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It was just a herbal tea ...

Recently I cared for a 13-year-old boy who was brought to our emergency department after being found by police wandering through his neighborhood in a disoriented state. By the time the ER doc called me, the child was exhibiting all the classic symptoms of what is known as "anticholinergic" poisoning.

Without going into too much biochemistry, this kind of poisoning is seen with excessive ingestions of atropine or substances like atropine. Atropine basically blocks the stimulation of cholinergic nerve receptors and this blockade results in the following symptoms: dilated pupils, dry and flushed appearing skin, urinary retention, elevated temperature, rapid heart rate, a significant increase in blood pressure, disorientation or delirium, seizures, hallucinations, heart rhythm disturbances, coma, and occasionally death. These symptoms are seen with overdoses of such drugs as diphenhydramine (Benadryl and other drugs), phenothiazines (Thorazine and others), tricyclic antidepressants (Elavil and others), some stomach products like dicyclomine (Bentyl), and many over the counter cold remedies and sleep aids.

The problem with our patient, we'll call him Jason, is that we could find no evidence that he had gotten into any of these medicines. Unless it is life threatening, there is really no specific treatment for anticholinergic poisonings. In life-threatening cases physostigmine sometimes helps. Supportive care (making sure the patient has enough fluids, is breathing normally, etc.), close observation, and treatment of individual symptoms is the most important treatment. Still, it is always better (and considerably easier!) if we are able to determine just what the child took that rendered him in this state. When I first examined Jason he was far too incoherent to be able to tell us what he had taken, which is often the case in teenage ingestion cases.

Once we were certain his heart, blood pressure and respiratory status were stable, we transferred him to the pediatric ICU where he would receive vigorous intravenous fluids and activated charcoal to try to bind up whatever toxin he had ingested and eliminate it through the GI tract. When he became more alert, we figured, he might be able to tell us just what it was he ingested.

For most of the first day, Jason remained incoherent. His pupils were widely dilated, and he was either deeply asleep or wide awake and agitated. At times he would hallucinate, describing objects in the room that no one else could see, or conversing with individuals who weren't actually there. Thankfully, he was mostly good natured about all of this. When he became agitated the nurses were forced to restrain him for his own and their protection.

Jason's mother was understandably upset. She had been raising him on her own, and was visibly frustrated and worn out. This was the second time he had been admitted to a hospital for an overdose, the first time it was alcohol. She knew he didn't drink anymore. He had been too horrified by that hospitalization, particularly the nasogastric tube that was inserted into his nose to pump his stomach and multiple needle pokes, not to mention the psychiatrist and the hangover!

She knew he occasionally smoked marijuana, but was aware that these symptoms could not have been caused by cannabis. Further, she couldn't imagine him taking medicines of any kind just to get high. (Over the years I have learned to minimize the importance of this particular parental observation since it is understandably borne out of denial.) She did admit, however, that she did not know the "friend" Jason had been spending the night with, and that he could have been the source of the intoxicating agent(s).

Finally, nearly 24 hours after is admission, Jason became coherent enough to recollect the events of the previous night. First of all he denied any alcohol or "drug" ingestion. All he could remember that was out of the ordinary that night was that his friend had mixed him an "herbal tea" as he called it. He told Jason that the tea would make him feel "weird" and might even cause hallucinations, "kind of like acid." Jason of course tried it and that was the last thing he remembered about the night with his friend.

It turns out that Jason's friend made his "herbal tea" from a pretty flowering plant in his own back yard, known as Angel's Trumpet or Thorn apple. This plant behaves very much like Jimsonweed, which is also known as "loco weed" because of the effect it has on cattle, who accidentally ingest it. The flowers, leaves and stems of Angel's Trumpet contain atropine and atropine-like substances. The most common symptoms produced by its ingestion include agitation, spasmodic movement, coma, drowsiness, hallucinations and elevated temperature. In other words, the classic symptoms of atropine or anticholinergic intoxication.

We later discovered that Jason's friend also added a little Benadryl to the mixture, further accentuating the effects of the tea. It is amazing how accomplished some of these kid are at pharmacology!

Thankfully, Jason did quite fine, and once the effects of all the chemicals wore off, he was a pleasant and polite young man. His mother was thankful, of course, but also realistic. "He won't do this again," she said confidently, and then added, "But he'll find something else."

John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
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Title Annotation:Children in Hospitals
Author:Monaco, John E.
Publication:Pediatrics for Parents
Geographic Code:1USA
Date:Jun 1, 2004
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