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Myristicin and phenytoin toxicity in an infant

Shobhana Sivathanu1, Sowmya Sampath1, Henry Suresh David1

  • 1Department of Pediatrics, ESI-PGIMSR, Chennai, Tamilnadu, India.

BMJ Case Reports
|June 7, 2014
PubMed

Insights

Nutmeg ingestion can trigger status epilepticus in infants. Phenytoin treatment for seizures may lead to toxicity and further seizures due to its narrow therapeutic range.

Area of Science:

  • Pediatric Neurology
  • Clinical Toxicology

Background:

  • Status epilepticus (SE) is a neurological emergency characterized by prolonged seizures.
  • Infants are particularly vulnerable to neurological insults.
  • Nutmeg (Myristica fragrans) is a common spice with psychoactive properties.

Observation:

  • A developmentally normal infant experienced recurrent afebrile status epilepticus.
  • Initial seizures were temporally associated with nutmeg ingestion.
  • Subsequent seizures occurred despite treatment with multiple loading doses of antiepileptic drugs, including phenytoin, phenobarbital, and midazolam.
  • The infant developed extrapyramidal movements, nystagmus, and visual dysfunction.

Findings:

  • Iatrogenic phenytoin toxicity was diagnosed based on clinical presentation and confirmed by elevated drug levels.
  • Discontinuation of phenytoin led to complete resolution of symptoms.
  • Initial seizures were attributed to myristicin, a component of nutmeg.
  • Recurrent seizures were ultimately caused by phenytoin toxicity.

Implications:

  • Nutmeg ingestion can induce severe neurological effects, including status epilepticus, in infants.
  • Phenytoin, a common antiepileptic drug, has a narrow therapeutic index and can cause toxicity, including seizures, especially with multiple loading doses.
  • Careful monitoring of drug levels and potential drug-induced side effects is crucial in managing status epilepticus, particularly in pediatric patients.

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