Diagnosis of the poisoned patient can often be accomplished before toxicologic laboratory tests by obtaining a detailed history and directed physical exam. In this first of three articles, we will examine the toxicology clues that can be found in eyes, hair, nails, and tongue. Part 2 will focus on skin findings, and Part 3 on body fluids including saliva, sweat, urine, breath, vomit, and stool.



  1. Narcotics, cholinergics (organophosphates, nerve agents, dementia drugs, myasthenia gravis drugs, physostigmine, pilocarpine)
  2. Clonidine, nicotine
  3. Non-toxic DDx
    1. Traumatic miosis (rare, usually unilateral)
    2. Horner’s Syndrome (unilateral, with ptosis): affected pupil is the smaller one
    3. Pontine hemorrhage or infarct, SAH


  1. Sympathomimetics: cocaine, amphetamines, methylphenidate, albuterol, TAC, LET
  2. Anticholinergics (diphenhydramine, scopolamine, atropine)
    1. Corn picker’s pupil (Jimson weed growing in the cornfield)
    2. Pupils often unreactive to light
  3. Non-toxic DDx
    1. Traumatic mydriasis (common, usually unilateral)
    2. Anoxia
    3. Uncal herniation
    4. Withdrawal


  1. Yellow: jaundice 2° hepatotoxicity or hemolysis (bili > 2 mg%)
    1. leading hepatotoxins: acetaminophen, Amanita mushrooms
    2. oxidizing gases (arsine, stibine) cause severe hemolysis
    3. no scleral “icterus” in carotenemia; sclerae remain white
  2. Blue: osteogenesis imperfecta
    1. no scleral bluing in methemoglobinemia


  1. orange with rifampin; red with hydroxocobalamin



  1. Alopecia areata vs alopecia totalis or universalis
  2. Toxic Etiologies (usually anagen effluvium secondary to anti-mitotic agents: onset in 1-2 weeks)
    1. Anagen effluvium: Radiation, heavy metals, cytotoxic drugs, vitamin A derivatives, colchicine, propranolol, antithyroid drugs, clofibrate, valproic acid, bromocriptine
    2. Telogen effluvium: Anticoagulants, oral contraceptives
  3. Non-toxic (usually telogen effluvium) : onset usually 2-4 months
    1. pregnancy/childbirth, endocrine, hereditary, fungus (tinea capitis), high fever, major surgery, illness, trauma; idiopathic




  1. Striate (As, Tl) vs punctate or irregular leukonychia (minor trauma)
  2. Mees-Aldrich Lines (1919)

Clinical course of arsenic poisoning

  1. Acute – Abdominal pain, N & V, tinnitus, hearing loss, garlic odor, metallic taste
  2. 2-10 days – Sensory neuropathy
  3. 10-30 days – Hair Loss (primarily scalp)
  4. 2-3 weeks – Mees Lines
  5. 3-4 weeks – Motor neuropathy
  6. Most common misdiagnosis: Guillain Barre Syndrome


  • Clubbing – Idiopathic, nontoxic, pulmonary disease
  • Spooning – Pb, macrocytic anemia
  • Banding – As, Tl, cyclophosphamide, melphan
  • Stippling – Non-toxic
  • Staining – Ag, acids, nicotine, hemochromatosis, tetracycline, chemotherapy  (Adriamycin, bleomycin, 5FU)
  • Ridging – cytoxan, melphalan, trauma, fungus
  • Forget about toenails the news is 6-12 months old.



  1. Angioedema
    1. Hereditary vs ACE inhibitor
  2. Bite wound
    1. Toxic seizure
    2. Cocaine, amphetamines, INH, TCA, Wellbutrin, SSRI’s, tramadol
  3. Burns from caustic ingestion
  4. Abnormal color
    1. Usually food dye
    2. Green: vanadium
    3. Orange: pyridium

Prepared by Dr. Dave Roberts, of the Hennepin Regional Poison Center.