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Colchicine poisoning occurs due to the ingestion of colchicine, a drug derived from the plant colchicum autumnale, and can be life-threatening.
Pathophysiology
Colchicine's toxicity arises primarily from its mechanism of action, which involves binding to tubulin and disrupting microtubule formation, leading to impaired cellular processes. This disruption affects rapidly dividing cells, particularly in the gastrointestinal tract and bone marrow, resulting in significant gastrointestinal symptoms such as nausea, vomiting, and diarrhea due to rapid turnover of intestinal mucosal cells. The drug is metabolized in the liver, primarily by cytochrome P450 enzymes, leading to the formation of several metabolites, including 3-demethylcolchicine (3DMC) and 2-demethylcolchicine (2DMC). These metabolites can exhibit increased toxicity compared to the parent compound, contributing to hepatic injury and other systemic effects. As colchicine inhibits mitosis by preventing spindle formation, it leads to multi-organ dysfunction. The early phase (10-24 hours post-ingestion) is characterized by gastrointestinal distress and initial leukocytosis. In the subsequent phase (2 to 7 days), patients may experience severe complications including renal failure, disseminated intravascular coagulation (DIC), and cardiac issues due to direct toxicity on cardiac myocytes. The high affinity of colchicine for tissues like the liver and kidneys contributes to its rapid accumulation in these organs, leading to further complications.
Symptoms
Symptoms typically manifest in three phases:
Phase 1 (10-24 hours)
This initial phase is characterized primarily by gastrointestinal symptoms, which can be severe and debilitating. The most common early symptoms include nausea, vomiting, and abdominal pain, often intense and persistent. Diarrhea is another hallmark symptom, potentially becoming profuse and even bloody in severe cases. These symptoms can lead to significant dehydration due to excessive fluid loss. patients may develop peripheral leukocytosis, an early increase in white blood cell count. This is often accompanied by electrolyte imbalances, including hyponatremia, hypocalcemia, and hypokalemia. The severe fluid loss and electrolyte disturbances can result in metabolic acidosis. Cardiovascular symptoms may also manifest during this phase. Hypotension can occur as a result of the severe vomiting and diarrhea, often accompanied by tachycardia as a compensatory mechanism. Some patients may develop a fever.
In more severe cases of colchicine poisoning, additional symptoms may appear during this initial phase. These can include scleral icterus (yellowing of the whites of the eyes), oliguria (decreased urine output), and peripheral cyanosis (bluish discoloration of extremities). Some may experience hypothermia. It's crucial to note that even if symptoms appear mild during this initial phase, patients should be closely monitored. The onset of severe toxicity can be delayed, and the progression to subsequent phases can occur rapidly. Therefore, any suspected case of colchicine poisoning should be treated as a medical emergency, regardless of the initial presentation's severity.
Phase 2 (2-7 days)
Phase 2 of colchicine poisoning is characterized by multi-organ dysfunction and potentially life-threatening complications. This phase is associated with a high mortality risk due to the potential for multi-organ failure and severe systemic effects.
One of the primary features of this phase is bone marrow suppression, which can lead to pancytopenia, including neutropenia, thrombocytopenia, and anemia. This hematopoietic inhibition increases the risk of severe infections, which can develop into sepsis, and bleeding tendencies. Cardiovascular complications are common during this phase. Patients may experience cardiac arrhythmias, hypotension, and in severe cases, cardiogenic shock or cardiac arrest. Respiratory complications can also occur, with some patients developing acute respiratory distress syndrome (ARDS) that may necessitate mechanical ventilation. Renal dysfunction is another hallmark of this phase, with oliguric renal failure being a common occurrence. This often requires renal replacement therapy, such as continuous kidney replacement therapy (CKRT). Hepatic dysfunction may also develop, contributing to coagulopathy and metabolic disturbances. Neurological effects can manifest as changes in mental status, ranging from confusion to coma. Rhabdomyolysis, the breakdown of muscle tissue, can occur during this phase, exacerbating renal failure. The combination of these multi-system effects often results in a clinical picture of multiple organ failure, which may include hepatic, renal, respiratory, and circulatory failure.
