Venous-arterial extracorporeal membrane oxygenation support for patients poisoned by Macleaya cordata.

Macleaya cordata is a Chinese herbal medicine containing a variety of highly cardiotoxic alkaloids, and might result in cardiac failure. Venous-arterial Extracorporeal membrane oxygenation (VA-ECMO) could be used as a therapeutic option in patients poisoned by Macleaya cordata complicating refractory cardiogenic shock or cardiac arrest. A 60-year-old man suffered from severe arrhythmia, cardiogenic shock and cardiac arrest after consuming Macleaya cordata. The patient received VA-ECMO support in the emergency department at 5 hours after hospitalization, and was weaned from VA-ECMO on day 4, and was discharged with complete clinical improvement on Day 12. VA-ECMO is an effective method in treating cardiogenic shock or cardiac arrest induced by severe poisoning from Chinese herbal medicine. Timely and appropriate interventions with venoarterial extracorporeal membrane oxygenation devices could improve clinical outcomes in these patients.

Analgesic effect of the main components of Corydalis yanhusuo (yanhusuo in Chinese) is caused by inhibition of voltage gated sodium channels.

ETHNOPHARMACOLOGY RELEVANCE: Pain often causes a series of abnormal changes in physiology and psychology, which can lead to disease and even death. Drug therapy is the most basic and commonly used method for pain relief and management. Interestingly, at present, hundreds of traditional Chinese medicines have been reported to be used for pain relief, most of which are monomer preparations, which have been developed into new painkillers. Corydalis yanhusuo is a representative of one of these medicines and is available for pain relief. AIM OF THE STUDY: This study aims to determine the analgesic effect and the potential targets of the monomers derived from Corydalis yanhusuo, and to explore any possible associated cardiac risk factors. MATERIALS AND METHODS: In this study, four monomers derived from Corydalis yanhusuo (tetrahydropalmatine, corydaline, protopine, dehydrocorydaline) were tested in vivo, using the formalin-induced pain model to determine their analgesic properties. Their potential targets were also determined using whole cell patch clamp recordings and myocardial enzyme assays. RESULTS: The results showed that all monomers showed analgesic activity and inhibited the peak currents, promoted the activation and inactivation phases of Nav1.7, which indicating that Nav1.7 might be involved in the analgesic mechanism of Corydalis yanhusuo. Protopine increased the level of creatine kinase-MB (CK-MB) and inhibited the peak currents, promoted the activation and inactivation phases of Nav1.5, indicating that Nav1.5 might be involved in the cardiac risk associated with protopine treatment. CONCLUSION: These data showed that tetrahydropalmatine produced the best analgesic effect and the lowest cardiac risk. Thus, voltage gated sodium channels (VGSCs) might be the main targets associated with Corydalis yanhusuo. This study, therefore, provides valuable information for future studies and use of traditional Chines medicines for the alleviation of pain.

Tu-San-Qi (Gynura japonica): the culprit behind pyrrolizidine alkaloid-induced liver injury in China.

Herbs and dietary supplement-induced liver injury (HILI) is the leading cause of drug-induced liver injury in China. Among different hepatotoxic herbs, the pyrrolizidine alkaloid (PA)-producing herb Gynura japonica contributes significantly to HILI by inducing hepatic sinusoidal obstruction syndrome (HSOS), a liver disorder characterized by hepatomegaly, hyperbilirubinemia, and ascites. In China, G. japonica has been used as one of the plant species for Tu-San-Qi and is often misused with non-PA-producing Tu-San-Qi (Sedum aizoon) or even San-Qi (Panax notoginseng) for self-medication. It has been reported that over 50% of HSOS cases are caused by the intake of PA-producing G. japonica. In this review, we provide comprehensive information to distinguish these Tu-San-Qi-related herbal plant species in terms of plant/medicinal part morphologies, medicinal indications, and chemical profiles. Approximately 2156 Tu-San-Qi-associated HSOS cases reported in China from 1980 to 2019 are systematically reviewed in terms of their clinical manifestation, diagnostic workups, therapeutic interventions, and outcomes. In addition, based on the application of our developed mechanism-based biomarker of PA exposure, our clinical findings on the definitive diagnosis of 58 PA-producing Tu-San-Qi-induced HSOS patients are also elaborated. Therefore, this review article provides the first comprehensive report on 2214 PA-producing Tu-San-Qi (G. japonica)-induced HSOS cases in China, and the information presented will improve public awareness of the significant incidence of PA-producing Tu-San-Qi (G. japonica)-induced HSOS and facilitate future prevention and better clinical management of this severe HILI.

