Near-fatal poisoning after ricin injection

Objective:To report a near-fatal poisoning after intentional injection of ricin from a castor bean (Ricinus communis) extract. Case report:A 21 year-old man self-injected similar to 3 mL of a castor bean extract intramuscularly and subcutaneously in the left antecubital fossa. Upon admission to our ED (1 h post-exposure; day 1, D1) he was awake and alert, but complained of mild local pain and showed slight local edema and erythema. He evolved to refractory shock (similar to 24 h post-exposure) that required the administration of a large volume of fluids and high doses of norepinephrine and vasopressin, mainly from D2 to D4. During this period, he developed clinical and laboratory features compatible with systemic inflammatory response syndrome, multiple organ dysfunction, capillary leak syndrome, rhabdomyolysis, necrotizing fasciitis and possible compartment syndrome. The patient underwent forearm fasciotomy on D4 and there was progressive improvement of the hemodynamic status from D7 onwards. Wound management involved several debridements, broad-spectrum antibiotics and two skin grafts. Major laboratory findings within 12 days post-exposure revealed hypoalbuminemia, proteinuria, thrombocytopenia, leukocytosis and increases in cytokines (IL-6, IL-10 and TNF-alpha), troponin and creatine kinase. Ricin A-chain (ELISA) was detected in serum up to D3 (peak at 24 h post-exposure), with similar to 79% being excreted in the urine within 64 h post-exposure. Ricinine was detected in serum and urine by LC-MS up to D5. A ricin A-chain concentration of 246 mu g/mL was found in the seed extract, corresponding to the injection of similar to 738 mu g of ricin A-chain (similar to 10.5 mu g/kg). The patient was discharged on D71, with limited range of motion and function of the left forearm and hand. Conclusion:Ricin injection resulted in a near-fatal poisoning that evolved with septic shock-like syndrome, multiple organ dysfunction and necrotizing fasciitis, all of which were successfully treated with supportive care.

Automated summary

This case report describes a near-fatal poisoning due to intentional injection of ricin, resulting in septic shock-like syndrome, multiple organ dysfunction, and necrotizing fasciitis. The patient was successfully treated with supportive care, leading to gradual improvement and discharge on day 71 with limited range of motion and function of the left forearm and hand.