Strange Appetite — Halloween Special

Want to know what can go wrong during a séance in an old Victorian house with a trunk that hasn't been opened in decades? Why can pregnancy cause a compulsion to eat dirt? And what medical diagnosis should you consider when someone compulsively chews ice?

Transcript

This is Pick Your Poison. I’m Dr JP. ER doctor. Toxicologist, and unapologetic lover of all things poison. Today we have a special Halloween episode.
Want to know what can go wrong during a séance in an old Victorian house with a trunk that hasn't been opened in decades while a pregnancy can cause a compulsion to eat dirt and what medical diagnosis should you think about when someone compulsively choose ice?. Listen to find out! Stay right here to find out. Will our patient live or die? Your diagnosis and your decisions matter. Your Halloween costume and let's get started.
Today’s episode starts with a séance.
Not a real one.
There’s no psychic.
There is a crystal ball and three friends in an old house on Halloween. Your friend’s grandmother recently passed away, and this is her beautiful old Victorian house. Your friend is moving in, but first, a massive cleanup is necessary, because the house sat empty for years and accumulated decades’, maybe centuries, worth of junk.
You’re there to help her sort the treasure from the trash and haul out the junk. It's Friday night you've gathered for a sleepover so you can get an early start Saturday morning. Since you’re adults, there won’t be any trick-or-treating.
There will be a séance.
You’re friend set the stage in the dining room, filling the room with candles. Faded wallpaper, climbs up to ornate moldings on the tall ceilings. Heavy curtains cover the windows. You take a seat at small round table she drapped in an old brocade tablecloth. Someone turns off the overhead lights, and suddenly you feel like you’re in another century. Another friend sits down next to you, crunching on the ice in her glass.
Candles flicker around the room, their flames reflected in crystal goblets your friend found buried in a cabinet. At one end of the room, an old grandfather clock marks the seconds with a slow, deliberate tick. Directly behind you hangs an enormous antique mirror.
The silvering has darkened around the edges, making reflection seem to disappear into the glass. Candle flames multiply across its surface, floating behind you in the darkness.
Every time you move, something moves in the mirror.
You know it’s you.
But it’s still creepy.
Two other friends disappear upstairs and returns staggering under the weight of an enormous wooden trunk they found in the attic.
One lifts the lid, and the smell reaches you before you can see what’s inside.
A sharp, sweet, medicinal smell—the unmistakable scent of an old closet.
Mothballs.
Fabric spills out: heavy velvets and brocades. Cream-colored lace gone yellow with age. There are high-necked blouses with rows of tiny pearl buttons, embroidered shawls with long silky fringe, stiff taffeta skirts, and a dark green velvet dress with jet-black beading sewn around the collar.
“Halloween costumes,” she says as everyone starts digging through it.
And everywhere—caught in the lace, buried in pockets, tucked between layers of velvet—are small white mothballs.
Your friend puts on a feathered hat and long, elbow-length gloves and announces she’ll be conducting the séance. Another friend is wearing a fox stole with creepy glass eyes. You pull on the green velvet dress.
Someone turns out the last light.
You sit at the table and join hands.
The room goes quiet.
Your friend closes her eyes.
“If anyone is here with us,” she says, “give us a sign.”
For several seconds, nothing happens.
Then you hear something hit the floor.
It rolls somewhere underneath the table.
Everyone freezes. You’re friend jerks her hand away from yours.
For a second, she looks strange.
Then she starts laughing.
“Sorry. Something touched my leg.”
The table erupts.
Someone screams. Someone else nearly knocks over a candle. You look underneath the table and find absolutely nothing supernatural—just four pairs of feet, a lot of dust, and a few mothballs from the trunk.
The séance deteriorates pretty quickly after that.
Pizza is ordered, drinks are poured. You spend the next hour trying on increasingly ridiculous clothes from the trunk and having a halloween photoshoot.
Eventually, everyone goes to bed so you can get an early start the next morning.
The next morning, you walk downstairs following the smell of fresh coffee. Your friend just scrolled up on the couch in the living room room.
“I feel awful,” she says. “Nausea and my stomach hurts.” She’s sipping from a glass of water and chewing on the ice. She says she barely slept.
She looks awful, too.
Her face is pale. Her hair is damp with sweat.
You ask if she’s hungover.
She shakes her head.
“I only had one glass of wine. “
A few minutes later, she drags herself off the couch to use the bathroom.
“It’s brown,” she shouts.
“It’s the water,” your other friend shouts back. “I think there’s something wrong with the pipes. The water keeps coming out gross.”
