[One case of acute poisoning with stramonium].

This paper reported 1 case of poisoning caused by stramonium. Cases of Datura poisoning have been reported nationwide, Its effect on the central nervous system of patients is characterized by first excitation and then inhibition, clinical manifestations include decreased gland secretion, dilated pupils, and tachycardia, etc. Its poisoning mechanism is anticholinergic effect, the effect on Peripheral nervous system is to inhibit Parasympathetic nervous system. Hemoperfusion combined with neostigmine anticholinergic therapy at the early stage of poisoning can effectively improve the clinical symptoms of patients in a short time.

Fatal overdose of Taxus baccata plant matter treated in a rural district general hospital.

A 25-year-old woman presented with cardiogenic shock following intentional overdose of Common Yew (Taxus baccata). The pharmacological mechanisms underlying yew toxicity resulted in failure of multiple treatment modalities including inotropes, vasopressors and attempted pacing. Resuscitation was ultimately unsuccessful. The limited literature available on this kind of overdose suggests that early extracorporeal membrane oxygenation (ECMO) is the mainstay of treatment in severe cases presenting with hypotension and arrhythmias. However, there may be a role for digoxin antibody fragments in maintaining patients presenting to remote sites, to allow transfer to a specialist centre.

Palicourea marcgravii (Rubiaceae) poisoning in cattle grazing in Brazil.

Palicourea marcgravii is the most important poisonous plant of cattle in Brazil. It contains monofluoroacetic acid and causes sudden death associated with exercise. Herein, we describe the temporal and spatial distribution of the toxic disease. The survey was based on the epidemiological, clinical, and pathological data of the Setor de Anatomia Patológica (SAP) of the Universidade Federal Rural do Rio de Janeiro (UFRuralRJ) to report outbreaks of poisoning by P. marcgravii, from 1953 to 2018. Clinical signs were peracute and included labored breathing, loss of balance, muscle tremors, lateral recumbency, and limb paddling. Gross lesions such as congestion of large vessels and edema and pulmonary congestion were observed. Multifocal areas of vacuolar hydropic degeneration of distal contorted tubule cells with nuclear pyknosis were observed in the kidneys. The plant is found in forests, and the poisoning occurs mainly after clearing forests for pasture, in areas of natural forest recovery called "capoeira," which provide a favorable environment for maintaining P. marcgravii growth. Outbreaks of P. marcgravii poisoning coincided with periods of creation of large deforested pastures in the Southeast and Midwest regions of Brazil, and the poisoning should be considered an additional risk after deforestation. The most effective prophylaxis is fencing off the forest areas that contain these plants.

Yew poisoning - pathophysiology, clinical picture, management and perspective of fat emulsion utilization.

The article presents pathophysiology, clinical picture and management of yew poisoning. Authors present also their own experiences with treating yew poisoning with fat emulsion. Plants of the yew genus, of which in Europe predominates Taxus baccata, are well known for their toxic properties. Particularly high concentrations of poisonous alkaloids are present in the needles of this evergreen and highly popular decorative plant. The danger associated with accidental or intentional ingestion of yew is primarily related to the cardiotoxic effects of the alkaloids (taxine A and B). Taxine B shows a much stronger toxic effect on the heart than taxine A. It affects atrio-ventricular conduction, what may result in a widening of the QRS complexes, atrio-ventricular blocks (A-V) of II/III degree and even in asystole. Yew poisoning is relative rare and evidence-based treatment guidelines on management of such poisoning is hard to prepare. The first-line treatement should base on suportive therapy. In some cases extracorporeal life support therapies such veno-arterial ECMO should be consider. There are also premise based on case reports and mechanism of action that the use of fat emulsion may be effective rescue treatment.

