A Boy Ate 25 Laxative Brownies in 1 Hour. This Is What Happened To His Kidneys.
BG is a 14 year old boy, presenting to the emergency room with an abnormal heart rate.
His older brother Nate, tells the admitting nurse
that BG had defecated 8 times in the last 10 hours, before stumbling around confused.
You see, BG and his friends decided to challenge each other: “First to PooPoo,
wears a tutu,” where friends would eat 10 laxative filled brownies within 15 minutes, and the first 2
to poop will be deemed full of crap and will have to wear a tutu to school the next day.
Clearly, this was for jokes and memes on behalf of
14 year olds. It didn’t help that Nate the older brother agreed to
buy the laxatives over the counter and an older sister agreed to bake the brownies.
BG, the alpha male in his group of friends was not only going to win the competition,
he was going to eat the most brownies— each one having the equivalent to 2
laxative tablets. You’re only supposed to take 2 as the recommended adult dose.
Contest day. The brownies are baked and the boys with fresh-faced determination decimate them,
eager to show each other up. 20 minutes after finishing 10 brownies each, one of the boys didn’t
feel well. He tried as hard as he could to resist the urge to defecate, but he gave in quickly.
Some of the other boys were feeling uncomfortable too.
And in the back of his mind, BG didn’t feel well, but the need to show up his
friends was greater than his urge to use the bathroom. He laughed at the others,
called them derogatory names, and ate 5 more brownies.
One of the boys was clenching his stomach. He was feeling major abdominal cramps. It
was uncomfortable. He was on the verge of tears. BG laughed in his
face and ate 5 more brownies to show him up, a total of 20 brownies now.
Finally, the second boy gives in and goes to the restroom. He was the final loser.
The other boys, now free to poop without fear of losing, all go use the bathrooms and BG, to show
up the others, ate 5 more brownies, for a total of 25, before finally using the bathroom himself.
It’s several hours later. The 2 boys who lost the competition are feeling great. Those who
fought the urge to poop aren’t feeling so great, and worst of all, BG is acting weird.
It started with him slurring his words and tripping over
his feet. These started appearing after the 6th time he defecated.
Around this time, he reported that his urine looked like coffee,
that the stools became diarrhea and that he felt his right calf muscle was sore and
cramping. He was found gasping for air as he complained his heart was racing.
He also started to develop a massive headache and was found gripping his
head in pain. The friends laughed, that BG was pooping his brains out.
But, after the 8th time in the bathroom, he didn’t come out. And in fact,
an hour later he was found unconscious on the floor. The friends immediately
called for an ambulance to bring him to the emergency room where we are now.
Given this past medical history, theres several clues as to whats happening.
First, BG is suffering from hypokalemia.
Hypo meaning low.
Kal referring to potassium,
or more formally Kalium as is shown by its symbol on the periodic table of elements.
And emia meaning presence in blood.
Low potassium presence in blood.
BG clearly overdosed on laxatives when he took 25 times the recommended adult dose in the brownies.
The laxative he consumed was sennoside,
a natural stimulant. It works by causing the muscles of your colon to contract,
helping you pass a stool. But it also softens the stool by drawing water into your colon.
Thats a problem because your body water is a soup of several chemicals,
an important one getting depleted in BG’s body by the laxatives is potassium.
Potassium, like Sodium above it on the periodic table,
is important in signaling in the body. Telling tissues and organs to do things.
One important signal on behalf of Sodium and Potassium, is muscle contraction.
Take for example these frog legs. That muscle is physiologically similar to human skeletal muscle.
When salt, or sodium chloride, is put on these legs, they twitch and contract. Despite there
being no brain attached to these legs to control them. So sodium helps promote muscle contraction.
On the other hand, potassium promotes muscle relaxation. A lot of it present means your
muscles relax for a very long time. Too little present means your muscles won’t stop contracting.
One part of Lethal injection, you know that one form of capitol punishment,
is potassium chloride injected directly to the heart to prevent it from contracting.
That kind of injection doesn’t tense your heart up, it just relaxes it.. forever.
You can start to see the problem here. If potassium is low in BG’s blood,
then his muscles would have a hard time relaxing then.
He is having cramps, both in his abdomen and his right calf muscle. His heart is a muscle
too and it’s beating irregularly because it doesn’t have sufficient resources to
signal relaxation. When his heart is beating irregularly, the amount of oxygen getting to his
brain is decreased. He’s drifting in and out of consciousness. Something very severe is happening.
BG is suffering from rhabdomyolysis.
Rhabdo meaning striated or in this case skeletal
Myo meaning muscle Lysis meaning breakdown
Skeletal muscle breakdown. This is life threatening and it’s a medical
emergency. This is happening because of BG’s hypokalemia onset by laxative overdose.
With low potassium in his blood, every time he contracts any of his muscles,
which is every time he moves, or every time he breathes, less potassium present
in the blood confuses the muscle cells and they start to malfunction. Instead
of potassium entering the cell to signal relaxation, the muscle cells allow in sodium.
The interesting thing about sodium is that it creates something called an
osmotic gradient. Which means wherever sodium is, water will flow towards it.
In this small science experiment, I dissolve salt in this water and place it into a tube.
I submerge the tube in a pool of water that has no salt dissolved in it. And
you’ll see that water flows into the tube, that water follows the sodium.
So BG’s muscle cells are not only malfunctioning, they are also swelling with water. Not only is
BG having water exit his intravascular space through his colon, but another large part of
his body water, up to 12 Liters is entering his muscle causing massive dehydration.
When you are dehydrated to this degree, your kidneys, which are responsible for
filtering your blood, removing wastes and maintaining electrolyte balance,
detect this and they constrict their own blood vessels in an attempt to conserve body water. This
is called vasoconstriction. This can damage the kidneys as renal perfusion is decreased. There is
less blood going to the kidneys, so less oxygen is going to the tissue, which can cause cell death.
