Ergotism is poisoning by ergot alkaloids trapped in flour, or taken as a medicine. Typical symptoms are convulsive muscle contractions, intense diarrhea, severe muscle pain, paresthesia, hallucinations, delirium. In severe cases, tissue necrosis occurs. With chronic pathology, amenorrhea is observed in women. Diagnosis of the disease is based on clinical data, careful collection of anamnesis, detection of toxins in food. Treatment of ergotism is symptomatic and pathogenetic, there is no specific etiotropic antidote.
T62.2 Toxic effect of other toxic substances contained in eaten foods. In another (their) eaten plant(s)
Ergotism is a fungal toxicosis. The first mention of pathology is found in the annals of the VI century, the symptoms and the connection with infected flour were described in more detail by the French doctor Tullier in 1650. The disease is common in countries with developed agriculture, in humid and cool climates with seasons of heavy rains, but currently cases of food poisoning are rare. The problem is the growing number of drug ergotism. There are no gender and age differences described.
The causative agent of the disease is a toxin produced by ergot (Claviceps purpurea Tul). The fungus affects the ears of cereals, more often rye, in which poisonous sclerotia are formed, or horns, the main components of which are alkaloids based on lysergic acid. The main effect of toxic substances is the contraction of smooth muscles and spasm of blood vessels, hallucinogenic effects.
The transmission path is food, through poorly processed grain. The main risk factors of ergotism:
- eating flour from non-industrial grain, wild grain and bakery products from it;
- simultaneous administration of drugs including ergotoxin and some other drugs – non-nucleoside HIV reverse transcriptase inhibitors, antiarrhythmics, macrolide antibiotics, antifungal azoles, HIV protease inhibitors, antidepressants, as well as food (grapefruit juice).
The pathogenesis of mycotoxicosis has not been definitively studied. It is believed that ingestion of the toxin with food leads to its absorption by the mucous membrane of the digestive apparatus. The effect exerted on the autonomic nervous system is similar to the adrenolytic one; in parallel, the transmission of the nerve impulse is disrupted. Pathological effect on the central nervous system – suppression of the vasomotor center, suppression of neuronal connections.
Pathohistological description of the lesion of nerve fibers in ergotism – degenerative processes in the posterior columns of the spinal cord (more often Burdakh), diffuse infiltrates in the brain. There is moderate hemorrhagic diathesis and congestive hyperemia in parenchymal organs, central nervous system, hemorrhages in the mucous membrane of the stomach, intestines, liver, spleen, cerebellar tissue.
Ergotism is classified depending on the type of course of the disease. With a high dose of the toxin that has entered the body, symptoms occur within a few hours, less than a day. The constant intake of small doses of a toxic substance, for example, when it is prescribed for medicinal purposes, leads to its accumulation and clinical manifestations of chronic intoxication. Thus, they distinguish:
- Acute ergotism. It proceeds with high mortality, predominant damage to the digestive tract, severe disorders of the central nervous system. The duration of the condition rarely exceeds a day.
- Subacute ergotism. Various disorders of the central nervous system develop with psychopathies or seizures or a gangrenous variant with the formation of a deep necrotic focus and dry, less often wet, gangrene.
- Chronic ergotism. It is characterized by periodic disorders of the gastrointestinal tract, erased intoxication symptoms, transient neurological syndromes, amenorrhea in women.
The incubation period of mycotoxicosis depends on the form. In acute poisoning, it is no more than a day, in subacute and chronic it is calculated for weeks. Ergotism can begin with copious, watery frequent stools, abdominal pain, increased excitability and irritability. Patients note a marked increase in sensitivity – the appearance of tingling, “goosebumps”, burning of the skin; fever over 38 ° C, delirium, vivid hallucinations often occur.
The subacute course is characterized by weakness, periodic nausea and diarrhea, abdominal discomfort, dizziness, unpleasant tingling or burning sensations on the skin. There are painful cramps, spasms of the swallowing muscles, repetitive rhythmic movements of the hands. Possible manifestations are depressive symptoms, hallucinatory, delusional disorders, mania. The duration of the condition reaches 3-6 weeks.
Gangrenous ergotism develops on the 3-7 day of the disease, begins with pain in the limb, which eventually acquires a bluish-reddish, then black hue, deformities of the nail plates appear, hair loss, dryness and flabbiness of the skin, spontaneous bleeding. Then the pain disappears, the body temperature normalizes, patients feel unwell, weak, various disorders of consciousness occur.
The chronic course of poisoning is manifested by a variety of symptoms. Patients complain of periodic disturbances in the digestive system, weakness, apathy, decreased performance. The condition is accompanied by skin sensitivity disorders, pulling muscle pains, menstrual cycle failures in women up to amenorrhea. The work of the brain, kidneys is disrupted, chronic limb ischemia occurs (cold hands, feet).
Ergotism, as a nosology with progressive vasospasm, most often leads to complications associated with impaired blood supply to tissues. So, dry gangrene with contamination and improper care can lead to the development of wet, including anaerobic. The long course of the disease leads to renal, heart failure, impaired cognitive functions of the brain, psychosis.
Sensitivity disorders create conditions for the penetration of infection (through abrasions, cuts, burns or scratches), frequent purulent-inflammatory lesions of the extremities. Due to the constant contraction of the vascular bed, the risk of blood clots and thromboembolic symptoms increases. Amenorrhea in the chronic course of ergotism is the cause of female infertility.