Herbaspirillum seropedicae as a degrading bacterium of monofluoroacetate: effects of its inoculation in goats by ingesting Amorimia septentrionalis and the concentrations of this compound in plants sprayed with the bacterium / Herbaspirillum seropedicae como bactéria degradadora de monofluoroacetato de sódio: efeitos de sua inoculação em caprinos ingerindo Amorimia septentrionalis e nas concentrações deste composto em plantas pulverizadas com a bactéria

Herbaspirillum seropedicae is a nitrogen-fixing bacterium capable of using toxic compounds as a source of carbon. Bacteria with this capacity can be used to make animals resistant to plant poisoning containing monofluoroacetate (MFA), such as Amorimia septentrionalis. The aim of this study was to evaluate if H. seropedicae is efficient in the degradation of MFA present in A. septentrionalis and if the inoculation of this bacterium in goats confers protection to A. septentrionalis intoxication. Two experiments were performed: in the first experiment 12 goats were divided into 2 groups. Goats in Group 1 were orally administered a solution containing the H. seropedicae bacterium for 10 days. From day 10 onwards, they received a daily dose of 5g/kg of A. septentrionalis with the bacteriauntil clinical signs of intoxication were observed. Group 2 goats received only the plant at the same dose, also until the observation of clinical signs of intoxication. The amount of MFA found in A. septentrionalis used in the experiment with goats was 1.6±0.058μg/mg. The total plant dose ingested by all goats in Group 1 was 80.83±12.81g/kg (129.33±20.50mg/kg MFA), which were significantly greater ​​(p<0.05) than those of Group 2 goats (39.16±19.08g/kg plant and 62.66±30.53mg/kg MFA). Group 1 goats took an average of 16.16±2.56 days to develop clinical signs of intoxication, significantly longer (p=0.0012) than Group 2 goats (7.83±3.81 days). Two Group 2 goats died on the same day that they developed clinical signs of intoxication. At necropsy of these two animals, no significant changes were observed. In the second experiment, samples of A. septentrionalis were sprayed with a solution containing H. seropedicae. Before and eight days after spraying, the samples were pressed and dried for quantitation of MFA. The amount of MFA present in samples of A. septentrionalis 8 days after spraying with H. seropedicae was significantly lower (p=0.017) than that found prior to spraying. It can be concluded that administration of H. seropedicae in goats is capable of causing greater resistance to A. septentrionalis intoxication, and spraying the plant with this bacterium significantly reduces the amount of MFA in the plant.(AU)

Herbaspirillum seropedicae é uma bactéria fixadora de nitrogênio, capaz de utilizar compostos tóxicos como fonte de carbono. Bactérias com essa capacidade podem ser utilizadas para tornar os animais resistentes à intoxicação por plantas que contém monofluoroacetato (MFA), como Amorimia septentrionalis. O objetivo do presente estudo é avaliar se H. seropedicae é eficiente na degradação do MFA presente em A. septentrionalis e se a inoculação dessa bactéria, em caprinos, confere proteção à intoxicação por A. septentrionalis. Foram realizados dois experimentos: no primeiro experimento foram utilizados 12 caprinos, divididos em dois grupos. Os caprinos do Grupo 1 receberam diariamente, oralmente, uma solução contendo a bactéria H. seropedicae durante 10 dias. A partir do décimo dia passaram a receber, diariamente, além da solução com a bactéria 5g/kg de A. septentrionalis até a observação de sinal clínico de intoxicação. Os caprinos do Grupo 2 receberam apenas a planta na mesma dose, também até que a observação de sinais clínicos de intoxicação. A quantidade de MFA encontrada em A. septentrionalis utilizada no experimento com caprinos foi de 1,6± 0,058µg/mg de planta em média. A dose total de planta ingerida por todos os caprinos do Grupo 1 foi de 80,83±12,81g/kg (129,33±20,50mg/kg de MFA), valores significativamente maiores (p<0,05) do que os dos caprinos do Grupo 2 (39,16±19,08g/kg de planta e 62,66± 30,53mg/Kg de MFA). Os caprinos do Grupo 1 demoraram em média 16,16 ±2,56 dias para desenvolver sinais clínicos da intoxicação, período significativamente maior (p=0,0012) que os caprinos do Grupo 2 (7,83±3,81dias). Dois caprinos do Grupo 2 morreram no mesmo dia que desenvolveram sinais clínicos da intoxicação. Na necropsia desses dois animais não foram observadas alterações significativas. No segundo experimento, amostras de A. septentrionalis foram pulverizadas com uma solução contendo a bactéria H. seropedicae. Antes e oito dias após a pulverização, as amostras foram prensadas e secas para posterior quantificação do MFA. A quantidade de MFA presente nas amostras de A. septentrionalis oito dias após a pulverização com H. seropedicae foi significativamente menor (p=0,017) do que a encontrada antes da pulverização. Pode-se concluir que a administração de H. seropedicae em caprinos é capaz de causar uma maior resistência à intoxicação por A. septentrionalis, e a pulverização da planta com esta bactéria reduz significativamente a quantidade de MFA na planta.(AU)