[Bradycardia and Hypotension from Improper Use of Aconite Root: A Case Report and Brief Review].

BACKGROUND: Adverse reactions associated with Chinese herbal medicines (CHMs) are usually the result of unpredictable active/toxic ingredients, inaccurate or mistaken beliefs, or poor supervision. The herb that most commonly induces severe adverse effects in Hong Kong and China is aconite root. More than 200 species of Aconitum plants are used for medicinal purposes, with aconite roots producing analgesic, anti-inflammatory, cardiotonic, and anti-tumor effects. The active components are alkaloids; these can be toxic, but CHM processing methods lower their toxicity and increase the pharmacological efficacy. However, aconite poisoning can result from inadequate decoction time or exceeding the recommended dose. CASE REPORT: Here we report the case of a 92-year-old woman who presented with life-threatening bradycardia and hypotension. This started 1 h after she inappropriately consumed a herbal decoction containing Fuzi for mood fluctuation and health maintenance; Fuzi, an aconite root, has known cardiotoxicity. Electrocardiography showed supraventricular abnormalities, including sinus bradycardia and low-amplitude P waves. After an infusion of normal saline and inotropic agents for 25 h, the clinical manifestations subsided, her sinus rhythm returned to normal, and she was discharged. At follow-up 2 weeks later, she was in good health and had ceased taking any CHM. CONCLUSIONS: Standardized processing methods, stringent regulations, and cooperation between health professions can ensure medication safety and establish a fully-fledged operating process for these valuable drugs. We hope this report will help establish correct attitudes toward CHM and will assist Traditional Chinese Medicine practitioners to become more familiar with Aconitum plants.

The Poisoning Information Database Covers a Large Proportion of Real Poisoning Cases in Korea.

The poisoning information database (PIDB) provides clinical toxicological information on commonly encountered toxic substances in Korea. The aim of this study was to estimate the coverage rate of the PIDB by comparing the database with the distribution of toxic substances that real poisoning patients presented to 20 emergency departments. Development of the PIDB started in 2007, and the number of toxic substances increased annually from 50 to 470 substances in 2014. We retrospectively reviewed the medical records of patients with toxic exposure who visited 20 emergency departments in Korea from January to December 2013. Identified toxic substances were classified as prescription drug, agricultural chemical, household product, animal or plant, herbal drug, or other. We calculated the coverage rate of the PIDB for both the number of poisoning cases and the kinds of toxic substances. A total of 10,887 cases of intoxication among 8,145 patients was collected. The 470 substances registered in the PIDB covered 89.3% of 8,891 identified cases related to poisoning, while the same substances only covered 45.3% of the 671 kinds of identified toxic substances. According to category, 211 prescription drugs, 58 agricultural chemicals, 28 household products, and 32 animals or plants were not covered by the PIDB. This study suggested that the PIDB covered a large proportion of real poisoning cases in Korea. However, the database should be continuously extended to provide information for even rare toxic substances.

Case reports of aconite poisoning in mainland China from 2004 to 2015: A retrospective analysis.

Aconitum species have long been used in key traditional medicines in China, but cases of fatal aconite poisoning have also been reported. This paper presents a review of 40 single and multi-person cases of fatal aconite poisoning. The cases involved 53 victims in mainland China described in 27 case reports published between January 2004 and September 2015. We summarize the details of the case reports in order to highlight the features of fatal aconite-poisoning cases in China, including victims' sex and age, route of intoxication, clinical symptoms, medicolegal autopsy findings, and results of toxicological analysis. Our results indicate a need for legal medical experts encountering cases of fatal aconite poisoning to pay increased attention to the methods used for collecting biological samples. In addition, prevention strategies should focus on increasing public awareness regarding the potential toxicity of Aconitum, harm caused by medicinal liquors containing aconitine, and possibility of Aconitum alkaloids accumulating in the body.

