Jamaican Susumber Berry Poisoning Mimicking Acute Stroke.

BACKGROUND: Stroke mimics are non-vascular conditions that present with acute focal neurological deficits, simulating an acute ischemic stroke. Susumber berry (SB) toxicity is a rare cause of stroke mimic with limited case reports available in the literature. OBJECTIVES: We report four new cases of SB toxicity presenting as stroke mimic, and we performed a systematic review. METHODS: MEDLINE/EMBASE/WoS were searched for "susumber berries," "susumber," or "solanum torvum." RESULTS: 531 abstracts were screened after removal of duplicates; 5 articles and 2 conference abstracts were selected describing 13 patients. A total of 17 patients who ingested SB and became ill were identified, including our 4 patients. All but one presented with acute neurologic manifestation; 16 (94%) presented with dysarthria, 16 (94%) with unstable gait, 8 (47%) with nystagmus/gaze deviation, 10 (59%) with blurry vision, and 5 (29%) with autonomic symptoms. Six (35%) required ICU admission, and 3 (18%) were intubated. Fourteen (82%) had a rapid complete recovery, and 3 were hospitalized up to 1 month. CONCLUSIONS: SB toxicity can cause neurological symptoms that mimic an acute stroke typically with a posterior circulation symptom complex. Altered SB toxins (from post-harvest stressors or temperature changes) might stimulate muscarinic/nicotinic cholinergic receptors or inhibit acetylcholinesterase, causing gastrointestinal, neurological, and autonomic symptoms. In cases of multiple patients presenting simultaneously to the ED with stroke-like symptoms or when stroke-like symptoms fail to localize, a toxicological etiology (such as SB toxicity) should be considered.

Cardiotoxicity in yew berry poisoning.

Yew plants (Taxus species) represent a genus of plants known to be highly toxic, though lethal intoxication is rare. The majority of deaths in yew berry poisonings occur due to its cardiotoxic effect, mediated through generation of a number of fatal tachy- and brady-arrhythmias. However, there are no guidelines on the most effective management in these cases, and interventions vary greatly between published reports. Here we report a case of a 20-year-old female who presented with refractory lethal arrythmia and shock refractory to conventional therapy. She presented to the emergency department and promptly required airway management and hemodynamic support necessitating intensive care unit management. She received many antiarrhythmics, digoxin immune Fab, lipid emulsification, and eventually transvenous pacemaker insertion for overdrive pacing. Despite our interventions, our patient ultimately died after a decision to withdraw care. We also reviewed 43 reports of yew poisoning cases described in the literature. We discuss the most common strategies used to treat such patients including gastric decontamination, antiarrhythmics, electrical pacing, extracorporeal life support and other therapies. We need better understanding of this condition, to identify which therapies offer maximal benefit and to optimize outcomes for this rare but often devastating toxidrome.

C-Fos expression in epileptogenic areas of nephropathic rats undergoing star fruit poisoning.

Purpose Studies have demonstrated that star fruit consumption by nephropathic patients triggers severe neurotoxic effects that can lead to convulsions or even death. Brain areas likely susceptible to star fruit poisoning have not been investigated. The objective of the present study was to map possible epileptogenic areas susceptible to star fruit intoxication in nephropathic rats. Methods The study analyzed 25 rats (5 groups). Rats in the experimental group underwent bilateral ureteral obstruction surgery and orogastric gavages with star fruit juice. An electroencephalogram was used to confirm convulsive seizures. Urea and creatinine levels were used to confirm the uremia model. Immunohistochemical analysis was used to map cells with c-Fos protein (c-Fos+ cells) to identify brain areas with increased neuronal activity. Control groups included non-nephropathic and nephropathic rats that did not receive star fruit. Results A statistically significant increase (p<0.01) in c-Fos+ cells was noted in nephropathic animals receiving star fruit juice compared to control groups, in brain areas commonly related to epileptogenic neural circuits including the hippocampus, amygdala, rhinal cortex, anterior cingulate area, piriform area, and medial dorsal thalamus. Conclusion These data corroborate the neurotoxic capacity of star fruit in nephropathic patients.

