Identification and Quantification of Thujone in a Case of Poisoning Due to Repeated Ingestion of an Infusion of Artemisia Vulgaris L.

Plants of the Artemisia genus are used worldwide as ingredients of botanical preparations. This paper describes the case of a 49-year-old man admitted to the emergency room at a Zurich hospital in a manic state after the ingestion of 1 L of an infusion of Artemisia vulgaris. Two monoterpenic ketones, α- and ß-thujone, are present in various concentrations in Artemisia spp., but adverse effects have previously been associated only with essential oil from Artemisia absinthium and attributed to the inhibition of gamma-aminobutyric acid receptors, with consequent excitation and convulsions. The aim of this work was to examine and quantify the possible presence of thujone in the patient's serum and urine. A High Performance Liquid Chromatography (HPLC) method with isocratic separation and fluorescence detection (FLD) was set up and validated. Serum thujone concentrations were found to be 27.7 ± 3.48 µg/mL at day 0 and 24.1 ± 0.15 µg/mL on day 1. Results were confirmed by a gas chromatography with flame ionization detection (FID). Poisoning due to thujone was thus confirmed, suggesting four possible scenarios: (1) an unusually high concentration of thujone in the A. vulgaris ingested; (2) chronic exposure as the cause of the poisoning; (3) low metabolic efficiency of the patient; (4) contamination or adulteration of the plant material with other Artemisia spp., for example, A. absinthium. PRACTICAL APPLICATION: These results could aid research in the field of adverse effects of botanicals, lead to better understanding and management of similar cases of poisoning, and promote more informed use of natural products.

Adverse Effects of Plant Food Supplements Self-Reported by Consumers in the PlantLIBRA Survey Involving Six European Countries.

BACKGROUND: The use of food supplements containing botanicals is increasing in European markets. Although intended to maintain the health status, several cases of adverse effects to Plant Food Supplements (PFS) have been described. OBJECTIVES: To describe the self-reported adverse effects collected during the European PlantLIBRA PFS Consumer Survey 2011-2012, with a critical evaluation of the plausibility of the symptomatology reported using data from the literature and from the PlantLIBRA Poisons Centers' survey. SUBJECTS/SETTING: From the total sample of 2359 consumers involved in the consumers' survey, 82 subjects reported adverse effects due to a total of 87 PFS. RESULTS: Cases were self-reported, therefore causality was not classified on the basis of clinical evidence, but by using the frequency/strength of adverse effects described in scientific papers: 52 out of 87 cases were defined as possible (59.8%) and 4 as probable (4.6%). Considering the most frequently cited botanicals, eight cases were due to Valeriana officinalis (garden valerian); seven to Camellia sinensis (tea); six to Ginkgo biloba (Maidenhair tree) and Paullinia cupana (guarana). Most adverse events related to the gastrointestinal tract, nervous and cardiovascular systems. CONCLUSIONS: Comparing the data from this study with those published in scientific papers and obtained by the PlantLIBRA Poisons Centers' survey, some important conclusions can be drawn: severe adverse effects to PFS are quite rare, although mild or moderate adverse symptoms can be present. Data reported in this paper can help health professionals (and in particular family doctors) to become aware of possible new problems associated with the increasing use of food supplements containing botanicals.

Adverse Effects of Plant Food Supplements and Plants Consumed as Food: Results from the Poisons Centres-Based PlantLIBRA Study.

Plant food supplements (PFS) are products of increasing popularity and wide-spread distribution. Nevertheless, information about their risks is limited. To fill this gap, a poisons centres-based study was performed as part of the EU project PlantLIBRA. Multicentre retrospective review of data from selected European and Brazilian poisons centres, involving human cases of adverse effects due to plants consumed as food or as ingredients of food supplements recorded between 2006 and 2010. Ten poisons centres provided a total of 75 cases. In 57 cases (76%) a PFS was involved; in 18 (24%) a plant was ingested as food. The 10 most frequently reported plants were Valeriana officinalis, Camellia sinensis, Paullinia cupana, Melissa officinalis, Passiflora incarnata, Mentha piperita, Glycyrrhiza glabra, Ilex paraguariensis, Panax ginseng, and Citrus aurantium. The most frequently observed clinical effects were neurotoxicity and gastro-intestinal symptoms. Most cases showed a benign clinical course; however, five cases were severe. PFS-related adverse effects seem to be relatively infrequent issues for poisons centres. Most cases showed mild symptoms. Nevertheless, the occurrence of some severe adverse effects and the increasing popularity of PFS require continuous active surveillance, and further research is warranted. Copyright © 2016 John Wiley & Sons, Ltd.

Adverse effects of plant food supplements and botanical preparations: a systematic review with critical evaluation of causality.

