Cyanide poisoning in Thailand before and after establishment of the National Antidote Project.

CONTEXT: Antidote shortage is a global problem. In Thailand, the National Antidote Project (NAP) has operated since November 2010 to manage the national antidote stockpile, educate the healthcare providers on appropriate antidote use, and evaluate antidote usage. OBJECTIVE: To evaluate the effect of NAP implementation on mortality rate and antidote use in cyanide poisoning cases arising from ingestion of cyanide or cyanogenic glycoside. METHODS: This is a retrospective cohort of poisoning cases involving cyanide or cyanogenic glycoside ingestion reported to Ramathibodi Poison Center from 1 January 2007 to 31 December 2015. Mortality rate, antidote use, and appropriateness of antidote use (defined as correct indication, proper dosing regimen, and administration within 90 min) before and after NAP implementation were compared. Association between parameters and fatal outcomes was analyzed. RESULTS: A total of 343 cases involving cyanide or cyanogenic glycoside ingestion were reported to Ramathibodi Poison Center. There were 213 cases (62.1%) during NAP (Project group) and 130 cases (37.9%) pre-NAP implementation (Before group). Implementation of NAP led to increased antidote use (39.9% in Project group versus 24.6% in Before group) and a higher rate of appropriate antidote use (74.1% in Project group versus 50.0% in Before group). All 30 deaths were presented with initial severe symptoms. Cyanide chemical source and self-harm intent were associated with death (OR: 12.919, 95% CI: 4.863-39.761 and OR: 10.747, 95% CI: 3.884-28.514, respectively). No difference in overall mortality rate (13 [10.0%] deaths before versus 17 [8.0%] deaths after NAP) was found. In subgroup analysis of 80 cases with initial severe symptoms, NAP and appropriate antidote use reduced mortality (OR: 0.327, 95% CI: 0.106-0.997 and OR: 0.024, 95% CI: 0.004-0.122, respectively). In the multivariate analysis of the cases with initial severe symptoms, presence of the NAP and appropriate antidote use independently reduced the risk of death (OR: 0.122, 95% CI: 0.023-0.633 and OR: 0.034, 95% CI: 0.007-0.167, respectively), adjusted for intent of exposure, cyanide source, age, and sex. CONCLUSIONS: After NAP implementation, both antidote use and appropriate antidote use increased. In cases presenting with severe symptoms, presence of the NAP and appropriate antidote use independently reduced the risk of mortality.

N-acetylcysteine in Cleistanthus collinus Poisoning: A Report of Two Cases in Children.

Cleistanthus collinus, also known as Oduvanthalai in Tamil, is the most commonly encountered plant poison in southern India. The leaves are used for poisoning humans (suicide or homicide) and animals (cattle and fish) and as an abortifacient, especially in rural south India. Although this poisoning is commonly reported in adults, data regarding the use of N-acetylcysteine in pediatric poisoning is lacking. We report two previously healthy male siblings of pediatric age group who ingested the liquid extracted from crushed leaves of this plant given to them by their mother as a means of deliberate harm. Both patients developed distal renal tubular acidosis, with hypokalemia. The younger sibling also developed myocardial toxicity. Other significant findings noted include hypocalcemia, hypomagnesemia and elevated liver enzymes. Both patients received supportive care along with N-acetylcysteine infusion, and showed complete recovery within 10 days.

Sweet Poisons: Honeys Contaminated with Glycosides of the Neurotoxin Tutin.

Poisonings due to consumption of honeys containing plant toxins have been reported widely. One cause is the neurotoxin tutin, an oxygenated sesquiterpene picrotoxane, traced back to honeybees (Apis mellifera) collecting honeydew produced by passionvine hoppers (Scolypopa australis) feeding on sap of the poisonous shrub tutu (Coriaria spp.). However, a pharmacokinetic study suggested that unidentified conjugates of tutin were also present in such honeys. We now report the discovery, using ion trap LC-MS, of two tutin glycosides and their purification and structure determination as 2-(ß-d-glucopyranosyl)tutin (4) and 2-[6'-(α-d-glucopyranosyl)-ß-d-glucopyranosyl]tutin (5). These compounds were used to develop a quantitative triple quadrupole LC-MS method for honey analysis, which showed the presence of tutin (3.6 ± 0.1 µg/g honey), hyenanchin (19.3 ± 0.5), tutin glycoside (4) (4.9 ± 0.4), and tutin diglycoside (5) (4.9 ± 0.1) in one toxic honey. The ratios of 4 and 5 to tutin varied widely in other tutin-containing honeys. The glycosidation of tutin may represent detoxification by one or both of the insects involved in the food chain from plant to honey.

