American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Factitious snake envenomation and narcotic-seeking behavior☆,☆☆,★ United States Poison Control Centers (PCCs) recorded nearly 7000 snakebites in 2013. We present a case of a factitious snakebite in a patient with a pattern of similar emergency department (ED) visits. A 47-year-old man presented to the ED with 5 snakebites on both forearms. He reported being bitten while milking venom from an eastern diamondback rattlesnake for the zoo. On ED arrival, he had punctures on both forearms, swelling on the right forearm, tachycardia, and leukocytosis. He requested CroFab (Crotalidae Polyvalent Immune Fab) and pain medication. Contact with the PCC revealed numerous similar visits at other EDs across the state and an adjacent state. In a series of at least 12 encounters, he received a total of at least 42 vials of antivenom without documented allergic reaction. The PCC recommendations curtailed his receipt of antivenom in later visits. This is an unusual case of repeated factitious snake envenomation. His misuse of epinephrine autoinjectors mimicked symptoms of envenomation. CroFab is an expensive antidote with a potential risk of sensitization with multiple exposures and is best reserved for patients with true pit viper envenomation. Astute PCC specialists detected the repetitive pattern of his ED visits and helped to reduce unnecessary treatment in later visits. Our patient had factitious disorder and narcotic-seeking behavior with repeated ED visits and hospital admissions for alleged pit viper bites. Poison Control Centers play an essential role in detecting patterns of abuse in individuals who change location frequently. Snake bites account for nearly 7000 human exposures recorded in the American Association of Poison Control Centers National Poison Data System in 2013 [1]. They are often painful and require opioid analgesia, both because of symptom severity and desire to avoid nonsteroidal anti-inflammatory drugs in the setting of potential coagulopathy [2]. Narcotic-seeking behavior is a frequent problem for emergency departments. It is commonly associated with exaggerated or inconsistent claims of painful injury [3,4]. A 47-year-old man presented with 5 bites involving both arms occurring 20 minutes before presentation, reportedly while milking venom from an eastern diamondback rattlesnake for a company making antivenom. He described holding the snake to milk it when the snake turned its head and bit him twice on the right arm and 3 times on the left arm as he struggled to control it. His medical history included a
☆ Presented at the North American Conference of Clinical Toxicology, October 21, 2014, New Orleans, LA. ☆☆ No conflicts of interest. ★ DA and MEM obtained written consent of the patient. JW contributed poison control center data. CSS and SLT contributed additional clinical data. DA, MEM, AAP, and ESS reviewed and compiled the data. DA and MEM drafted the manuscript. All authors substantially contributed to its revision. DA and MEM take responsibility for the manuscript as a whole.
snake bite 5 months earlier treated with Fab antivenom (CroFab; BTG International, Conshohocken, PA), multiple traumatic injuries, and coronary artery disease status poststents. He appeared in moderate distress with a blood pressure of 135/87 mm Hg, a heart rate of 135 beats per minute, a respiratory rate of 21 breaths per minute, and an oxygen saturation of 100% on room air. He had punctate lesions on both forearms with some swelling on the right forearm. Radiographs showed soft tissue swelling on the right forearm and no retained foreign bodies. Based upon the initial presentation, the toxicology service recommended a loading dose of Fab antivenom. Contact with the Poison Control Center (PCC) revealed that he had presented to multiple hospitals across Missouri using multiple similar aliases. Characteristic tattoos, ironically including one which said “snakebite” next to an image of snake’s head, confirmed his identity. With this information, we canceled the antivenom and observed the patient to monitor serial arm circumferences. His swelling never progressed, and no erythema or discoloration ever developed. The patient continued to complain of pain in his right arm. His laboratory test results were all normal (Table). We confronted him with our knowledge of multiple admissions for unproven injuries and discharged him with primary care clinic referral. Information obtained from the Missouri