Keep an eye on the pupil: developing countries under chemical attack

A 32-year-old man presented late in the night at the emergency department (ED) of our hospital for diarrhea, excessive salivation, and muscle weakness. The patient was an active, highly educated business man. The patient was doing fine till the previous afternoon when he consumed khat with some friends and relatives. He reported to be being a ‘‘weekend khat consumer’’. The patient’s relatives suggested that the symptoms could be explained by the fact that he was not a regular khat consumer, and/or that he could have bought a bad quality of khat. Therefore, they asked for a prompt discharge from the ED. Physical examination revealed mild bradycardia (52 beats per minute), blood pressure 140/85 mmHg, temperature 36.5C, respiratory rate 25 breaths per minute and oxygen saturation 98% while breathing air. The lung and heart examinations were unremarkable. However, the ED physician noticed that there was a pinpoint miosis. Khat (chatha edulis) contains amphetamine-like compounds (cathinone and cathine), and it is commonly consumed as fresh, unwashed, leaves in Yemen and the Horn of Africa. The ED emergency physician contacted an ophthalmologist who postulated that miosis could be related to some kind of associated intoxication.