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Josh Trebach, MD

Feb 16 • 7 tweets • 2 min read

A 23yo male presents to the hospital after an overdose of unknown medications. He is watched for 24 hours, has no symptoms, and is sent home.

7 days later, he develops palpitations, tremor, sweating, and diarrhea. He denies taking any other meds.

What is going on?🤔☠️

7 days ago, this patient overdosed on LEVOTHYROXINE (aka synthroid). But why the delay in symptoms?

Levothyroxine contains T4 hormone which is inactive and requires conversion to the active form T3. This conversion can be delayed, and symptoms may take up to 10 days to appear!

Once T4 gets converted to the active T3 form, it can cause symptoms that resemble hyperthyroidism/thyroid storm. People have had hyperthermia, agitation, seizures, heart attacks, and multiorgan failure.

Some patients will have no symptoms or barely any symptoms at all.

You may be thinking…can't we just check T4 levels and see how high they are and predict symptoms based off that? Unfortunately, it doesn't seem to really change management…T4 levels and clinical symptoms do not tend to correlate well.

Treatment depends on the patient (toddler? adult? intentional? unintentional? dose? exam? history?) and can vary from watching at home to see if they develop symptoms to hospital admission for observation, GI decon, and even medications like benzodiazepines and propanolol.

If you ever need help managing a case like this, remember that you can always call your local poison control center or your friendly neighborhood toxicologist!

Further reading: Goldfranks Tox Emergencies 11th ed Ch53, PMID 25905265, 4046139

Thanks for tuning in! #ToxTweets

Ps I’m glad y’all enjoy these teaching cases, I’ll do my best to keep ‘em coming :)

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More from @jtrebach

Josh Trebach, MD

@jtrebach

Dec 30, 2022

A family of five arrives to the emergency department with "the flu." They all have headache, nausea, vomiting, and generally feel unwell. You are about to discharge them when they let you know that even their dog is sick with "the flu"!

What do you think is going on? 🤔☠️

This time of year can be tricky...because CARBON MONOXIDE toxicity can mimic things like the flu or a viral illness.

Carbon monoxide is an odorless, tasteless, invisible gas that comes from things like automobile exhaust, fires, fuel-burning heaters, gas stoves, generators, etc.

More than 1/3rd of deaths from carbon monoxide in the United Sates occur during winter months. Clusters of carbon monoxide cases are associated with ice storms/blizzards/hurricanes probably because people are crowded inside and using fuel-burning items.

Read 9 tweets

Josh Trebach, MD

@jtrebach

Nov 30, 2022

After taking tons of tests over the years, I have honed a study technique that works well for me.

And hopefully, it works for you too!

A thread on the study technique that got me through med school, residency, fellowship, and one of the hardest board exams I’ve ever taken:🧵📚

Step 1: Gather materials

This technique requires a white board (or a wall with paper on it), sticky notes, a pen, and your study material. Ideally, the white board would be in a place you are studying in each day such as your bedroom, office, or cubicle.

Step 2: Create categories

For me, the categories were either lectures (Lecture #1, Lecture #2, etc) or subjects (Endocrine, Hematology, etc). It doesn’t matter how many categories there are. I have had anywhere from 6 to 30 categories depending on the test. Put 'em on the board.

Read 13 tweets

Josh Trebach, MD

@jtrebach

Nov 28, 2022

A 18-year-old male presents to the emergency department with confusion and hallucinations for over 24 hours. He keeps muttering that he was "bitten by the dragonfly."

What do you think is going on?☠️☠️

Turns out it wasn't an actual dragonfly, but rather, the compound known as 1-(8-Bromobenzo[1,2-b;4,5-b]difuran-4-yl)-2-aminopropane!!!!!!

Because the structure of this compound kind of looks like a dragonfly and it has a bromine on it, it is also called Bromo-DragonFLY.🐉🪰

Bromo-DragonFLY was first synthesized in the lab in 1998. It was briefly looked into as a potential antidepressant. It works by being agonist at serotonin receptors (and this is likely what mediates the hallucinogenic effects). It can be a powder, liquid, or on blotter paper.