Absinthe toxicity

Background

• bitter, green liqueur derived form Wormwood tree extract
• active ingredient: thujone, which antagonizes GABA-A receptors (now thujone concentrations are thought to be too small to pose any danger to patient)
• illegal in most countries

Clinical Features

• confusion
• delirium
• euphoria
• auditory and visual hallucinations
• can cause generalized tonic-clonic seizures

Differential Diagnosis

Hallucinations

Serotonin-Like Agents

• Lysergic acid diethylamide (LSD)
• Psilocybin ("magic mushrooms")
• N,N-Dimethyltryptamine (DMT)
• 5-methoxy- dimethyltryptamine (5-MeO-DMT)
• 25C-NBOMe

Enactogens

• Designer amphetamines
• Bath salts
• Ecstasy (MDMA)
• Mescaline (peyote)
• Synthetic cannabinoids

Dissociative Agents

• Phencyclidine (PCP)
• Ketamine
• Dextromethorphan
• Nitrous oxide

Plant-based Hallucinogenics

• Marijuana
• Salvia
• Absinthe
• Isoxazole Mushrooms
• Hawaiian baby woodrose (Argyreia nervosa)
• Hawaiian woodrose (Merremia tuberosa)
• Morning glory (Ipomoea violacea)
• Olili- uqui (Rivea corymbosa)

Organic causes

• Delirium
• Intracranial mass to occipital or temporal lobes
• Encephalitis, limbic encephalitis, anti-NMDA receptor encephalitis
• Migraine
• Seizure
• Hypocalcemia/Hypercalcemia
• Rift valley fever
• Rabies
• Syphilis
• Vitamin B7 deficiency
• Pellagra
• Dementia
  • Parkinson's Disease

Other Toxicologic Causes

• Alcohol withdrawal
• Anticholinergic Toxicity
• Tricyclic (TCA) Toxicity
• Synthetic cannabinoids
• Inhalant abuse
• Nitrogen narcosis
• GHB withdrawal
• Hydrocarbon toxicity
• Heavy metal toxicity
• Multiple medications: montelukast, doxapram, hyoscyamine, tizanidine, peramivir, amantadine, rimantadine, bromocriptine, methylergonovine, benztropine, doxepin, voriconazole, acyclovir, valacyclovir, ganciclovir, cimetidine, penicillin G Procaine, clarithromycin, metoclopramide
• Inhalant abuse

Psychiatric Causes

• Schizophrenia, schizoaffective disorder, schizophreniform disorder
• Depression with psychotic features
• Bipolar disorder
• Charles Bonnet Syndrome (in the visually impaired)

Sedative/hypnotic toxicity

• Absinthe
• Barbiturates
• Benzodiazepines
  • Flunitrazepam (Rohypnol)
• Chloral hydrate
• Gamma hydroxybutyrate (GHB)
• Baclofen toxicity
• Opioids
  • Lomotil toxicity
  • Loperamide toxicity
• Toxic alcohols
  • Ethanol
  • Ethylene glycol
  • Isopropyl alcohol
  • Methanol
• Xylazine toxicity

Evaluation

• Typically a clinical diagnosis, based on history

Management

• Supportive

References

• Rosen's