PCC, the Kansas PCC, and hospitals in Columbia and Kansas City revealed 11 prior hospital visits across the state between 2010 and 2014. These included 4 intensive care unit admissions and a total of 42 vials of Fab antivenom given on 5 separate occasions. There are very few published reports of factitious snake bites. One case in India described a falsified insurance claim of snake bite in a patient who died because of a myocardial infarction [5]. Another case in Louisiana involved a man who presented to at least 8 different hospitals on 10 occasions in 17 months for snake bite to obtain opioid analgesia [6]. Two reports describe a single patient who repeatedly presented with factitious snakebite more than 100 times in New Mexico and Colorado [7,8]. Drug-seeking behavior often includes using multiple aliases, getting narcotic prescriptions from multiple providers, claims of missing or lost prescriptions, exaggerated or inconsistent claims of painful injury, and requesting narcotic pain medications by name or requesting parenteral administration [3,4]. Our patient exhibited all of these at one time or another. A concern for both repeat envenomation as well as repeat exposure to antivenin is the risk of hypersensitivity reaction. Cannon et al [9] reported hypersensitivity reactions in 5 (5.4%) of 93 patients treated with Fab antivenom in Phoenix. A meta-analysis by Schaeffer et al [10] estimated the probabilities of hypersensitivity or serum sickness as up to 8% and 13%, respectively. An inherent limitation of both the case series and the meta-analysis is that the observed reactions could be effects of venom and not necessarily effects of the antivenom. Our patient’s lack of hypersensitivity reaction to Fab antivenom despite having been
0735-6757/© 2015 Published by Elsevier Inc.
Please cite this article as: Abdelmalek D, et al, Factitious snake envenomation and narcotic-seeking behavior, Am J Emerg Med (2015), http://dx. doi.org/10.1016/j.ajem.2015.03.020
2
D. Abdelmalek et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Table Laboratory test results at ED arrival and 8 hours later. Laboratory test
Initial presentation
8 h after presentation
White blood cell (×1000/mm3) Hemoglobin (g/dL) Hematocrit (%) Platelets (×1000/mm3) Prothrombin time (s) International normalized ratio Partial thromboplastin time (s)
13.9 12.4 38.5 456 11.8 1.12 31.1 137
14.7 11.0 34.9 416 11.4 1.08 28.6 122
535
405
D-Dimer
(ng/mL) Fibrinogen (mg/dL)
exposed to at least 42 vials over the course of 5 medical encounters supports the low risk of hypersensitivity reactions. The patient in New Mexico and Colorado far exceeded this with a total of at least 153 vials of Fab antivenom over a 17-year period without evidence of hypersensitivity [7,8]. The lack of data exchange among different electronic medical record systems in different hospitals is often a barrier to tracking narcoticsseeking patients with frequent emergency department visits. Without the PCC’s unique capacity to bridge the information chasms between health care systems, this patient’s maladaptive and manipulative behavior may have continued indefinitely without detection. This case illustrates a rare, but not unique, pattern of factitious snake bite used to obtain narcotics. The use of at least 42 vials of Fab antivenom over at least 5 visits without a recorded hypersensitivity reaction supports the safety of Fab antivenom. The PCC has a central role in communicating clinical information among multiple health care systems. Dimyana Abdelmalek MD Anna Arroyo-Plasencia MD Evan S. Schwarz MD Division of Emergency Medicine, Washington University School of Medicine, St. Louis MO USA Julie Weber RPh Missouri Regional Poison Center, SSM Cardinal Glennon Children’s Hospital, St. Louis MO USA
Christopher S. Sampson MD Department of Emergency Medicine, University of Missouri School of Medicine, Columbia MO USA Stephen L. Thornton MD Department of Emergency Medicine University of Kansas School of Medicine, Kansas City KS USA Michael E. Mullins MD Division of Emergency Medicine, Washington University School of Medicine, St. Louis MO USA Corresponding author. E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2015.03.020 References [1] Mowry JB, Spyker DA, Cantilena LR, McMillian N, Ford M. 2013 Annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st annual report. Clin Toxicol 2014;52:1032–283. [2] Lavonas EJ, Ruha AM, Banner W, Bebarta V, Bernstein JN, Bush SP, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med 