Poisonous delicacy: Market-oriented surveys of the consumption of Rhododendron flowers in Yunnan, China.

ETHNOPHARMACOLOGICAL RELEVANCE: Plants from the family Ericaceae, and in particular those in the genus Rhododendron are frequently reported to contain grayanotoxins. Plant products such as honey and herbal medicines made from these plants occasionally contain grayanotoxins, and in turn may lead to intoxication. The balance between the benefits and risk of poisoning from Rhododendrons is of concerns. This study explores the ethnobotanical knowledge of the people in Yunnan, China as regards the consumption of Rhododendron flowers, and gives special focus to their assessment of the benefit-risk balance. MATERIALS AND METHODS: An ethnobotanical survey was conducted across 14 county-level local markets in north and central Yunnan province, during which a total of 82 stalls selling Rhododendron flowers were visited and 204 people were interviewed. Voucher specimens were obtained under the guidance of collectors, and details about local practices and knowledge were recorded using semi-structured interviews and participatory observations. RESULTS: The consumption of the corollas of Rhododendron decorum Franch. Flowers (RDf) or Rhododendron pachypodum Balf. f. & W.W. Sm. Flowers (RPf) as a seasonal delicacy is a long-standing tradition in the study area. RDf are widely consumed in northwest and northeast Yunnan, while RPf are more prevalent in the central regions of Yunnan, and there is a high consistency in the knowledge of the process for detoxification or palatability for each species. The main reasons for eating the flowers were listed as health benefits (mostly clear heat), wild collected, tradition and good flavor. All RPf consumers stated that the corolla from this species is not toxic, while 67.4% of the RDf consumers claim that the corolla from RDf is toxic. We compared the two species and analyzed their process intensities, poisoning cases and cautions, market trade forms and existing toxicity studies, which agreed well and consistently that the corolla of RDf deserve more toxicity attention than RPf. CONCLUSION: Our study provides a window to look into the ways, beyond honey and herbal medicine, by which Rhododendron species have influenced human wellbeing. The local culture can justify eating Rhododendron flowers, and meanwhile, has developed a series of skills to avoid the side effects of eating them, and therefore the study also provides a good case to answer more general questions about the rationality of eating any plant products by assessing the trade-off between benefits and side effects.

Poisonous medicinal plants used in the popular pharmacopoeia of the Rif, northern Morocco.

Popular herbal medicine has served as a unique health provider for human beings for thousands of years. In the present study, we document the toxic plants used as medicines in the Rif, intending to assess the knowledge of indigenous people on the toxicity of the natural products used. Ethnobotanical survey was conducted in the Rif, northern Morocco between June 2016 and June 2018 using semi-structured questionnaires and focus groups. An investigation of the scientific literature was conducted to sustain or verify the claimed toxicological information. A total of 84 species of plants belonging to 67 genera and 30 families were reported as being used in the prevention and treatment of diseases. The families reported to be most representatives of these kinds of plants are Asteraceae and Fabaceae (7 species). However, the highly toxic plant prescribed was Rosmarinus officinalis L. Leaf was the most commonly used plant part, and the majority of herbal remedies were prepared from a decoction (40.6%). The results of this investigation showed that the local people in the Rif are still dependent on herbal medicine. These species used for remedial purposes are noted to have a potential toxic impact associated with their irrational consumption. Therefore, we recommend that attention should be observed when using them as medicinal sources.

Poisoning by toxic plants in Hong Kong: a 15-year review.

