4/6/2020
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Warm Weather Toxins: A Short Review of Timely Woes
April 7, 2020
Renee D Schmid, DVM, DABTDVM Supervisor, Senior Consulting Veterinarian, Clinical ToxicologyPet Poison Helpline
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Warm Weather Toxins: A Short Review of Timely Woes
April 7, 2020
Renee D Schmid, DVM, DABTDVM Supervisor, Senior Consulting Veterinarian, Clinical ToxicologyPet Poison Helpline
Today’s DiscussionDiscuss:
• Different types of cyanobacteria toxins
• Signs expected
• Treatment and prognosis
Blue Green Algae (Cyanobacteria)
• Potential toxicity concerns
• MOA/Signs/Therapy
Bifenthrin
Lilies
Fipronil in rabbits
Chocolate
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Audience Poll
All blue‐green algae is toxic
• True
• False
Photo courtesy of Dr. Steve Ensley, DVM (K‐State CVM)
Cyanobacteria (Blue‐Green Algae)
Found in fresh and salt water
Blooms are most common in hot, calm, dry weather and occur in nutrient rich waters
Toxins can be present any time of the year
Run‐off from fer lizers ↑ risk of growth
Water looks pea‐green with thick mats of green or blue‐green algae on the surface
Most are NOT toxic
Cyanobacteria (Blue‐Green Algae)
2,000 species
95 can produce toxins
Organized as
•Individual cells (ex. Synechococcus)
•Filaments (ex. Plankothrix)
•Colonies (ex. Microcystis)
Benthic and pelagic can proliferate into blooms
Toxin concentration ≠ cell count
Toxins enclosed within cyanobacteria
•Only release with cell damage or lysis
•Acidic stomach environment → Release of toxin
Destruc on of algal mat → Large release of toxin
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Cyanobacteria (Blue‐green Algae)Risk Factors
All species, all breeds at risk if a sufficient dose is ingested
Dogs that swim or hunt
Pets with access to backyard ponds
Livestock, especially cattle, using ponds and lakes as water source
Horses have had fewer case reports
Humans
Cyanobacteria (Blue‐Green Algae)Common species to produce toxins
Anabaena spp Microcystis spp
Aphanizomenon flos‐aquaae
Cyanobacteria (Blue Green Algae)Microcystin
Produced by numerous types of cyanobacteria
•Microcystis, Anabaena, Planktothrix and others
> 100 structural variants
• Microcystin‐LR most common
Absorbed in the S.I. and rapidly distributed to liver, also lungs, heart,
capillaries
Oral LD50 mice
5‐11 mg/kg
Irreversibly inhibits protein phosphatase 1
and 2AAcute hepatotoxicosis
Cytocellular collapse, apoptosis, necrosis
Shock, death from hepatic failure
Poor prognosis → Death within a few hours for most
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Cyanobacteria (Blue‐Green Algae)
Anatoxin (neurotoxin)
Primarily produced by Anabaena, Aphanizomenon and others
Anatoxin‐a
• Oral LD50 mice = 5 mg/kg
• Nicotinic agonist (continuous stimulation @ nicotinic receptors)
• Depolarizing blockade & paralysis
Anatoxin‐a(s)
• Acetylcholinesterase inhibitor (like OPs and carbamates), irreversible
• Continuous stimulation @ cholinergic receptors
• ‘S’ for salivation
• Does not cross blood brain barrier (insecticides can)
Cyanobacteria (Blue‐Green Algae)Clinical Signs
• Rapid onset of diarrhea, weakness, pale mucous membranes, icterus, shock, liver failure (few hours)
Microcystin (hepatobiliary)
• Rapid onset of muscle tremors, muscle rigidity, paralysis, cyanosis (minutes to hours)
Anatoxin‐a (neurologic)
• Cholinergic signs (SLUD) within hours
• Nicotinic signs (tremors, incoordination, seizures, respiratory arrest) within 30 minutes
Anatoxin‐a(s) (neurologic)
MicrocystinTherapy
No specific antidote
Rarely caught early enough for successful intervention
• Location of exposure
• Speed of onset
Emesis
+/‐ Activated charcoal with cathartic
Rifampin?
• Competes for specific transporter → prevents uptake into hepatocytes
• Success shown in mice
Glutathione, silymarin, vitamin E, selenium, cyclosporine A
• Benefits only shown when used prophylactically
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Anatoxin‐a and Anatoxin‐a(s)Therapy
No specific antidote
EmesisActivated charcoal with cathartic
Atropine for SLUD signs
AnticonvulsantsMethocarbamol for tremors
Mechanical ventilation
2PAM not effective
• Does not reactivate inhibited AChE
Cyanobacteria (Blue‐Green Algae)Testing
Multiple veterinary diagnostic labs across U.S.
