Unknowing ingestion of Brugmansia suaveolens leaves presenting with signs of anticholinergic toxicity: a case report.

BACKGROUND: Brugmansia suaveolens is the commonest species under the Solanacea ("Angels Trumpet" in English; "Attana" in Sinhalese) plant family in Sri Lanka. It contains alkaloids like scopolamine, atropine and hyoscyamine which can cause an anticholinergic toxindrome. There have been a few reported cases of accidental ingestion of Brugmansia seeds among children, seeds being the most toxic part, but no such reported cases of Brugmansia leaves poisoning among adults. CASE PRESENTATION: A 60-year-old-female Sinhalese presented with acute confusion, delirium, and agitation. She had ingested a herbal drink made from leaves of an unknown plant from her garden prior to onset of symptoms. She had urinary retention, mydriasis and sinus tachycardia. She was managed supportively with activated charcoal and hydration and the delirium completely resolved within 15 hours. The presented unkown plant leaves were identified as Brugmansia suaveolens. CONCLUSION: Although seeds are the most toxic plant part in most cases of Brugmansia poisoning, leaves also have a significant degree of toxicity. It is important that medical professionals promptly recognize the features of anticholinergic syndrome, and have a high index to suspect Brugmansia poisoning and start prompt treatment. It is also important to improve awareness of toxic plants among the general community to prevent toxicities and fatalities.

An autopsy case of death due to metabolic acidosis after citric acid ingestion.

A man in his 40s was found unconscious on a sofa in a communal residence for people with various disabilities. He appeared to have drunk 800 ml of undiluted citric acid from a commercial plastic bottle. The instructions on the label of the beverage specified that the beverage be diluted 20- to 30-fold before consumption. The patient was admitted to an emergency hospital with severe metabolic acidosis (pH, 6.70; HCO3(-), 3.6 mEq/L) and a low ionized calcium level (0.73 mmol/L). Although ionized calcium and catecholamines were continuously administered intravenously to correct the acidosis, the state of acidemia and low blood pressure did not improve, and he died 20 h later. Citric acid concentrations in the patient's serum drawn shortly after treatment in the hospital and from the heart at autopsy were 80.6 mg/ml and 39.8 mg/dl, respectively (normal range: 1.3-2.6 mg/dl). Autopsy revealed black discoloration of the mucosal surface of the esophagus. Microscopically, degenerated epithelium and neutrophilic infiltration in the muscle layer were observed. In daily life, drinking a large amount of concentrated citric acid beverage is rare as a cause of lethal poisoning. However, persons with mental disorders such as dementia may mistakenly drink detergent or concentrated fluids, as in our case. Family members or facility staff in the home or nursing facility must bear in mind that they should not leave such bottles in places where they are easily accessible to mentally handicapped persons.

[Severe poisoning by plants used for traditional medicine in Mayotte]. / Intoxications graves lors de traitements traditionnels par les plantes à Mayotte.

The authors describe three cases of severe accidental poisoning by plants used as part of a traditional treatment in Mayotte. The established, or suspected, toxicity of Thevetia peruviana (Yellow oleander), Cinchona pubescens (Red quinine-tree), Melia azaderach (Persian lilac, also called china berry) and Azadirachta indica (Neem), is discussed. The clinical presentation is cardiac (atrioventricular block) and well known for Thevetia and Cinchona intoxications. Neurological signs and multi-organ failure are found for Azadirachta and Melia. The identification of the plants is never easy, nor is the evidence of their accountability. In the three cases reported, no other cause than the traditional treatment has been found to explain the clinical presentation. The outcome was favorable in all cases. The authors emphasize the difficulties to investigate these accidents, the poor medical knowledge of these practices in tropical areas, and in Mayotte particularly. The need for cooperation with local botanists, familiar with traditional medicine, is also underlined.

[Anaphylaxis to PR-10 proteins (Bet v1 homologues)]. / Anaphylaxie auf PR-10-Proteine (Bet v1-Homologe).