She leaves the bathroom, tying her sweaty hair into a messy bun. She comes over to help you with the bookshelf you're sorting through, but keep stopping to lean against the wall for support. You send her back to the couch.
An hour later, she yells again from the bathroom.
“No, it’s definitely my pee that’s brown, not the water.”
You go in to check on her. She’s leaning against the bathroom counter, breathing rapidly. Her skin is extremely pale. You check her pulse, her heart rate is in the 120s.
It’s time to go to the emergency department. This is fiction, so of course you’re the doctor.
Once there, her vital signs are as follows: temperature 98.6°F, or 37°C; blood pressure 120/80; heart rate 120; respiratory rate 25; with oxygen saturation 100% on room air.
You start with the history. She says she doesn’t have any medical problems., no medicines, no allergies. No tobacco, or illicit drugs. Occasional alcohol, like last night.
She says the symptoms started after the séance. She developed nausea and abdominal pain, but thought maybe it was the pizza. This morning, she felt weak and had the dark urine. Now she has shortness of breath and mild chest tightness. She says no fevers or chills, no cough or flu symptoms, no constipation or diarrhea, and no other complaints.
On exam, she’s pale and sweaty, as mentioned, but awake and alert and answering questions. Her cranial nerves are intact. Her heart and lungs are clear. She has mild nonfocal abdominal tenderness when you press. She has good muscle strength.
At this point, we have a patient who’s pale, with generalized weakness and a rapid heart rate. This is fairly nonspecific. One thing that does stand out is her dark urine. It's common to see dark urine impatience, who are dehydrated the less water you drink the darker your urine gets, but there are some things that can really truly change the color of the urine.
Somethings do change the color of your urine. My favorite is probably green urine. In fact I'm gonna save that for the last question in today's podcast.
Question #1, which of the following foods can change the color of your urine.
1. Beets (ie beetroot)
2. Squash
3. Carrots
4. Bannanas
5. Avacodo
Answer: Beets and carrots
A common cause of color change in the urine are things you ate for example beets (ie beetroot) can make your urine reddish if you eat a lot, carrots can make it orange. Blood in your urine can make it dark. It can be a small amount from a urinary tract infection which we call hemorrhagic cystitis or it can be a lot like. Bladder cancer, for example, can cause bleeding which you then see in the urine, we call that hematuria.
A classic medical boards question is the cause of tea-colored or Coca-Cola-colored urine. Often caused by myoglobin in the urine. Myoglobin is supposed to be inside muscles. We've talked about rhabdomyolysis before where you get muscle breakdown and then the myoglobin is in the urine making it dark.
Liver problems can classically cause dark urine because bilirubin is yellow. Some drugs cause dark urine, like iron and antimalarials. phenazopyridine, brand name Azo in the US and over-the-counter medicine for pain with urinary tract infections, makes the body fluids in urine orange even tears can be orange.
How do we figure this out? what we need a urinalysis to tell us if there are red blood cells in the urine signs of infection, etc. I’d also send basic lab work, including a complete blood count, creatinine—ie renal function—liver function tests, and a CK, or creatine kinase, to check for rhabdo.
You move on to you other patients, and an hour later her lab results come back.
The urine dipstick— a quick 2 minute test is very strongly positive for blood in the urine. However, when the lab looks at urine under the microscope, there are no red cells present, meaning, there's something other than actual blood in the urine typically hemoglobin from inside the red cells or myoglobin from inside the muscles. It doesn't show any evidence of infection.
You check your blood work. Her creatinine i.e. her kidney function is normal as is her CK. So this isn’t Rabdo or myoglobin in the urine
You check her CBC her complete blood count, then look at it again to make sure you're reading it correctly. Her white blood cell count is normal meaning no evidence of infection or inflammation, but her hemoglobin is 4 grams/dL. A normal hemoglobin for a woman is around 12 to 15. We've talked before about the indications for blood transfusion, and that's generally speaking below a hemoglobin of seven so her hemoglobin of four is extremely low.
Is this a lab error?
Question #2. Should you send another specimen?
1. Yes
2. No
The answer is a yes we always want to confirm abnormal lab results because sometimes labs occur and we would hate to treat a patient mistakenly. But the more you think about it, it fits with her symptoms. A low blood count, anemia in medical terms, makes people look pale, can cause a rapid heart rate as well as chest pain and shortness of breath.
You go into the room and ask her if she’s had any bleeding. Rectal bleeding in women heavy vaginal bleeding from periods is a common cause. She says no. She said she wasn't taking any medicines, but you ask specifically about anticoagulants i.e. blood thinners she says no again. You ask if she's ever anemic before I'm sure you know this is very common and otherwise healthy young women do menstruation, but she says no she's never been diagnosed with it.