But here’s another problem. Now that the muscle cells are starting to rupture,
they’re releasing protein, an important one known as myoglobin. Myoglobin causes
something called lipid peroxidation, which destroys the outer membrane of cells.
In general, myoglobin’s buildup can be toxic to
the rest of your body. But where would it build up?
As the blood flows around in your body, you could say, maybe myoglobin could accumulate in
your heart, but theres nothing there to catch it. Protein is a large molecule and likely would just
pass through the chambers of the heart. There isn’t a reservoir where it can accumulate.
But how about the liver? Well the liver breaks proteins down,
so it probably wont build up there either.
But what about, the kidney? The nephron, the functional unit of the kidney, contains tubules.
These filter out your blood and act as a net to catch toxins in your blood, secreting them into
the urine. It’s kind of like this strainer. If myoglobin is a large molecule, then it’s likely
to get caught in the tubules of the nephrons and can cause the breakdown of cell membranes. So,
when the myoglobin reaches the nephron, it builds up, gunks up the tubules, and ruptures
the membranes of your nephrons. It’s something like dissolving the net of this strainer.
We call this acute kidney injury. The reddish brown urine is because myoglobin contains heme,
a compound that has iron responsible for making your blood red when exposed to oxygen. The
myoglobin builds up in the nephron and spills into your urine once it starts to damage the tubules.
This indicates that BG’s rhabdomyolysis is very severe. Because he’s a 14 year old boy,
he hasn’t finished puberty yet, meaning his muscle mass is lower than an adult
man. In pediatric rhabdomyolysis, boys have a higher risk of getting it than
girls because of decreased female muscle mass. But also for pediatric patients,
the discolored urine doesn’t usually appear because it takes upwards of 200g of muscle to
be lysed for it to appear. Thats nearly half a pound of muscle, and it’s very significant for
any 14 year old and the fact that BG has it precipitates the urgency of this situation.
While the muscle damage can be fixed, this kidney injury is irreversible. Those nephrons
won’t come back, they don’t regenerate. BG’s capacity to filter metabolic waste in his blood
is quickly waning and this is a problem. When the kidneys aren’t removing wastes,
it’s a vector for things like metabolic acidosis, where the pH of the blood decreases. This
can cause nutritional deficiency, impaired enzymatic activity and increased mortality.
Chronic kidney disease which can arise out of this injury, precipitates uremic bone
syndrome— a disorder that deforms the bones and weakens them, causing them to fracture easily.
This isn’t something that you want to have while you are still growing as a human being.
If your kidneys don’t function, your body, down to its bones, will rot away,
and eventually you will die in a pool of your waste that should have been your urine.
All of this seems to be a nonintuitive series of events. Rhabdomyolysis is
both a multifactorial, and an ancient problem.
Eating too much licorice candy can cause one to have dark urine and muscle aches.
Licorice contains glycyrrhizic acid, a compound that keeps cortisol levels high in the body,
which leads to hypokalemia, causing muscle breakdown and ultimately,
rhabdomyolysis. This was documented as far back as 300 BC by the ancient Chinese, who used licorice
as a remedy for digestives disorders. And they called it “striped muscle dissolution.”
The Old Testament of the Bible, Numbers 11:31-34, Jews ate quail during their
exodus from Egypt and suffered a great plague. Quail in that region eat Hemlock herbs and
seeds during their spring migration across the Mediterranean Sea. Hemlock contains coniine,
the poison that was used to execute Socrates, and that causes rhabdomyolysis.
Napoleon occupied Berlin in 1806, his soldiers heated their living quarters with burning coal.
They breathed in the carbon monoxide gas because of bad ventilation. Carbon monoxide binds strongly
to the hemoglobin in the blood and starves your muscles of oxygen, causing the tissue to necrose,
or die, resulting in rhabdomyolysis. Back then they called it limb gangrene.
In world war 2. crush syndrome, where the physical destruction
through crushing of muscle tissue from falling objects due to bombings,
induced bruising underneath severe muscle damage, is known as rhabdomyolysis.
So, this is not a direct problem. As nonintuitive as it may be that overdosing on laxatives,
something that makes you poop, causes your muscles to dissolve in your body
thus damaging your kidneys.. Well, at the very least, the treatment for BG is very
simple. We just go by the symptoms in this case. We can save his muscles and kidneys,
but hell have to bear the pain of laxative overdose until it passes through his body.
We will give him potassium supplement to raise his blood potassium levels. We’ll
have to monitor it constantly, because too much potassium will stop his heart,
and too little got him into the situation he’s in now. Keeping his potassium stable will prevent any
more of his muscles from breaking down in his body and stop any further release of myoglobin.
Second, because his kidneys have vasoconstricted because they detected low blood volume,
then we correct that by infusing water into his veins. We won’t give it to him orally because
the absorption will be too slow. In this way, it will replace his body water and increase the
amount of fluid going into his kidneys, increasing renal perfusion allowing for more oxygen to get
into that tissue. It’s kind of like how we wash something out when things get trapped in a net,
with enough fluid replacement, we’ll minimize any further renal damage to BG. While the renal
damage will stay forever in his medical history, at the very least his kidneys will still function.
After monitoring and symptomatic treatment, a strong lesson learned, and an experience that
would never be lived down amongst his friends for the rest of his life, BG because he was
so young was able to recover from his laxative induced hypokalemia and resulting rhabdomyolysis.
Please don’t ever take more than the recommended dose of laxatives for anything.. its just not
worth the consequences. Thank you so much for watching. Take care of yourself, and be well.