Diagnosis and treatment of ergotism is mainly carried out by toxicologists or resuscitators. Other specialists are involved according to indications. It is mandatory to carefully collect anamnesis for food consumed, taking toxin-containing drugs, and the presence of HIV infection. Basic clinical, instrumental and laboratory examinations for poisoning:
- Physical examination. Symptoms of dyspepsia are objectively determined, the neuropsychic status is assessed. Patients are excited or are in a sopor. Tonic seizures, hyperkinesis, delirium, hallucinatory disorders are possible. Limbs may be hyperemic, with sharp soreness, bullae, or necrosis and lack of sensitivity.
- Laboratory tests. In general clinical blood analysis – leukocytosis, a shift of the leukocyte formula to the left, acceleration of ESR, moderate anemia in chronic course. There is an increase in the activity of CRP, ALT, AST, total bilirubin, creatinine, and urea. General analysis of urine with increased density, proteinuria, sometimes cylindrical, erythrocyturia.
- Research of biological environments. For differential diagnosis, microscopy of stained corneal smears, cultures of gastric lavage, feces, vomit, urine and blood on nutrient media for acute bacterial intestinal infections, PCR diagnostics of biological material (for rotaviruses, noroviruses, adenoviruses, etc.) are prescribed.
- Instrumental methods. According to the indications, abdominal ultrasound, retroperitoneal space, small pelvis is performed. Skull x-ray and examination of the Willis circle with contrast enhancement are used among the radiation methods. It is recommended to conduct electromyography, ultrasound Doppler examination of the main arteries of the brain, vessels of the extremities.
The differential diagnosis of ergotism is carried out with food poisoning, the main difference from which is the three-fold negative results of bacteriological and virological examination of biological fluids. Poisoning of a different etiology is clinically indistinguishable, a thorough laboratory analysis of suspicious foods and beverages is necessary. Sometimes Raynaud’s disease has similar manifestations, in which there is no intoxicating agent.
Treatment of patients with suspicious symptoms should be carried out in a hospital. One of the main measures is the abolition of drugs containing ergotoxin, food products, gastric lavage to clean waters, a siphon enema. If the patient is conscious, at the pre-medical stage it is allowed to induce vomiting independently after taking 3-4 glasses of warm water, take sorbents inside. Questionable products need to be saved for examination.
In an unstable mental state, it is necessary to ensure the safety of the patient and others. The therapeutic and protective regime depends on the severity of the condition, more often – bed rest. The diet is gentle, with the exception of fatty, pickled, fried food, seasonings, milk, coffee, alcohol. The drinking regime is increased, if there are no contraindications, with the help of polyionic oral solutions, clean drinking water. It is important to avoid hypothermia.
Therapeutic procedures for suspicious symptoms should be started immediately. Standards for the treatment of ergotism have not been developed. The fight against the toxin is carried out in the direction of relieving vasoconstriction and reducing the amount of effector substance in the body, complications are also treated. The main measures of therapeutic effect on symptoms are:
- Etiotropic treatment. It has not been developed at the moment. It is recommended to refuse simultaneous intake of caffeine, nicotinic acid, beta-blockers. Intravenous administration of calcium chloride and parathyroidin is indicated.
- Pathogenetic methods. The positive effect of prostaglandin preparations, calcium channel blockers, nitroglycerin, pentoxifylline, especially in critical tissue ischemia, is described. Detoxification treatment with infusion solutions is shown, enterosorbents are used.
- Symptomatic therapy. It is carried out with analgesics, sedatives, desensitizing, improving rheological properties and blood microcirculation, anticonvulsants, thrombolytic drugs, according to indications, glucocorticosteroids and other anti-shock measures are administered.
- Physical therapy. During the recovery period, physiotherapy is indicated. Patients receive therapeutic massages, ultratonotherapy, electrophoresis with vasodilators. Laser therapy, barotherapy, magnetotherapy are effective.
When the initial symptoms of dry gangrene appear, patients are hospitalized in a surgical hospital, where prevention of the transition to wet gangrene is carried out: rest of the limb, bandages, means that improve tissue trophism, circular novocaine blockades to reduce angiospasm. After the appearance of the demarcation line, the limb is amputated, then reconstructive, plastic surgery is performed.
Cases of severe progressive angiospasm in patients with HIV infection and ergotism have been described. These patients were treated with balloon angioplasty, interventional therapy with aspiration of thrombotic material and thrombolysis.
A recorded casuistic case of cerebral ergotism in an HIV-positive patient was manifested by left-sided hemiparesis with confirmed symmetrical narrowing of the carotid arteries on MRI with contrast in the absence of embolic lesions. It was stopped by the withdrawal of ergotamine, a single dose of acetylsalicylic acid and rest. At the same time, the attack of a transient ischemic attack lasted 20 minutes, then the symptoms spontaneously disappeared.
Prognosis and prevention
The prognosis depends on the amount of toxin that has entered the body and the premorbid state of a person; in acute form, mortality reaches 90%. Specific prevention (vaccination) has not been developed. Non-specific methods are: sowing fields with ergot-resistant varieties, control over the cultivation of grain crops, disinfection of grain and flour, weed control, veterinary control of farm animals.
It is important to exclude milk from sick animals from consumption, it is mandatory to voice the HIV status and the composition of the antiretroviral therapy taken when receiving drugs with ergotamine. It is necessary to inform the attending physician about other pharmacological forms for the treatment of other chronic pathology in order to exclude medicinal ergotism, which is currently coming to the fore.