C-Fos expression in epileptogenic areas of nephropathic rats undergoing star fruit poisoning

Abstract Purpose Studies have demonstrated that star fruit consumption by nephropathic patients triggers severe neurotoxic effects that can lead to convulsions or even death. Brain areas likely susceptible to star fruit poisoning have not been investigated. The objective of the present study was to map possible epileptogenic areas susceptible to star fruit intoxication in nephropathic rats. Methods The study analyzed 25 rats (5 groups). Rats in the experimental group underwent bilateral ureteral obstruction surgery and orogastric gavages with star fruit juice. An electroencephalogram was used to confirm convulsive seizures. Urea and creatinine levels were used to confirm the uremia model. Immunohistochemical analysis was used to map cells with c-Fos protein (c-Fos+ cells) to identify brain areas with increased neuronal activity. Control groups included non-nephropathic and nephropathic rats that did not receive star fruit. Results A statistically significant increase (p<0.01) in c-Fos+ cells was noted in nephropathic animals receiving star fruit juice compared to control groups, in brain areas commonly related to epileptogenic neural circuits including the hippocampus, amygdala, rhinal cortex, anterior cingulate area, piriform area, and medial dorsal thalamus. Conclusion These data corroborate the neurotoxic capacity of star fruit in nephropathic patients.

Severity of manchineel fruit (Hippomane mancinella) poisoning: A retrospective case series of 97 patients from French Poison Control Centers.

In this retrospective series of 97 cases of manchineel fruit ingestion reported to French Poison Control Centers between 2009 and 2017, we investigated cases of poisoning due to manchineel fruit (from the Hippomane mancinella tree). This fruit is known to be responsible for oropharyngeal and gastrointestinal tract lesions and possibly hypotension and bradycardia (previously attributed to the presence of physostigmine). The most commonly observed clinical signs were oropharyngeal pain, abdominal pain, diarrhea and oropharyngeal irritation. No major gastrointestinal tract lesions were observed in the five cases in which upper gastrointestinal (GI) endoscopy was performed. One case of laryngeal edema and one case of bradycardia were observed, but analysis of the harvested fruits did not confirm the presence of physostigmine. Ingestion of manchineel fruit can cause mild abdominal pain and digestive irritation, requiring medical attention. Rarely, when several fruits have been ingested, severe oropharyngeal injury or hemodynamic disorders may require otorhinolaryngological consultation or cardiac monitoring for several hours, respectively.

Suspected poisoning in beef cattle from ingestion of Prosopis nigra pods in north-western Argentina.

The aim of this paper was to present the first report of Prosopis nigra poisoning of cattle in Argentina. Outbreaks occurred in five farms located in Salta and Santiago del Estero provinces. All animals were examined, euthanized and necropsied. Clinical signs included tongue protrusion, twitches and tremors of muscles of mastication, weight loss and lethargy. Severe atrophy of the masseter, buccinator and lingual muscles was observed, along with neuronal vacuolation in the nuclei of the trigeminal, facial, and hypoglossus nerves. These findings and the clinical signs are consistent with results obtained in animals, spontaneously and experimentally intoxicated with Prosopis juliflora in previous studies. Several species of this genus are native to Argentina. Farmers should be warned about the suspected toxicity by Prosopis nigra, since this species has wide geographical distribution in the country.

First aid interventions by laypeople for acute oral poisoning.

