# Presentation: 139601

## GOAL 1

- Background
- Clinical Presentation
- Recognition and Diagnosis
- Personal Protective Equipment
- Decontamination
- Management
- Reporting

**To provide clinicians and public health officials with the following information related to ricin: **

## GOAL 2

- To provide clinicians and public health officials with information on epidemiological clues that may suggest illness associated with ricin or another chemical or biological toxin in the correct clinical context.

## Objectives

- Describe the epidemiology of nonterrorism-associated ricin poisoning
- Describe the epidemiology of terrorism-associated ricin poisoning

## Objectives

- Describe the clinical manifestations of oral, inhalational, and parenteral ricin poisoning
- Describe differential diagnosis for ricin poisoning

## Objectives

- Explain the diagnosis of ricin poisoning
- Identify epidemiological clues suggestive of a possible covert ricin (or other chemical/biological toxin) release
- Describe the clinical management of ricin poisoning

## Objectives

- Describe the disposition of patients with ricin-associated illness
- Identify the proper authorities for reporting of suspected or known ricin-associated illness

## CDC/ATSDR Training and Continuing Education Online System

- www.phppo.cdc.gov/phtnonline

## Caster Bean Photos

## Ricinus Communis

## Castor Beans

## Ricin Characteristics 

- Ricin can be prepared in a liquid, crystalline, or dry powder form
- Ricin is water soluble, odorless, tasteless, and stable under ambient conditions

## Mechanism of Action and Toxicity of Ricin

## Biological Toxalbumins

- Abrus precatorius (contains abrin)
- Ricinus communis (contains ricin)
- Robinia pseudoacacia (contains robin
- and phasin)
- Hura crepitans
- Jatropha curcas
- Jatropha gossypifolia

## Category B Diseases/Agents

- are moderately easy to disseminate;
- result in moderate morbidity rates and low mortality rates; and
- require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance.

**Second highest priority agents include those that**

## Other Category B Bioterrorism Agents

- Brucellosis
- Glanders
- Q Fever
- Typhus Fever
- Psittacosis
- Staphylococcal Enterotoxin B

## Ricin Exposure

- Inhalation and intravenous injection are the most lethal routes
- Ricin is not well absorbed orally or dermally

## Oral Administration

- The absorption of orally administered ricin is poor, _but_ if enough ricin is ingested, the potential for significant morbidity and mortality exists.

## Ricin Absorbtion

- Not likely to be absorbed through unabraded skin; however, there are no reported studies on the dermal toxicity of ricin
- The effect of adding a carrier solvent to ricin to increase dermal absorption is unknown

## Nonterroism Ricin Poisoning

- Over 400 cases of poisoning by ingestion
- 14 deaths (12 prior to 1930)

## Ricin: Aerosol Exposure

## Ricin: Parenteral Exposure

## Ricin as a Chemotherapeutic Agent

## Ricin and Terrorism

- Properties make it a potential terrorist agent
- Would need to be aerosolized, added to food, beverage or consumer products

## Ricin and Terrorism

**Georgi Markov**

**500 micrograms of ricin was injected**

## Ricin and Terrorism

- 1991- Unsuccessful dermal attack plan to kill 100 people
- 1995-Agents find 130 grams of ricin at Canadian border, enough to kill 10,000 people.

## Ricin and Terrorism

## Ricin and Terrorism

- December 2002, six terrorist suspects were arrested in Manchester, England
- January 2003, subtoxic quantities of ricin were found in the Paris Metro, leading to an investigation of a plan to attack the Russian embassy

## Osama bin Ladin

## Clinical Manifestation

## Route of Exposure

- Inhalation
- Ingestion
- Parenteral

## Aerosol Dispersion

- Not considered persistent in the environment
- Particles under 5 microns may stay suspended for many hours
- Re-suspension of settled ricin may occur
- Technologically difficult to produce particles of this small size

## Systemic Toxicity

- Severe systemic toxicity has been described in humans only following ingestion or injection of ricin into the body

## Ricin Ingestion

- Ricin release from beans requires mastication
- Swallowing whole beans not likely to poison
- Beans have bitter taste
- No reports of people who have ingested purified ricin

## Ricin Fatal Dose

- Ingestion and mastication of 3-6 beans is the estimated fatal dose in adults (presumed less in children)

## Ricin: Mild Toxicity Symptoms

- Nausea
- Vomiting
- Diarrhea
- Abdominal cramping
- Oropharyngeal irritation

**Symptoms of mild toxicity include:**

## Onset of Gastrointestinal Symptoms

- Typically occurs in less than 10 hours.
- Delayed presentation of gastrointestinal symptoms, beyond ten hours of ingestion, is unlikely to occur.

