTT WNL

Radiographs @ ER

• Small caudal vena cava

– Incidental or hypovolemia?

• Mineralized GI contents

– Stomach through small intestine• Charcoal?

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Rosie’s treatment

• 85 mL Norm-R, BP normal

• 8 mL 25% dextrose, BG = 79

• Cerenia, ranitidine

• O2 PRN

• 3 hrs later

– Pupils mid-range, responsive. Menace absent.

– Sternal and looking around.

– Mild ataxia

Rosie Day 2

• 4am: PCV/TP: 60% / 6.0– Worsening petechia on gums

– Frank blood on rectal

– PT/PTT out of range. FFP transfusion (17 ml/kg)

– If off dextrose, BG = 20

• 4pm: PCV/TS: 50%/7.0– ALT >1,000; GGT 77; platelets 70K

– Bleeding R nostril/mouth, petechia worsening

– 2nd FFP transfusion

– ↑ IV fluids! (3.5 x maint)

Day 2, con’t

• 7 pm

– Rads: Same mineral material in stomach/sm intest• Suspect functional ileus vs outflow obstruction

– Gastric lavage• “Sand and various particles”

• Gave charcoal

• 8 pm

– PT 56, PTT 121 (improved!)

– BG = 84 on dextrose

• 11pm

– 3rd FFP transfusion (13 ml/kg)

– Vomits and defecates charcoal

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Day 3

• Slight mental improvement/standing some

• 4th FFP transfusion

• Continues dextrose

• Cardiopulmonary arrest

Differential Diagnoses?

What toxin could cause Rosie’s signs?

A. Raisins or grapes

B. Sunscreen

C. Toxic jellyfish

D. Euthanized carcass

E. Blue-green algae

Audience Poll

Rosie, tox testing

• Cornell University

• Stomach contents– Visible blue-green

algae (cyanobacteria)

– Microcystin ELISA,

strong positive

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Blue-green algae

• Actually, they’re bacteria

– 2,000 species

– 95 can produce toxins

– Anabaena spp, Microcystis spp, and Aphanizomenonspp.

– Warm, sunny, nutrient rich water

• 3 main toxins– Microcystin

– Anatoxin-a

– Anatoxin-a(s)

Dr. Birgit Puschner, UC Davis

Cyanobacteria toxins

1. Microcystin(hepatotoxin)– Most common

– Oral LD50 mice = 5-11 mg/kg

– Irreversibly inhibit protein phosphatase 1 and 2A

– Cellular collapse, apoptosis, necrosis

– Shock, +/- rapid death, death from hepatic failure

– Poor prognosis

Dr. Birgit Puschner, UC Davis

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Cyanobacteria toxins

2. Anatoxin-a (neurotoxin)– Oral LD50 mice = 5 mg/kg

– Nicotinic agonist (continuous stimulation @ nicotinic receptors)

– Immediate signs!

– Tremors, muscle rigidity, seizures… depolarizing blockade & paralysis.

3. Anatoxin-a(s) (neurotoxin)– Acetylcholinesterase inhibitor (like OPs and carbamates), irreversible

– Immediate signs!

– Continuous stimulation @ cholinergic receptors

• SLUD signs, vomiting, excess respiratory secretions

• ‘S’ for salivation

• Give atropine!

– Does not cross blood brain barrier (insecticides can)

• 2-PAM ineffective

• Brain AChE concentrations normal (depressed with most insecticides)

Cyanobacteria toxins

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info@petpoisonhelpline.com

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Tox Goodies!Free to order: info@petpoisonhelpline.com

Our iPhone appDetails 200+ toxins

$1.99

Blackwell’s Five-Minute Veterinary Consult Clinical Companion:

Small Animal Toxicology 2nd Edition

Drs. Lynn Hovda, Ahna Brutlag, Robert Poppenga, Katherine Peterson

www.wiley.com/go/vet

Paperback | May 2016 | 960 pages | 978-1-119-03654-8 | $109.99 · CAN $120.99

• Provides concise, bulleted information focused on the most important facts needed when treating a poisoned cat or dog

• Carefully organized for ease of use in an emergency, with important toxicants arranged alphabetically within categories

• Details clinically relevant information on the most common toxicants encountered by small animals

• Presents a wealth of color photographs to aid in plant identification

• Includes 14 new topics to this edition covering cyclosporine A, sleep aids, tacrolimus, bath salts, synthetic marijuana, poisonous lizards, imidacloprid, spring bulbs, and sodium monofluoroacetate

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Acknowledgements

• Robert H. Poppenga, DVM, PhD, DABVT

CAHFS Toxicology Laboratory

School of Veterinary Medicine

University of California, Davis

• Karyn Bischoff, DVM, MS, DABVT

NY State Animal Health Diagnostic Center

Cornell University

• Jo Marshall, CVT

Pet Poison Helpline (Montana)

• Lynn Hovda, RPh, DVM, MS, DACVIM

Pet Poison Helpline (Minnesota)

Thank you for attending!

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2. I attended the webinar but wasn’t the person who logged in. Can I still get interactive CE credit? Yes. Send your name and email address to info@petpoisonhelpline.comby 1pm central time on June 14, 2017 (strict deadline).

3. Can I watch the recorded webinar online for CE credit? Yes. You can receive non-interactive CE credit. Go to the “For Vets” page on our website, www.petpoisonhelpline.comfor more info.

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