2011;11:2. [3] Grover CA, Close RJ, Wiele ED, Villarreal K, Goldman LM. Quantifying drug-seeking behavior: a case control study. J Emerg Med 2012;42:15–21. [4] Hansen GR. The drug-seeking patient in the emergency room. Emerg Med Clin North Am 2005;23:349–65. [5] Pathak A, Mangal HM. A case of fabricated snake bite. J Indian Acad Forens Med 2007;29:28. [6] Ryan ML, Arnold TC. Multiple intentional snake envenomations as novel drugseeking behavior. Clin Toxicol 2008;46:642 [abstract]. [7] Wilson L. Repeated administration of crotalid Fab antivenin in the same patient. Ann Emerg Med 2002;20:572. [8] Lavonas EJ, Benson BE, Seifert SA. Failure to develop sensitization despite repeated administration of ovine Fab snake antivenom: update of a single-patient, multicenter case series. Ann Emerg Med 2013;61:371–2. [9] Cannon R, Ruha AM, Kashani J. Acute hypersensitivity reactions associated with administration of crotalidae polyvalent immune Fab antivenom. Ann Emerg Med 2008;51:407–11. [10] Schaeffer TH, Khatri V, Reifler LM, Lavonas EJ. Incidence of immediate hypersensitivity reaction and serum sickness following administration of crotalidae polyvalent immune Fab antivenom: a meta‐analysis. Acad Emerg Med 2012;19:121–31.
Please cite this article as: Abdelmalek D, et al, Factitious snake envenomation and narcotic-seeking behavior, Am J Emerg Med (2015), http://dx. doi.org/10.1016/j.ajem.2015.03.020
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Factitious snake envenomation and narcotic-seeking behavior☆,☆☆,★ United States Poison Control Centers (PCCs) recorded nearly 7000 snakebites in 2013. We present a case of a factitious snakebite in a patient with a pattern of similar emergency department (ED) visits. A 47-year-old man presented to the ED with 5 snakebites on both forearms. He reported being bitten while milking venom from an eastern diamondback rattlesnake for the zoo. On ED arrival, he had punctures on both forearms, swelling on the right forearm, tachycardia, and leukocytosis. He requested CroFab (Crotalidae Polyvalent Immune Fab) and pain medication. Contact with the PCC revealed numerous similar visits at other EDs across the state and an adjacent state. In a series of at least 12 encounters, he received a total of at least 42 vials of antivenom without documented allergic reaction. The PCC recommendations curtailed his receipt of antivenom in later visits. This is an unusual case of repeated factitious snake envenomation. His misuse of epinephrine autoinjectors mimicked symptoms of envenomation. CroFab is an expensive antidote with a potential risk of sensitization with multiple exposures and is best reserved for patients with true pit viper envenomation. Astute PCC specialists detected the repetitive pattern of his ED visits and helped to reduce unnecessary treatment in later visits. Our patient had factitious disorder and narcotic-seeking behavior with repeated ED visits and hospital admissions for alleged pit viper bites. Poison Control Centers play an essential role in detecting patterns of abuse in individuals who change location frequently. Snake bites account for nearly 7000 human exposures recorded in the American Association of Poison Control Centers National Poison Data System in 2013 [1]. They are often painful and require opioid analgesia, both because of symptom severity and desire to avoid nonsteroidal anti-inflammatory drugs in the setting of potential coagulopathy [2]. Narcotic-seeking behavior is a frequent problem for emergency departments. It is commonly associated with exaggerated or inconsistent claims of painful injury [3,4]. A 47-year-old man presented with 5 bites involving both arms occurring 20 minutes before presentation, reportedly while milking venom from an eastern diamondback rattlesnake for a company making antivenom. He described holding the snake to milk it when the snake turned its head and bit him twice on the right arm and 3 times on the left arm as he struggled to control it. His medical history included a
☆ Presented at the North American Conference of Clinical Toxicology, October 21, 2014, New Orleans, LA. ☆☆ No conflicts of interest. ★ DA and MEM obtained written consent of the patient. JW contributed poison control center data. CSS and SLT contributed additional clinical data. DA, MEM, AAP, and ESS reviewed and compiled the data. DA and MEM drafted the manuscript. All authors substantially contributed to its revision. DA and MEM take responsibility for the manuscript as a whole.