BACKGROUND: Oral poisoning is a major cause of mortality and disability worldwide, with estimates of over 100,000 deaths due to unintentional poisoning each year and an overrepresentation of children below five years of age. Any effective intervention that laypeople can apply to limit or delay uptake or to evacuate, dilute or neutralize the poison before professional help arrives may limit toxicity and save lives. OBJECTIVES: To assess the effects of pre-hospital interventions (alone or in combination) for treating acute oral poisoning, available to and feasible for laypeople before the arrival of professional help. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, ISI Web of Science, International Pharmaceutical Abstracts, and three clinical trials registries to 11 May 2017, and we also carried out reference checking and citation searching. SELECTION CRITERIA: We included randomized controlled trials comparing interventions (alone or in combination) that are feasible in a pre-hospital setting for treating acute oral poisoning patients, including but potentially not limited to activated charcoal (AC), emetics, cathartics, diluents, neutralizing agents and body positioning. DATA COLLECTION AND ANALYSIS: Two reviewers independently performed study selection, data collection and assessment. Primary outcomes of this review were incidence of mortality and adverse events, plus incidence and severity of symptoms of poisoning. Secondary outcomes were duration of symptoms of poisoning, drug absorption, and incidence of hospitalization and ICU admission. MAIN RESULTS: We included 24 trials involving 7099 participants. Using the Cochrane 'Risk of bias' tool, we assessed no study as being at low risk of bias for all domains. Many studies were poorly reported, so the risk of selection and detection biases were often unclear. Most studies reported important outcomes incompletely, and we judged them to be at high risk of reporting bias.All but one study enrolled oral poisoning patients in an emergency department; the remaining study was conducted in a pre-hospital setting. Fourteen studies included multiple toxic syndromes or did not specify, while the other studies specifically investigated paracetamol (2 studies), carbamazepine (2 studies), tricyclic antidepressant (2 studies), yellow oleander (2 studies), benzodiazepine (1 study), or toxic berry intoxication (1 study). Eighteen trials investigated the effects of activated charcoal (AC), administered as a single dose (SDAC) or in multiple doses (MDAC), alone or in combination with other first aid interventions (a cathartic) and/or hospital treatments. Six studies investigated syrup of ipecac plus other first aid interventions (SDAC + cathartic) versus ipecac alone. The collected evidence was mostly of low to very low certainty, often downgraded for indirectness, risk of bias or imprecision due to low numbers of events.First aid interventions that limit or delay the absorption of the poison in the bodyWe are uncertain about the effect of SDAC compared to no intervention on the incidence of adverse events in general (zero events in both treatment groups; 1 study, 451 participants) or vomiting specifically (Peto odds ratio (OR) 4.17, 95% confidence interval (CI) 0.30 to 57.26, 1 study, 25 participants), ICU admission (Peto OR 7.77, 95% CI 0.15 to 391.93, 1 study, 451 participants) and clinical deterioration (zero events in both treatment groups; 1 study, 451 participants) in participants with mixed types or paracetamol poisoning, as all evidence for these outcomes was of very low certainty. No studies assessed SDAC for mortality, duration of symptoms, drug absorption or hospitalization.Only one study compared SDAC to syrup of ipecac in participants with mixed types of poisoning, providing very low-certainty evidence. Therefore we are uncertain about the effects on Glasgow Coma Scale scores (mean difference (MD) -0.15, 95% CI -0.43 to 0.13, 1 study, 34 participants) or incidence of adverse events (risk ratio (RR) 1.24, 95% CI 0.26 to 5.83, 1 study, 34 participants). No information was available concerning mortality, duration of symptoms, drug absorption, hospitalization or ICU admission.This review also considered the added value of SDAC or MDAC to hospital interventions, which mostly included gastric lavage. No included studies investigated the use of body positioning in oral poisoning patients.First aid interventions that evacuate the poison from the gastrointestinal tractWe found one study comparing ipecac versus no intervention in toxic berry ingestion in a pre-hospital setting. Low-certainty evidence suggests there may be an increase in the incidence of adverse events, but the study did not report incidence of mortality, incidence or duration of symptoms of poisoning, drug absorption, hospitalization or ICU admission (103 participants).In addition, we also considered the added value of syrup of ipecac to SDAC plus a cathartic and the added value of a cathartic to SDAC.No studies used cathartics as an individual intervention.First aid interventions that neutralize or dilute the poison No included studies investigated the neutralization or dilution of the poison in oral poisoning patients.The review also considered combinations of different first aid interventions. AUTHORS' CONCLUSIONS: The studies included in this review provided mostly low- or very low-certainty evidence about the use of first aid interventions for acute oral poisoning. A key limitation was the fact that only one included study actually took place in a pre-hospital setting, which undermines our confidence in the applicability of these results to this setting. Thus, the amount of evidence collected was insufficient to draw any conclusions.

Hepatotoxicosis in cattle associated with consumption of Punica granatum (pomegranate).

CASE REPORT: Ingestion of pomegranates was associated with the deaths of 9 of 35 young cattle; 8 were found dead without any prior clinical signs being noted and 1 animal was observed to be weak with pale-pink mucous membranes. Gross pathological changes included widespread subcutaneous and serosal haemorrhages and the liver showed an enhanced acinar or 'nutmeg-like' pattern. The significant histopathological lesion was severe, acute periacinar to midzonal hepatocellular necrosis. These findings were considered characteristic of a hepatotoxicosis; however, other than the possible involvement of pomegranates, no known hepatotoxins were detected in the pasture or water sources. CONCLUSION: Consumption of large quantities of whole pomegranates is capable of causing severe hepatic necrosis resulting in the death of cattle. At this stage it is unknown whether the toxic principle is within the pomegranates or produced by a microbe associated with the deteriorating fruit.

Acute Oxalate Nephropathy due to "Averrhoa Bilimbi": A Case Report.

Averrhoa bilimbi found in bilimbi tree is a well known fruits of warm climates, found throughout Bangladesh, India, Myanmar and South East Asian countries. This fruit contents high level of oxalate. Acute renal failure due to tubular necrosis caused by oxalate crystal has been reported. We present a patient who developed acute kidney injury following ingestion of bilimbi fruit juice and had complete recovery with conservative management and concluded that star fruit and bilimbi fruit juice should be avoided in CKD and on dialysis patients.

Poisoning by non-edible squash: retrospective series of 353 patients from French Poison Control Centers.