So we have a young woman with dark, urine, severe anemia, and no evidence of actual bleeding. How do we put this together?
In the emergency department were used to people bleeding bleeding from their bowels bleeding in pregnancy bleeding from a gunshot wound or stabbed wound bleeding in their urine. But if you're a hematologist, you're probably used to people with anemia from other causes, sickle cell anemia, bone marrow failure, anemia from chemotherapy.
In her case, what comes to mind is hemolytic anemia. This is when red blood cells are being broken down inside the body, so the person is losing the red cells due to destruction rather than bleeding. This goes along with her urine because the broken down red cells can cause hemoglobin to get into the urine. We need more tests to find out if this is the case, starting with the liver function test, which we already sent her ALT and AST the main markers of the liver it's all for normal so she doesn't have evidence of liver disease, but her LDH and her bilirubin are high. These are inside red blood cells and go up if the cells are being lysed, ie broken-down. Another marker we check is haptoglobin you know the hematologist will want this so you add it on and it also comes back high.
What we need now is a hematology consult. We need an expert opinion. The hematologist asks you to send a peripheral blood smear. This is when the lab looks at the blood under the microscope they can look for things like abnormal, red blood cells malaria, depending on what you're looking for. They agree with you that this is likely a hemolytic anemia and recommend she be admitted to the hospital for further evaluation.
The peripheral smear comes back showing Heinz bodies, bite cells, and blister cells, confirming hemolysis. Heinz bodies are dark spots in red blood cells, due to hemoglobin clumping inside instead of being evenly distributed. Bite cells are where macrophages in the spleen have tried to remove these areas, and it looks like a Pac-Man situation. Blister cells are similar but with a clear blister over the area where the bite occurred.
You can see these in G6PD, hereditary disease due to a chromosome abnormality. We talked about this in the episode on methemoglobinemia. Hematology recommends sending a test as a precaution, but you've seen your friend eat fava beans without an issue. Something that typically triggers a G6PD crisis. Other causes of these abnormal red cells include liver cirrhosis, which she doesn't have dapsone and antibiotic, which she hasn't been taking.
Standing in the room, talking to her about this you notice she still reeks of the mothballs from your Victorian costume photo shoot last night. You wonder if you smell as bad.
Shortly thereafter, the nurse walks past you with her urine and tells you she's gonna do a pregnancy test. The urine specimen reeks of mothballs.
You think you know what happened.
It’s time to Pick Your Poison.
Question 3: Is this:
1. Arsenic toxicity from the green dress
2. Mothball poisoning
3. Formaldehyde poisoning from the fox fur stole
The answer is B. mothball poisoning.
Are you gonna get sick next? What about the rest of your friends? Everybody was trying on the same clothes from the old trunk stuffed with layers of mothballs.
Mothball toxicity doesn’t happen from just touching them. Otherwise, everybody would get sick from clothes stored in mothballs. This is the friend who's constantly chewing on ice meaning she has pika the medical term for eating non-food items chewing on ice often indicates iron deficiency, anemia or low ferritin levels which she probably has despite saying she's never been diagnosed with anemia, but this hemoglobin of four is from hemolytic anemia and it's obviously not caused by chewing on ice. Pica, however, can be a very strange and unusual disease. It's most often associated with pregnant women, causing a compulsion to eat things they shouldn’t.
It has a fascinating history and honestly, we could probably do a whole podcast on theories and speculations in the history of pica itself. For example, there are cases of pregnant women eating dirt yes exactly soil and in some cases these women have nutritional deficiencies and of course soil can have minerals in it like iron just as one example one theory about pika is that it's an ancient adaptation, causing pregnant women to try to obtain nutrients that they were otherwise missing in their diet.
You go back in the room and ask your friend if she ate anything other than the ice.
She says, “Pizza.”
You raise an eyebrow. A few seconds pass.
“Mothballs?” she says sheepishly. “I just ate a few, they were small.”
All right, so we’ve figured out what she ingested, but we still have to figure out what specific toxin is causing this.
There are three general types of mothballs each made out of a different compound. They're typically naphthalene, paradichlorobenzene, or camphor.
How do we figure it out? That's question number four.
1. Color
2. Smell
3. Shape
4. None of the above
Answer D. You can't tell from the appearance, the color or the smell which mothballs are made out of which chemicals.
There is a way - With chemistry.
You call the friend who owns the house and ask her to bring the mothballs into the emergency department. She is little confused and a lot surprised, but say she’ll be there in 20 minutes.
