The purpose of this case study is to highlight how medical algorithms can be used by physicians to evaluate risk and obtain information on the diagnosis and management of illnesses related to environmental exposures.

It was time to get ready for the holidays, and Little Joey was a handful. While the family tried to set up the decorations he was running around and putting everything he saw into his mouth. He was found chewing on poisonous holiday plants — poinsettia leaves — sucking on mistletoe berries and later he had a nutmeg kernel in his mouth.

To keep him occupied, his uncle pulled out a box of brightly colored metal toys made in China. These toys were similar to ones that he plays with regularly at his grandparents house. His grandparents love to spoil him by buying inexpensive toys at flea markets.

The new toys kept Joey quiet for some time so everyone was thankful. When the uncle picked up the toys to put them away he thought that one or two were missing. Luckily the family found the missing toys under the sofa, but it was also noted that the mistletoe near the front door was missing several berries and leaves that were bitten off.

The next day Joey was quiet and looked somewhat ill. He started vomiting and developed diarrhea. When it did not get better his parents took him to the pediatrician.

Based on the history and known exposures, his pediatrician considered mistletoe (Phoradendron serotinum) toxicity. With the inability to tolerate any food or drink by mouth and the noted diarrhea, there was a major concern for dehydration.

On presentation to the pediatric ward at the local hospital, IV fluids were started and labs drawn. A complete blood count was normal as was the complete metabolic profile.

The patient made significant improvements over the next 18 hours and was discharged home the following morning tolerating food and drink well. The diarrhea persisted for a few more days, but was manageable for the parents.

Differential Diagnosis

The differential diagnosis is quite large.  Medical algorithms that can help pinpoint the proper diagnosis are presented below.

A young child may have viral gastroenteritis picked up from other children at day care. There are opportunities for food poisoning. Dehydration is also a significant concern among young children.

  • Estimating Dehydration and Fluid Volume Depletion in Cholera and Other ConditionsEstimating Dehydration and Fluid Volume Depletion in Cholera and Other Conditions
  • Clinical Dehydration Scale for Infants and Young ChildrenClinical Dehydration Scale for Infants and Young Children
  • Indications to Hospitalize a Sick Child with Acute Diarrhea or Severe DehydrationIndications to Hospitalize a Sick Child with Acute Diarrhea or Severe Dehydration

There was a history of exposure to several plant toxins. As long as no nutmeg kernel was swallowed the risk is relatively low.

  • Poinsettia ExposurePoinsettia Exposure
  • Mistletoe (Phoradendron) ExposureMistletoe (Phoradendron) Exposure
  • Plant Nutmeg ExposurePlant Nutmeg Exposure

The exposure to small metal toys is more serious. A number of problems have been associated with toys made in China. This has included heavy metals used in casting toys as well as in enamel paints. Lead, cadmium and other heavy metals have been implicated.

  • Lead Intoxication Associated with a Swallowed Foreign BodyLead Intoxication Associated with a Swallowed Foreign Body
  • Clinical Features of Acute Cadmium PoisoningClinical Features of Acute Cadmium Poisoning

Swallowing a metal toy is the most likely way of developing a heavy metal exposure. An X-ray can locate a metal toy but locating a non-metal toy can be more challenging. Toys can also be aspirated to cause asthma-like wheezing or placed in the nose or ear.

  • Pseudo-Asthma Following Foreign Body AspirationPseudo-Asthma Following Foreign Body Aspiration

Take-Home Points

  • Holidays can bring with them numerous hazards
  • In recent years, with the recalls of manufactured goods containing high levels of lead, some companies that produce inexpensive children’s toys and jewelry turned to cadmium as an inexpensive alternative to lead to manufacture their products. Exposure to high levels of cadmium can cause stomach irritation, vomiting, and diarrhea.
  • Mistletoe ingestion can lead to nausea, vomiting, diarrhea, weakness, blurry vision, electrolyte abnormalities. Treatment is supportive.
  • Nutmeg is a common spice that can cause serious side effects at high amounts of ingestion, especially with whole kernel ingestion. Symptoms can include headache, nausea/vomiting, abdominal pains, chest pain, tachycardia, CNS agitation, sense of doom, hallucinations, and/or hepatotoxicity.
  • Dehydration is a leading cause of hospitalization of children
  • Poison control hotline phone number is: 1-800-222-1222
  • With uncommon exposures to products, plants, or foods during the winter holidays, physicians can utilize medical algorithms to evaluate risk and obtain information on the diagnosis and management of illnesses related to environmental exposures.
  • The medical algorithms highlighted in this case study are available at The Medical Algorithms Company and also on

About the Authors

Umang Jain is the Health Innovations Fellow at Apervita. He is passionate about medicine, research, and business. He is a fourth year medical student at Northwestern University’s Feinberg School of Medicine and will pursue Emergency Medicine residency. Umang’s scholarly interests include surgical outcomes research, in which he is published in the fields of ENT, orthopedic, plastic, cardiac, and urologic surgery. He has also participated in research in neurodegenerative disease at MIT and Boston University. Umang’s business experience stems from his work at the Institute of Healthcare Improvement (IHI) in Boston, MA. He worked closely with Dr. Donald Berwick, Administrator of Medicare and Medicaid Services (CMS) and Sir Nigel Crisp, the former Chief Executive of UK’s National Health Service, on engaging in evidence-based healthcare improvement interventions on a global scale. Umang was also an intern at Senticare Inc. and Personica, where he evaluated EHRs and in-home health monitoring equipment.

Dr. Chad Rudnick, MD, FAAP is a board-certified pediatrician in Boca Raton, FL. He is the Medical Director of The Medical Algorithms Company. A proponent of incorporating medical technology into his practice, Dr. Rudnick uses telemedicine and medical algorithms from The Medical Algorithms Company in his daily practice to better serve his patients and their families. An accomplished medical writer, he maintains a popular pediatric blog, All Things Pediatric, and has written for numerous online and print publications including

John Svirbely, MD is a founder and Chief Medical Officer of The Medical Algorithms Company and the primary author of its medical algorithms. John is a co-founder of the Medical Algorithms Project and has developed its medical content for nearly 20 years. He has a BA degree from the Johns Hopkins University and his MD from the University of Maryland. He is a board-certified pathologist with a fellowship in medical microbiology and biomedical computing at Ohio State University. Currently he is in private practice in Cincinnati, Ohio. He has authored multiple books and articles on medical algorithms.