Chronic colchicine toxicity in the context of cyclosporine use in a renal transplanted patient: report of a recovery case

SESSION TITLE: Toxicology SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Colchicine is a well-known medication used in the management of diseases such as gout and pericarditis. Inappropriate doses and drug interactions can lead to Colchicine Toxicity (CT). The poisoning generally presents with three phases: the first is characterized by gastrointestinal irritation and usually persists for 24 hours; the second, and most severe, is characterized by widespread organ failure; if the patient survives, by day 7 the third phase is usually observed with resolution of organ failure, rebound leukocytosis and alopecia. Case reports with multi-organ involvement and progression through all phases are still rare in the literature. CASE PRESENTATION: 56-year-old woman, kidney transplanted on cyclosporine, presented for watery diarrhea, and vomiting for one week. She was inadvertently taking colchicine (1.2mg/ day) for 2 weeks. On admission was found to have profound neutropenia and thrombocytopenia, thyroid dysfunction, rhabdomyolysis and progressive liver and renal failure. The liver failure etiology work up was negative for hepatitis, CMV infection, biliary pathologies, or malignancy. Once colchicine was discontinued, and supportive therapy with N-acetylcysteine and Filgrastim provided, she started improving. On the fourth day of admission, she developed an asymmetric ascending bilateral lower extremity weakness. Brain and spine magnetic resonance revealed nonspecific findings with patchy enhancement associated with the fractures of the T12 vertebral body and superior endplates of L2 and L3. Cerebrospinal fluid analysis was unremarkable. Electromyography was compatible with a myopathic process and excluded demyelinating conditions. On the fourteenth day, a rebound leukocytosis and alopecia were noted. She started improving and was discharged to a rehabilitation facility, where she continued to regain muscle strength. DISCUSSION: Although a safe medication, colchicine has a low threshold for toxicity given its narrow therapeutic index. This case reinforces the need for extra vigilance in monitoring colchicine therapy despite the indication and dose - especially in transplanted patients due to possible drug interactions. A recent cohort study proved that inappropriate colchicine dosing occurred more frequently than expected and late-onset CT may have contributed to one-third of the deaths in patients who were taking colchicine. The treatment is mainly supportive, and the prompt discontinuation of the drug is imperative. Therefore, a high index of suspicion is necessary if it allows implementation of appropriate care. CONCLUSIONS: The vague nature of its presentation makes the diagnosis of CT very challenging.The authors aim to raise awareness of this condition, since its early recognition can lead to better outcomes and improve survival. When suspected, a detailed review of the patient's medications is warranted. REFERENCE #1: 1. Medani S, Wall C. Colchicine toxicity in renal patients - Are we paying attention? Clin Nephrol. 2016 Aug; 86(2):100-5. REFERENCE #2: 2. Garrouste C, Philipponnet C, Kaysi S, Enache I, Tiple A, Heng AE. Severe colchicine intoxication in a renal transplant recipient on cyclosporine. Transplant Proc. 2012 Nov;44(9):2851-2. REFERENCE #3: 3. Aghabiklooei A, Zamani N, Hassanian-Moghaddam H, Nasouhi S, Mashayekhian M. Acute colchicine overdose: report of three cases. Reumatismo. 2014 Mar 17;65(6):307-11. DISCLOSURES: No relevant relationships by Christiana Atuaka No relevant relationships by Claudia De Araujo Duarte No relevant relationships by Bruno Augusto De Brito Gomes No relevant relationships by Varun tej Gonuguntla No relevant relationships by Tracey O'Brien No relevant relationships by kiran para No relevant relationships by Benjamin Weindorf