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.

Eyes

Miosis

  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

Mydriasis

  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

Sclera

  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

Tears

  1. orange with rifampin; red with hydroxocobalamin

 

Hair

  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,