A Mysterious Case of Weakness, Low Potassium, and Kidney Injury

Show NotesIn this special live episode from the 2025 North American Congress of Clinical Toxicology (NACCT), Ryan takes you inside the conference to hear directly from the researchers themselves. Covering 11 abstracts that span high-stakes management decisions, surprising case reports, and challenges to toxicology dogma, this year’s highlights feature everything from amlodipine overdoses to naturopathic misadventures, metformin-associated blindness, and more. The show kicks off with a foreword from Ryan and Dr. Jon Cole (abstract co-chair for AACT) discussing some of their favorite research from the conference. If you couldn’t make it to NACCT or just want to catch up on some of the most impactful new research in our field, this episode will give you a front-row seat. Check below for links to the published abstracts, the full list of studies discussed, and timestamps for where you can hear each one.Link to published abstract manuscriptForeword with Dr. Jon Cole 10:43 #7. Is beta blocker toxicity associated with hypoglycemia?Lead author: Dr. Megan Audette, MD18:17 #237. V-A ECMO as a treatment for vasoplegic shock in amlodipine poisoning: a comparisonLead author: Dr. Daniel Tirado, MD27:59 #247. Blocked but not beaten: ECMO’s role in severe amlodipine toxicity – a poison center case seriesLead author: Dr. Carlos Saldarriaga, MD28:18 #26. Amlodipine double-dose therapeutic errors reported to Poison CentersLead author: Johanne Freeman30:38 #27. Dosing on the edge: unpacking inadvertent amlodipine ingestions reported to a single poison centerLead author: Dr. Tiana Patriarca, PharmD34:03 #292. Intravenous administration of sodium zirconium cyclosilicate resulting in deathLead author: Dr. Stephen Thornton, MD Researcher interviews44:16 – #21. Quantitative analysis of amlodipine removal by plasmapheresisGuest: Dr. Keahi Horowitz, MD – Acute and Intensive Care Research Award winner48:33– #23. Relationship between reported ingestion dose and outcome in amlodipine poisoningGuest: Dr. Colleen Cowdery, MD51:37 – #24. Management of severe amlodipine toxicity with high-dose calcium aloneGuest: Dr. Vincent Ma, MDHigh dose norepinephrine in amlodipine overdose Case report of calcium death 56:56– #70. Iatrogenic exposure to long-acting buprenorphine injectable in an opioid-naïve patientGuest: Dr. Conor Young, MD01:00:11 – #182. Left in the dark: a case of blindness in the setting of metformin toxicityGuest: Dr. Madison Bombard, MD01:12:11 – #169. Just because it’s natural doesn’t mean it’s safe: a case of pediatric toxicity from topical and herbal remediesGuest: Dr. Aria Darling, MD01:04:31 – #203. Serotonin syndrome after vaping MoocahGuest: Dr. Connor Murphy, MD01:07:06 – #307. Intravenous ozone autohemotherapy: a retrospective observational case seriesGuest: Nicole McLarty 01:11:25 – #134. Do they really need n-acetylcysteine? Exploratory analysis of outcomes in patients with elevated...

Show NotesIn this special live episode from the 2025 North American Congress of Clinical Toxicology (NACCT), Ryan takes you inside the poster hall to hear directly from the researchers themselves. Covering 11 abstracts that span high-stakes management decisions, surprising case reports, and challenges to toxicology dogma, this year’s highlights feature everything from amlodipine overdoses to naturopathic misadventures, metformin-associated blindness, and more.If you couldn’t make it to NACCT or just want to catch up on some of the most impactful new research in our field, this episode will give you a front-row seat. Check below for links to the published abstracts, the full list of studies discussed, and timestamps for where you can hear each one.Link to published abstract manuscriptPreamble with Dr. Jon Cole09:20 - Abstract #7. Is beta blocker toxicity associated with hypoglycemia?First author: Dr. Megan Audette17:00 - Abstract #237. V-A ECMO as a treatment for vasoplegic shock in amlodipine poisoning: a comparisonFirst author:Dr. Daniel Tirado26:50 - Abstract #247. Blocked but not beaten: ECMO’s role in severe amlodipine toxicity – a poison center case series?First author: Dr. Carlos Saldarriaga28:15 Abstract #27. Amlodipine double-dose therapeutic errors reported to Poison CentersFirst author: Carlos Saldarriaga29:00 Abstract #27. Dosing on the edge: unpacking inadvertent amlodipine ingestions reported to a single poison centerFirst author: Dr. Tiana Patriarca32:38 - 292. Intravenous administration of sodium zirconium cyclosilicate resulting in deathFirst author: Dr. Stephen ThorntonAbstracts & Guests40:06 – Abstract #21. Quantitative analysis of amlodipine removal by plasmapheresisGuest: Dr. Keahi Horowitz, MD – Acute and Intensive Care Research Award winner44:00 – Abstract #23. Relationship between reported ingestion dose and outcome in amlodipine poisoningGuest: Dr. Colleen Cowdery, MD47:30 – Abstract #24. Management of severe amlodipine toxicity with high-dose calcium aloneGuest: Dr. Vincent Ma, MD53:00 – Abstract #70. Iatrogenic exposure to long-acting buprenorphine injectable in an opioid-naïve patientGuest: Dr. Connor Young, MD55:51 – Abstract #182. Left in the dark: a case of blindness in the setting of metformin toxicityGuest: Madison Bompard, MD57:56 – Abstract #169. Just because it’s natural doesn’t mean it’s safe: a case of pediatric toxicity from topical and herbal remediesGuest: Dr. Aria Darling, MD59:57 – Abstract #203. Serotonin syndrome after vaping "Moocah"Guest: Dr. Connor Murphy, DO1:03:00 – Abstract #307. Intravenous ozone autohemotherapy: a retrospective observational case seriesGuest: Nicole McLarty 1:05:59 – Abstract #134. Do they really need n-acetylcysteine? Exploratory analysis of outcomes in patients with elevated liver function tests but no detectable acetaminophenGuest: Dr. Seth Carroll PharmD1:09:30 – Abstract #130. Outcomes of acute acetaminophen-poisoned patients treated with and without fomepizole: a Toxic registry studyGuest: Dr. Jordan Woollum, PharmD1:15:30 – Abstract #295. Evaluation of onset and resolution...