Secondary food allergies to PR-10 proteins (Bet v1 homologues) are the most common food allergies in Germany. Clinically they present with an oral allergy syndrome (intraoral pruritus and perhaps swelling). When drinks containing PR-10 proteins are rapidly consumed, for example after sporting activities, large concentrations of allergen can be reached without any intraoral symptoms and then lead to anaphylaxis. This phenomenon has often been described for soja milk and occurred in our case with an apple drink with 60% fruit concentration. It seems likely that such cases of anaphylaxis are not adequately represented in the anaphylaxis registry.

Rhabdomyolysis associated with kava ingestion.

We report a case of rhabdomyolysis temporally related to the ingestion of a large amount of kava. Kava is a naturally occurring plant used in the United States and elsewhere in the world for its sedative properties. A previous case report also related rhabdomyolysis to the ingestion of kava. It is not clear whether this is an action of the kava itself, perhaps, due to its action on voltage ion channels or, perhaps, due to an adulterant in the product. Our patient developed peak creatine phosphokinase levels in excess of 30 000 U/L but had no significant renal damage.

[Methanol poisoning in a 61-year old male with recently diagnosed diabetes--a case report]. / Zatrucie metanolem u 61-letniego mezczyzny ze swiezo wykryta cukrzyca--opis przypadku.

The aim of this paper is to present a case of a 61-year-old male transferred to the Regional Center of Clinical Toxicology from the Department of Endocrinology with suspected methanol poisoning. The patient presented symptoms of diabetes with extreme hyperglycemia >1600 mg/dl and nonketotic hyperosmolar coma. Laboratory tests showed metabolic/respiratory acidosis, methanol 80 mg/dl, ethanol 0.47 g/l, creatinine 3.5 mg/dl, urea 140 mg/dl, lactic acid 4.11 mmol/l, myoglobin >1000 ng/ml, HbA1C >14.5%. During a few days prior to the hospitalization the patient was drinking a great amount of fruit juices and milk (a dozen or so litres per twenty four hours). The eventuality of metabolizing glucose and aspartame into methanol is known from professional literature. The possibility of excessive consumption of aspartame and its metabolites causing methanol poisoning in the presented patient was considered.

Fatality involving the ingestion of phenazepam and poppy seed tea.

Phenazepam is a benzodiazepine derivative that has been in clinical use in Russia since 1978 and is not available by prescription in the United States; however, it is attainable through various internet websites, sold either as tablets or as a reference grade crystalline powder. Presented here is the case of a 42-year old Caucasian male who died as the result of combined phenazepam, morphine, codeine, and thebaine intoxication. A vial of white powder labeled "Phenazepam, Purity 99%, CAS No. 51753-57-2, Research Sample", a short straw, and several poppy seed pods were found on the scene. Investigation revealed that the decedent had a history of ordering medications over the internet and that he had consumed poppy seed tea prior to his death. Phenazepam, morphine, codeine, and thebaine were present in the blood at 386, 116, 85, and 72 ng/mL, respectively.

Black hairy tongue in a 2-month-old infant.

Black hairy tongue (BHT) is an unusual condition in adults, and is characterised by marked accumulation of keratin on the filiform papillae of the dorsum of the tongue resulting in a hairlike appearance. The colour of the papillae may vary from brown to black. We describe a case of BHT in a 2-month-old infant. An extended review of the literature suggests that our case is the youngest ever reported. In conclusion, although BHT is considered benign, clinical, haematological and histological, evaluation is recommended to exclude several entities which can present as pigmented lesions of the oral mucosa.

[Agauria salicifolia intoxication]. / Intoxication par bois de gale (Agauria salicifolia).

INTRODUCTION: Several plants of the Ericaceae family produce grayanotoxins, which can poison humans. The best-known of these intoxications involves the eating of "mad honey" contaminated by rhododendron nectar grayanotoxins. The authors report a case of poisoning due to ingestion of Agauria salicifolia, an Ericaceae species endemic in the Mascarene Islands. CASE: A 28-year-old woman mistakenly ingested a herbal tea made with leaves of this plant. Symptoms were characteristic of grayanotoxin intoxication, with vomiting, arterial hypotension and bradycardia. The patient was managed in an intensive care unit and recovered within a few hours after symptomatic treatment of the low blood pressure and the severe digestive disorders. CONCLUSION: This case underlines that ingestion of some plants can be toxic.