Aconitum Alkaloid Poisoning Because of Contamination of Herbs by Aconite Roots.

Aconitum alkaloid poisoning can occur after drinking decoction and soup made from non-toxic herbs contaminated by aconite roots. In the present review, the main objective is to describe the clinical features, investigations and possible sources of contamination. A combination of neurological, gastrointestinal and cardiovascular signs and symptoms was seen. Ventricular tachyarrhythmias could occur in 18% of subjects. Yunaconitine and crassicauline A, mainly found in certain aconite roots from Southwest China, are most commonly involved. Herbal residues and unused herbs should first be inspected for gross contamination. On-site inspection at the retailer should exclude accidental mix-up or cross-contamination when handling aconite roots. Samples of prescribed herbs are examined for gross contamination and analysed for the presence of Aconitum alkaloids. Samples of the implicated herb are also collected from the wholesaler for investigation. If post-import contamination is unlikely, the regulatory authorities of the exporting countries should be notified for follow-up actions. It is a challenging task to work out how non-toxic herbs become contaminated by aconite roots. The source control with good agricultural and collection practices and quality assurance must be enhanced.

An 88-year-old man with syncope and an alternating axis.

CLINICAL INTRODUCTION: An 88-year-old man, admitted to the emergency room (ER) after three episodes of syncope within 1 day, reported a precursory of syndrome of light-headedness with rapid palpitations that led to an abrupt loss of consciousness. After undergoing percutaneous and surgical revascularisation, he started complaining of chest and back discomfort for the past 20 years and searching for help from Chinese medicine, Fuzi. He had history of chronic renal failure and heart failure, but denied neither taking digitalis nor having family history related to sudden death.On arrival, heart rate was 150 bpm and blood pressure (BP) by cuff was 91/81 mm Hg (non-invasive BP could not be accurately obtained during tachycardia) plus oedema on both lower extremities. There were diffuse crackles and indistinct heart sounds on auscultation.The admission ECG was performed in the ER (figure 1). His serum creatinine was 139.7 mmol/L, serum K(+) was 4.7 mmol/L, N-terminal of the prohormone brain natriuretic peptide was highly elevated (12 000 pg/mL) and troponin I was negative. QUESTION: What is the most likely diagnosis suggested based on the patient's ECG and history? Aconite poisoningDigitalis toxicityCatecholaminergic polymorphic ventricular tachycardia (CPVT)Andersen-Tawil syndrome (ATS).

Computed tomography findings of hepatic veno-occlusive disease caused by Sedum aizoon with histopathological correlation

This study investigated the value of computed tomography (CT) in the diagnosis and treatment of hepatic veno-occlusive disease (HVOD) caused by Sedum aizoon (SA). The clinical manifestations, treatment results, imaging findings, and histological findings of the liver were analyzed in 39 patients with HVOD caused by SA. Hepatomegaly, liver dysfunction, abdominal effusion, and geographic density changes on liver CT scans were found in all 39 patients. The pathological findings of histological liver examination included swelling and point-like necrosis of liver cells, significant expansion and congestion of the sinuses, endothelial swelling, and wall thickening with incomplete lumen occlusion of small liver vessels. CT geographic density changes were confirmed by histological examination of the liver in 18 patients. Sixteen patients with small amounts of ascites that started within 4 weeks of treatment recovered completely or significantly improved after symptomatic and supportive treatment. However, only 43.75% of the patients with larger amounts of ascites improved following symptomatic and supportive treatment. In conclusion, liver CT examination is a valuable, safe, and noninvasive tool for the diagnosis of HVOD caused by SA. In selected cases, liver CT examination may replace liver biopsy and histological analysis.