In this episode of The Poison Lab, host Ryan Feldman is joined by Dr. Joe Kennedy, medical toxicologist at the University of Vermont and consultant for the Northern New England Poison Center. Together they work through real poisoning cases to sharpen toxic differentials, sum up practical resuscitation priorities, and connect first-principles pharmacology to bedside decisions. They also answer listener questions on THAM vs bicarbonate, when to dialyze even with “normal” kidneys, and why rattlesnake antivenom costs so much—plus the real-world logistics of sourcing exotic antivenoms in the U.S.Dr. Kennedy and Ryan discuss the topics below. Looking for timestamps? Join the subscribed feed!Case set #1: Shock with hyperglycemia, big pupils, and probably NOT what you think it is. Case set #2: Massive bleeding after gas-station “herbal” productsCase set #3: Refractory wide-complex rhythms in a teen overdoseCase set #4: Sudden collapse at a hog farm- (SPOLIER) Recent outbreak of deaths as related to case 4Want the cases summarized and sent to you so you can come up with your differential before the show? SIGN UP FOR THE NEWS LETTER! Listener Q&amp;ATHAM vs bicarbonate (closed vs open buffering; “breathe for bicarb, tinkle for THAM”)Why dialyze if the kidneys work? (EXTRIP-style thinking, gradients, and properties)Snake antivenom pricing &amp; how zoos help hospitals obtain non-U.S. antivenomsCall outs from the showNACCT Abstracts!Clover coagulopathy!THAM VS BICARB ElectrolytesPotato quality video of dialysis from RyanArticle on snake antivenom costing &gt;200,000 for one patientArticle on exotic antivenom procurementCase report Ryan published on treating blue Indonesian pit viperSupport the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game! Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and Resources<a href="https://www.thepoisonlab.com" rel="noopener noreferrer"...

GOTTA PICCEM: The Poisonous Mushroom Card Game👉 Order now right here OR go to www.gottapiccem.com and click "Buy GOTTA PICCEM"Why this is awesomeWhat started as a nerdy teaching tool made to teach mushroom poisoning by folks who treat mushroom poisoning is now a full-fledged card game—equally great for Friday game night and the classroom.What’s inside the deck58 Poisonous Mushroom CardsFull-color pictures, toxin info, clinical syndromes, key anatomy, U.S. + global distribution, and spore print colors.88 Play Cards + 30 Bonus CardsCollect mushrooms, play antidotes and modifiers, stack combos, and score big.Toxin-Based ScoringPoint systems reflect real-world toxicity—every round plays differently based on your hand and bonus cards.Endless ReplayabilityRule variants at gottapiccem.com keep things fresh.Learn while you playDive into the companion blog at www.gottapiccem.com for:Deep-dive toxin explainers for each mushroomCase reports &amp; real-world clinical notesControversies and mysteries in mushroom poisoning📖 Start here: gottapiccem.com (Companion Blog → “Learn the Mushrooms”)How to get it👉 Order now right here OR go to www.gottapiccem.com and click "Buy GOTTA PICCEM"Multiple box options (pick your fancy)Ships direct from our manufacturer in South Korea🌍 Global availability (shipping costs + tariffs may apply)P.S. We’re exploring U.S. manufacturing to lower costs and expand distribution—timeline TBD—so we made the game available now.Join the funIf you grab a copy:📸 Snap a photo of your first round✉️ Send it to [email protected] or tag @LabPoison / @tox_talkNothing would make Ryan happier than seeing the community play!