AIMS: The objective of this review was to collect available data on the following: (i) adverse effects observed in humans from the intake of plant food supplements or botanical preparations; (ii) the misidentification of poisonous plants; and (iii) interactions between plant food supplements/botanicals and conventional drugs or nutrients. METHODS: PubMed/MEDLINE and Embase were searched from database inception to June 2014, using the terms 'adverse effect/s', 'poisoning/s', 'plant food supplement/s', 'misidentification/s' and 'interaction/s' in combination with the relevant plant name. All papers were critically evaluated according to the World Health Organization Guidelines for causality assessment. RESULTS: Data were obtained for 66 plants that are common ingredients of plant food supplements; of the 492 papers selected, 402 (81.7%) dealt with adverse effects directly associated with the botanical and 89 (18.1%) concerned interactions with conventional drugs. Only one case was associated with misidentification. Adverse effects were reported for 39 of the 66 botanical substances searched. Of the total references, 86.6% were associated with 14 plants, including Glycine max/soybean (19.3%), Glycyrrhiza glabra/liquorice (12.2%), Camellia sinensis/green tea ( 8.7%) and Ginkgo biloba/gingko (8.5%). CONCLUSIONS: Considering the length of time examined and the number of plants included in the review, it is remarkable that: (i) the adverse effects due to botanical ingredients were relatively infrequent, if assessed for causality; and (ii) the number of severe clinical reactions was very limited, but some fatal cases have been described. Data presented in this review were assessed for quality in order to make the results maximally useful for clinicians in identifying or excluding deleterious effects of botanicals.

Fire eater's lung: retrospective analysis of 123 cases reported to a National Poison Center.

BACKGROUND: Fire eater's lung (FEL) is a distinct form of acute chemical toxic pneumonitis, which is caused by aspiration of flammable petrochemical derivatives used by street performers for 'fire eating'. The optimal management of this condition has not yet been determined. OBJECTIVE: The aim of this study was to investigate patient characteristics, clinical features, treatment, and outcome of FEL. METHODS: A single-center retrospective review of consecutive cases of FEL in children and adults reported to a national poison center (the Swiss Toxicological Information Center) between 1995 and 2012. RESULTS: 123 cases (83.7% males, mean age 21.9 years) were included. The most frequently reported symptom was cough (50.4%), followed by chest pain (45.5%), and fever (35.8%). Dyspnea was reported by 23.6%. Cough (p = 0.002) and chest pain (p = 0.02) were significantly more prevalent in subjects reporting to have aspirated the fuel compared to those who have swallowed it or who did not perceive poison exposure. A pulmonary infiltrate was detected in 83% of the cases in whom chest X-ray was performed. Overall, 22% were treated with an antibiotic agent for a mean duration of 10.4 days. Corticosteroids were administered in 4.9%. All showed complete recovery irrespective of the therapeutic management. CONCLUSION: The combination of intense pleuritic chest pain, cough, dyspnea, and fever, or any of these symptoms after 'fire eating' or erroneous swallowing of a petroleum distillate should alert the clinician to the diagnosis of FEL. Early antibiotic treatment of severe cases seems justified, considering that clinical, laboratory, and radiologic findings of FEL are overlapping with bacterial superinfection.

Paracetamol orodispersible tablets: a risk for severe poisoning in children?

PURPOSE: Childhood paracetamol (acetaminophen) ingestion with subsequent risk of hepatotoxicity is a major medical problem. The aim of this study was to investigate the risk of high-dose ingestion of orodispersible, fast-disintegrating paracetamol tablets in children. METHODS: A retrospective single-center case study of all accidental selfadministrations of solid or orodispersible 500-mg paracetamol tablets occurring in children ≤ 6 years, reported to the Swiss Toxicological Information Centre between June 2003 and August 2009. RESULTS: We found 187 cases with ingestion of solid 500-mg paracetamol tablets and 16 cases with ingestion of orodispersible 500-mg tablets. The mean ingested dose in the orodispersible-tablet group was 59% higher than in the solid-tablet group (p = 0.085). Administration of activated charcoal and/or N-acetylcysteine because of ingestion of a potentially hepatotoxic paracetamol dose ( ≥ 150 mg/kg body weight) was recommended in 32 patients (17.1%) in the solid-tablet group and in five (31%) in the orodispersible-tablet group. CONCLUSIONS: Orodispersible paracetamol formulations may represent an important risk factor for severe paracetamol poisoning in children. Over-the-counter availability may contribute to increasing the use of this galenic formulation and eventually the number of poisonings in children.

Low-dose exposure to Veratrum album in children causes mild effects--a case series.

INTRODUCTION: White or false hellebore (Veratrum album) has a toxicological relevance because of the potential for misidentification of this plant as yellow gentian (Gentiana lutea). CASE SERIES: We report a retrospective case series of 11 children (8-12 years) with accidental intake of V. album at a youth camp where they had collected herbs for preparing fresh herb tea. Two children (18%) remained asymptomatic. Nine (82%) developed mild gastrointestinal symptoms, six (55%) presented neurological symptoms, and three (27%) showed bradycardia. All children recovered completely within 10 h of ingestion. The plant was identified at the emergency department; however, detection of veratridine and cevadine by means of high-performance liquid chromatography-Mass spectrometry from the blood of the child with the most severe symptoms was negative (limit 0.01 ng/mL). DISCUSSION: Veratrum species contain more than 200 different alkaloids, which are the principal toxins and are responsible for most clinical symptoms. There are likely multiple mechanisms of toxicity and some of them are only partially understood. The opening of voltage-gated sodium channels is probably one of the most relevant pathophysiological mechanisms. CONCLUSIONS: Veratrum album intoxication in children demonstrated the same clinical course as observed in adults. Accidental ingestion of a low dose of the plant had a favorable outcome with supportive care.