INTRODUCTION: Hong Kong has a great diversity of plants, many of which are toxic to humans. The aim of this study was to identify the plant species most commonly involved in cases of plant poisoning in Hong Kong and to provide clinicians with a reference tool for the diagnosis and management of plant poisoning. METHODS: We retrospectively reviewed all plant poisoning cases referred to the Hospital Authority Toxicology Reference Laboratory from 1 January 2003 to 31 December 2017. Demographics, clinical presentation, laboratory findings, treatment and outcomes of patients, as well as morphological identification and analytical testing of the plant specimens, were investigated. RESULTS: A total of 62 cases involving 26 poisonous plant species were identified, among which Alocasia macrorrhizos (Giant Alocasia), Gelsemium elegans (Graceful Jessamine), and Rhododendron (Azalea) species were the three most commonly encountered. Gastrointestinal toxicity (n=30, 48%), neurological toxicity (n=22, 35%), and hepatotoxicity (n=6, 10%) were the three most common clinical problems. Forty-nine (79%) and eight (13%) patients had mild and moderate toxicity, respectively; they all recovered shortly with supportive treatment. The remaining five (8%) patients experienced severe toxicity requiring intensive care support. Most patients (n=61, 98%) used the plants intentionally: as a medicinal herb (n=31), as food (n=29), and for attempting suicide (n=1). Reasons for using the poisonous plants included misidentification (n=34, 55%), unawareness of the toxicity (n=20, 32%), and contamination (n=6, 10%). CONCLUSIONS: Although most plant exposure resulted in a self-limiting disease, severe poisonings were encountered. Epidemiology of plant poisonings is geographically specific. Clinicians should be aware of local poisonous plants and their toxicities.

[M'khinza-related intoxication: about two observations]. / Intoxication au M'khinza: à propos de deux observations.

Dysphania ambrosioides or anserine, known in Morocco as M'Khinza, is a plant belonging to family Chenopodiaceae. In Morocco, it is used for its therapeutic properties including, in particular, antipyretic properties. However, it can be toxic if it is incorrectly calibrated. We report two cases of poisoning whose data were collected in the Pediatric Emergency Department in Rabat. The study involved a 5-month old infant and a 10 year old girl with, respectively, toxic encephalopathy and severe dehydration associated with acute gastroenteritis after the ingestion of undetermined doses of infusion of this plant used as antipyretic. They both died in less than 12 hours. This study highlights the importance of considering M'Khinza-induced neurotoxicity and enterotoxicity in order to reach a correct diagnosis, the role of information and the need to fight against harmful consumption. Research on traditional pharmacopoeia should be encouraged in order to identify the therapeutic properties and to formalize, streamline and codify prescriptions.

An Increase in Dietary Supplement Exposures Reported to US Poison Control Centers.

INTRODUCTION: The objective of this study was to investigate the epidemiology of dietary supplement exposures in the USA. METHODS: A retrospective analysis was conducted of out-of-hospital dietary supplement exposures reported to the National Poison Data System from 2000 through 2012. RESULTS: There were 274,998 dietary supplement exposures from 2000 through 2012. The annual rate of dietary supplement exposures per 100,000 population increased by 46.1% during 2000-2002, decreased 8.8% during 2002-2005, and then increased again by 49.3% from 2005 to 2012. These trends were influenced by the decrease in ma huang exposures starting in 2002. Miscellaneous dietary supplements accounted for 43.9% of all exposures, followed by botanicals (31.9%), hormonal products (15.1%), and other supplements (5.1%). The majority of dietary supplement exposures (70.0%) occurred among children younger than 6 years old and were acute (94.0%) and unintentional (82.9%). Serious medical outcomes accounted for 4.5% of exposures and most (95.0%) occurred among individuals 6 years and older. Ma huang products, yohimbe, and energy products were the categories associated with the greatest toxicity. CONCLUSIONS: There was an overall increase in the rate of dietary supplement exposures from 2000 through 2012. Although the majority of these exposures did not require treatment at a health care facility or result in serious medical outcomes, exposures to yohimbe and energy products were associated with considerable toxicity. Our results demonstrate the success of the FDA ban on ma huang products and the need for FDA regulation of yohimbe and energy products in the USA.

Rhubarb (Rheum species): the role of Edinburgh in its cultivation and development.

Rhubarb was grown and used throughout China for thousands of years. It then found its way to St Petersburg where the Romanovs developed a flourishing trade in the plant to the rest of Europe. James Mounsey, a physician to the Tsar, brought back seeds from Russia to Scotland at considerable risk to himself. He passed some of the seeds to Alexander Dick and John Hope. Both these physicians then grew rhubarb at Prestonfield and the Botanic Garden (both in Edinburgh), respectively. Eventually rhubarb, in the form of Gregory's powder, became a common and popular medicine throughout the UK.

