Forensic Toxicology Practice Questions

Q: Identify the flowers shown below:

Aconite. ***Aconite*** - The image displays characteristics consistent with **Aconite** (monkshood) flowers, which are typically **dark purple to blue** and have a distinctive **hooded shape**. - Aconite is known for its **highly toxic** alkaloids, especially **aconitine**, which can cause rapid and severe symptoms upon ingestion or skin contact. *Cerbera Thevetia* - **Cerbera Thevetia** (yellow oleander) flowers are typically **yellow or orange** and are bell-shaped, which differs significantly from the flowers shown. - Poisoning from *Cerbera Thevetia* is primarily due to **cardiac glycosides**, leading to symptoms like bradycardia, nausea, and vomiting. *Datura* - **Datura** flowers are typically **large, trumpet-shaped**, and vary in color from white to purple, but lack the distinctive hooded appearance seen in the image. - *Datura* species contain **tropane alkaloids** (e.g., scopolamine, atropine), which cause anticholinergic effects like mydriasis, delirium, and tachycardia. *Nerium Odorum* - **Nerium Odorum** (pink oleander) flowers are typically **pink, red, or white** and have a pinwheel shape with five petals, which does not match the flowers in the image. - Like *Thevetia*, *Nerium Odorum* is toxic due to **cardiac glycosides**, causing similar cardiovascular and gastrointestinal symptoms.

Q: The following presentation occurs due to? (AIIMS Nov 2018)

Long term ingestion of arsenic in drinking water. ***Long term ingestion of arsenic in drinking water*** - The image shows **hyperpigmentation and hyperkeratosis** on the palms, often described as "raindrop pigmentation" or diffuse darkening with scattered paler lesions (leukomelanosis). This is a classical dermatological manifestation of **chronic arsenic poisoning**, particularly from contaminated drinking water. - **Arsenicosis** can also cause palmar and plantar keratoses, which can progress to malignant skin lesions over time. *Chronic Copper sulfate poisoning* - Chronic copper poisoning is rare and typically affects the liver, leading to conditions like **cirrhosis** and **hepatitis**, as seen in Wilson's disease. - Skin manifestations from copper poisoning are not typically characterized by the diffuse hyperpigmentation and hyperkeratosis seen in the image. *Application of mercury ointment* - Topical mercury exposure can cause localized skin irritation, dermatitis, or systemic toxicity with features like **acrodynia** (pink disease) in children, characterized by a pink rash, irritability, and hypertension. - It does not typically lead to the described pattern of diffuse hyperpigmentation and hyperkeratosis on the palms. *Application of Calotropis* - **Calotropis** (such as *Calotropis gigantea* or *procera*) is a plant known for its toxic latex, which can cause intense local irritation, vesication, or ulceration upon skin contact. - Its effects are primarily acute irritant or allergic reactions and do not produce the chronic skin changes of hyperpigmentation and hyperkeratosis seen in the image.

Q: A 40-year-old farmer tried committing suicide by consuming two Sulphas (aluminium phosphide) tablets. On admission pulse is 110 bpm with BP of 80 / 60 mm Hg and GCS of 7 / 15 . SpO2 in room air is 80 %. ECG was performed. All are true about this poisoning except:

Emergent gastric lavage. ***Emergent gastric lavage*** - **Gastric lavage is contraindicated** in aluminum phosphide poisoning due to the risk of **phosphine gas release** upon contact with stomach acid, which can exacerbate lung injury or expose healthcare workers. - The use of **emetics** or **charcoal** is also generally not recommended for the same reasons. *Sodium bicarbonate* - **Sodium bicarbonate is indicated** in aluminum phosphide poisoning to help neutralize gastric acid, which reduces the release of toxic phosphine gas. - It also aids in managing metabolic acidosis, a common complication of severe poisoning. *Toxic agent is phosphine* - When **aluminum phosphide** reacts with **gastric acid**, it releases the highly toxic gas **phosphine (PH3)**, which is responsible for the systemic effects of the poisoning. - Phosphine gas causes **cellular dysfunction** by inhibiting cytochrome c oxidase, leading to **multiorgan failure**. *ECG in lead II shows sinus tachycardia and ST segment depression* - The provided ECG image indeed shows evidence of **sinus tachycardia** (increased heart rate) and **ST segment depression**, which are common findings in aluminum phosphide poisoning. - These ECG changes reflect **cardiac toxicity**, including myocardial injury and ischemia, due to the metabolic disturbances and direct cellular damage caused by phosphine.

Q: The seeds of this plant produce which toxin?