snake bite 5 months earlier treated with Fab antivenom (CroFab; BTG International, Conshohocken, PA), multiple traumatic injuries, and coronary artery disease status poststents. He appeared in moderate distress with a blood pressure of 135/87 mm Hg, a heart rate of 135 beats per minute, a respiratory rate of 21 breaths per minute, and an oxygen saturation of 100% on room air. He had punctate lesions on both forearms with some swelling on the right forearm. Radiographs showed soft tissue swelling on the right forearm and no retained foreign bodies. Based upon the initial presentation, the toxicology service recommended a loading dose of Fab antivenom. Contact with the Poison Control Center (PCC) revealed that he had presented to multiple hospitals across Missouri using multiple similar aliases. Characteristic tattoos, ironically including one which said “snakebite” next to an image of snake’s head, confirmed his identity. With this information, we canceled the antivenom and observed the patient to monitor serial arm circumferences. His swelling never progressed, and no erythema or discoloration ever developed. The patient continued to complain of pain in his right arm. His laboratory test results were all normal (Table). We confronted him with our knowledge of multiple admissions for unproven injuries and discharged him with primary care clinic referral. Information obtained from the Missouri PCC, the Kansas PCC, and hospitals in Columbia and Kansas City revealed 11 prior hospital visits across the state between 2010 and 2014. These included 4 intensive care unit admissions and a total of 42 vials of Fab antivenom given on 5 separate occasions. There are very few published reports of factitious snake bites. One case in India described a falsified insurance claim of snake bite in a patient who died because of a myocardial infarction [5]. Another case in Louisiana involved a man who presented to at least 8 different hospitals on 10 occasions in 17 months for snake bite to obtain opioid analgesia [6]. Two reports describe a single patient who repeatedly presented with factitious snakebite more than 100 times in New Mexico and Colorado [7,8]. Drug-seeking behavior often includes using multiple aliases, getting narcotic prescriptions from multiple providers, claims of missing or lost prescriptions, exaggerated or inconsistent claims of painful injury, and requesting narcotic pain medications by name or requesting parenteral administration [3,4]. Our patient exhibited all of these at one time or another. A concern for both repeat envenomation as well as repeat exposure to antivenin is the risk of hypersensitivity reaction. Cannon et al [9] reported hypersensitivity reactions in 5 (5.4%) of 93 patients treated with Fab antivenom in Phoenix. A meta-analysis by Schaeffer et al [10] estimated the probabilities of hypersensitivity or serum sickness as up to 8% and 13%, respectively. An inherent limitation of both the case series and the meta-analysis is that the observed reactions could be effects of venom and not necessarily effects of the antivenom. Our patient’s lack of hypersensitivity reaction to Fab antivenom despite having been
0735-6757/© 2015 Published by Elsevier Inc.