CONTEXT: Among the numerous varieties of squash that exist, some are edible while other bitter-tasting ones are not fit for human consumption. Cases of confusion seem to be multiplying and are characterized by digestive problems (diarrhea, vomiting, and abdominal pain). METHODS: This is a descriptive retrospective study of cases of exposure reported to French Poison Control Centers between 1 January 2012 and 12 December 2016. RESULTS: 353 patients were included, with 71.7% belonging to collective cases of poisoning. The male to female sex ratio was 0.75 for an average age of 38.2 ± 23.6 years. The circumstances of exposure were dietary for 337 patients (95.5%). The majority of the squash consumed was purchased at a store (55.8%) but some also came from the garden (25.5%). 204 patients (57.8%) mostly presented with diarrhea, vomiting, abdominal pain, sometimes with the consequent dehydration, hypotension, tachycardia, headaches, or vertigo. There were no deaths or severe (Poisoning Severity Score (PSS) 3) cases, but there were 14 patients (4.0%) of moderate severity, 190 patients (53.8%) of minor severity (PSS 1), and 149 patients (42.2%) without severity (PSS 0) but among which we include the bitter taste of the squash. The average age of PSS 2 patients was significantly (p = .003) older than that of the PSS <2 patients. CONCLUSION: As the first consequential series in Europe, our study shows that exposure to non-edible squash is frequent. Usually benign, poisoning could be the consequence of the irritating effect of certain cucurbits, the molecules responsible for the taste and toxicity of the fruits. In terms of prevention therefore, we recommend disposing of any squash with a bitter taste.

Pediatric Nandina domestica ingestions reported to poison centers.

Nandina domestica is grown as an ornamental plant in the United States but has also been reported as an invasive plant in a number of states. Parts of the plant, particularly the berries, contain cyanogenic glycosides that convert to hydrogen cyanide when ingested. This investigation characterized N. domestica ingestions involving patients of age 5 years and less reported to Texas poison centers during 2000-2015. There were 875 total N. domestica ingestions. A seasonal pattern was observed with the highest proportion of ingestions occurring in March (18.5%) and April (14.7%). The patients were male in 55.0% of the cases; 40.8% of the patients were of age 1 and 37.0% of age 2. Berries were specifically mentioned in 709 ingestions, of which 57.3% involved one berry and 28.5% an unknown number of berries. The ingestion occurred at the patient's own residence in 92.9% of the cases, and the patient was managed on site in 97.0%. The most frequently reported clinical effects were vomiting (3.7%), abdominal pain (1.0%), diarrhea (0.9%), and nausea (0.7%). In conclusion, N. domestica ingestions among young children generally do not result in serious outcomes and can be managed successfully outside of a healthcare facility.

Datura fruit poisoning.

Datura plants contain anticholinergic properties. Consumers may present with a spectrum of anticholinergic symptoms, including hallucination, agitation, tachycardia, delirium, hyperthermia, and dilated pupils. Prompt identification of the symptoms with appropriate treatment can be life-saving. Some patients might not be able to provide history and therefore recognition of toxidromes is imperative. Awareness should be built among the public who may be exposed to such fruits or plants.

Association of renal function and symptoms with mortality in star fruit (Averrhoa carambola) intoxication.

BACKGROUND: Star fruit (SF) is a commonly available fruit produced and eaten in tropical and subtropical countries. Since 1993, various reports have described neurotoxicity after eating SF, but this clinical condition remains unfamiliar. We aimed to describe this clinical entity, the role of renal dysfunction in this disorder, treatment strategies, and prognosis of patients with SF intoxication. METHODS: We conducted a search of PubMed and Google Scholar databases from 1993 to 2016. We included reports describing patients with a clear history of SF ingestion with acute symptoms. We described the demographic characteristics, reported SF intake, treatments used, and outcomes. RESULTS: We reviewed totally 126 patients (male:female = 1.5:1) from 33 articles with mean age 54.4 ± 11 (range: 30-84). The most common symptom was hiccups (65%), whereas confusion and seizure were the most common symptoms associated with mortality (42% and 61%, respectively). Pre-intoxication renal function also affected mortality. While there was no mortality in patients with normal renal function (NRF), the mortality of patients among reported cases with chronic renal insufficiency and end-stage renal disease undergoing dialysis were 36% and 27%, respectively. With the inclusion of patients reported to have NRF, the overall mortality was 24%. Consistently, the number of SF consumed was substantially higher in the patients with NRF than those with renal functional impairment. The most common treatment strategy was hemodialysis (59%). CONCLUSIONS: Patients with impaired renal function were at higher risks of SF intoxication. Severe neurologic symptoms mandate immediate medical intervention because of the association between their occurrence and high mortalities. Toxin removal through dialysis, rather than symptomatic relief, seems to be beneficial to patient survival. Early and continuous dialysis appears to alleviate severe symptoms and prevent symptom rebounds.