Author: Jonathan Pun, MD, Emergency Medicine Resident, PGY I

Faculty: Alexis Cates, DO, Medical Toxicology/Emergency Medicine Attending

 ** Disclosure:  This fictional case will discuss COVID-19, the disease caused by SARS-CoV-2, as well as purported treatments that may cause toxicity.  This fictional case is created purely for educational purposes. This is not medical advice, and does not reflect any opinions of the authors or affiliates.  Please seek the guidance of your physician in regards to prevention of and treatment for COVID-19.

The Case:

A 35 year-old male presents to the emergency department (ED) with gray-blue skin, cough and shortness of breath.  He reports concern that he cannot find a cure for his diagnosis of COVID-19.  He continues to have symptoms of COVID-19, among some other new symptoms he goes on to describe.

He states that he watched an online video from a purported health professional that cited the plants among the genus Datura as a possible treatment.  He felt that since Datura was known to be a part of medicine from many cultures, this should help his symptoms.  Unfortunately, he felt “tipsy” and started to vomit.  He did not feel any better.  He continued his search for a cure.  

He found a video of a self-proclaimed medicine specialist recommending camel urine as a treatment for COVID-19.  With over 600,000 followers, he felt this expert would surely know what they were talking about.  He acquired camel urine, and drank one cup fresh from the source as recommended.  Unfortunately, he could not tolerate the total of three times daily as recommended, and so he moved on.  

His cousin knows a friend whose sister recommended cocaine as a sterilant to the nose.  When researching, he realized that many health officials recommended against it but he figured his cousin’s friend’s sister did it, so he gave it a try.  

Other than becoming quite diaphoretic and tachycardic, this did not seem to change anything for him.  He found another source online that recommended something called “Loló,” a mixture of chloroform and ether.  The patient states he passed out after huffing it for over an hour.  

He continues to search for some pharmaceutical that will help him overcome the symptoms of COVID-19.  Next on his list to try was colloidal silver, which didn’t do anything except turned him blue. He then sniffed something called “miracle mineral solution” and decided that it smelled too much like bleach to be a good idea to drink it. His friend told him to try “Arsenicum Album” and nebulized hydrogen peroxide. Nothing really happened after the arsenicum album and it tasted a lot like just water. The nebulized hydrogen peroxide burned a little but didn’t do much either.

He had heard of hydroxychloroquine, but could not get a prescription.  Thus, he pursued a final treatment: ivermectin. He presented to the ED after using two “tubes” of ivermectin he acquired from a pet store and felt a little dizzy and clumsy.

Overwhelmed, you decide to resuscitate this patient first after noting that he became hypoxic and had trouble breathing when telling you the history.  You order oxygen supplementation,  blood work including inflammatory markers, and a chest X-ray.  You are a bit puzzled by some of the therapies he mentioned, so you hit the books.

Learning Point 1: What is Datura?

Datura is a genus of poisonous plants with several species that can be found around the United States and the world.  There are reports of people crushing the seeds found in the pods of the plants and mixing it in oils to ingest and treat COVID-19.¹  This resulted in significant illness.  The unwanted effects include vomiting, dizziness, tachycardia, and an anticholinergic delirium caused by tropane alkaloids such as scopolamine and atropine.  Treatment is largely supportive, but benzodiazepines can be used for agitation.

Learning Point 2: What is colloidal silver?

Colloidal silver is a suspension of silver particles in liquid. When consumed in large quantities, argyria can develop. Argyria is a gray-blue discoloration from silver deposition that is permanent and is usually considered cosmetically undesirable. It is considered generally safe but might be associated with night vision loss and decline in renal function. The EPA states that colloidal silver exposure of up to 5 ug/kg/day is likely safe; however, this may be difficult to quantify depending on the source.²

Learning Point 3: Why is camel urine dangerous?

Treatment of COVID-19 by drinking camel urine was popularized online in a video by a self-proclaimed medicine specialist.³  When this was noted, the World Health Organization recommended against drinking camel urine as it increases the risk for MERS-CoV, or the Camel Flu.⁴ The CDC states that camel contact is correlated to MERS-CoV pulmonary disease and that mortality is 39%.⁵ Treatment is largely supportive. However, there is one trial that shows Interferon Beta-1b and Lopinavir-Ritonavir may reduce mortality (28 vs 44%).⁶

Learning Point 4: Which illicit drugs are being purported as COVID-19 treatments?

Multiple illicit drugs are purported as COVID-19 treatments. Cocaine is a common one seen internationally.^7,8  The main route of exposure for these drugs is inhalation. Loló, which has been circulating on messaging apps as a cure for COVID-19, is a mixture of chloroform and ether. It is unique to Brazil and can cause hepatotoxicity, coma, seizures and cardiac dysrhythmias.⁸  

N-acetylcysteine (NAC) may be beneficial in the treatment of the hepatotoxicity, as it is believed that the toxicity is from free radicals produced from the halogenated hydrocarbon.⁹ Ether has a high volatility that may encourage aspiration or chemical pneumonitis. In cardiac dysrhythmias, standard ACLS/PALS protocol should be used with the subtraction of epinephrine as the due to increased sensitivity of the myocardium to catecholamines.¹⁰ Seizures should be treated with benzodiazepines; avoid pro-dysrhythmic medications such as fosphenytoin or phenytoin. Treatment is otherwise supportive.