## Moderate to Severe Toxicity 

- Gastrointestinal symptoms persistent vomiting, voluminous diarrhea-bloody or non-bloody (which typically leads to significant fluid losses)
- Dehydration, hypovolemic shock, tachycardia, hypotension, decreased urine output, altered mental status (e.g., confusion, disorientation).

**May Include:**

**May Result In:**

## Severe Poisoning 

- Hepatic and renal failure and death are possible within 36 – 72 hours of exposure

## Ricin Inhalation

- Very limited data in humans
- Animal studies suggest it is the most lethal form of exposure.

## Ricin Allergic Syndrome

- Nasal and throat congestion
- Eye irritation
- Hives and other skin irritation
- Chest tightness
- Wheezing (severe cases)

## 1940’s : An Unintentional and Sublethal Aerosol Exposure

- Fever
- Chest tightness
- Cough
- Dyspnea
- Nausea
- Arthralgias
- Diaphoresis
- No reported progression

## Progression

- Pulmonary edema and hemorrhage
- Hypotension
- Respiratory failure
- Death within 36-72 hours

## Parenteral Exposure

## Clinical Trial

- Flu-like symptoms
- Fatique
- Myalgias
- Symptoms lasting 1-2 days

## Lethal Injection (Markov-1978)

- Immediate pain
- Weakness within 5 hours
- Fever
- Vomiting
- Shock
- Multi-organ failure
- Death in 3 days

## Lethal Injection Example 2

- Nausea
- Weakness
- Dizziness
- Myalgias
- Anuria
- Hypotension
- Hepatorenal and cardiorespiratory failure
- Death

## Ricin: Clinical Course

## Significant ricin poisoning through inhalation, ingestion and parenteral exposure would consist of progressive worsening of symptoms over approximately 4-36 hours.

## Early Ricin poisoning through ingestion may resemble typical gastroenteritis-type or a respiratory illness through inhalation

## May be difficult to discern early poisoning from other common and less virulent illnesses such as an upper respiratory infection or gastroenteritis. 

## Cases should be deemed suspicious in conjunction with

- A highly suspected or known exposure
- A credible threat
- An epidemiologic clue suggestive of a chemical release.

## Differential Diagnosis

## Inhalation: 

- Staphylococcal enterotoxin B
- Exposure to pyrolysis by-products of organofluorines (Teflon, Kevlar)
- Oxides of nitrogen
- Phosgene
- Influenza
- Anthrax
- Q-fever
- Pneumonic plague

## Ingestion:

- Enteric pathogens (e.g., salmonella, shigella)
- Mushrooms
- Caustics
- Iron
- Arsenic
- Colchicine

## Clinical Diagnosis

## Overt Event

- Letter identifying ricin in contents of package
- Restaurant patrons unknowingly consume food contaminated with ricin

- Covert Event

## Illness Resulting from Covert Event

- Symptoms similar to flu or gastroenteritis
- Early symptoms may be nonexistent or mild
- Reports of illness may occur over a long period and in multiple locations

## Illness Resulting from Covert Event

- Symptoms may not suggest a single chemical
- Healthcare providers may be less familiar with clinical presentations of chemical or biological-induced poisonings

## Epidemiologic Clues Suggesting Covert Release of a Chemical or Biological toxin 

- Unusual increase in patients with possible chemical or biological toxin related illness
- Unexplained deaths among healthy or young people
- Unexplained odors on patients
- Clusters of illness in people with common characteristics

## Epidemiologic Clues Suggesting Covert Release of a chemical or biological toxin 

- Rapid onset of symptoms
- Unexplained death of plants, fish, or animals
- Presence of a particular syndrome associated with a chemical agent or biological toxin

## Clinical diagnosis largely depends on route of exposure
Clinical findings associated with ricin poisoning may be nonspecific and may mimic signs and symptoms of less virulent diseases

- Clinical findings associated with ricin poisoning may be nonspecific and may mimic signs and symptoms of less virulent diseases

## Confirmation of Ricin Poisoning

- Clinical manifestations of illness
- Laboratory detection of ricin in biological fluids or environmental samples

## Laboratory Testing

- No validated assays for detection of ricin in biologic fluids
- Testing of environmental samples may not be immediately available to assist in clinical decision making

