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.

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.

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.

Large and prolonged food-borne multistate hepatitis A outbreak in Europe associated with consumption of frozen berries, 2013 to 2014.

In May 2013, Italy declared a national outbreak of hepatitis A, which also affected several foreign tourists who had recently visited the country. Molecular investigations identified some cases as infected with an identical strain of hepatitis A virus subgenotype IA. After additional European Union/European Economic Area (EU/EEA) countries reported locally acquired and travel-related cases associated with the same outbreak, an international outbreak investigation team was convened, a European outbreak case definition was issued and harmonisation of the national epidemiological and microbiological investigations was encouraged. From January 2013 to August 2014, 1,589 hepatitis A cases were reported associated with the multistate outbreak; 1,102 (70%) of the cases were hospitalised for a median time of six days; two related deaths were reported. Epidemiological and microbiological investigations implicated mixed frozen berries as the vehicle of infection of the outbreak. In order to control the spread of the outbreak, suspected or contaminated food batches were recalled, the public was recommended to heat-treat berries, and post-exposure prophylaxis of contacts was performed. The outbreak highlighted how large food-borne hepatitis A outbreaks may affect the increasingly susceptible EU/EEA general population and how, with the growing international food trade, frozen berries are a potential high-risk food.

Food-borne diseases associated with frozen berries consumption: a historical perspective, European Union, 1983 to 2013.

Epidemiological investigations of outbreaks of hepatitis A virus (HAV) and norovirus (NoV) infections in the European Union/European Economic Area (EU/EEA) in the last five years have highlighted frozen berries as a vehicle of infection. Given the increasing berry consumption in the EU over the last decades, we undertook a review of the existing evidence to assess the potential scale of threat associated with this product. We searched the literature and four restricted-access online platforms for outbreak/contamination events associated with consumption of frozen berries. We performed an evaluation of the sources to identify areas for improvement. The review revealed 32 independent events (i.e. outbreak, food contamination) in the period 1983­2013, of which 26 were reported after 2004. The identified pathogens were NoV, HAV and Shigella sonnei. NoV was the most common and implicated in 27 events with over 15,000 cases reported. A capture­recapture analysis was performed including three overlapping sources for the period 2005­2013. The study estimated that the event-ascertainment was 62%. Consumption of frozen berries is associated with increasing reports of NoV and HAV outbreaks and contamination events, particularly after 2003. A review of the risks associated with this product is required to inform future prevention strategies. Better integration of the available communication platforms and databases should be sought at EU/EEA level to improve monitoring, prevention and control of food-borne-related events.

Elucidating the neurotoxicity of the star fruit.

Caramboxin: Patients suffering from chronic kidney disease are frequently intoxicated after ingesting star fruit. The main symptoms of this intoxication are named in the picture. Bioguided chemical procedures resulted in the discovery of caramboxin, which is a phenylalanine-like molecule that is responsible for intoxication. Functional experiments in vivo and in vitro point towards the glutamatergic ionotropic molecular actions of caramboxin, which explains its convulsant and neurodegenerative properties.

Accidental poisoning after ingestion of "aphrodisiac" berries: diagnosis by analytical toxicology.

BACKGROUND: A large number of plants, seeds, and berries have been used for medicinal, psychotropic, or aphrodisiac purposes for a thousand years. Mandragora officinarum belongs to the family of Solanaceae and is traditionally known as an aphrodisiac and is closely associated with witchcraft. OBJECTIVES: In this study we report a case of an accidental poisoning after ingestion of some "aphrodisiac" berries and the contribution of the toxicological analysis in the case investigation. CASE REPORT: A 35-year-old man was admitted to the hospital with clinical signs and symptoms of an anticholinergic syndrome. The diagnosis of the poisoning was made by the toxicological analysis of the patient's urine. The cause of the poisoning was revealed by his girlfriend's disclosure that the patient had intentionally consumed some "aphrodisiac" berries to enhance his sexual performance. Subsequently, berries similar to the ones consumed were sent to the laboratory. The analysis of the urine and the berries revealed the presence of hyoscyamine and scopolamine; the berries were identified as Mandragora officinarum berries. Decontamination and symptomatic treatment were proven effective for the control of this poisoning. The patient recovered completely after hospitalization for 4 days. CONCLUSION: This case report indicates the importance of analytical toxicology in diagnosis of intoxications after the consumption of unknown plants or plant products and presents the clinical aspects of Mandragora intoxication.

Sustained low-efficiency daily diafiltration with hemoperfusion as a therapy for severe star fruit intoxication: a report of two cases.

Over the past decade, star fruit (Averrhoa carambola) intoxication decreased in the Taiwanese society due to improved public education on chronic kidney disease (CKD). Various complications including hiccups, altered levels of consciousness, coma, and seizures have been reported in individuals with renal failure who ingested fresh star fruit or star fruit juice. A high mortality rate (from 33 to 80%) was observed in patients with altered levels of consciousness, despite prompt dialysis and supportive care. According to previous case reports, the proposed treatment of choice for severe star fruit intoxication may be continuous renal replacement therapy with or without hemoperfusion. We report two cases of star fruit intoxication with stage V CKD (one case is predialysis) presenting with coma and generalized tonic-clonic seizures. The two patients were treated with sustained low-efficiency daily diafiltration (SLEDD-f) and charcoal hemoperfusion. Status epilepticus was controlled fairly quickly after treatment with SLEDD-f and hemoperfusion. However, the outcomes in this report are still poor (both remained comatose; one of two patients died). Currently, there are no data for the use of SLEDD-f with hemoperfusion for severe star fruit intoxication. SLEDD-f with charcoal hemoperfusion may play a role in managing refractory status epilepticus in patients with severe star fruit poisoning.