Mutagenicity and cytotoxicity of liquid waste, press water and pond water, produced in the cassava flour industry, and of antitoxic sodium thiosulfate.

BACKGROUND: Cassava (Manihot esculenta Crantz), a plant used as food and an ingredient in industry, contains cyanogenic glycosides. The cassava root contains wastewater, popularly known as manipueira, which is a toxic substance. Its ingestion by animals causes poisoning although they react positively to treatment with sodium thiosulfate. The present research evaluates the cytotoxicity and the mutagenicity of liquid waste produced in the process of industrialization of the bitter cassava, olho-junto variety. The liquid wastes are characterized as press water, which is obtained when the cassava roots are pressed; pond water, which is press water stored in impounded ponds; and a solution of sodium thiosulfate, pure and with other waste. RESULTS: The system tests comprised root meristematic cells of Allium cepa L. and bone marrow cells of Rattus norvegicus. Treatment with saline solution was cytotoxic for Allium cepa L. and significantly reduced cell division rate. Although no treatment was cytotoxic in any of the tests with rats, the thiosulfate solution was clastogenic for the chromosomal aberrations test. CONCLUSION: Since it is harmful to the genetic material submitted within the conditions of current research, sodium thiosulfate should only be used in emergency conditions in which the benefits exceed the risks.

Norsesquiterpene glycosides in bracken ferns (Pteridium esculentum and Pteridium aquilinum subsp. wightianum) from Eastern Australia: reassessed poisoning risk to animals.

Austral bracken Pteridium esculentum contains three unstable norsesquiterpene glycosides: ptaquiloside, ptesculentoside, and caudatoside, in variable proportions. The concentration of each of the glycosides was determined in this study as their respective degradation products, pterosin B, pterosin G and pterosin A, by HPLC-UV analysis. Samples of P. esculentum collected from six sites in eastern Australia contained up to 17 mg of total glycoside/g DW, with both ptaquiloside and ptesculentoside present as major components accompanied by smaller amounts of caudatoside. Ratios of ptaquiloside to ptesculentoside varied from 1:3 to 4:3, but in all Australian samples ptesculentoside was a significant component. This profile differed substantially from that of P. esculentum from New Zealand, which contained only small amounts of both ptesculentoside and caudatoside, with ptaquiloside as the dominant component. A similar profile with ptaquiloside as the dominant glycoside was obtained for Pteridium aquilinum subsp. wightianum (previously P. revolutum ) from northern Queensland and also P. aquilinum from European sources. Ptesculentoside has chemical reactivity similar to that of ptaquiloside and presumably biological activity similar to that of this potent carcinogen. The presence of this additional reactive glycoside in Australian P. esculentum implies greater toxicity for consuming animals than previously estimated from ptaquiloside content alone.

Cleistanthus collinus poisoning.

Cleistanthus collinus is an extremely toxic plant poison. Cleistanthin A and B, the toxins of Cleistanthus collinus, are diphyllin glycosides which produce cardiac arrhythmias, urinary potassium wasting, hypoxia, metabolic acidosis and hypotension. We report ARDS, distal renal tubular acidosis and distributive shock secondary to inappropriate vasodilatation in a case following ingestion of its leaves.

Acute Cycas seed poisoning in Taiwan.

OBJECTIVE: The seeds of cycads contain cycasin and neocycasin, which belong to the family of cyanogenic glycosides. These glycosides of cycads are considered pseudocyanogenic with little potential to liberate hydrogen cyanide as other cyanogenic glycosides do. This study investigated the clinical spectrum of Cycas seed poisoning and its cyanogenic potential. METHODS: This was a retrospective chart review conducted at the Poison Control Center in Taiwan (PCC-Taiwan) from 1990 to 2001. RESULTS: Twenty-one cases of Cycas seed poisoning were identified. The reasons for seed ingestion were misuse as an edible food (70%), health promotion (10%), cancer prevention (10%), cosmetic use (5%), and gastrointestinal discomfort (5%). All patients had eaten the seeds after washing and cooking them. The time from ingestion to the onset of symptoms ranged from 30 min to 7 h (mean 2.8 h); patients had ingested between 1 to 30 seeds. Respiratory depression did not occur. Severe vomiting was the most striking symptom. All patients except one presented with gastrointestinal disturbance, and 90% sought medical care at the emergency department. Within 24 h, all patients had recovered. Six patients had blood cyanide or thiocyanate levels measured. Although the levels were higher than normal, they did not reach the toxic range. CONCLUSIONS: The cyanogenic potential of Cycas seeds is documented in our cases. The gastrointestinal symptoms were severe enough that most patients sought medical attention but recovery was quick and complete.