Phase 3 (beyond 7 days)
Phase 3 typically occurs beyond 7 days after ingestion and is characterized by recovery and some distinctive symptoms.
A significant increase in white blood cell count occurs during this phase, contrasting with the bone marrow suppression seen in earlier stages. Alopecia is a common feature of this phase, often temporary but sometimes extensive. While improvement begins, full recovery can take several weeks.
It's important to note that not all patients experience all three phases distinctly. Some may have overlapping symptoms or skip certain phases entirely. Additionally, long-term effects may persist even after the acute poisoning has resolved. The occurrence and severity of Phase 3 symptoms largely depend on the initial dose ingested, the timeliness of treatment, and individual patient factors.
Diagnosis
Diagnosis of colchicine poisoning is primarily clinical and relies on a combination of patient history, presenting symptoms, laboratory findings, and sometimes electrocardiographic (ECG) changes. A thorough history is crucial; it includes details about the timing of ingestion, amount consumed, and any co-ingestants. Patients often present with gastrointestinal symptoms shortly after ingestion. Blood tests show an increase in white blood cell count, as well as possible hypokalemia or hypocalcemia. Elevated liver enzymes (AST and ALP) indicate hepatic involvement. Prolonged prothrombin time (PT) and activated partial thromboplastin time (PTT) are significant indicators of coagulopathy associated with severe poisoning. ECG monitoring is critical due to potential cardiac toxicity. Common abnormalities include ST segment changes (elevation or depression), sinus tachycardia, and left atrial enlargement. These findings correlate with poorer outcomes. While not routinely employed for diagnosis, imaging may be utilized to assess for complications such as pulmonary edema or abdominal pathology if indicated by clinical presentation.
Treatment
The treatment of colchicine poisoning is primarily supportive since there is no specific antidote available. If colchicine ingestion has occurred within a few hours, activated charcoal should be administered promptly. Multiple-dose activated charcoal (MDAC) may be beneficial since colchicine undergoes Enterohepatic recirculation; this helps interrupt the cycle and enhances elimination. However, it must be noted that this approach is less effective in patients who are vomiting or have significant gastrointestinal distress. Patients often present with hypovolemia due to fluid losses from vomiting and diarrhea. Large volumes of intravenous fluids are required for rehydration. Monitoring fluid balance is critical throughout the treatment process. Electrolyte imbalances such as hypokalemia should be corrected promptly through supplementation. Continuous monitoring of electrolyte levels is essential during treatment. Patients exhibiting signs of multi-organ failure require intensive monitoring and supportive care measures. This may include vasopressors for hypotension, renal replacement therapy if renal failure occurs, and management of any infectious complications that arise during hospitalization. Although hemodialysis and hemoperfusion are generally considered ineffective due to colchicine's large volume distribution, they have been used in severe cases where patients do not respond adequately to other treatments. In some instances, plasma exchange has been explored but remains controversial. In extreme cases involving severe cardiogenic shock or multi-organ failure unresponsive to conventional therapies, extracorporeal life support has been utilized successfully. This approach provides temporary support while allowing time for recovery from toxic effects.
Risks
Many cases of colchicine poisoning occur unintentionally. Children are particularly at risk; studies indicate that approximately 43% of reported cases involve toddlers who gain unsupervised access to colchicine tablets. Due to their small size, even one or two tablets can lead to severe toxicity. A substantial proportion of poisonings arise from dosing errors among adults who misunderstand how to take colchicine properly or exceed recommended doses in attempts to manage gout symptoms effectively. Doses greater than 0.5 mg/kg can be fatal. Certain groups are at higher risk for severe toxicity including individuals with pre-existing renal or hepatic impairment, those with gastrointestinal or cardiac diseases, and patients at extremes of age—particularly elderly individuals who may have multiple comorbidities.
Prognosis
The prognosis of colchicine poisoning varies significantly depending on the severity of the overdose and the timeliness of treatment. Colchicine doses >0.5 mg/kg, and especially >0.8 mg/kg, are generally fatal. In severe cases, the mortality rate can be significant. In one series of 21 cases of colchicine poisoning, 14.3% of patients died. Survivors may experience a prolonged recovery period, with some symptoms persisting for weeks or even months after the acute poisoning event.