Dietary supplement for energy and reduced appetite containing the ß-agonist isopropyloctopamine leads to heart problems and hospitalisations.

In 2013 the Dutch authorities issued a warning against a dietary supplement that was linked to 11 reported adverse reactions, including heart problems and in one case even a cardiac arrest. In the UK a 20-year-old woman, said to have overdosed on this supplement, died. Since according to the label the product was a herbal mixture, initial LC-MS/MS analysis focused on the detection of plant toxins. Yohimbe alkaloids, which are not allowed to be present in herbal preparations according to Dutch legislation, were found at relatively high levels (400-900 mg kg(-1)). However, their presence did not explain the adverse health effects reported. Based on these effects the supplement was screened for the presence of a ß-agonist, using three different biosensor assays, i.e. the validated competitive radioligand ß2-adrenergic receptor binding assay, a validated ß-agonists ELISA and a newly developed multiplex microsphere (bead)-based ß-agonist assay with imaging detection (MAGPIX(®)). The high responses obtained in these three biosensors suggested strongly the presence of a ß-agonist. Inspection of the label indicated the presence of N-isopropyloctopamine. A pure standard of this compound was bought and shown to have a strong activity in the three biosensor assays. Analysis by LC-full-scan high-resolution MS confirmed the presence of this 'unknown known' ß3-agonist N-isopropyloctopamine, reported to lead to heart problems at high doses. A confirmatory quantitative analysis revealed that one dose of the preparation resulted in an intake of 40-60 mg, which is within the therapeutic range of this compound. The case shows the strength of combining bioassays with chemical analytical techniques for identification of illegal pharmacologically active substances in food supplements.

Accidental overdose in the deep shade of night: a warning on the assumed safety of 'natural substances'.

There is an increasing use of herbal remedies and medicines, with a commonly held belief that natural substances are safe. We present the case of a 50-year-old woman who was a trained herbalist and had purchased an 'Atropa belladonna (deadly nightshade) preparation'. Attempting to combat her insomnia, late one evening she deliberately ingested a small portion of this, approximately 50 mL. Unintentionally, this was equivalent to a very large (15 mg) dose of atropine and she presented in an acute anticholinergic syndrome (confused, tachycardic and hypertensive) to our accident and emergency department. She received supportive management in our intensive treatment unit including mechanical ventilation. Fortunately, there were no long-term sequelae from this episode. However, this dramatic clinical presentation does highlight the potential dangers posed by herbal remedies. Furthermore, this case provides clinicians with an important insight into potentially dangerous products available legally within the UK. To help clinicians' understanding of this our discussion explains the manufacture and 'dosing' of the A. belladonna preparation.

Gloriosa superba poisoning mimicking an acute infection- a case report.

BACKGROUND: Gloriosa superba (GSb) is a highly poisonous plant and its toxicity is due to anti-mitotic effects of constituents such as colchicine and gloriosine on rapidly proliferating cells. Poisoning is known to cause very rapid and severe clinical manifestations due gastro intestinal, neurological, cardiac and bone marrow toxicity. CASE PRESENTATION: A young male presented with an acute onset febrile illness associated with diarrhoea, confusion, haematuria and aggressive behavior of 4 days duration. He developed subconjunctival haemorrhages, bleeding gums, neck stiffness, bilateral papilloedema, tender hepatomegaly and features suggestive of subacute intestinal obstruction. He had progressive reduction in white cell counts, platelets and derrangements in liver functions. The illness mimicked acute severe leptospirosis or dengue. On day 9 of illness he started to loose his hair and was totally alopecic by day 14. At this stage of illness, possibility of GSb poisoning was suspected. He admitted the act of self harm after repeated questioning. CONCLUSION: His presentation mimicked an acute severe tropical febrile illness such as leptospirosis or dengue until he started to loose his hair. Therefore we feel that Clinicians practicing in tropical setting where Gloriosa superba is endemic should be aware of its clinical presentations and should always consider the possibility of ingestion of Gloriosa superba when the patient has pancytopenia and develops shedding of hairs which results in total alopecia in a case of unexplained gastroenterocolitis, rather investigating.