## Suspicion and clinical diagnosis of ricin poisoning should occur when clinically compatible illness is present in conjunction with:

- A highly suspected or known exposure,
- A credible threat, OR
- An applicable epidemiologic clue

## Decontamination and Personal Protective Equipment

## Patient Contaminated with Ricin

- Provide gross decontamination at the scene unless medical condition dictates immediate transport to hospital

## Gross Decontamination

- Cut away/remove all suspected contaminated clothing
- Remove jewelry and watches
- Wash off obvious contamination with soap and copious amount of water
- Shower with liquid soap and warm water

## Gross Decontamination

- Provide privacy
- Secure personal belongings
- Explain procedure to victims

## Decontamination

- Clean environmental surfaces or equipment with soap and water or 0.1% sodium hypochlorite solution
- Double bag, label and secure victims’ clothing

## Decontamination of Nondisposable PPE

- Thoroughly rinse with soap and water
- Soak in 0.1% sodium hypochlorite solution for 15 minutes
- Rinse with water and air dry

## PPE for First Responders

- Determined by incident commander
- Based on hazard assessment and site conditions
- PPE should prevent droplets from contacting broken skin or mucosal membranes

## PPE if Victims Inadequately Decontaminated at Scene

- Chemical-resistant suit with gloves
- Surgical mask
- Eye/face protection

## Decontamination

- Should be done at scene or hospital but prior to entering emergency department
- Removing contaminated clothing reduces contaminant 75%-90%

## Standard Precautions

- Scrubs or disposable gown
- Lab coat
- Disposable nitrile gloves
- Surgical mask
- Safety glasses, goggles, or face shield
- Good hand hygiene

## Clinical Management

## Primary Management

- Supportive
- No antidote
- Dialysis ineffective

## Standard Precautions

- After skin decontamination
- With patient’s belongings
- With patient’s secretions

**Continue use:**

## Ricin Ingestion

- Patient presents <1 hour after exposure
- No vomiting
- No contraindications

**Consider gastric lavage if**

**If ricin powder ingested, may consider nasogastric tube**

## Ricin Ingestion

- If no vomiting and airway is secure, give a single dose of activated charcoal

## Ricin Ingestion

- Administer intravenous fluids
- Provide blood pressure support using intravenous vasopressors
- Consider alternative diagnoses and treat appropriately (e.g., antibiotics for possible infection)

## Inhalational and Parenteral Poisoning

- Supplemental oxygen
- Pulmonary toilet
- Mechanical ventilation
- May require hemodialysis

## National Poison Control Center Hotline

- 1-800-222-1222

## Disposition

- Is there a highly suspected or known exposure?
- Is there a credible threat?
- Is there an applicable epidemiologic clue to suggest an illness potentially related to a chemical or biological toxin?

## Disposition

- Treat and admit patients with clinical findings consistent with ricin poisoning plus
- A highly suspected or known exposure
-       OR
- Presentation occurs with a credible threat

## Disposition

- Due to limited experience with ricin poisoning, a definitive  period of observation cannot be specified at this time

## Disposition

- Asymptomatic patients exposed to highly suspected or known ricin-containing compound should be observed for symptoms
- Instruct patients sent home to return to hospital immediately if symptoms consistent with ricin poisoning develop

## Contact the regional poison control center and the local and/or state public health agency in all cases of illness consistent with ricin poisoning in the presence of:

- A suspected or known exposure
- A credible threat  OR
- An applicable epidemiologic clue

## National Poison Control Center Hotline

- 1-800-222-1222

## Public Health Surveillance and Reporting

## Contact the regional poison control center and the local and/or state public health agency in all cases of illness consistent with ricin poisoning in the presence of:

- A suspected or known exposure,
- A credible threat, OR
- An applicable epidemiologic clue

## E-mail questions to:

- ricinquestions@cdc.gov

## Course Overview

- www.phppo.cdc.gov/phtn/ricin

## CDC Ricin Website

- www.bt.cdc.gov/agent/ricin

## Public Health Foundation

-  Phone:  1-877-252-1200
-      Fax:  301-843-0159
- Online:  bookstore.phf.org

## CDC Training and Continuing Education Online System

- www.phppo.cdc.gov/phtnonline

## Course Numbers

- WC0048 - webcast
- WD0035 - web-on -demand
- CB3093 - CD-ROM

## Registration Questions:

- 800-41-TRAIN
- 404-639-1292
- E-mail ce@cdc.gov