Computed tomography findings of hepatic veno-occlusive disease caused by Sedum aizoon with histopathological correlation.

This study investigated the value of computed tomography (CT) in the diagnosis and treatment of hepatic veno-occlusive disease (HVOD) caused by Sedum aizoon (SA). The clinical manifestations, treatment results, imaging findings, and histological findings of the liver were analyzed in 39 patients with HVOD caused by SA. Hepatomegaly, liver dysfunction, abdominal effusion, and geographic density changes on liver CT scans were found in all 39 patients. The pathological findings of histological liver examination included swelling and point-like necrosis of liver cells, significant expansion and congestion of the sinuses, endothelial swelling, and wall thickening with incomplete lumen occlusion of small liver vessels. CT geographic density changes were confirmed by histological examination of the liver in 18 patients. Sixteen patients with small amounts of ascites that started within 4 weeks of treatment recovered completely or significantly improved after symptomatic and supportive treatment. However, only 43.75% of the patients with larger amounts of ascites improved following symptomatic and supportive treatment. In conclusion, liver CT examination is a valuable, safe, and noninvasive tool for the diagnosis of HVOD caused by SA. In selected cases, liver CT examination may replace liver biopsy and histological analysis.

Herb-induced cardiotoxicity from accidental aconitine overdose.

Patients who overdose on aconite can present with life-threatening ventricular arrhythmia. Aconite must be prepared and used with caution to avoid cardiotoxic effects that can be fatal. We herein describe a case of a patient who had an accidental aconite overdose but survived with no lasting effects. The patient had prepared Chinese herbal medication to treat his pain, which resulted in an accidental overdose of aconite with cardiotoxic and neurotoxic effects. The patient had ventricular tachycardia, bidirectional ventricular tachycardia and ventricular fibrillation. Following treatment with anti-arrhythmic medications, defibrillation and cardiopulmonary resuscitation, he made an uneventful recovery, with no further cardiac arrhythmias reported.

Incidence and Causes of Aconitum Alkaloid Poisoning in Hong Kong from 1989 to 2010.

Aconite roots contain Aconitum alkaloids, which are highly toxic cardiotoxins and neurotoxins. In this review, the main objective was to determine the incidence and causes of Aconitum alkaloid poisoning in Hong Kong between 1989 and 2010, based on six published reports from the territory-wide poison control units. In the New Territories East of Hong Kong, the incidence of aconite poisoning showed a sudden and sustained decrease from 0.60 (1989-1991) to 0.16 (1992-1993) and 0.17 (1996-1998) per 100 000 population, after publicity measures in late 1991 to promote awareness of the toxicity of aconite roots. In the whole of Hong Kong, the incidence of aconite poisoning was even lower in January 2000-June 2004 (0.03 per 100 000 population). However, aconite poisoning became more common again in April 2004-July 2009 and 2008-2010 (0.15 and 0.28 per 100 000 population). Overdoses and use of inadequately processed aconite roots were important causes. As from 2004 to 2009, 'hidden' aconite poisoning (toxicity caused by contaminants in other dispensed herbs) emerged as an important cause. It is important to continue the safety monitoring of potent herbs and the networking of poison control units. Further systematic studies would be required to identify the likely sources of contamination of herbs.

Thyroid storm caused by a chinese herb contaminated with thyroid hormones.

BACKGROUND: We report a case of thyroid storm caused by consuming a Chinese herb contaminated with thyroid hormones. CASE REPORT: A 70-year-old man presented to an emergency department after 2 days of nausea, vomiting, and weakness. Three days previously, he had started taking Cordyceps powder and "Flower Man Sang Hung" as recommended by his Chinese physician. Following admission, the patient deteriorated and was eventually diagnosed with thyroid storm complicated by rapid atrial fibrillation requiring cardioversion, intubation, and intensive care admission. The analysis of the Chinese herb "Flower Man Sang Hung" was positive for levothyroxine. The patient was extubated 11 days after admission and discharged to a rehabilitation centre after 17 days of hospitalization. The Chinese medicine physician was informed of the events. CONCLUSIONS: Herbal products can be the source of illness, medication interactions, and contamination. Awareness should be raised among Chinese medicine physicians, allopathic physicians, and their patients. Clinicians should also have a low threshold of suspicion to seek laboratory analysis of suspect substances when the cause of the clinical presentation is unclear.

