Abstract
Context: We report on systemic toxicity caused by ingestion of large quantities of ‘neem extract’, a traditional medicine widely used throughout the Indian subcontinent and increasingly imported to the developed world. There are case reports of neem extract causing renal impairment and liver damage in a microvesicular pattern but no cases of distal renal tubular acidosis (RTA) have been reported thus far. Case details: A 51-year old Solomon Islander was transferred to a Sydney Hospital with encephalopathy and a metabolic acidosis. A diagnosis of distal RTA was made requiring four days of continuous veno-venous hemodialysis. He also showed signs of bone marrow suppression, coagulopathy and liver damage, which were successfully managed with supportive care. Further history following the resolution of his encephalopathy revealed ingestion of large quantities of ‘neem extract’ over the preceding three months. Discussion: Liver damage is the predominant toxicity reported thus far with ‘neem extract’ and almost exclusively in children. This is the first report of neem extract causing distal RTA with evidence of mitochondrial toxicity. Physicians should be aware of the increasing use of ‘neem extract’ as a complimentary medicine and the potential toxicities this may lead to.
Highlights
Neem is the name used to describe a heterogenous group of compounds derived from the tree Azadirachia indica, an evergreen of the mahogany family Melaceae and endemic to the Indian subcontinent and other tropical and subtropical areas
There are reports of Neem extract causing acute tubular necrosis [2] but we are unaware of any reports describing renal tubular acidosis (RTA) associated with Neem
We report a 51-year-old Solomon Islander presenting with RTA, toxic encephalopathy, hepatotoxicity, anemia and coagulopathy after ingesting large quantities of Neem extract
Summary
It is highly likely that Mr FA was poisoned with Neem extract causing distal RTA, hepatitis with metabolic encephalopathy and disturbances in hematopoiesis and coagulation. There are numerous human case reports as well as animal studies of Neem extract revealing toxic effects including toxic encephalopathy and status epilepticus [8,9], Reye’s like syndrome of microvesicular fatty liver [10,11] and metabolic acidosis [12]. Almost all of these case reports are from children receiving Neem oil and the case fatality rate was high. Distal RTA is a documented complication of amphotericin B, lithium carbonate and toluene exposure [19] but to our knowledge this is the first documented case of distal RTA caused by a traditional herbal medicine
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