Consequently, she presented with multiorgan failure including encephalopathy, lactic acidosis, and shock. This amount is about 1.8 times higher than the minimum lethal dose of 50 mg of cyanide. This patient ingested 1500 mg of amygdalin (vitamin B17) as prescribed, which contains approximately 90 mg of cyanide. Intake of amygdalin with foods containing beta-glucuronidase such as bean sprouts, peaches, celery, and carrots or concurrent intake with high doses of vitamin C has been shown to increase the conversion of amygdalin to cyanide in vitro. Severe cases may present with cyanosis, coma, convulsions, cardiac arrhythmias, cardiac arrest, and death. Mild to moderate cases of cyanide toxicity consist of tachycardia, headache, confusion, nausea, and weakness. Cyanide binds to the ferric ion on cytochrome oxidase and abruptly halts the electron transport chain and oxidative metabolism, resulting in cellular hypoxia and lactic acidosis. A minimum lethal dose of cyanide is approximately at 50 mg or 0.5 mg/kg body weight. Cyanide toxicity is highly fatal by interfering with mitochondrial oxygen utilization leading to cell death. Oral amygdalin is estimated to be 40 times more potent than intravenous form due to its enzymatic conversion to hydrogen cyanide in the gastrointestinal tract. Oral intake of 500 mg of amygdalin may contain as much as 30 mg of cyanide. Upon ingestion, amygdalin is hydrolyzed to cyanide by beta-glucuronidase in the small intestine. Her repeat laboratory tests showed a leukocyte count of 12.2 × 10 3 cells/ μL, HCO3 − of 18.0 mmol/L, anion gap of 8, glucose level of 98 mg/dL, and estimated GFR of 85.95 mL/min/1.73 m2 according to the CKD-EPI equation. Her clinical condition improved overnight in the ICU and she was discharged home the next day with instructions to stop B17 treatment permanently and follow up with her oncologist. The patient was subsequently admitted to the ICU for close monitoring. Her mental status returned to baseline at 3 hours and a repeat ABG at that time revealed a pH of 7.32, pCO2 of 33 mmHg, a PaO2 of 129 mmHg, and HCO3 − of 16.8 mmol/L on 3 L/min nasal cannula. At 2 hours after treatment, her blood pressure improved to 113/72 mm Hg and lactic acid level 6.5 mmol/L. Approximately an hour after the administration of hydroxocobalamin, her blood pressure improved to 99/63 mmHg. Her clinical deterioration led us to initiate 5 grams of intravenous hydroxocobalamin over 15 minutes. Her other electrolytes and liver function tests were within normal range. The patient's other abnormal laboratory tests included a leukocyte count of 27.9 × 10 3 cells/ μL, HCO3 − of 11.0 mmol/L, anion gap of 23 mmol/L, glucose level of 255 mg/dL, estimated GFR of 44.80 mL/min/1.73 m2 according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Her laboratory data revealed a lactic acidosis of 14.2 mmol/L and an arterial blood gas (ABG) showed a pH of 7.24, pCO2 of 20 mmHg, a PaO2 of 141 mmHg, and HCO3 − of 8.4 mmol/L on 3 L/min nasal cannula. She was given 1 liter of normal saline, which improved her blood pressure to 92/48 mm Hg. We contacted the poison control center due to concern of cyanide toxicity from amygdalin ingestion, who recommended to give hydroxocobalamin (Cyanokit®) as an antidote if the patient had significant metabolic acidosis (pH < 7.2).Īn hour into her ED stay, the patient's blood pressure decreased to 61/38 mm Hg.
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The patient had pale, cool, and red skin discoloration. Her initial vital signs revealed a temperature of 37.2 degrees Celsius, heart rate of 133 beats per minute, respiratory rate of 13 acts per minute, blood pressure of 116/61 mm Hg, and an O2 saturation of 97% on 3 liters/minute nasal cannula. In the emergency department, the patient was noted to be confused, making incomprehensible sound and withdrawing from pain with a GCS of 10. Approximately 45 minutes later, she developed altered mental status, along with diaphoresis, tachycardia, vomiting, dizziness, and crampy abdominal pain. On the day of presentation, she took three amygdalin tablets for the first time as instructed by her holistic medicine doctor. She declined chemotherapy and recently began seeing a holistic medicine doctor who prescribed her vitamin B17 500 mg (amygdalin) tablets. Unfortunately, follow-up imaging revealed metastatic disease to her liver and lungs.
History from the patient's son revealed that the patient was diagnosed with pancreatic cancer a few months ago and underwent Whipple surgery. A 73-year-old Arabic female with history of pancreatic adenocarcinoma came to the emergency department (ED) for altered level of consciousness via emergency medical service.
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