Hypoventilation, cardiac dysrhythmia, and cardiac arrest following acute Brunfelsia species (Yesterday, today, tomorrow) intoxication in a dog.

BACKGROUND: Intoxication following ingestion of the popular garden shrub 'Yesterday, today, tomorrow' (Brunfelsia sp.) is known to result in gastrointestinal and central nervous system clinical signs in dogs. CASE REPORT: A 2-year-old dog developed acute-onset vomiting, profuse diarrhoea and ptyalism after unsupervised access to an enclosed backyard that contained a Brunfelsia sp. shrub. During initial assessment the watery diarrhoea contained plant material and the dog appeared painful on abdominal palpation. Soon after admission, severe neurological abnormalities developed. Decontamination was undertaken by gastric and colonic lavage under general anaesthesia, but on recovery the patient had generalised seizures that were unresponsive to benzodiazepines. Following treatment with multiple antiepileptic medications and endotracheal intubation for loss of gag reflex, the patient developed respiratory failure requiring mechanical ventilation. Four days after initial presentation, the patient developed cardiac dysrhythmia leading to fatal cardiac arrest. Plant material recovered from the shrub and the patient's gastrointestinal tract were identified as Brunfelsia spp. CONCLUSION: This is the first report of hypoventilation, severe cardiac dysrhythmia and cardiac arrest associated with Brunfelsia sp. intoxication in a dog. Previous reports described clinical signs of gastrointestinal disease and mild cardiac dysrhythmia progressing to seizure activity and opisthotonus. Electrocardiography should form part of patient monitoring and mechanical ventilation considered for patients that develop respiratory failure, especially if massive ingestion is suspected.

Evaluation of resistance to natural poisoning by Amorimia septentrionalis in goats which had received sodium monofluoroacetate degrading bacteria / Avaliação da resistência à intoxicação natural por Amorimia septentrionalis em caprinos que receberam bactérias degradadoras de monofluoroacetato de sódio

Amorimia septentrionalis is an important sodium monofluoroacetate (MFA) containing plant that causes sudden death in ruminants in northeastern Brazil. MFA degrading bacteria are being used in the prevention against poisoning by this plant. The aim of this study was to evaluate if goats which had per os received MFA degrading bacteria remained resistant when exposed to natural poisoning by A. septentrionalis. Eighteen goats were randomly distributed into three groups: the goats of Group 1 previously received, during 40 days, a solution containing the bacteria Ralstonia sp. and Burkholderia sp., those goats in the Group 2 received the bacteria Paenibacillus sp. and Cupriavidus sp. and goats from Group 3 did not receive any bacteria. After the administration period, during 60 days, the animals of all groups were released to graze on a one hectare paddock, with significant amount of A. septentrionalis. They were observed daily for the spontaneous consumption of A. septentrionalis leaves and the occurrence of clinical signs of poisoning or sudden death. Goats from all groups consumed significant amounts of A. septentrionalis during the experimental period. Goats that did not receive MFA-degrading bacteria (Group 3) became sick and died from the 25th to the 27th day of the experiment, whereas the goats of the groups that received MFA-degrading bacteria showed only clinical sings when A. septentrionalis regrowth after the 55th day of the experiment. The days elapsed from field observation to death of Group 3 goats (25.5±0.9 days) were significantly lower (p<0.05) than Group 1 (58.6±1.3 days) and Group 2 (57.8±1.5 days). Thus, it can be concluded that administration of MFA degrading bacteria increases the resistance to natural poisoning by A. septentrionalis.(AU)

