Toxicology and Overdose Management Practice Questions

Q: Acute liver failure is a clinical feature of which of the following?

B. Amanita Phalloides poisoning. Correct Option B: Amanita Phalloides poisoning - This is due to the presence of potent hepatotoxins, primarily **alpha-amanitin**, which severely damages hepatocytes by inhibiting **RNA polymerase II**. - Ingestion often leads to a delayed presentation of **fulminant hepatic failure** (acute liver failure), necessitating aggressive supportive care and often liver transplantation [1]. *Incorrect Option A: OP poisoning* - Organophosphate poisoning primarily causes a **cholinergic crisis** by inhibiting acetylcholinesterase, leading to massive accumulation of acetylcholine (e.g., SLUDGE syndrome) [2]. - While severe hypoxia or shock might secondarily damage the liver, **acute liver failure** is not the characteristic or primary toxicity of organophosphates [2]. *Incorrect Option C: Belladonna poisoning* - Belladonna contains **atropine** and other anticholinergic compounds, causing profound **anticholinergic syndrome** (e.g., delirium, mydriasis, tachycardia, urinary retention). - Hepatic necrosis or **acute liver failure** is not a feature of anticholinergic toxicity. *Incorrect Option D: Morphine poisoning* - Morphine, an opioid, causes toxicity characterized by the classic triad of **respiratory depression**, altered mental status, and **pinpoint pupils** (miosis). - Opioid toxicity is centered on the central nervous system and respiratory system; it does not directly cause primary **acute liver failure**.

Q: An industrial worker was brought to a medical facility due to health problems. On his workup including laboratory tests, a finding of basophilic stippling of Red Blood Cells (RBC) was observed. Which among the following is he/she likely to be having?

Lead poisoning. ***Lead poisoning*** - **Basophilic stippling** of **RBCs** is a classic hematological hallmark of **lead poisoning**, resulting from the inhibition of **5'-nucleotidase** by lead, which impairs the degradation of ribosomal RNA [2]. - This condition is common in industrial workers exposed to lead-containing materials, such as those in battery manufacturing, smelting, or painting [1]. *Brucellosis* - This is an infectious disease caused by bacteria from the genus **Brucella**, usually acquired from animals or contaminated animal products. - It typically presents with fever, sweating, malaise, and arthralgia, and is not associated with **basophilic stippling**. *Asbestosis* - **Asbestosis** is a chronic lung disease caused by inhaling **asbestos fibers**, leading to lung fibrosis and impaired respiratory function. - Its clinical presentation involves progressive shortness of breath, cough, and characteristic radiographic findings of interstitial lung disease, with no direct hematological findings like **basophilic stippling**. *Farmer's lung* - **Farmer's lung** is a **hypersensitivity pneumonitis** caused by inhaling organic dusts from moldy hay or other agricultural products. - Symptoms include cough, fever, chills, and shortness of breath, reflecting an inflammatory response in the lungs, without any associated **basophilic stippling**.

Q: A young man sustained a scorpion sting 2 hours ago. On examination, his blood pressure is $108 / 60 \mathrm{~mm} \mathrm{Hg} ; \mathrm{HR}, 72$ beats / minute and respiratory rate, 32 breaths/ minute. He also complains of breathlessness. How do you manage this patient?

Prazosin. ***Prazosin*** - The patient's presentation with scorpion sting complicated by **breathlessness** and a respiratory rate of 32 breaths/minute suggests a **neurotoxic reaction** leading to **pulmonary edema** or **myocardial dysfunction**. - **Prazosin**, an alpha-1 adrenergic blocker, is recommended in such cases to counteract the **sympathomimetic effects** of scorpion venom, particularly reducing pulmonary and systemic vascular resistance, thereby alleviating pulmonary edema and improving cardiac function. *Frusemide* - While frusemide is a diuretic used to treat pulmonary edema, its use in scorpion envenomation is controversial and generally not recommended as a primary treatment. - The underlying cause is sympathetic overactivity, and diuresis alone without addressing the root cause may not be sufficient and could exacerbate hypovolemia in some settings. *Ivabradine* - Ivabradine is a **heart rate-lowering agent** that acts by selectively inhibiting the funny current (If) in the sinoatrial node. - It is primarily used for the treatment of **stable chronic heart failure** with reduced ejection fraction and stable angina, not for acute scorpion envenomation. *Metoprolol* - Metoprolol, a beta-blocker, could potentially worsen bronchoconstriction in patients with underlying respiratory issues and is generally not recommended in the acute management of severe scorpion envenomation, especially if there are signs of respiratory distress or cardiogenic shock. - While scorpion venom can cause tachycardia, directly blocking beta-receptors without addressing alpha-adrenergic overactivity may not be beneficial and could lead to adverse effects.

