Case: 22 year old female is admitted to the ICU with supraventricular tachycardia (SVT), premature atrial complexes (PACs), and hypotension. EKG also showed inverted T waves and prolonged QT and PR intervals. FoCUS at the bedside showed pericardial effusion. On exam, the patient appears to have weak skeletal muscle tone, strength, and weak reflexes. Lab showed elevated Liver enzymes. The patient has been previously admitted to the hospital with electrolyte imbalances and has been diagnosed with bulimia nervosa. Patient acknowledged that recently she started using Ipecac.
Answer: About one in five patients with bulimia nervosa may ingest ipecac to induce vomiting. Ipecac contains emetine, which, along with electrolyte imbalances, causes severe cardiac and skeletal muscle myopathy. Emetine is eliminated from patients very slowly. It can be found in urine even after two months of use. Small, chronic doses may have cumulative and fatal toxicity. Moreover, the absorption of emetine is enhanced in patients who become refractory to the emetic effects of the drug with chronic misuse. The worst part is that emetine accumulates in cardiac muscle cells, is toxic and emetine induced cardiomyopathy may be irreversible. Although cases have been reported of reversibility but cardiac dysfunction from associated electrolyte abnormalities is hard to distinguish. The only treatment is supportive care. There is no antidote.
Fortunately, skeletal muscle weaknesses can be reversed, though slowly, with physical therapy as emetine gets eliminated from the body.
#toxicology
References:
1. Effects of ipecac on the heart. N Engl J Med. 1986 May 8;314(19):1253-5. doi: 10.1056/NEJM198605083141914. PMID: 2871487.
2. Steffen KJ, Mitchell JE, Roerig JL, Lancaster KL. The eating disorders medicine cabinet revisited: a clinician's guide to ipecac and laxatives. Int J Eat Disord 2007; 40:360.
3. Westmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. Am J Med 2016; 129:30.
4. Dresser LP, Massey EW, Johnson EE, Bossen E. Ipecac myopathy and cardiomyopathy. J Neurol Neurosurg Psychiatry. 1993 May;56(5):560-2. doi: 10.1136/jnnp.56.5.560. PMID: 8099367; PMCID: PMC1015020.
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