Recipes and general herbal formulae in books: causes of herbal poisoning.

Traditional Chinese medicine is commonly used locally, not only for disease treatment but also for improving health. Many people prepare soups containing herbs or herbal decoctions according to recipes and general herbal formulae commonly available in books, magazines, and newspapers without consulting Chinese medicine practitioners. However, such practice can be dangerous. We report five cases of poisoning from 2007 to 2012 occurring as a result of inappropriate use of herbs in recipes or general herbal formulae acquired from books. Aconite poisoning due to overdose or inadequate processing accounted for three cases. The other two cases involved the use of herbs containing Strychnos alkaloids and Sophora alkaloids. These cases demonstrated that inappropriate use of Chinese medicine can result in major morbidity, and herbal formulae and recipes containing herbs available in general publications are not always safe.

Eighteen cases of liver injury following ingestion of Polygonum multiflorum.

OBJECTIVES: Polygonum multiflorum is a popular Chinese herbal medication. In this case series, we report on 18 otherwise healthy non-viral hepatitis patients who developed liver dysfunction following consumption of P. multiflorum alone. METHODS: Concurrent and retrospective analysis was used in this study. The causality of P. multiflorum in liver injury was graded by the Council for International Organizations of Medical Sciences (CIOMS) toxicity scale. RESULTS: From 2005 to 2012, 18 cases of hepatotoxicity potentially involving P. multiflorum. The median age was 42 years old (range from 18 to 63). Median time of onset of symptoms was 27 days (1-120). Prevailing clinical symptoms were fatigue, loss of appetite and jaundice. Sixteen patients had elevated level of total bilirubin (>21 mol/L); liver enzymes elevated markedly in all patients (ALT>40 U/L, AST>40 U/L, GGT>50 U/L), except for alkaline phosphatase which elevated only in nine patients. Based on the liver enzyme pattern, the type of liver injuries were hepatocellular according to CIOMS. In terms of causality, 14 of 18 patients were evaluated as being highly probable. All patients were responding well to P. multiflorum stoppage, and liver protective-supportive care. CONCLUSIONS: P. multiflorum products can be associated with hepatotoxicity in otherwise healthy non-viral hepatitis infected patients, regardless of herbal processing.

Toxic epidermal necrolysis after extensive dermal use of realgar-containing (arsenic sulfide) herbal ointment.

BACKGROUND: Realgar (arsenic sulfide) is thought to be safe with few reports on toxicities or adverse effects and has been used in Traditional Chinese Medicine for many centuries. Serious realgar poisoning is rare, and we report a fatal case resulted from short-term use of realgar-containing herbal medicine through dermal route. CASE DETAILS: A 24-year-old man with atopic dermatitis had received 18 days of oral herbal medicine and realgar-containing herbal ointments over whole body from a Traditional Chinese Medicine (TCM) practitioner. Seven days after the herbal use, he had diminished appetite, dizziness, abdomen discomfort, itching rash, and skin scaling. He later developed generalized edema, nausea, vomiting, decreased urine amount, diarrhea, vesico-edematous exanthems, malodorous perspiration, fever, and shortness of breath. He was taken to the hospital on Day 19 when the dyspnea became worse. Toxic epidermal necrolysis complicated with soft tissue infection and sepsis was noted, and he later died of septic shock and multiple organ failure. The post-mortem blood arsenic level was 1225 µg/L. Herbal analysis yielded a very high concentration of arsenic in three unlabeled realgar-containing ointments (45427, 5512, and 4229 ppm). CONCLUSION: Realgar-containing herbal remedy may cause severe cutaneous adverse reactions. The arsenic in realgar can be absorbed systemically from repeated application to non-intact skin and thus should not be extensively used on compromised skin.