After she arrives, you bring 2 cups into the room one is filled with the regular water and one is filled with salt water. (sidenote please, please never eat any mothballs, but feel free to try this chemistry trick at home. Put as much salt into the 2nd cup as you can get to dissolve and that should do the trick.)
You put one mothball in each cup and see what happens.
It sinks to the bottom of the cup of water, but it floats in the salt water.
Camphor mothballs float in both cups, and paradichlorobenzene sinks in both cups. This means that the mothballs are made out of naphthalene.
These days in the US most mothballs are made out of paradichlorobenzene. Naphthalene more toxic but it was used commonly in older mothballs. In the EU, naphthalene has been completely banned. That said, Naphthalene mothballs are very common worldwide.
Are you surprised these are naphthalene? No because they're probably as old as the clothes in the trunk. Also, the symptoms fit. Camphor causes seizures and paradichlorobenzene causes little acute toxicity, but it causes severe neuropsychiatric changes in the brain with chronic exposure.
As you're conducting the chemistry experiment, the nurse comes back in the room, announcing the patient's pregnancy test is negative. You breathe a sigh of relief not because you were concerned that she was pregnant, but because you know that there are cases of babies born with significant hemolytic anemia due to their mothers eating mothballs.
What specifically does naphthalene do in the body?
It’s metabolized in the liver to alpha-naphthol, which causes oxidative stress on red blood cells, and free radical generation. Hemoglobin is a big molecule around iron in the center. Oxidative stress causes the iron which is supposed to be Ferris iron FE +2 to become ferric iron FE +3 causing methemoglobinemia and making it difficult for oxygen to bind. Oxidized hemoglobin becomes unfolded and can't work properly. They also bind to other abnormal hemoglobins. These are the Heinz bodies that you can see on the red blood cell smear macrophages in the spleen. See these abnormal cells and try to remove the inclusions Ing the bite cells, and also the abnormal hemoglobin causes cell lysis meaning the cells breakdown in the patient becomes anemic.
The 2nd tube of blood you sent to confirm your patient was really anemic, comes back with an even lower hemoglobin than the first. She's definitely going in the wrong direction and we need to do something to treat her.
Is there an antidote? Question #5.
1. Yes
2. No
Answer, Unfortunately, no.
Naphthalene causes hemolytic anemia, which is what our patient has. It also causes methemoglobinemia. We talked about this and more detail in the fresh air episode so check that out if you wanna hear more. Our patient pulse ox is normal so I think it's unlikely but it might be worth sending a methemoglobin level on co-oximetry just to be sure. In fact I met hemoglobinemia is easier to treat because we do have methylene blue and antidote for this, but that isn't gonna help hemolytic anemia.
We need more help from the hematologist so you give them a call back with the updated information. They recommend a transfusion of two units of red blood cells to get her hemoglobin back up and general supportive care.
How long is this gonna last typically it takes a few days for Naphthalene to be eliminated from the body. Once it is, the hemolytic anemia will resolve. They say you can also try vitamin C. It's a free radical scavenger in a reducing agent. The evidence is plus minus as to whether it works, but certainly there's no harm so you order a dose and get her admitted to the hospital.
Over the next two days, she requires several more blood transfusions. By the fourth day, her blood count is normal and her urine returns to a normal color. All symptoms have resolved.
You tell her that her primary care doctor needs to check for iron deficiency anemia, as well as check her ferritin levels once she gets back to normal to see if this is the cause of the pica. These numbers won't be reliable in the hospital due to the underlying illness.
A few months later, she texts you: “You were right about the ferritin. Suddenly, I'm not chewing on ice anymore..”
This is a fictional case, as are all our cases to protect the innocent, but it is based on real poisonings.
A little more on pica because I think it's a fascinating and very poorly understood phenomenon it crosses across cultures countries in history hypocrisies recognized it. The name “pica” is from the Latin word for magpie, a bird known for its large and random appetite.
There are plays from the 15 and 1600s talking about pica. It can be man, but it's most often. Women who've been noted to eat soil, talcum powder, sponges, paper, clay and drywall. Severe cases are associated with underlying psychiatric disease. A lot has been written about pika in the setting of hormones, social factors environmental factors nutritional factors and psychiatric concerns, but the bottom line we really understand very little about it.
Last question in today’s podcast. What compound causes green urine?
1. Arsenic
2. Thallium
3. Ketamine
4. Propofol
Follow the X and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else. Thanks for listening. It helps if you subscribe, leave reviews and/or tell your friends. Transcripts are available at pickpoison.com. While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Until next time, take care and stay safe.




Answer to last question in podcast: Propofol