EVALUATION OF TOXIC HEAVY METALS IN AYURVEDIC SYRUPS SOLD IN LOCAL MARKETS OF HAZARA, PAKISTAN.

BACKGROUND: Herbal and Ayurvedic preparations, widely used in Pakistan and the developing world, present serious risk of heavy metal toxicity related to their medicinal content and prolonged use by patients. The objective of this study was to find out the concentration of heavy metals in Herbal & Ayurvedic liquid preparations commonly used for treatment of different diseases, from local markets of Hazara. METHODS: The cross sectional survey of traditional herbal & Ayurvedic medicine shops included ten liquid preparations selected from local shops of Mansehra and Abbottabad after interviewing the shopkeepers; so as to select the most commonly sold preparations along with their indications. All samples were analysed on standard Atomic Absorption Spectroscopy for qualitative and quantitative study of toxic heavy metals (Mercury, Iron, Zinc, Lead, Manganese and Arsenic). RESULTS: Toxic levels of Mercury were present in seven syrups, i.e., (Kashneeze, Akseer e Pachas, Tankar, Sharbat e folad, Urosinal, Akseer e Jigar and Amrat dhara) while Arsenic was present only in Urosinal. Iron, Zinc, Manganese and Lead were present in permissible limits in all syrups. CONCLUSION: Mercury and Arsenic are present in local Herbal & Ayurvedic liquid preparations far beyond the permissible limits as proposed by the International Regulatory Authorities for health drugs while the rest of metals, i.e., Zinc, Manganese, and Iron are within the therapeutic limits.

From arrow poison to herbal medicine--the ethnobotanical, phytochemical and pharmacological significance of Cissampelos (Menispermaceae).

ETHNOPHARMACOLOGICAL RELEVANCE: Cissampelos species have a rich history of traditional use, being used for both therapeutic and toxic properties. It is traditionally applied therapeutically in a diverse range of conditions and diseases including asthma, cough, fever, arthritis, obesity, dysentery, snakebite, jaundice and heart, blood pressure and skin-related problems. Conversely, it was traditionally included in preparations of curare applied as arrow poison during hunting to cause death of animals by asphyxiation. This review unites the ethnobotanical knowledge on Cissampelos with the phytochemistry and pharmacological activity which has been explored thus far. In addition, it identifies knowledge gaps and suggests further research opportunities. METHODS: The available electronic literature on the genus Cissampelos was collected using database searches including Scopus, Google Scholar, Pubmed, Web of Science, etc. The searches were limited to peer-reviewed English journals with the exception of books and a few articles in foreign languages which were included. RESULTS: The literature revealed that pharmacological activity including analgesic and antipyretic, anti-inflammatory, anti-allergic, bronchodilator, immunomodulatory, memory-enhancing, antidepressant, neuroprotective, antimicrobial, antimalarial, antiparasitic, anti-ulcer, anticancer, anti-oxidant, cardiovascular, muscle-relaxant, hepatoprotective, antidiabetic, antidiarrhoeal, antifertility, and antivenom activity have been confirmed in vitro and/or in vivo for various Cissampelos species. Cissampelos pareira L. and Cissampelos sympodialis Eichl. are the most explored species of this genus and the smallest number of studies have been conducted on Cissampelos laxiflora Moldenke and Cissampelos tenuipes Engl. Many alkaloids isolated from Cissampelos such as warifteine, methylwarifteine, berberine, hayatin and hayatidin showed promising anti-allergic, immunosuppressive, antidepressant, anticancer, vasodilatory and muscle-relaxant activities. CONCLUSION: The plants of this genus are used in traditional medicine for the treatment of various ailments. These plants are a rich source of bioactive bisbenzylisoquinoline and aporphine alkaloids together with other minor constituents. Although these plants are reputable and revered in various traditional medicine systems, many have not yet been screened chemically or pharmacologically and so there is a vast amount of research still to be conducted to validate their traditional use.