[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.

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.

Karwinskia humboldtiana (buckthorn) fruit causes central nervous system damage during chronic intoxication in the rat.

Karwinskia humboldtiana fruit (Kh) causes a neurological disorder 3-4 weeks after ingestion, characterized by flaccid, symmetrical, ascending paralysis, similar to the Guillain-Barre syndrome. In this polyneuropathy the lesion (demyelization) in peripheral nerves has been described in several animal species, both in acute and in chronic intoxication. However, no reports exist about the presence of lesions in the Central Nervous System (CNS), in chronic intoxication. We considered it important to evaluate, with histological techniques, the possible presence of lesions in the brain, by using a model of chronic intoxication that reproduces the same stages present in the human intoxication, to better understanding of this pathological process. In our present work we fed the ground Kh fruit to Wistar rats and samples of brain, cerebellum, and pons were embedded in paraffin. Sections were stained with Hematoxylin & Eosin (HE) and special stains for nerve tissue. Histopathological changes were evaluated in the CNS through the different stages of the polyneuropathy and comparison to a control group. With this methodology, we found lesions in the motor pathway. This is the first report about the presence of neuronal damage caused by Kh in the Central Nervous System in chronic intoxication.

Star fruit intoxication successfully treated by charcoal haemoperfusion and intensive haemofiltration.

We report on a case of an elderly woman with chronic renal impairment, secondary to diabetic nephropathy, who developed a deep coma and seizure shortly after consumption of star fruit. She was managed in the intensive care unit, and her consciousness level improved dramatically after an 8-hour charcoal haemoperfusion and 30 hours of continuous haemofiltration. There were no long-term neurological or renal sequelae 9 months later. Early recognition of this condition, intensive dialytic therapy and supportive measures, as well as early initiation of charcoal haemoperfusion may improve the management of this potentially treatable condition.

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.

Solanaceous steroidal glycoalkaloids and poisoning by Solanum torvum, the normally edible susumber berry.

Ingestion of immature, environmentally stressed, or cultivar-specific Solanum species (particularly the potato) has been previously associated with gastrointestinal and neurological symptoms caused by solanaceous steroidal glycoalkaloids (SGAs). We report on two geographically, temporally disparate outbreaks of poisoning by susumber berries (Solanum torvum- Solanaceae) and on detection of alkaloids not present in non-toxic berries. Five family members in New York City participated in a traditional evening meal containing Jamaican susumber berries. All those consuming berries were symptomatic the following morning with varying degrees of gastrointestinal distress, dizziness, slurred speech, cranial nerve deficits, and ataxia. The most seriously afflicted patient developed hypertension, confusion, proximal upper extremity weakness, and hypercapnic respiratory failure requiring prolonged mechanical ventilation. A separate cohort of six patients in Toronto ate unripe Jamaican susumber berries. They presented 14h post-ingestion with varying degrees of diarrhea, weakness, facial paralysis, slurred speech, ataxia, early hypertension, and proximal weakness. Two patients had ventilatory decompensation; one required intubation. Poisonous berries appeared indistinguishable from non-toxic varieties. We isolated solasonine, larger amounts of solamargine, and other steroidal glycoalkaloids in the toxic berry strains. S. torvum poisoning can produce significant neurological and gastrointestinal effects which appear to be mediated by SGAs present in the berries.

Fatal injury in eastern Sri Lanka, with special reference to cardenolide self-poisoning with Cerbera manghas fruits.

OBJECTIVE: Self-poisoning with plant seeds or fruits is a common method of self-harm in South Asia. While most deaths follow ingestion of Thevetia peruviana (yellow oleander) seeds, other plants are locally common. During review of fatal injuries seen in a teaching hospital in eastern Sri Lanka, we noted cases of fatal self-poisoning with Cerbera manghas (sea mango, pink eyed cerbera, odollam tree) fruits. METHODS: We reviewed the post-mortem records of the Batticaloa Teaching Hospital and extracted data on all cases of fatal injury. RESULTS: During 2001 and 2002, 315 post mortems for injury were performed in Batticaloa Teaching Hospital. Intentional self-harm was responsible for 48.6% of cases. While T. peruviana was responsible for 33 deaths, C. manghas self-poisoning caused seven deaths. C. manghas cases had typical features of cardenolide poisoning with cardiac dysrhythmias and hyperkalemia. In the absence of pacing facilities and anti-digoxin Fab, management involved administration of atropine and of insulin and dextrose to lower serum potassium concentrations. CONCLUSIONS: C. manghas self-poisoning has only previously been reported from Kerala and Tamil Nadu in south India. While uncommon in other parts of Sri Lanka, it has become a common method of self-harm in one east coast district, accounting for 20% of fatal self-harm with plants in one hospital. Management was inadequate with the available resources, emphasising the need for an affordable antitoxin for plant cardenolide poisoning.

[MRI findings in star-fruit intoxication]. / IRM cérébrale dans l'intoxication à la carambole.

Star-fruit ingestion has been previously reported to cause severe neurotoxicity in uremic patients with symptoms ranging from hiccups, vomiting and consciousness disturbances to refractory status epilepticus, coma and death. MRI examinations of five uremic patients with severe neurological disturbances following star-fruit intoxication were reviewed. At the time of MRI, all patients presented with a confusional state, preceded by seizures in three cases. MRI showed focal (four patients) and diffuse (one patient) cortical hyperintensity on diffusion-weighted sequences, with a corresponding low apparent diffusion coefficient. An additional area of increased diffusion intensity was observed in the pulvinar (two patients) and hippocampus (two patients). MRI and diffusion-weighted imaging may be useful for the diagnosis of star-fruit neuro-intoxication which is associated with a poor prognosis and requires acute and appropriate treatment.