Listen here (https://www.wpr.org/shows/larry-meiller-show) to hear Ryan Live on AIR for the Larry Meiller show, Thursday July 17th 11:45AM-12:30 PM CST. Check this "Listen Live" link if your having trouble!

Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game! Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website The Poison Lab: Outbreak – Markham Aconite PoisoningOn August 29, 2022, twelve diners at a Markham, Ontario restaurant fell critically ill with vomiting, numbness, and life-threatening arrhythmias. The culprit? A deadly plant toxin: aconite.In this episode—the first of a new Poison Lab Outbreak series—we go inside the Markham mass poisoning case. Join host Ryan Feldman, clinical toxicologist and emergency medicine pharmacist, as he investigates how a rare and lethal toxin ended up in a restaurant spice jar and nearly cost lives.You’ll hear firsthand from the experts who responded to the outbreak:Dr. Jessica Kent, toxicology fellow at the time at the University of TorontoDr. Abinhay Sathya, intensivist at Markham Stouffville HospitalDr. Margaret Thompson, toxicologist and on-call consultant for the Ontario Poison CentreDr. Randy Purves, research scientist at the Canadian Food Inspection Agency (CFIA)Bryn Shurmer, MS- analytical chemist at the Canadian Food Inspection Agency (CFIA)&nbsp;Together, they walk us through the outbreak timeline—from the first patients in VT to the public health investigation that uncovered a mislabeled spice bag full of pure aconite root.Looking for timestamps?A fully timestamped version of the episode—so you can jump to any topic—is available to our supporting members.💡 Key topics:Clinical presentation and toxic effects of aconiteChallenges in mass poisoning recognition and coordinationThe crucial role of poison centers in outbreak responsePublic health trace-back to contaminated galangal powderLessons for emergency departments and toxicologists📍 Resources &amp; Mentions:Case series about the incident written by Dr. Kent, Sathya, and ThompsonTwitter/X post by Dr. David Juurlink that helped disseminate early infoThe Poison Lab previous aconite episode: Open and shut (Mystery Case #31)Paper written by Ryan, Dan McCabe, and Crissy Lawson🎧 Listen now at: <a href="http://www.thepoisonlab.com/"...

In this episode of The Poison Lab, host Ryan Feldman is joined by Dr. Amy Zosel, a medical toxicologist, emergency physician, and educator. Together, they use real poisoning cases to practice identifying toxins and flexing their toxic differential The conversation dives into intriguing and challenging toxicology cases, with a focus on educating listeners about real-world poisoning scenarios, myth-busting internet misinformation, and providing practical clinical insights. Mini episode with Dr. Robert Bassett on Remembering Poisonous Mushrooms Dr. Zosel and Ryan discuss:14:15 Case 1 33:04 Case 2News story37:00 Case 3 New story48:00 Case 4 News storyUS outbreak "Robocough"Study about Naloxone in Clonidine overdose++Spoiler++: Below this will be key takeaways regarding managing the poisonings discussed, it may ruin your experience if you are guessing the poisons Key Takeaways:Amatoxin Mushroom Poisoning: The classic delayed onset of severe GI symptoms, followed by a latent phase, can mask progressive liver damage. Early recognition and treatment with hydration, silibinin, and possible liver transplant are critical.Tetramine Toxicity: Known for causing refractory seizures, tetramine is a rare but serious poisoning often requiring aggressive supportive care and anticonvulsants.A Lethal mushroom hiding in edible mushrooms Mushroom foraging dangerResources Mentioned:National Poison Control Hotline: 1-800-222-1222National Suicide Prevention Lifeline: 1-800-273-8255SAMHSA Free Helpline: 1-800-662-HELP (4357)Follow The Poison Lab:Twitter: @LabPoisonInstagram: @tox_talkWebsite: www.ThePoisonLab.comSubscribe and Review:Love what you're hearing? Help us reach more toxicology enthusiasts by leaving a review on Apple Podcasts, Spotify, or wherever you listen. Don’t forget to share this episode with...