Q: Gastric lavage is contraindicated in the following:

Kerosene poisoning. ***Kerosene poisoning*** - Gastric lavage is contraindicated in **hydrocarbon poisoning** like kerosene due to the high risk of **aspiration pneumonitis**. [1] - Aspiration of hydrocarbons can lead to severe **chemical pneumonitis**, acute respiratory distress syndrome (ARDS), and even death. *Barbiturate poisoning* - Gastric lavage can be useful in **barbiturate poisoning**, especially if presenting within 1-2 hours of ingestion, to remove unabsorbed drug. - It's part of the management strategy to reduce drug absorption and potentially speed up recovery. *Paracetamol poisoning* - **Gastric lavage** may be considered in paracetamol overdose, particularly if performed within 1-2 hours of ingestion, to remove unabsorbed drug. - However, **activated charcoal** is usually the preferred method for gastric decontamination in paracetamol overdose, followed by **N-acetylcysteine**. *Carbolic acid poisoning* - While typically considered a corrosive, gastric lavage might be cautiously used in **carbolic acid (phenol) poisoning** in specific circumstances, such as very early presentation or large ingestions, but it carries risks of esophageal injury. [2] - Dilution with milk or water is often preferred, but lavage should be avoided if there's evidence of significant caustic injury or perforation risk.

Q: A 35-year-old construction worker presents with a 3-month history of abdominal pain, fatigue, and recent onset of numbness and tingling in his hands and feet. He works in renovation of old buildings. Physical examination reveals mild pallor and decreased sensation in a stocking-glove distribution. Blood tests show microcytic anemia with basophilic stippling on peripheral smear. What is the most likely diagnosis?

Lead poisoning. **Lead poisoning** - The patient's occupation in **renovating old buildings** poses a significant risk for lead exposure [1]. - Classic symptoms of lead poisoning, such as **abdominal pain** [1], **fatigue**, **peripheral neuropathy** (numbness/tingling in stocking-glove distribution) [2], **pallor** [2], **microcytic anemia**, and **basophilic stippling** [1], are all present. *Coeliac disease* - While it can cause **abdominal pain** and **fatigue** due to malabsorption, it typically leads to **iron deficiency anemia**. - **Neuropathy** is less common and **basophilic stippling** is not a feature of coeliac disease. *Sickle cell disease* - Causes **hemolytic anemia** and painful crises, but is a genetic disorder typically diagnosed in childhood and presents with different symptoms. - While it can present with **fatigue** and **pallor**, **basophilic stippling** is not typical, and neuropathy in a stocking-glove distribution is rare. *Hookworm infestation* - Primarily causes **iron deficiency anemia** due to chronic blood loss from the gut, leading to **fatigue** and **pallor**. - It does not typically cause **basophilic stippling** or prominent **peripheral neuropathy** as described.

Q: Miosis is caused by all EXCEPT -

Cyanide. **Cyanide** - **Cyanide poisoning** primarily affects cellular respiration by inhibiting **cytochrome c oxidase**, leading to **anoxia** at the cellular level. - Its typical ocular manifestation is **mydriasis** (pupil dilation) due to **hypoxia-induced sympathetic overactivity**, not miosis. *Organophosphates* - **Organophosphates** inhibit **acetylcholinesterase**, causing an excess of **acetylcholine** at muscarinic receptors [2]. - This leads to **parasympathetic overstimulation**, including pinpoint pupils (miosis). *Pontine hemorrhage* - **Pontine hemorrhage** can disrupt the **sympathetic pathways** that run through the pons. - Loss of sympathetic input to the eye results in unopposed **parasympathetic tone**, causing **miosis**. *Opiates* - **Opiates**, such as morphine and heroin, centrally stimulate the **Edinger-Westphal nucleus**, increasing **parasympathetic outflow** to the eye [1]. - This increased parasympathetic activity leads to **constriction of the pupils**, commonly referred to as "pinpoint pupils" [1].

Q: All of the following are treatments for snakebite, EXCEPT:

Incision over wound. ***Incision over wound*** - Incision over a **snakebite** is contraindicated as it can introduce infection, cause further tissue damage, and may worsen bleeding due to **coagulopathy** caused by some venoms [1]. - This practice has no proven benefit in removing venom and is associated with significant risks [1]. *Reassure the patient* - Reassurance is a crucial initial step as **fear and anxiety** can worsen the patient's condition, leading to symptoms like **tachycardia** and **hyperventilation** [2]. - A calm approach helps in assessing the patient effectively and preparing them for further medical intervention [2]. *Firm bandage to occlude lymphatic* - A **pressure immobilization bandage** can delay the systemic absorption of venom, particularly from elapid snakebites, by reducing **lymphatic flow** [1], [3]. - The bandage should be applied firmly, similar to an ankle sprain bandage, but not so tight as to impair **arterial circulation** [1]. *Immobilization of bitten part* - Immobilizing the bitten limb, preferably at or below heart level, helps to reduce the spread of venom by minimizing muscle movement and **lymphatic drainage** [1], [3]. - This is often achieved using a **splint** or sling along with the pressure bandage [1], [2].

