Anticholinergic poisoning associated with frozen spinach

ABSTRACT

Objective: In some countries the Thursday before Easter is called Green Thursday according to the Christian calendar, and in this tradition, a green meal should be eaten on this day to ensure good health throughout the coming year. A few days before Easter the National Toxicological Information Centre (NTIC) registered an increased number of toxicological consultations following consumption of deep-frozen spinach puree which was sold in retail chains throughout Slovakia. Symptoms were characteristic of tropane alkaloid intoxication and experts suspected the spinach was contaminated with Jimson weed (Datura stramonium). Methods: A retrospective analysis of all telephone calls concerning frozen spinach products from the database of the NTIC from 1 March 2021 to 30 April 2021 was conducted. Results: The NTIC received 93 telephone calls from people who had consumed frozen spinach, of which 64 people (7 children) had mild symptoms of intoxication (PSS1) and 5 moderate poisoning (PSS2). The most commonly reported symptoms were malaise, dizziness, dry mouth, mydriasis and blurred vision that appeared within 1 to 2 hours after ingestion. Patients with moderate symptoms of intoxication were confused, disoriented and had hallucinations. The symptoms disappeared spontaneously within 48 hours. The country was in a state of emergency that had been declared before Easter due to COVID-19 and people were afraid to attend hospitals. Therefore, only 7 out of 69 people with symptoms arrived in hospital. Only 3 patients were hospitalised. Treatment was symptomatic, without the administration of an antidote physostigmine. The other patients were treated at home. Unfortunately, an increased number of consultations was recorded on Good Friday afternoon, when it was very difficult to initiate a wide scale alert informing the public through the media. Over the Easter weekend, the NTIC alerted the public to avoid the contaminated spinach via social media and the NTIC website. The State Veterinary and Food Administration of the Slovak Republic arranged analyses of contaminated frozen spinach samples in an accredited laboratory and this confirmed the presence of atropine and scopolamine. Conclusion: Datura stramonium grew with spinach in the field as a weed and contaminated the spinach due to insufficient entry and exit controls. As a result of promptly spreading information and informing the public about the contaminated spinach product in the media, further cases of poisoning over the Easter holidays were successfully averted.