Report of accidental CS ingestion among seven patients in central Israel and review of the current literature.

A report of seven people who accidentally drank a juice contaminated with CS (o-chlorobenzylidene malononitrile) is given. Due to its mucosal irritating properties, CS (also known as "tear gas") is commonly used by policemen and soldiers in riot control. However, only a few reports of its ingestion by humans exist. Ingestion of CS may cause immediate irritation of the oral mucosa and gastrointestinal symptoms later on. Damage of internal organs, which has been shown in animals but only rarely in humans, is probably related to the dose ingested. The extensive use of CS gas merits recognition of the signs and symptoms of its exposure in order to reduce anxiety in both patients and medical staff and to facilitate fast and efficient management.

[Star anise poisoning in infants]. / Intoxication aiguë par la badiane chez le nourrisson.

UNLABELLED: Star anise is used as herbal tea, for the treatment of colicky pain in infants. It may cause neurological troubles. CASE REPORTS: We report 2 cases of star anise poisoning in infants before 6 months of age. Star anise herbal tea was given by parents. Tremors or spasms, hypertonia, hyperexcitability with crying, nystagmus, and vomiting were observed. Contamination or adulteration of Chinese star anise (Illicium verum Hook), with Japanese star anise (Illicium religiosum) was proved in one child. CONCLUSION: Confusion or blending between Chinese and Japanese star anise may cause poisoning. Japanese star anise is a neurotoxic plant indeed, because it contains sesquiterpenic lactones. From November 2001, star anise products are theoretically prohibited in France, but they may be still available in some small groceries, or imported by families themselves.

Collective poisoning with hallucinogenous herbal tea.

An incident wherein more than 30 people were poisoned with a herbal infusion during a meditation session is described. The clinical features observed were hallucinations, aggression, agitation, amnesia, mydriasis, dry skin, tachycardia, hyperthermia, hypotension, collapse, coma and respiratory depression. All patients recovered, although mechanical ventilation was required in some instances. A portion of the herbal infusion was found to contain atropine (hyoscyamine), scopolamine (hyoscine), harmine, and other alkaloids. The estimated ingested doses (free bases) were atropine 4 mg, harmine 27 mg, and scopolamine 78 mg. The mean concentrations in 21 serum samples obtained approximately 6h after ingestion of the infusion were atropine 5 ng/ml, harmine 8 ng/ml, and scopolamine 13 ng/ml.

[An epidemic of epileptic seizures after consumption of herbal tea]. / Een epidemie van epileptische aanvallen na drinken van kruidenthee.

UNLABELLED: At the end of September 2001 the Inspectorate for Health Protection and Veterinary Public Health and the National Poisons Control Centre (NPCC) were informed about adverse health effects after consumption of a herbal tea. During consultations it was suggested that Japanese star anise (Illicium anisatum L.), which is known to contain a neurotoxin, may have been inadvertently mixed into the herbal tea. In view of the severity of the adverse health effects and the clear association with consumption of a specific herbal tea, the supplier was urgently advised to withdraw the suspected herbal tea from the market. A total of 63 persons reported symptoms of general malaise, nausea and vomiting 2-4 hours following consumption of the herbal tea. Twenty-two persons required hospitalisation, of whom 16 due to generalised tonic-clonic seizures. Medical investigations revealed no underlying pathology and after supportive treatment, the patients were discharged in good health. Morphologic and organoleptic investigations of the suspected herbal tea indicated that this possibly contained Japanese star anise. NMR analysis of the herbal tea confirmed the presence of the neurotoxin anisatin, a non-competitive GABA-antagonist which can cause hyperactivity of the central nervous system and tonic-clonic seizures. CONCLUSION: Ingestion of a herbal tea containing anisatin caused the reported serious adverse health effects. Close cooperation between clinicians, the Inspectorate for Health Protection and Veterinary Public Health and the NPCC played a vital role in preventing further harm to public health.