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Plant poisoning--an observational study in a tristate region emergency department.

Introduction

Poisoning is the 3rd most common cause of self-harm. [1] Common causes of poisoning in India include insecticides, household chemicals such as sanitation fluids, plants, animal bites, and stings. [2] According to one study, plants accounted for 1.7% of all poisonous exposures. [3] In the United States, 100,000 exposures to poisonous plants were reported per year. [4] Most exposures are accidental and occur in children and are mild. [5] Life-threatening exposures occur in adults who intentionally ingested in some form or other. Poisonous plants encountered in India include [6] (1) contact irritant poisons-castor, calotropis, croton, glory lily, marking nut, papaya, and red pepper; (2) cardiotoxic glycosides--aconite, autumn crocus, and common oleander; (3) neurotoxic plants--calotropis, cassava, datura, strychnos; (4) hepatotoxic plants--neem; and (5) miscellaneous toxic plants and plant products--areca nut and Cleistanthus collinus. There are no specific data available in India as of the most common plants and their toxicity pattern. The current study is intended to describe common plants of medical importance by retrospective analysis of data available over a period of 2 years in a tertiary tristate region emergency department.

Materials and Methods

Plant poisons are one of most common poisonings presenting to emergency department. Emergency physicians should be well versed with common types of plant poisons. The current study intended to describe the most common plant poisons in the tristate region of Andhra Pradesh, Tamilnadu, and Karnataka in a tertiary care center. A retrospective observational study was conducted over a period of 2 years. All patients presenting to emergency department following exposure to poisonous plants were included. The results were presented as percentages of the total.

Results

A total number of 62 cases of exposure to poisonous plants were studied. Male to female distribution was almost equal. Fifty (80.64%) cases were suicidal and 12 (19.36) cases were accidental. In 56 (90.32%) cases, the poisoning was by ingestion and in 6 (9.7%) cases by dermal exposure. Out of the total, 13% of patients were unaware of poisonous effects of the plants. Majority of cases were adults (67.74%), while adolescents made up 20% of cases and the rest were children. Four patients were from urban region and 58 (93.4%) from rural areas and villages near forest and hilly regions. Among the accidental exposures, 6 (50%) were due to consumption by children, rest were occupational while clearing the vegetation.

Most common reason for presentation to emergency department was fear of consuming the poisonous plant. Most common presenting symptom was vomiting (67.74%) followed by abdominal discomfort (61.29%), convulsions (6.45), fever (9.6), altered mental status (9.6), and rash and itching (9.6%). Suicidal exposure was mostly in adults while children were accidentally exposed to poisonous plants. Forty-six (74.19%) cases needed ICU admission. Most common indication for ICU admission was electrolyte abnormalities, seizures, and altered mental status. Twenty-six patients died, causes being refractory arrhythmias and status epilepticus. Risk of death was highest for Cleistanthus (83.3%) and strychnine (83.3%) followed by oleander (50%), Gloriosa (50%), and Datura (16%).

Discussion

Plant poisoning and death due to poisonous plant exposure is rare in industrialized parts of the world but continues to be significant cause in India especially in the rural parts. Most studies reported accidental exposure in children as the most common cause of plant poisoning. But this study differed in this regard having more adults and suicidal ingestion as the most common cause of poisoning with plants. One study reported almost equal incidence in males and females, which was reflected in this study.

There is no data available on relative incidence for each of the plants. This study has detected relative incidence in this region of the country. Cleistanthus collinus is the commonest plant followed by oleander, strychnine, kalli paal (a poisonous cactus), datura, papaya, and chrysanthemum in that order.

Cleistanthus [7]--This is a toxic herb/shrub growing wildly in India (Figure 1). The toxic principles are cleistanthin A, cleistanthin B, and diphyllin. All parts of the plant are toxic. Patients commonly present with gastrointestinal symptoms such as nausea, vomiting, and abdominal discomfort. Late presentations include chest pain, palpitations, dyspnea, and bradypnea. Mainly causes hypokalemia with normal anion gap, metabolic acidosis, leukocytosis, raised liver enzymes and creatinine kinase, and coagulopathy. The cause of death is intractable metabolic acidosis and hypokalemia leading to neurovascular paralysis and ventilatory failure. Our study noted almost 50% deaths in patient consuming cleistanthus. The management includes gastric lavage, activated charcoal, W-acetyl cysteine, correction of metabolic acidosis, and hypokalemia.

Oleander [8]--This plant is grown widely as ornamental plant (Figure 2). Different varieties are known: pink oleander, yellow oleander (Thevitia peruviana), and white oleander. All parts of the plant including nectar are poisonous. Inhalational poisoning has been reported when dried twigs are burnt as biomass fuel. The toxic principles are cardiac glycosides similar to digoxin. They are oleandrin, oleandrigenin, and oleandroside. Various cardiac dysrhythmias and hyperkalemia are the most common complications. Severe bradycardia leading to cardiogenic shock is the cause of death. Treatment includes IV fluids, activated charcoal, N-acetyl cysteine, and hyperkalemia correction. Calcium chloride is contraindicated in the management of hyperkalemia due to oleander. Digoxin-specific Fab fragment is the specific antidote, which is not available in India. Most cases can be managed symptomatically.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Strychnos nux vomica [6,9]--The plant grows widely in India. The toxic principles include strychnine and brucine extracted from seeds as a colorless, odorless, bitter material. Toxic dose is 1-3 g seeds. Symptoms include agitation, apprehension of fear, ability to easily startled, opisthotonus, lock jaw, convulsions, and status epilepticus. Most patients die of intractable seizures and respiratory failure. Treatment includes benzodiazepines, barbiturates, and mechanical ventilation with neuromuscular paralysis. Current study reported 83% of mortality.