Amorimia septentrionalis que contém monofluoroacetato de sódio (MFA) é responsável pela ocorrência de mortes súbitas em ruminantes no nordeste do Brasil. Bactérias degradadoras desse composto estão sendo utilizadas na prevenção contra a intoxicação por essa planta. O objetivo deste estudo foi avaliar se caprinos que receberam, via oral, bactérias degradadoras de MFA permaneciam resistentes quando expostos a intoxicação natural por A. septentrionalis. Dezoito caprinos foram divididos em três grupos, os caprinos do Grupo 1 receberam anteriormente, durante 40 dias, uma solução contendo as bactérias Ralstonia sp. e Burkholderia sp., os do Grupo 2 receberam, também por 40 dias as bactérias Paenibacillus sp. e Cupriavidus sp. e os do Grupo 3 não receberam nenhuma bactéria. Após o período de administração, durante 60 dias, os animais de todos os grupos foram soltos para pastar em um piquete de um hectare, que apresentava uma quantidade significativa da planta. Diariamente eles foram observados quanto ao consumo espontâneo das folhas de A. septentrionalis e quanto à presença de sinais clínicos de intoxicação ou morte. Os caprinos de todos os grupos consumiram quantidades significantes da planta durante o período experimental. Os caprinos que não receberam as bactérias degradantes de MFA (Grupo 3) adoeceram e morreram entre o 25º e o 27º dia de experimento, enquanto que os que receberam as bactérias degradantes de MFA (Grupo 1 e 2) só apresentaram sinais clínicos no 55º dia de experimento, o que coincidiu com a rebrota da planta. Os dias transcorridos desde a observação a campo até a morte dos caprinos do Grupo 3 (25,5±0,9 dias) foram significativamente menores (p<0,05) que os do Grupo 1 (58,6±1,3 dias) e do Grupo 2 (57,8±1,5 dias). Com isso pode-se concluir que a administração de bactérias degradadoras de MFA aumenta à resistência a intoxicação natural por A. septentrionalis.(AU)

Respiratory Failure Due To Plant Poisoning: Nicotiana glauca Graham.

BACKGROUND: Cases of human poisoning associated with Nicotiana glauca Graham are quite rare. Patients may consume the plant by mistaking it for spinach or use it as a folk remedy. The toxin stimulates the acetylcholine receptors in the central and autonomic nervous systems. A prompt and appropriate supportive treatment is crucial for survival. CASE REPORT: A 72-year-old female with a known breast cancer was brought to our emergency department (ED) with complaints of nausea and vomiting. The patient stated that her complaints started 2 h after she had cooked and eaten a plant in the hopes that it would help cure her cancer. On the second hour after arrival, the patient became confused. It was observed that the chest wall movements had decreased and that the patient had difficulty breathing. Due to respiratory failure, orotracheal intubation was performed to secure the airway. A sample of the plant that was eaten was requested from the patient's relatives. According to an Internet search, the plant sample was identified as N. glauca Graham. The patient was diagnosed with N. glauca Graham poisoning. The patient was extubated after 30 h. On 3-month follow-up, the patient was neurologically intact and had no complaints related to poisoning. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with incurable diseases such as cancer tend to try folk remedies and can end up in ED. In patients who present with muscle paralysis and respiratory failure, emergency physicians should consider N. glauca Graham as a cause of plant poisoning.

Recurrent Ventricular Arrhythmia Caused by Ingestion of Aconitum (Monkshood) Flowers.

We report the case of a patient who presented with respiratory failure, recurrent ventricular fibrillation, ventricular arrhythmias, and hypotension after an intentional ingestion of aconite flowers. Significant ingestion of this plant can produce life-threatening cardio- and neurotoxicity that may require evacuation from the wilderness to a medical facility capable of advanced treatment and intensive care monitoring.