Learning Point 5: What is miracle mineral solution (MMS)?

MMS was first popularized in 2000 and purported to treat any disease. However, in 2016 the original creator recognized that his claims were false and disavowed this treatment. A church in south Florida proclaims that MMS is a sacrament and it is their religious right to use it in the treatment of diseases such as COVID-19.¹¹

MMS is sodium chlorite (NaClO₂) mixed with an acid that makes chlorine dioxide (ClO₂). It is equivalent to 28% sodium chlorite which is effectively concentrated bleach.¹² The usual instructions is to titrate to the presence of “rope worms.” “Rope worms” are pieces of mucosa sloughing off through the gastrointestinal tract. There has been a resurgence in popularity with it in diseases that are difficult to treat such as Alzheimer’s, autism, HIV/AIDS, multiple sclerosis and, now, some use in COVID-19.

Learning Point 6: What is Arsenicum Album?

Arsenicum album is a homeopathic quantity of arsenic trioxide. However, during dilution, the math can be done wrong and toxic amounts of arsenic trioxide can be ingested. Arsenic causes allosteric inhibition of pyruvate dehydrogenase which results in multi-organ toxicity. Treatment is chelation with 2-3-dimercapto-1-propanesulfonate (DMPS) or meso 2, 3-dimer-captosuccinic acid (DMSA) in some cases of acute poisoning.¹³ Treatment is otherwise supportive.¹³ Whole bowel irrigation can be considered.¹³

Learning Point 7: What does nebulized hydrogen peroxide do?

There have been reports of multiple videos online recommending nebulized 1.5% to 3% hydrogen peroxide with a touch of iodine. Videos are often of kids receiving the treatment. There is risk of chemical pneumonitis worsening already diseased lungs. There is also risk of facial, ocular, and mucosal irritation. Large amounts of ingested or inhaled hydrogen peroxide may cause cerebral infarcts or emboli to other organs from large amounts of liberated oxygen.¹⁴ 1 mL of 3% hydrogen peroxide produces 10 mL of oxygen.¹⁴

Treatment for toxicity is typically supportive.¹⁴ At 3% concentration, serious injury from dermal exposure of hydrogen peroxide is unlikely to occur. Steroids can be considered but likely have unproven benefits.¹⁴ 

Learning Point 8: How toxic is ivermectin?

Tiktok videos show that you can ingest 1 mL as a “vaccine” and others show using “two tubes” with varying frequency and may approach a dose of 2 mg/kg.¹⁵ The normal dosing for humans is anywhere from 150 to 400 ug/kg/day when used for appropriate conditions.¹⁵ The LD50 in humans is estimated to be 2 to 40 mg/kg. The research that showed in-vitro 50% inhibition of COVID-19 would correspond to an oral dose of 7 mg/kg which is well within the LD50. In each “tube” of ivermectin, meant as an antiparasitic for horses, there is 114 mg of ivermectin which treats a horse up to 1250 lbs. 

Ivermectin’s mechanism of action is to bind to glutamate-gated chloride channels in invertebrate nerve and muscle cells resulting in hyperpolarization. Mammals are usually unaffected because their chloride channels are in the brain and spinal cord which is largely protected by blood-brain barrier.¹⁵ In toxic doses, ivermectin can be neurotoxic and can cause CNS depression, ataxia, coma, and death.¹⁵ It is potentiated by CYP3A4 inhibitors. 

Treatment for toxicity is supportive. Some research in dogs show that single-pass lipid dialysis may be effective but this cannot be extrapolated to humans at this time.¹⁶

The Case Concluded: 

Whew – that was a lot of research.  You also consulted your local Poison Control Center and toxicologist.  You determined that the patient’s gray-blue appearance is actually permanent due to silver deposition from the colloidal silver.  His CNS symptoms are likely related to the more recent ingestion of ivermectin, which will result in him needing close monitoring in the ICU setting.  Though he had quite a bit of other exposures, it seemed that he was no longer directly experiencing those effects.  He was provided supportive care and other evidence-based treatments while in the hospital setting, and was ultimately discharged several months later following his severe COVID-19 infection. 

 References

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2. Man C. Fung & Debra L. Bowen (1996) Silver Products for Medical Indications: Risk-Benefit Assessment, Journal of Toxicology: Clinical Toxicology, 34:1, 119-126, DOI:10.3109/15563659609020246
3. Fazeli, Y. (2020, April 20). Iranian ‘Islamic medicine specialist’ says camel urine cures coronavirus. Alarabiya News. https://english.alarabiya.net/coronavirus/2020/04/20/Watch-Iranian-Islamic-medicine-specialist-says-camel-urine-cures-coronavirus
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11. Quinn, M. (2020, April 17). Feds go after self-described church in Florida selling bleaching agent as cure for COVID-19. CBS News. https://www.cbsnews.com/news/florida-church-coronavirus-bleaching-agent-cure-covid-19/
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