Kansas State University
CyanoPros‐Auburn University
New Bolton Center‐University of Pennsylvania
University of California Davis
Iowa State University
Purdue
Others
Microcystin, anatoxin‐a and anatoxin‐a(s) conc.
Blood AChE ac vity↓ with anatoxin‐a(s) (Brain AChE levels normal)
Specimens
Water
GI contents
Urine
Bile
Serum
Kidney
Rose11.5yr Healthy F/S 30kg Chesapeake Bay Retriever
October 22, 2016
With family at a bonfire along the banks of the Snake River near
Burley/Rupert area southern Idaho
Temperatures in the 60’s to low 70’s
Areas of standing water present due to low water levels
Normal for time of year
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Rose
Out playing along the
riverbank in the dark for approx. 45 minutes
Wet from being in the water once returned
to family
Possibly ADR but assumed to
be due to playing
Family loaded up to leave
Rose
Lateral recumbent
Unresponsive
Tremors
Cyanotic
No spontaneous breathing
Intermittent HR on palpation
15‐20 minutes later
Rose
Presentation to clinic
• T 95.0˚F
• Pulse 50‐70, not correlating with auscultation
• Unresponsive/Absent palpebral, menace and corneal reflexes
• No spontaneous respirations
• Cyanotic without manual ventilation
• ALT elevated but other hepatic enzymes wnl
• Mild hypokalemia
Immediate differentials
• Organophosphate/Carbamate
• Blue‐Green Algae
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Rose
• Intubated with ventilation support
• IV fluids with Dextrose
• Vitamin K1
• Lidocaine
• Lactulose enemas
• Doxapram
• Methylprednisolone
• Vitamin B complex
• KCl
Therapy
Rose
3 ½ hours after presentation
Slight palpebral No corneal/menaceDiazepam found and
given
slow return of stronger palpebral, mild
respiratory effort, mild eye movement,
blinking
4 hours after presentation
Swallowing on ownIsoflurane initiated
to help with manual ventilation
Good palpebral, jaw tone and
respiratory effort
Tremors still very pronounced
Temperature normalized
Rose6 ½‐7 ½ hours after presentation
• Methocarbamol obtained and given rectally
• Improvement in tremors
• Patient extubated and alert, responsive
• Apparent cortical blindness and deaf
8 ½‐10 hours after presentation
• Ambulatory but ataxic
• Urinated on own
• Ravenous appetite
• Recheck labwork showed continued elevation to ALT only
• Bathed
• Started SAM‐e
• Sent home
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RoseDiagnosis
Taxonomy scan:
12 different algae types
4 toxin producers including anatoxins
Rose
Rose made a full recovery
and is still doing well 3 years
later!
Big thank you to Briedi Gillespie of Washington State University for allowing us to share Rose’s story and pictures!
Cyanobacteria in humansCase Report
Wichita, KS August 2019
Shoplifting suspect tried to escape police by jumping in a retention pond but could not swim.
Two police officers rescued the teenager and all became ill soon after exposure
Water samples sent to Kansas State University VDL = Microcystin
All those affected were treated and made a full recovery
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Audience PollWhich picture contains toxic blue green algae?
A. Left
B. Right
C. Both
D. Neither
What About Algae Supplements?
Toxicity is possible, however…..
Most supplements contain Spirulina spp.
Low likelihood of toxin
contamination
Supplements may contain
other ingredients of
concern
Blue‐Green AlgaeRecap
Not all algae contain toxins
Familiarize yourself with problem water sources in your area
Most common toxins result in hepatoxicity and neurotoxicity
Onset of signs is often sudden with death occurring within a few hours
No antidote is available
Consider in any patient who has been exposed to a water source and is showing consistent clinical signs
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Bifenthrin
Synthetic Type I pyrethroid pesticide
Over 600 products available in the U.S
Supplied in sprays, granules, aerosols
Commonly found in products to treat fire ants
Bifenthrin
LOW TOXICITY TO BIRDS AND MOST MAMMALS
HIGHLY TOXIC TO FISH AND BEES
DOGS SHOW SENSITIVITY THAN
OTHER PYRETHRINS/ PYRETHROIDS
Bifenthrin
Larger ingestions expected to result in more severe signs
No specific toxic dose
Low concentrations may result in signs
Lethargy
Ataxia
Tremors
Hyperesthesia
Seizures, less common
Clinical signs
Possible delay by 12‐24 hours
Onset of signs within 30 minutes‐3 hours
Signs resolve within 24‐48 hours
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Frank
Bifenthrin
Induce emesis if asx and <2 hours post ingestion
Activated Charcoal with cathartic
• 1g/kg
Sub q fluids +/‐ IV fluids depending on severity of signs
Methocarbamol for tremors
Anticonvulsants for seizures
Symptomatic and supportive care
TherapyTherapy
Oral Methocarbamol until tremors resolve
Mild signs may be treated at homeMild signs may be treated at home
BifenthrinWhen should bifenthrin be included in your differential list?