Sanguinarine. ***Sanguinarine*** - **Sanguinarine** is the primary and most clinically significant alkaloid found in *Argemone mexicana* seeds, responsible for **epidemic dropsy** syndrome. - It causes **oxidative stress**, **capillary damage**, and **generalized edema** by inhibiting various cellular enzymes, particularly Na-K-ATPase and protein kinases. - Epidemic dropsy presents with bilateral leg edema, breathlessness, erythema, and gastrointestinal symptoms, making sanguinarine the predominant toxin associated with this plant. *BOAA* - **BOAA (β-N-oxalylamino-L-alanine)** is the neurotoxin found in *Lathyrus sativus* (grass pea/khesari dal), NOT in *Argemone mexicana*. - BOAA causes **neurolathyrism**, characterized by irreversible spastic paraplegia, which is a completely different condition from epidemic dropsy. - This option is incorrect as it is associated with a different plant toxin syndrome. *Pyrrolizidine* - **Pyrrolizidine alkaloids** are found in *Senecio* species (ragwort), *Crotalaria* species, and *Heliotropium* species. - They cause **hepatic veno-occlusive disease** (Budd-Chiari syndrome) with hepatomegaly, ascites, and liver failure. - They are not associated with *Argemone mexicana* and do not cause the epidemic dropsy syndrome. *Hydrocyanic acid* - **Hydrocyanic acid (cyanide)** is found in stone fruit pits (apricot, peach, cherry), cassava, and bitter almonds. - It causes rapid **cellular hypoxia** by inhibiting **cytochrome c oxidase** in the mitochondrial electron transport chain. - Clinical features include sudden collapse, cherry-red discoloration, and smell of bitter almonds - completely different from the gradual edema of epidemic dropsy.

Q: Comment on the diagnosis:

Plumbism. ***Plumbism*** - The image shows a **lead line** or **Burton line** which is a blue-black line visible on the gums at the junction with the teeth, indicative of chronic lead poisoning (plumbism). - This line is caused by the precipitation of **lead sulfide** in the gingival capillaries. *Lathyrism* - This is a neurotoxic disorder caused by the consumption of **Lathyrus sativus (grass pea)**, leading to **neurological symptoms** such as paralysis and spasticity. - It does not present with characteristic oral findings like the lead line seen in the image. *Fluorosis* - Dental fluorosis is characterized by **mottling, discoloration, and pitting of tooth enamel** due to excessive fluoride intake, typically appearing as white streaks or brown stains. - While it affects teeth, the appearance of a distinct blue-black gingival line is not a feature of fluorosis. *Selenosis* - Selenosis is a condition caused by **chronic selenium toxicity**, which can result in symptoms like hair loss, brittle nails, and neurological issues. - It does not present with specific oral manifestations such as a gingival lead line.

Q: A radiopaque density may be noticed in poisoning by which of the following agents?

Chloral hydrate. ***Chloral hydrate*** - Due to its halogenated structure, **chloral hydrate** can be radio-opaque on X-rays, making it one of the "CHIPES" substances. - This property allows for radiological detection of its presence in the **gastrointestinal tract** following ingestion, particularly in large overdoses. *Chloroquine* - **Chloroquine** is not significantly radio-opaque and is generally not detectable on plain radiographs following overdose. - Clinical diagnosis of chloroquine poisoning relies on symptoms such as **hypotension**, **cardiac arrhythmias**, and **hypokalemia**, not radiological findings. *Phenazopyridine* - **Phenazopyridine** is a urinary analgesic that does not possess properties that render it radiographically detectable. - Its metabolism and excretion do not produce **radio-opaque metabolites** or complexes. *Ethylene glycol* - **Ethylene glycol** itself is not radio-opaque on plain X-rays, and its presence is typically diagnosed through laboratory tests like anion gap metabolic acidosis. - While it can lead to the formation of **calcium oxalate crystals** in the kidneys, these are typically microscopic and not visible as general radiopacities in the GI tract.

Q: Which one of the following prevents gastrointestinal absorption of thallium?

Prussian blue. ***Prussian blue*** - **Prussian blue** (ferric hexacyanoferrate) acts as an ion exchanger in the gastrointestinal tract, binding to thallium and preventing its absorption. - This complex of thallium and Prussian blue is then **excreted in the feces**, reducing systemic toxicity. *Calcium carbonate* - **Calcium carbonate** is an antacid primarily used to neutralize stomach acid or as a calcium supplement. - It does not specifically bind to or prevent the absorption of **thallium**. *Potassium permanganate* - **Potassium permanganate** is a strong oxidizing agent sometimes used for gastric lavage in certain poisonings. - It does not form a stable, non-absorbable complex with **thallium** to prevent its gastrointestinal uptake. *Penicillamine* - **Penicillamine** is a chelating agent used for heavy metal poisoning, such as copper (in Wilson's disease) or lead. - While it can chelate some metals, its primary mechanism involves forming soluble complexes that are excreted renally, rather than directly preventing **gastrointestinal absorption** of thallium.