Support the showReview the show where ever your listeningGet Messages from Toxo (Join the Newsletter!)Join as a supporting memberAd free episodesBonus content and early accessDiscounts and give aways on GOTA PICCEM Mushroom card gameThe GOTTA PICCEM Poisonous Mushroom Game! Tox trinkets (Rep the show at home!)Reach the showEmail: [email protected] Show ResourcesRyan's Medical Games and ResourcesShow Website If you are looking for links to Dr. Basset's initiatives check back later, they are not fully launched yet!Check it out on Dr. Hamilton's website as well Poison Mushrooms! Got’a Pic’em (GOTAAPPICEM) A mnemonic device to sort through mushroom ingestions – The Hot Stove League of EM/ToxThe GOTAA PPICCEM MnemonicLate-Onset (Severe) Toxic Mushrooms ("GOTA")These mushrooms have delayed symptoms (&gt;6 hours) and are associated with significant toxicity:G – Gyromitrin (Gyromitra esculenta) – False morels; inhibits GABA, leading to seizures.O – Orellanine (Cortinarius spp.) – Causes renal failure; famously poisoned The Horse Whisperer author.T – Tricholoma equestre (Man on Horseback) – Leads to rhabdomyolysis.A – Amatoxin (Amanita phalloides, Galerina spp.) – Causes liver failure; the most lethal mushroom toxicity.&nbsp;Early Onset Nausea, Late Toxicity Mushrooms ("A²P²")A² – Allenic norleucine (Amanita smithiana) – Found in the Pacific Northwest; early GI symptoms followed by renal failure.These may present early but still cause significant toxicity.P² – Paxillus spp. – Can cause hemolytic anemia and multi-organ injury.&nbsp;Early-Onset Nausea Mushrooms ("PICCEM")P– Psilocybin (Psilocybe spp.) – Hallucinogenic, similar to LSD, typically low toxicity but may cause hyperthermia or seizures.Symptoms appear within 6 hours and are usually self-limited.I – Ibotenic Acid &amp; Muscimol (Amanita muscaria, Amanita pantherina) – Acts like a “mushroom speedball”, causing both stimulant and sedative effects.C – Coprine (Coprinus spp., Inky Caps) – Induces disulfiram-like reaction with alcohol.E – &nbsp;Emetic Mushrooms (LBMs: Little Brown Mushrooms) – Various species that cause self-limited vomiting and diarrhea.M – Muscarine (Clitocybe, Inocybe spp.) – Cholinergic...

In this special collaboration with NephMadness, we're diving into the world of nephrotoxins with an expert panel from Virginia Commonwealth University. NephMadness is an educational competition modeled after March Madness, and this year, one of the featured regions focuses on plant-based nephrotoxins. Together, with our expert panel we break down the competing nephrotoxin teams: Tubular Toxins vs. Oxalate Offenders. Joining us are Dr. Anna Vinnokova (Nephrologist), Dr. Rachel Khan PharmD (Neph pharmacist), Dr. Ethan Downes (Nephrology fellow), and the legendary nephrotoxicologist, Dr. Josh King (Board certified Nephrologist and Toxicologist). We ALMOST named this episode "Getting Downe with the Mad Neph King and the Bean Queens"... but we didn't, your welcome. After the show, go to the blog and vote for your favorite!Expect irreverent musings, deep dives into toxic plant exposures, and a mystery case reveal that will leave you questioning your diet.Topics and Timeline of Episode:IntroListener Guesses With Josh and Ryan– 8:30Listener Winner – 25:42NephMadness and Guest Introductions – 28:07Toxin Reveal – 33:41NEJM Case reportTubular Toxins – 35:46Aristolochic Acid &amp; the Belgian Weight-Loss Clinic Outbreak – 40:30Black Licorice &amp; Its Surprising Toxic Effects – 47:16The Oxalate Offenders Team: How Dietary Oxalates Harm the Kidneys – 52:00Historical Context: First recognized through sheep die-offs when herds grazed on Halogeton glomeratus, a high-oxalate plant, leading to fatal poisoning.Oxalate in Plants: Functions to bind excess calcium in the soil.Impact on the Body: Plants high in oxalate but low in calcium can contribute to oxalate accumulation, this leads to binding calcium in the blood, creating calcium oxalate crystals and acute renal calculi. Chronic inflammation from excess oxalate deposition leads to CKD progression.High-Oxalate Foods: Spinach, Swiss chard, rhubarb, cashews. Everything in moderation!Practical Advice for Clinicians &amp; Patients on Herbal Medicine Use – 1:00:00Resources for identifying nephrotoxic herbal productsTalk to your patients non judgmentally, open conversations, discuss efficacy (or lack there of, see resources below) and safetyHerbal medicines are not FDA approved and may not contain what they claim toHerbals may not all be safe: Josh King Discovering Contaminants– 1:01:11Wrap up– 1:08Key Takeaways:Aristolochic acid is a direct nephrotoxin, associated with progressive kidney damage and urothelial cancers.Black licorice toxicity results from...

Do you think you know the cause of these symptoms? Send your guesses to [email protected] to take part in the next episode&nbsp;Support the show!Rep the show!Show website