Please cite this article as: Abdelmalek D, et al, Factitious snake envenomation and narcotic-seeking behavior, Am J Emerg Med (2015), http://dx. doi.org/10.1016/j.ajem.2015.03.020
2
D. Abdelmalek et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Table Laboratory test results at ED arrival and 8 hours later. Laboratory test
Initial presentation
8 h after presentation
White blood cell (×1000/mm3) Hemoglobin (g/dL) Hematocrit (%) Platelets (×1000/mm3) Prothrombin time (s) International normalized ratio Partial thromboplastin time (s)
13.9 12.4 38.5 456 11.8 1.12 31.1 137
14.7 11.0 34.9 416 11.4 1.08 28.6 122
535
405
D-Dimer
(ng/mL) Fibrinogen (mg/dL)
exposed to at least 42 vials over the course of 5 medical encounters supports the low risk of hypersensitivity reactions. The patient in New Mexico and Colorado far exceeded this with a total of at least 153 vials of Fab antivenom over a 17-year period without evidence of hypersensitivity [7,8]. The lack of data exchange among different electronic medical record systems in different hospitals is often a barrier to tracking narcoticsseeking patients with frequent emergency department visits. Without the PCC’s unique capacity to bridge the information chasms between health care systems, this patient’s maladaptive and manipulative behavior may have continued indefinitely without detection. This case illustrates a rare, but not unique, pattern of factitious snake bite used to obtain narcotics. The use of at least 42 vials of Fab antivenom over at least 5 visits without a recorded hypersensitivity reaction supports the safety of Fab antivenom. The PCC has a central role in communicating clinical information among multiple health care systems. Dimyana Abdelmalek MD Anna Arroyo-Plasencia MD Evan S. Schwarz MD Division of Emergency Medicine, Washington University School of Medicine, St. Louis MO USA Julie Weber RPh Missouri Regional Poison Center, SSM Cardinal Glennon Children’s Hospital, St. Louis MO USA
Christopher S. Sampson MD Department of Emergency Medicine, University of Missouri School of Medicine, Columbia MO USA Stephen L. Thornton MD Department of Emergency Medicine University of Kansas School of Medicine, Kansas City KS USA Michael E. Mullins MD Division of Emergency Medicine, Washington University School of Medicine, St. Louis MO USA Corresponding author. E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2015.03.020 References [1] Mowry JB, Spyker DA, Cantilena LR, McMillian N, Ford M. 2013 Annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st annual report. Clin Toxicol 2014;52:1032–283. [2] Lavonas EJ, Ruha AM, Banner W, Bebarta V, Bernstein JN, Bush SP, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med 2011;11:2. [3] Grover CA, Close RJ, Wiele ED, Villarreal K, Goldman LM. Quantifying drug-seeking behavior: a case control study. J Emerg Med 2012;42:15–21. [4] Hansen GR. The drug-seeking patient in the emergency room. Emerg Med Clin North Am 2005;23:349–65. [5] Pathak A, Mangal HM. A case of fabricated snake bite. J Indian Acad Forens Med 2007;29:28. [6] Ryan ML, Arnold TC. Multiple intentional snake envenomations as novel drugseeking behavior. Clin Toxicol 2008;46:642 [abstract]. [7] Wilson L. Repeated administration of crotalid Fab antivenin in the same patient. Ann Emerg Med 2002;20:572. [8] Lavonas EJ, Benson BE, Seifert SA. Failure to develop sensitization despite repeated administration of ovine Fab snake antivenom: update of a single-patient, multicenter case series. Ann Emerg Med 2013;61:371–2. [9] Cannon R, Ruha AM, Kashani J. Acute hypersensitivity reactions associated with administration of crotalidae polyvalent immune Fab antivenom. Ann Emerg Med 2008;51:407–11. [10] Schaeffer TH, Khatri V, Reifler LM, Lavonas EJ. Incidence of immediate hypersensitivity reaction and serum sickness following administration of crotalidae polyvalent immune Fab antivenom: a meta‐analysis. Acad Emerg Med 2012;19:121–31.
Please cite this article as: Abdelmalek D, et al, Factitious snake envenomation and narcotic-seeking behavior, Am J Emerg Med (2015), http://dx. doi.org/10.1016/j.ajem.2015.03.020