Q: Which one of the following is the correct description of Mee's lines, seen in chronic arsenic poisoning?

Transverse white lines on nails of fingers and toes. ***Transverse white lines on nails of fingers and toes*** - **Mee's lines** are characteristic **white transverse bands** seen specifically on the **nails** of the fingers and toes. - They are typically associated with **arsenic poisoning** but can also be seen in other systemic illnesses. *Transverse white lines on the skin of palms and soles* - While chronic arsenic poisoning can cause **skin pigmentation changes** (melanosis) and **hyperkeratosis** on the palms and soles, it does not typically manifest as distinct white transverse lines on the skin. - Mee's lines are exclusively a **nail finding**. *Transverse red lines on the nails of fingers and toes* - **Red lines on nails** are not characteristic of Mee's lines; Mee's lines are described as **white**. - Red nail changes, such as splinter hemorrhages, are often associated with other conditions, like **endocarditis**. *Transverse red lines on the skin of palms and soles* - This description does not correspond to Mee's lines, which are **white nail changes**, nor is it a typical manifestation of chronic arsenic poisoning on the skin in this specific pattern. - Skin manifestations of arsenic poisoning on palms and soles are usually **hyperpigmentation** and **hyperkeratosis**.

Question 1

Identify the flowers shown below:

Accepted Answer

Aconite

Answer

Datura

Answer

Nerium Odorum

Answer

Cerbera Thevetia

Question 2

The following presentation occurs due to? (AIIMS Nov 2018)

Accepted Answer

Long term ingestion of arsenic in drinking water

Answer

Chronic Copper sulfate poisoning

Answer

Application of mercury ointment

Answer

Application of Calotropis

Question 3

A 40-year-old farmer tried committing suicide by consuming two Sulphas (aluminium phosphide) tablets. On admission pulse is 110 bpm with BP of 80 / 60 mm Hg and GCS of 7 / 15 . SpO2 in room air is 80 %. ECG was performed. All are true about this poisoning except:

Accepted Answer

Emergent gastric lavage

Answer

Sodium bicarbonate

Answer

Toxic agent is phosphine

Answer

ECG in lead II shows sinus tachycardia and ST segment depression

Question 4

A child was bitten by this snake while playing. He develops blurred vision and develops hypotension with respiratory difficulty. On examination two fang marks are seen on his left foot. All are true about the management except: (Recent NEET Pattem 2016-17)

Accepted Answer

Dose of ASV in children is 1 mL/kg body weight

Answer

Give neostigmine and check for improvement in the form of millimeters of iris covered

Answer

Fasciotomy to be performed in case of compartment syndrome

Answer

ASV reaction managed with temporary discontinuation and adrenaline usage

Question 5

A snake charmer was bitten by a snake in the evening hours while catching a snake which had entered in the bathroom of the village sarpanch. He was brought to the hospital late at night with inability to talk and breathing difficulty. On examination gag reflex was absent, neck floppiness and tongue flaccidity was noted. His wife identified the snake from the pictures shown by the doctor as the one shown below. Which of the following should not be done in this case? (Recent NEET Pattem 2016-17)

Accepted Answer

Intravenous neostigmine

Answer

Urgent intubation and ventilation

Answer

ASV within four hours and upper limit of 24 hours

Answer

20WBCT

Question 6

The seeds of this plant produce which toxin?

Accepted Answer

Sanguinarine

Answer

BOAA

Answer

Pyrrolizidine

Answer

Hydrocyanic acid

Question 7

Comment on the diagnosis:

Accepted Answer

Plumbism

Answer

Lathyrism

Answer

Fluorosis

Answer

Selenosis

Question 8

A radiopaque density may be noticed in poisoning by which of the following agents?

Accepted Answer

Chloral hydrate

Answer

Chloroquine

Answer

Phenazopyridine

Answer

Ethylene glycol

Question 9

Which one of the following prevents gastrointestinal absorption of thallium?

Accepted Answer

Prussian blue

Answer

Calcium carbonate

Answer

Potassium permanganate

Answer

Penicillamine

Question 10

Which one of the following is the correct description of Mee's lines, seen in chronic arsenic poisoning?

Accepted Answer

Transverse white lines on nails of fingers and toes

Answer

Transverse white lines on the skin of palms and soles

Answer

Transverse red lines on the nails of fingers and toes

Answer

Transverse red lines on the skin of palms and soles

Forensic Toxicology — MCQs

Forensic Toxicology — MCQs

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