Mucosal Injury From Calcium Oxalate Crystals Resembling Anaphylaxis and Angioedema.

BACKGROUND: There are 215 families of plants that contain insoluble needle-shaped calcium oxalate crystals on the surface of their tissues. Upon mucosal contact, injury can cause extreme pain, soft-tissue swelling, salivation, dysphagia, and even aphonia. This presentation can resemble angioedema or anaphylaxis. CASE REPORT: A 55-year-old Asian female presented to the emergency department complaining of oral pain, swelling, and numbness. Her family reported that she began to experience sharp pain of the tongue and lips immediately after eating "elephant root." Physical examination revealed a patient sitting in an upright position, leaning forward with pooling secretions. She had few lingual petechiae, a subtle diffuse erythema, and mild edema of the lower lip. Due to pain, she was unable to speak and swallow. Her vitals remained within normal limits. The patient was taking lisinopril for hypertension. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Injury by calcium oxalate crystals is a relatively common occurrence that will present to the emergency department. Although most exposures are benign, patients can develop critical illness, requiring emergent therapies and airway management. Due to the nature of presentation, exposure can easily be misdiagnosed as anaphylaxis or hereditary and drug-induced angioedema. Severe pain and the temporal relationship to plant ingestion distinguish insoluble calcium oxalate crystal exposure from these alternative causes of angioedema. There is minimal evidence-based data evaluating treatment of these injuries. Standard treatment regimen includes a local anesthetic, corticosteroids, opioids, and antihistaminergic agents. Given the relative low cost, ease of administration, and benign adverse effect profile, sodium bicarbonate rinse may have a role as an adjunct therapy, however, research is needed.

Acute oxalate intoxication associated to ingestion of eshnan (Seidlitzia rosmarinus) in sheep.

An outbreak of acute oxalate intoxication in a sheep flock was associated to Seidlitzia rosmarinus (Chenopodiaceae) with a mortality rate of about 19%. Affected sheep showed marked azotemia and hypocalcemia. Post-mortem findings included congestion and hemorrhage in visceral organs, ruminitis frequently associated with precipitation of birefringent calcium oxalate crystals, and acute nephrosis with numerous birefringent calcium oxalate crystals in renal tubules. This is the first report of oxalate poisoning due to ingestion of S. rosmarinus in sheep.

[Current researching situation of mucosal irritant compontents in Araceae family plants].

Plants in Acaceae family are often considered as ornamental and medicines. However many of them have irritation properties. As medicinal plants some of them are recorded in Chinese Pharmacopoeia and they are figured as poisonous. Through investigating the domestic and overseas studied paper, the needle-like calcium oxalate crystal exits in the plants of Acaceae family could be thought as irritation components of them. This conclusion is same with the studied conclusion of our study group in the medicines plant of Pinellia ternate belonging to the Acaceae family and our studies showed that the needle-like calcium oxalate crystal was the main irritation component of raw P. ternate. The irritated mechanism of raphides is relevant to its special shape, the protein enzyme adhering to it and idioblasts in plants.

Acute renal failure due to oxalate ingestion.

A 47-year-old man presented with acute renal failure following oxalate ingestion. Nausea and hematoemesis appeared four hours after attempted suicide and acute oliguric renal failure ensued the following day. The patient underwent four sessions of hemodialysis and then reverted to normal state. Histopathologic examination of renal biopsy specimen revealed the degeneration of the renal tubular epithelial cells associated with intracellular calcium oxalate crystal deposition. Most of the renal tubules were patent despite the intraluminar crystal deposition. These findings suggest that dysfunction of the renal tubular epithelial cell plays a more important role than tubular obstruction in developing acute renal failure.

Calcium oxalate is the main toxic component in clinical presentations of alocasis macrorrhiza (L) Schott and Endl poisonings.

Alocasia macrorrhiza (L) Schott and Endl is called Hai Yu, Tien Ho, Shan Yu, Kuan Yin Lien, Tu Chiao lien, Lao Hu Yu and Lang Du in Chinese. Its common English name is Giant Elephant's Ear. The toxic effects of A macrorrhiza arise from sapotoxin and include gastroenteritis and paralysis of the nerve centers. From 1985 to 1993 all individuals who called the Poison Control Center asking for information regarding macrorrhiza were included in this retrospective study. A questionnaire filled out by the Poison Control Center staff collected the demographic data of the victim, the reason for consumption, the prescribed part, clinical symptoms and signs of the victim, and medical outcome of poisonings. Among 27 cases of A macrorrhiza poisoning, the age was 1.5 to 68 y with 12 females and 15 males. One had skin contact and 1 had eye contact. In the 25 cases that consumed the plant leaf or tuber either raw or cooked, the primary symptom was in injected sore throat and the secondary symptom was numbness of the oral cavity. Some patients had salivation, dysphonia, abdominal pain, ulcers of the oral cavity, difficulty in swallowing, thoracodynia, chest tightness and swollen lips. We believe the presence of sapotoxin alone is not sufficient to explain the injected swollen and ulcerative lesions. Calcium oxalate is reported distributed in the entire plant and results in inflammation of the oral cavity and mucous membranes just as our patients had.

Subclinical renal oxalosis in wild-caught Japanese macaques (Macaca fuscata).

Various degrees of crystal deposition were found in the kidneys of 12 out of 59 Japanese macaques (Macaca fuscata) caught in the wild in Gifu, Japan. The needle- or rod-shaped crystals, which were radially arranged and occurred in the lumen and epithelium of the renal (mainly the proximal) tubules, were birefringent under polarized light. They stained with alizarin red S at a pH of 7.0 but not 4.2, and were identified as calcium oxalate. The morphological features of the renal lesions were similar to those previously reported in oxalate poisoning, and it was believed that the macaques ingested the oxalate in plants.

Injury to the oral mucous membranes caused by the common houseplant, dieffenbachia. A review.

The common houseplant, dieffenbachia, causes painful edematous swelling of the oral mucous membranes when chewed. This property, which is well known to the staffs of poison control centers, can be dangerous to the unwary or to victims of practical jokes. The microscopic features of the injury are those of acute inflammation, but the nature of the plant's toxicity remains controversial. The numerous needles (raphides) of calcium oxalate, which are contained in specialized cells (idioblasts) in the plant, and proteases have both been implicated. When stimulated, the idioblasts fire the raphides with some force for a distance of two to three cell lengths. One possibility is that the local toxicity of dieffenbachia may be caused by a combination of this mechanical release of the raphides, which results in traumatic injury, and the effects of a chemical toxin carried on their surfaces and in their grooves.

[Skin and mucous membrane reactions caused by Dieffenbachia species house plants]. / Haut- und Schleimhautreaktionen durch Zimmerpflanzen der Gattung Dieffenbachia.

A survey, based on 60 essays in the relevant medical and botanical literature, reviews the erosive effects, on skin and mucous membranes, caused by contact with plants of the Dieffenbachia species. Although these common house plants are the most frequent cause of skin and mucous membrane damage by flora and fauna, the pathogenesis of these rapidly occurring caustic actions has not been satisfactorily explained. The assumption that "injection" of proteolytic enzymes into healthy tissue by "shooting cells" (raphid-idioblasts), full of calcium oxalate needles, is responsible, must be viewed as the most readily acceptable explanation. Unfortunately, this hypothesis can not be regarded as proven.