Q: Which of the following is the MOST COMMON condition that can cause absent pupillary response, despite the patient not being brainstem dead?

Drug overdose. ***Drug overdose*** - Certain drugs, particularly **opioids** and other central nervous system depressants, can cause **pinpoint pupils** that are unresponsive to light, mimicking neurological damage without brainstem death [1]. - This is a common presentation in emergency settings and must be differentiated from brainstem death [2]. *Hypothermia* - **Severe hypothermia** can cause sluggish or fixed pupils due to systemic effects on neural pathways [3]. - However, it is a less common cause than drug overdose for an absent pupillary response in a non-brain dead patient. *Use of mydriatic eye drops* - Mydriatic eye drops directly block parasympathetic innervation or stimulate sympathetic innervation to the iris, leading to **dilated and fixed pupils**. - While it can cause an absent pupillary response, it is usually due to medical intervention rather than a systemic condition mimicking brainstem death, and is therefore not the "most common" condition in general medical presentations. *Severe structural damage to the eye* - Direct **structural damage to the eye**, such as significant trauma, can impair the pupillary light reflex. - This is a localized problem and less common as a general condition causing absent pupillary response in the context of avoiding a brainstem death diagnosis.

Question 1

Which of the following conditions can cause rhabdomyolysis with myoglobinuria?

Accepted Answer

Multiple hornet stings

Answer

Viper bite

Answer

Heat stroke

Answer

Malignant hyperthermia

Question 2

All are true about aspirin poisoning except?

Accepted Answer

Hypothermia

Answer

Acidosis

Answer

Dehydration

Answer

Oliguria

Question 3

Acute liver failure is a clinical feature of which of the following?

Accepted Answer

B. Amanita Phalloides poisoning

Answer

C. Belladonna poisoning

Answer

D. Morphine poisoning

Answer

A. OP poisoning

Question 4

An industrial worker was brought to a medical facility due to health problems. On his workup including laboratory tests, a finding of basophilic stippling of Red Blood Cells (RBC) was observed. Which among the following is he/she likely to be having?

Accepted Answer

Lead poisoning

Answer

Brucellosis

Answer

Asbestosis

Answer

Farmer's lung

Question 5

A young man sustained a scorpion sting 2 hours ago. On examination, his blood pressure is $108 / 60 \mathrm{~mm} \mathrm{Hg} ; \mathrm{HR}, 72$ beats / minute and respiratory rate, 32 breaths/ minute. He also complains of breathlessness. How do you manage this patient?

Accepted Answer

Prazosin

Answer

Frusemide

Answer

lvabradine

Answer

Metoprolol

Question 6

Gastric lavage is contraindicated in the following:

Accepted Answer

Kerosene poisoning

Answer

Barbiturate poisoning

Answer

Paracetamol poisoning

Answer

Carbolic acid poisoning

Question 7

A 35-year-old construction worker presents with a 3-month history of abdominal pain, fatigue, and recent onset of numbness and tingling in his hands and feet. He works in renovation of old buildings. Physical examination reveals mild pallor and decreased sensation in a stocking-glove distribution. Blood tests show microcytic anemia with basophilic stippling on peripheral smear. What is the most likely diagnosis?

Accepted Answer

Lead poisoning

Answer

Coeliac disease

Answer

Sickle cell disease

Answer

Hookworm infestation

Question 8

Miosis is caused by all EXCEPT -

Accepted Answer

Cyanide

Answer

Organophosphates

Answer

Pontine hemorrhage

Answer

Opiates

Question 9

All of the following are treatments for snakebite, EXCEPT:

Accepted Answer

Incision over wound

Answer

Reassure the patient

Answer

Firm bandage to occlude lymphatic

Answer

Immobilization of bitten part

Question 10

Which of the following is the MOST COMMON condition that can cause absent pupillary response, despite the patient not being brainstem dead?

Accepted Answer

Drug overdose

Answer

Hypothermia

Answer

Use of mydriatic eye drops

Answer

Severe structural damage to the eye

Toxicology and Overdose Management — MCQs

Toxicology and Overdose Management — MCQs

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