An immunocompromised and polymedicated patient presenting a confusional syndrome

Objective We present the case of a 52-year-old patient, 108 kg, admitted to the Emergency Department (ED) of New Caledonia Hospital Center in August 2018 for confusional syndrome and major agitation requiring the establishment of an important chemical restraint. Case history In terms of medical history, the patient, a bricklayer with chronic cough in a context of diffuse interstitial pneumonitis related to chronic cement inhalation treated with long-term oxygen therapy and an association of micophenolate mofetil and prednisone, presented a month earlier a respiratory decompensation of infectious origin. On the morning of his new admission, he was perfectly fine. Then, he progressively presented coughing fits as well as neurological disorders. Medical examination in ED found tachycardia with heart rate = 92, confusional state associated with non-reactive bilateral mydriasis, language disorder, obsession and severe agitation, no fever. A mucocutaneous dryness was also noted. Blood and CSF biological investigations, cerebral CT with injection performed under midazolam sedation, revealed no abnormality. Patient was transferred to ICU for further sedation in front of persistent agitation, despite cyamemazine, haloperidol and clorazepate administrations. EEG found well-organised activity without seizure or paroxysm. From the interview with the family, it finally emerged that, if the patient did not consume any intoxicant, he was treated in addition to his immunosuppressive treatment with Lercanidipine, Esomeprazole, Allopurinol and Amitryptiline. Furthermore, he has been self-medicating for a week by plant decoctions for an episode of ichthyosarcotoxism of the ciguatera type. In front of the characteristic symptomatology of an anticholinergic syndrome, a poisoning by plants of the genus Datura or Brugmensia was considered. Methods Blood and urine samples were taken 4 h after the appearance of the disorders for toxicological analysis using LC-UV-DAD (Acquity ® Waters ® system) and LC-MS/MS (Alliance ® and QuatroMicro ® Waters ® system). Results LC-UV-DAD urine analysis showed the presence of scopolamine and signed an acute intoxication by a probable tropical datura. Quantification, performed a posteriori by LC-MS/MS, confirmed the intoxication. Atropine concentrations were: undetected and 6.2 ng/mL in blood and urine, respectively; scopolamine concentrations were: 1.6 ng/mL and 643 ng/mL in blood and urine, respectively. Taking into account an elimination half-life of scopolamine between 1 h and 3 h, these concentrations are compatible with the clinical signs observed. It is likely that the patient has mistaken the leaves of “octopus bush” ( Heliotropium foertherianum , Boraginaceae ), a reputed traditional medicine plant to treat ciguatera fish poisoning, with leaves of a Brugmensia spp ( Solanaceae ). Conclusions Given the heavy medical history of this patient, the questioning of his entourage has been crucial in the rapid orientation of the investigations in search of poisoning by plant and, taking into account the toxidrome presented in a tropical context, to look more specifically for the presence of scopolamine in the patient's urine. Subsequently, evolution was gradually favourable with normal neurological examination and hospital discharge at day 7.