Clinical Toxicology of Yew Poisoning.

OBJECTIVES: Yew plant materials contain highly toxic taxine alkaloids. Serious ingestions can result in life-threatening toxicity. The purpose of this article is to summarize the literature on the treatment of acute yew poisoning. DATA SOURCES: PubMed (January 1946 to November 2017) was searched using the search terms "taxus/po". EMBASE (1980 to November 2017) was searched using the search terms "taxus/to" and "yew.mp." Web of Science (1945 to November 2017) was searched using the text words taxus, taxine, and yew. STUDY SELECTION AND DATA EXTRACTION: Available English language articles involving case reports, epidemiology, treatment, and outcomes were included. DATA SYNTHESIS: Although not uncommon, unintentional yew poisoning rarely results in significant morbidity or mortality. A total of 26 case reports of yew poisoning were evaluated along with 4 case series articles (totaling 22 additional cases). Only 4 of the 48 total cases (8%) were accidental poisonings, the rest being deliberate ingestions. In 20 patients (42%), it resulted in fatalities. Severe, acute yew poisoning results in symptomatology largely resistant to pharmacotherapy intervention. CONCLUSIONS: Most nonintentional ingestions of yew plant constituents are asymptomatic and require little intervention. Severe poisoning can result in life-threatening cardiac toxicity and require aggressive supportive care. Therapeutic interventions, such as sodium bicarbonate, digoxin immune fab, and hemodialysis that have been utilized in case studies and case series in the literature have little proven benefit. Extracorporeal life support should be considered in severe yew poisoning.

Human Plant Exposures Reported to a Regional (Southwestern) Poison Control Center Over 8 Years.

BACKGROUND: There is little published data about human plant exposures reported to US poison control centers (PCCs). METHODS: A retrospective chart review of all reported plant exposures to a single regional PCC between January 1, 2003 and December 31, 2010 was done to understand better the characteristics of plant exposure cases. Specific generic plant codes were used to identify cases. Recorded variables included patient demographics, plant involved, exposure variables, symptoms, management site, treatments, and outcome. Univariate and multivariate regression was used to identify outcome predictors. RESULTS: A total of 6492 charts met inclusion criteria. The average age was 16.6 years (2 months-94 years); 52.4% were male. The most common exposure reason was unintentional (98%), and the majority (92.4%) occurred at the patient's home. Ingestions (58.3%) and dermal exposures (34.3%) accounted for most cases. Cactus (27.5%), oleander (12.5%), Lantana (5.7%), and Bougainvillea (3.8%) were most commonly involved. Symptoms developed in 47.1% of patients, and were more likely to occur following Datura (66.7%), and Morning Glory or Milkweed (25% each) exposures. Almost 94% of patients were managed onsite (home) and only 5.2% involved evaluation in a health care facility (HCF). Only 37 (0.6%) patients required hospital admission, and 2.9% of cases resulted in more than minimal effects. Exposures resulting in more than minimal clinical effects were predicted by several variables: abnormal vital signs (OR = 35.62), abnormal labs (OR = 14.87), and management at a HCF (OR = 7.37). Hospital admissions were increased for patients already at a HCF (OR = 54.01), abnormal vital signs (OR = 23.28), and intentional exposures (OR = 14.7). CONCLUSION: Plant exposures reported to our poison control center were typically unintentional ingestions occurring at home. Most patients were managed onsite and few developed significant symptoms.

Fatal cardiac glycoside poisoning due to mistaking foxglove for comfrey.

