Faculty Bibliography

INTRODUCTION: Palytoxin (PTX) is considered a severe marine toxin. Although rare, reports of human exposure from consumption of PTX have described significant morbidity and mortality. PTX is the suspected agent in Haff disease, in which rhabdomyolysis occurs within 24 h of eating contaminated fish such as buffalo fish. PTX is primarily present in soft corals or in dinoflagellates, and it can contaminate crustaceans and other fish as it bioaccumulates up the food chain. Only 23 cases have been reported in the USA, including two recent cases in New York City. Reports of inhalational exposure to PTX are uncommon. CASE REPORTS: We describe a case series of six patients, including four adults and two children, with inhalational exposure to PTX aerosolized from Palythoa corals. Their symptoms included some degree of respiratory involvement, myalgias, paresthesias, low-grade fevers, and gastrointestinal symptoms. Fortunately, there were no serious outcomes and all patients survived without sequelae. DISCUSSION: Although rare, exposure to palytoxin is not restricted to people visiting marine environments because of Palythoa coral in some home aquariums. Routes of exposure go beyond consumption of fish that feed on the coral and include dermal as well as inhalational exposure. Palytoxin exposure should be considered in the differential diagnosis of patients who own or work with fish tanks and present with symptoms that include respiratory complaints, myalgias, neuromuscular dysfunction, hemolysis, and cardiac toxicity. There is no known antidotal therapy and treatment should focus on meticulous supportive care.

BACKGROUND: Little is known about the effects of synthetic cannabinoids. There has been only one previous report of a withdrawal syndrome from synthetic cannabinoids. We report two cases of a withdrawal syndrome from prolonged habitual use of synthetic cannabinoids. DISCUSSION: Withdrawal from delta-9-THC has been described as a syndrome of anxiety, myalgias, chills, and anorexia. Synthetic cannabinoids are potent than delta-9-THC and thus the withdrawal syndrome is similar but more severe; however the symptoms do not seem to improve with delta-9-THC. The differences in presentation could be due to the fact that synthetic products may contain several heterogeneous compounds, including amphetamine-like substances. CONCLUSIONS: The acute withdrawal syndrome appears to be characterized mainly by anxiety and tachycardia in the absence of any neurological findings or electrolyte disturbances. We describe two patients with symptoms consistent with withdrawal presumably due to synthetic cannabinoid use. The most appropriate treatment for such patients remains unknown, however benzodiazepines are a reasonable first line approach and quetiapine may have some efficacy.