Pediatric marijuana exposures in a medical marijuana state.

IMPORTANCE: An increasing number of states are decriminalizing the use of medical marijuana, and the effect on the pediatric population has not been evaluated. OBJECTIVE: To compare the proportion of marijuana ingestions by young children who sought care at a children's hospital in Colorado before and after modification of drug enforcement laws in October 2009 regarding medical marijuana possession. DESIGN: Retrospective cohort study from January 1, 2005, through December 31, 2011. SETTING: Tertiary-care children's hospital emergency department in Colorado. PARTICIPANTS: A total of 1378 patients younger than 12 years evaluated for unintentional ingestions: 790 patients before September 30, 2009, and 588 patients after October 1, 2009. MAIN EXPOSURE: Marijuana ingestion. MAIN OUTCOMES AND MEASURES: Marijuana exposure visits, marijuana source, symptoms, and patient disposition. RESULTS: The proportion of ingestion visits in patients younger than 12 years (age range, 8 months to 12 years)that were related to marijuana exposure increased after September 30, 2009, from 0 of 790 (0%; 95% CI, 0%-0.6%) to 14 of 588 (2.4%; 95% CI, 1.4%-4.0%) (P < .001). Nine patients had lethargy, 1 had ataxia, and 1 had respiratory insufficiency. Eight patients were admitted, 2 to the intensive care unit. Eight of the 14 cases involved medical marijuana, and 7 of these exposures were from food products. CONCLUSIONS AND RELEVANCE: We found a new appearance of unintentional marijuana ingestions by young children after modification of drug enforcement laws for marijuana possession in Colorado. The consequences of unintentional marijuana exposure in children should be part of the ongoing debate on legalizing marijuana.

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: what are the clinical features of Salvia divinorum toxicity?

A short-cut review was carried out to determine the clinical features associated with acute intoxication with Salvia divinorum. Sixty-six papers were found using the reported searches, of which three presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that the most common features of intoxication are tachycardia, hallucinations and acute alteration in mental status.

Acute toxicity due to the confirmed consumption of synthetic cannabinoids: clinical and laboratory findings.

AIMS: Recently, several synthetic cannabinoids were identified in herbal mixtures consumed as recreational drugs alternative to cannabis products. The aim was to characterize the acute toxicity of synthetic cannabinoids as experienced by emergency patients. DESIGN: This was a retrospective study targeting patients seeking emergency treatment after recreational use of synthetic cannabinoids. SETTING AND PARTICIPANTS: Patients were selected from the database of the Poisons Information Center Freiburg between September 2008 and February 2011. The inclusion criteria were: hospitalization, available clinical reports and analytical verification of synthetic cannabinoid uptake. In total, 29 patients were included (age 14-30 years, median 19; 25 males, four females). MEASUREMENTS: Clinical reports were evaluated and synthetic cannabinoids and other drugs were determined analytically. FINDINGS: CP-47,497-C8 (one), JWH-015 (one), JWH-018 (eight), JWH-073 (one), JWH-081 (seven), JWH-122 (11), JWH-210 (11), JWH-250 (four) and AM 694 (one) were quantified in blood samples. JWH-018 was most common in 2008-9, JWH-122 in 2010, and JWH-210 in 2011. Tachycardia, agitation, hallucination, hypertension, minor elevation of blood glucose, hypokalaemia and vomiting were reported most frequently. Chest pain, seizures, myoclonia and acute psychosis were also noted. CONCLUSIONS: There appears to have been an increase in use of the extremely potent synthetic cannabinoids JWH-122 and JWH-210. Acute toxic symptoms associated with their use are also reported after intake of high doses of cannabis, but agitation, seizures, hypertension, emesis and hypokalaemia seem to be characteristic to the synthetic cannabinoids, which are high-affinity and high-efficacy agonists of the CB(1) receptor. Thus, these effects are due probably to a strong CB(1) receptor stimulation.