CONTEXT: Accidental ingestion of foxglove (Digitalis purpurea) can cause significant cardiac toxicity. We report a patient who ingested foxglove mistaking it for comfrey and developed refractory ventricular arrhythmias. The patient died despite treatment with digoxin-specific antibody fragments (DSFab) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). CASE DETAILS: A 55-year-old woman presented to the emergency department with nausea, vomiting and generalized weakness eight hours after drinking "comfrey" tea. She had bradycardia (54 beats/min) and hyperkalemia (7.6 mEq/L). Electrocardiogram revealed a first-degree atrioventricular conduction block with premature atrial contractions, followed by polymorphic ventricular tachycardia three hours after arrival. A serum digoxin level was 151.2 ng/mL. The patient developed ventricular fibrillation while waiting for Digibind infusion. Resuscitation was performed and an emergent VA-ECMO was set up. A total of eight vials of Digibind were given over the next 16 hours. She temporarily regained consciousness, but remained hemodynamically unstable and subsequently developed lower limb ischemia and multiple organ failure, and she expired on hospital day seven. A botanist confirmed that the plant was foxglove. CONCLUSIONS: The diagnosis of cardiac glycoside plant poisoning can be difficult in the absence of an accurate exposure history. In facilities where DSFab is unavailable or insufficient, early VA-ECMO might be considered in severely cardiotoxic patients unresponsive to conventional therapy.

Suicide attempt with self-made Taxus baccata leaf capsules: survival following the application of extracorporeal membrane oxygenation for ventricular arrythmia and refractory cardiogenic shock.

CONTEXT: Yew intoxication has been known for many years; high dose ingestion of Taxus baccata leads to cardiac toxicity mediated by calcium and sodium channel blocking properties. We present a case report of a patient who attempted suicide after T. baccata ingestion, causing refractory cardiogenic shock requiring temporary circulatory assistance by veno-arterial extra corporeal membrane oxygenation (VA ECMO). CASE DETAILS: A 28-year-old man was admitted to the critical care unit of a university hospital for arrhythmia after ingestion of self-made T. baccata leaf capsules. He rapidly developed cardiovascular collapse requiring mechanical ventilation, high dose intravenous catecholamines and electrical cardioversion. A femoro-femoral VA ECMO was implanted due to severe biventricular dysfunction and ventricular arrhythmia, associated with continuous renal replacement therapy. Taxol A, taxol B and baccatin III were detected and measured in both blood and urine samples by high-performance liquid chromatography tandem mass spectrometry, and kinetics suggested urinary excretion. Two days after hospital admission, VA ECMO and continuous renal replacement therapy were removed with full recovery of cardiac function. DISCUSSION: Our experience suggests that circulatory assistance by VA ECMO and continuous renal replacement therapy seem to be effective safe second-line therapeutic options in critically ill cases of severe yew intoxication with refractory cardiogenic shock due to arrhythmia.

Administración accidental de aceite puro esencial de arbol de té (Melaleuca alternifolia) en lactantes / Accidental pure essential tea tree oil (Melaleuca alternifolia) administration in two infants

El aceite de árbol de té es una sustancia que se obtiene mediante la destilación de las hojas y ramas frescas del árbol Melaleuca alternifolia. En los últimos años se ha popularizado su uso sobre todo como agente antiinfeccioso tópico en una gran variedad de enfermedades. Se trata de una sustancia natural que tiene un potencial efecto tóxico demostrado sobre todo si se ingiere. Presentamos dos casos de pacientes atendidos en nuestro Servicio de Urgencias tras administración e ingestión accidental de aceite esencial de árbol de té, en ambos casos los padres confundieron el envase con el de la vitamina D. La atención de estos pacientes nos llevó a realizar una búsqueda bibliográfica de casos publicados de intoxicación por ingesta de aceite de árbol de té y a poner de manifiesto la ausencia de advertencias de seguridad en los envases de aceite de árbol de té que actualmente se comercializan en nuestro país (AU)

Tea tree oil is an essential oil obtained by steam distillation of the leaves and terminal branches of Melaleuca alternifolia. In recent years, it has become popular as an antimicrobial agent against a large number of diseases. It is a natural substance that has a potential toxic effect especially if ingested. We report two cases of infants who came to our Emergency Department because they were accidentally given tea tree oil. In both cases parents mistook the tea tree oil bottle with the D vitamin bottle. The care of these patients led us to perform a literature search of published cases of tea tree oil poisoning and highlight the absence of safety warnings on tea tree oil packages currently marketed in our country (AU)