Hey all, it’s ERP from erstories.net. Haven’t done a guest post in a while but here ya go.

Recently there has been a huge uptick of visitors to my ER violently ill with vomiting and diarrhoea.  They (the CDC) thinks it is Norovirus, but that got me thinking.   We see episodes of this sort of thing so often that we almost turn off our brains as clinicians.  We say “you have a virus” before the patient has finished telling us the full story.  We blindly order Zofran, IV fluids and check some electrolytes.  If they feel better after a bolus of fluids and they tolerate some liquids, they go home.  Quick and easy.  Anyway, I got to thinking, what if something else is going on?  Something weird or random (I know I am a geek like that). Something sinister?   During such outbreaks, it would be easier to avoid detection if you were poisoning someone.  This thought got me back to one of my favourite murder-mystery/science books, the Elements of Murder by John Emsley.  You may remember when I blogged here a while back about the cause of death of Napoleon.  My interest in this subject was piqued by reading this book.

Anyway, if you want to poison someone (not that I would advocate such a thing), the way to do it is to do it SLOWLY.  Don’t give a huge lethal dose since that will trigger suspicion that one was poisoned. Also, don’t use things that have very distinctive toxidromes, such as alopaecia.   This includes radioactive stuff like Thallium and Polonium – 210.   If  you give small doses of things that give more common, run of the mill symptoms (such as vomiting and diarrhoea) that are easily mistaken for things like GI viruses, most MD’s won’t be the wiser.  If you are offing  your great-great grandmother to collect her inheritance or life insurance, no one will bat an eye when she kicks it.  The idea is not to trigger an autopsy or official medical examiner evaluation.   Of course, in this day and age, it is much harder since random deaths of young healthy people will almost invariably trigger an investigation even if it occurs over time. Still, I was thinking about this when I saw a 70 year old lady with N/V/D with dehydration, abdominal cramps, low grade fever, mixed in with  about 5 others I had seen with the same thing during a shift.   Perhaps she was rich and some evil nephew could not wait for her to bite the bullet naturally.  Maybe the poisoner was some evil genius with access to all sorts of nasty stuff?

That got me back to my Elements of Murder book and I read about Antimony, the element with the symbol Sb and an atomic number of 51.  It’s  not something that’s usually lying around these days like it was from the 1500′s to the early 20th century, but it is still around in industrial applications and still can be used in a some forms therapeutically to treat some parasitic infections.   There are some problems with using Antimony to poison someone, mostly that unless the body is cremated, it stays detectable in the corpse nearly forever. Thus the key is to avoid an autopsy.  The advantages of it however are that it causes vomiting, headaches, cramps, and sweating – hence it used to be used to treat fevers.  This lady that I saw pretty much had all this – as did many others that I saw last week.  Just giving her small recurrent doses which would be perceived as a relapse over time, and eventually levels would build up to lethal levels where it blocks anticholinesterase enzymes and causes cardiac arrest.   Now, if I were to suspect this poisoning, I could administer chelating agents like Dimercaprol and the patient would likely survive, so the key is to get the patient poisoned during a big Norovirus outbreak when I have the blinders on.

There were some famous murderers that used Antimony, usually in the form of James’ Powder or Tartar Emetic.  One victim’s case that I found pretty interesting was that of Wolfgang Amadeus Mozart. His death at age 35 in 1791, at the height of his creative genius was officially attributed to “Military Fever”, an archaic term no longer used that could represent many real conditions – infectious or otherwise but may in fact really be Antimony poisoning.    There are many other theories about his death that you can read about (head trauma, Trichinosis, complications of Rheumatic fever), however there seems a real possibility that he was poisoned.  Antimony seems to make the most sense (over Arsenic which would be much more common) due to his symptoms of raging fever, vomiting,depression, and severe edema of the extremities and abdomen from renal failure.   He also exhibited a rash (which my lady fortunately did not have) that has been observed in known cases of poisoning.  The theory is that the composer was treated with Antimony for “melancholia” or severe depression (saddled with stress and debt, this would not be surprising) by his doctor  (ironically Antimony was used to treat this but often CAUSES more depression!) and apparently he was pretty sensitive to it.   When he got more ill and appeared to be febrile (“Military Fever” again) he got more Antimony (and some Mercury which is also nasty stuff) until he succumbed 15 days later, leaving his final composition, the Requiem Mass, unfinished.

Some consorts reportedly came forward much later stating that they had poisoned him on purpose, but the evidence seems to point strongly to yet another case of historical medical malpractise!  Back then, you could do what you and most of medical establishment thought was right, and kill someone unintentionally.  If I could go back to virtually any time before the US Civil War, I would tell people to avoid doctors like the plague!  Meanwhile, my lady felt better after her treatment and I discharged her with an Rx for Zofran – which I subsequently realised might contribute to her death if she were being slowly poisoned with Antimony (since expelling the compound from one’s body is critical in avoiding absorption of acutely deadly doses).  Well, lets just hope she had that virus and get back to work clearing the board.