Gloriosa superba--The toxic principles colchicine and gloriosin are contained in the root. Early phase of toxicity presents with gastrointestinal symptoms. Later, more severe effects may occur such as hypotension, bone marrow suppression, hemorrhagic gastroenteritis leading to electrolyte disturbances, and multisystem organ failure leading to death. Management is symptomatic and includes fluid replacement and correction of electrolyte imbalance.

Calotropis [10]--is a shrub growing in the wild. Milky wax exuding from the stem contains cardiac glycosides (calotropin, uscharin) and fatty acids. It is regarded as a contact irritant poison, cardiotoxic and neurotoxic. Poisoning is most commonly by accidental exposure and ingestion of juice in suicidal cases. Deaths have been reported in the literature but the current study did not report any death due to calotropis.

Datura[11]--Other names include devil's trumpet, angel's trumpet, devil's weed, stinkweed, locoweed, and hell's bells. All parts of the plant contain tropane alkaloids such as atropine and hyoscyamine. The seeds are crushed and taken for suicidal purposes and also as drugs of abuse for its deliriant effects. In the past, the seeds were used to stupefy sacrificial victims and also abused for its euphoric effects. It causes symptoms of atropinic overdose such as dry mouth and mucous membranes, hyperpyrexia, mydriasis, flushing, tachycardia, agitation and hallucinations, and features of central nervous system stimulation. Diagnosis is usually clinical but studies have reported use of liquid chromatography and mass spectrometry for the detection of alkaloids in the blood. Another study reported more common incidents of accidental poisoning in children due to their inherent susceptibility to even small doses of atropine. Treatment is mostly supportive. Physostigmine is the specific antidote, which can be given in serious cases.

Kalli paal [12]--The extract of this poisonous cactus is used as abortifacient. Chemical composition is not known. it is also a contact irritant. No serious toxicity or deaths have been reported.

Chrysanthemum [13]--It is an ornamental plant. Extracts from the plants contain pyrethroids and have the potential to cause irritation and seizures. But in this study no serious manifestations have been reported.

Papaya carica [9]--The juice of the plant is a contact irritant. Most common symptoms are dermatitis, conjunctivitis, and acute gastritis. No serious effects are noted in this study.

There are other plants such as cannabis, Abrus precatorius, toxalbumin in Ricinus communis, cocaine from Erythroxylum coca, ergot alkaloids from Claviceps purpureaand morning glory lily, poison hemlok, reserpine, and digitalis glycosides in foxglove involved in toxic manifestations in other parts of the country. [6] But the current study did not come across other plant poisonings during the study period. These data might not represent the whole picture of plant poisoning but this an attempt at the epidemiology of plant poisoning. Further multicenter studies are needed to delineate the same.

Conclusion

Although many commonly occurring plants are toxic, only some plants are potentially lethal when consumed in sufficient quantity. All the physicians should have knowledge about the commonly occurring and potentially lethal poisonous plants of the region. Emergency physicians should have the proficiency to deal with exposure to lethal plants and their management. Supportive therapy is sufficient to save most victims. Public has to be educated about the ill effects of exposure and high mortality associated with poisonous plants. As most of them do not have antidotes and treatment is mainly supportive, early recognition and management plays an important role in reducing morbidity and mortality.

DOI:10.5455/ijmsph.2016.14032016462

References

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[2.] Manzar N, Saad SM, Manzar B, Fatima SS. The study of etiological and demographic characteristics of acute household accidental poisoning in children--a consecutive case series study from Pakistan. BMC Pediatr. 2010;10:28. doi: 10.1186/ 1471-2431-10-28.

[3.] Maharani B, Vijayakumari N. Profile of poisoning cases in a Tertiary care Hospital, Tamil Nadu, India. J Appl Pharm Sci. 2013;3(1):91-4. DOI: 10.7324/JAPS.2013.30117

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[6.] Pillay VV. Modern Medical Toxicology, 4th edn. New Delhi, India: Jaypee Brothers Medical Publication (P) Ltd, 2013.

[7.] Chrispal A. Cleistanthus collinus poisoning. J Emerg Trauma Shock 2012;5(2):160-6.

[8.] Rajapakse S. Management of yellow oleander poisoning. Clin Toxicol (Phila) 2009;47(3):206-12.

[9.] Centers for Disease Control and Prevention (CDC). Emergency Preparedness and Response--Strychnine. Available at: http://emergency.cdc.gov/agent/strychnine/ (last accessed on February 1,2016).

[10.] Al-Shaikh AM, Sablay ZM. Hallucinogenic plant poisoning in children. Saudi Med J 2005;26(1):118-21.

[11.] Parentous. Common Dangerous Plants. Available at: http:// www.parentous.com/2013/03/26/common-dangerous-plants some-poisonous-plants-for-children-nature/ (last accessed on February 1, 2016).

[12.] Ciganda C, Laborde A. Herbal infusions used for induced abortion. J Toxicol Clin Toxicol 2003;41(3):235-9.

[13.] Casida JE. Pyrethrum flowers and pyrethroid insecticides. Environ Health Perspect 1980;34:189-202.

S Prakash Babu, Chandrika DG, Kulkarni MR

P.E.S. Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India.

Correspondence to: S Prakash Babu, E-mail: drprakashsanny29@gmail.com

Received March 14, 2016. Accepted March 29, 2016
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Article Details
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Title Annotation:Research Article
Author:Babu, S. Prakash; Chandrika, D.G.; Kulkarni, M.R.
Publication:International Journal of Medical Science and Public Health
Geographic Code:9INDI
Date:Oct 1, 2016
Words:1854
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