Witnessed ingestion
Relevant location
Hx of recent use
Disturbance of ant mounds
Consistent clinical signsAtaxia
Tremors
No other exposure
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BifenthrinRecap
Consider bifenthrin in your differential list for tremoring/ataxic patients especially in warm weather months
Even low concentrations may result in signs
Dogs are particularly sensitive to bifenthrin poisoning
Severe signs of toxicity are not likely, however, medical intervention is generally necessary
‘Tis the Season
Lilium and Hemerocallis Sp. (True Lilies)
Risk for ARF in cats only
All parts of the plant are toxic including pollen and water from vase
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Not True Lilies
Non‐ToxicPeruvian LilyAlstroemeria spp
Peace LilySpathiphyllum
Calla Lily Zantedeschia
LiliesAggressive therapy recommended
Decontaminate
Emesis
Activated charcoal with cathartic x 1
Baseline labwork (CBC, chemistry, u/a)
Monitor renal values daily for 72 hours
IV fluids in clinic for 48 hours
Monitor urine output if azotemia develops
Anti‐emetic and GI protectants as needed
Fipronil and Rabbits
Wide margin of safety in mammals EXCEPT rabbits
• Lethargy
• Anorexia
• CNS signs may be delayed for 3‐9 days
• Tremors
• Seizures
• Death 11‐14 days post exposure
Signs expected with dermal and oral exposures
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Fipronil and RabbitsTherapy
BATHE IN LIQUID DISHWASHING
DETERGENT IF DERMAL
ACTIVATED CHARCOAL WITH CATHARTIC IF
ORAL
IV OR SUB Q FLUIDS ANTICONVULSANTS
NUTRITIONAL SUPPORT
ChocolateTheobromine
Toxicity varies by type
Unsweetened > semi‐sweet > dark >
milk > white
Absorption can be delayed up to 6
hours
17.5 hr half‐life (dogs)
Toxicity
Mild >20 mg/kg
Moderate >40 mg/kg
Severe toxicity >60 mg/kg
Chocolate
GI upset
Vomiting
Diarrhea
Agitation/restlessness
Increased thirst
Mild toxicity
Tachycardia
Hypertension
Possible tremors
Moderate toxicity
Arrhythmias
Tremors
Seizures
Severe toxicity
Pancreatitis possible
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Chocolate
DecontaminationInduce emesis up to 6 post ingestion
+/‐Activated charcoal/Enterohepatic recirculation
Anti‐emetics, GI support
Fluids SQ or IV fluids
Outside frequently to urinate Bladder wall reabsorption
Sedation
Methocarbamol
Beta blockers
Anti‐convulsants
Wrapping it all up
Not all algae contain toxins consistent with blue‐green algae
Watch for exposures to any concentration of bifenthrin products
Keep true lilies away from cats
Keep fipronil containing products away from rabbits
Identify the type and amount of chocolate ingested when determining toxicity risks
Special thanks to Dr. Steve Ensley, DVM and K‐State’s VDL for the many blue‐green algae photos
Sign up for…
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Blackwell’s Five‐Minute Veterinary Consult Clinical Companion:
Small Animal Toxicology 2nd Edition
• Provides concise, bulleted information focused on the most important facts needed when treating a poisoned cat or dog
• Carefully organized for ease of use in an emergency, with important toxicants arranged alphabetically within categories
• Details clinically relevant information on the most common toxicants encountered by small animals
• Presents a wealth of color photographs to aid in plant identification
• Includes 14 new topics to this edition covering cyclosporine A, sleep aids, tacrolimus, bath salts, synthetic marijuana, poisonous lizards, imidacloprid, spring bulbs, and sodium monofluoroacetate
Drs. Lynn Hovda, Ahna Brutlag, Robert Poppenga, Katherine Peterson
www.wiley.com/go/vet
Paperback | May 2016 | 960 pages | 978‐1‐119‐03654‐8 | $109.99 ∙ CAN $120.99
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• February 2ndRecorded and available for non-interactive CE credit!
• Essential Oils
• April 9th
• Remote Leadership: How to Get the Most Out of Your Team When Distance Separates You
• June 2nd
• Hot Topic TBD
• October 6th
• Worst of the Worst. Evaluating the Most Dangerous Toxins for Pets.
• November 10th
• Hot Topic TBD
2020 Webinars Announced
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