Plant Ingestions Research Articles

Toxic Christmas and New Year Holiday Plants...or Are They

Background: Poinsettia (Euphorbia pulcherrima), holly (Ilex opaca) and mistletoe (Phoradendron flavescens) adorn homes during the Christmas and New Year holiday season and create the potential for curious children to sample their colorful leaves and enticing berries. This study was aimed to review the American Association of Poison Control Centers National Poison Data System (AAPCC NPDS) to describe the epidemiologic profile of ingestion of these plants and to determine whether there was associated morbidity and mortality. Methods: All plant ingestion exposures reported to American poison centers (PCs) from 2000-2009 were analyzed to identify all exposures to E. pulcherrima, I. opaca and P. flavescens. The data analysis included ingestions by age, gender, patient management site, symptoms, intention and outcome. Results: The AAPCC NPDS database included 668,111 plant ingestions during 2000 to 2009. E. pulcherrima (19,862; 3.0%), I. opaca (5,432; 0.8%) and P. flavescens (1,138; 0.2%) exposures accounted for 26,632 (4.0%) of all plant ingestion exposures. Children younger than six years were responsible for majority of ingestions (88.0%). Ingestions were more likely to occur unintentionally (P < 0.001). Most cases (96.1%) were asymptomatic. When clinical effects developed (1,046 cases), the most frequent reported signs were gastrointestinal in nature (59.8%) including abdominal pain, diarrhea and/or vomiting. Moreover, the development of gastrointestinal signs was higher in patients who ingested P. flavescens compared to the other two species. Most exposures (96.1%) were managed at home with the guidance from PC experts. When the outcome was known, the majority of exposures (89.2%) experienced no adverse effects. Moderate effects occurred in only 28 ingestions (0.1%), and one major effect was recorded in a patient who ingested poinsettia. Conclusion: These holiday plants were associated with extremely low morbidity and no mortality. Home management along with expert guidance can be adequate intervention in the majority of these exposures.

Assessment of serum creatine kinase among adolescent patients following jimsonweed (Datura stramonium) and moonflower (Datura inoxia) ingestions: a review of 11 cases

Introduction. Datura stramonium (DS) (jimsonweed) is well known for its abuse potential for hallucinogenic effects and Datura inoxia (DI) (moonflower) has been abused for similar effects. To our knowledge, only one case report describes rhabdomyolysis in association with DS or DI ingestion. Case identification and details. Patient hospital charts were retrospectively screened from January 1, 2002 to December 31, 2007 to identify patients with qualifying ICD-9 codes for toxic plant ingestions. We report on 11 patient cases of DS/DI ingestions in which serum creatine kinase (CK) concentrations were monitored. These admissions occurred at our hospital over a 6-year period. Serum CK concentrations ranged from 72 to 70,230 U/L. Only three patients had serum CK concentrations greater than 1,000 U/L. One patient with a peak concentration of 70,230 U/L and a positive myoglobinuria was diagnosed with rhabdomyolysis. Discussion. Based on our review of the literature and these cases, it is possible that serum CK concentrations may be elevated more frequently than previously realized. The clinical significance of this abnormal laboratory value is uncertain with the majority of patients remaining asymptomatic without any clinical evidence of rhabdomyolysis.

Toxic Plants

More than 60,000 calls are made annually to poison control centers (PCCs) for cases of suspected plant toxicity. Children younger than age 6 years comprise two thirds of cases, due to their natural curiosity and limited judgment. Most of these exposures are benign; fewer than 10% result in treatment by a health professional. The PCC is a valuable source of information to assist in management. Most ingestions of plant material by young children are of small quantity, and symptoms, if present, typically are short-lived and self-limited. Gastrointestinal effects are common and may be a clue to seek other, more subtle signs of poisoning. Plant ingestions in older children and adolescents generally are intentional and of larger quantity, the result of either substance experimentation or attempted self-harm.Autonomic toxidromes can be seen in many plant poisonings. Deadly nightshade (Atropa belladonna) and Jimson weed (Datura stramonium) produce atropine, scopolamine, and hyoscyamine, all anticholinergic toxins. Victims can present with classic symptoms of flushing, hyperthermia, blurred vision, dry mouth, and hallucinations. Common garden vegetables in the Solanum genus, including tomatoes, potatoes, and eggplants, also can cause anticholinergic symptoms when blossoms or unripe buds are ingested. Physostigmine may be indicated to treat severe or persistent symptoms.A variety of central nervous system (CNS) responses follow plant ingestion. Hallucinations are common with marijuana ingestion by children and with ingestion of nutmeg or morning glory seeds by teenagers. Tobacco plant exposure results in parasympathetic symptoms (miosis, bronchorrhea, gastrointestinal distress) as well as neuromuscular derangement due to unchecked nicotinic receptor response.Cardioactive glycosides are produced by foxglove (Digitalis), but they also are found in lily of the valley (Convallaria) and oleander (Nerium and Thevetia). Symptoms cannot be distinguished from those of digoxin toxicity and include hyperkalemia, CNS depression, and cardiac conduction abnormalities. Treatment with digoxin-specific antibody fragments can be lifesaving.Potentially dangerous toxins can show up in unexpected sources. Berries of the holly and mistletoe plants, common in holiday decorations, carry a risk of significant gastrointestinal distress. Amygdalin, contained in seeds and pits of Prunus species fruits (cherries, apricots, peaches, apples, plums), generates cyanide when metabolized. The resulting inhibition of cellular respiration can be lethal.Ingestion of mushrooms also may have fatal consequences. Species that harbor amatoxins (Amanita) and related compounds typically cause delayed onset (6 hours) of nausea, vomiting, and diarrhea. A second latent period is followed by acute and possibly fulminant hepatitis beginning 48 to 72 hours after ingestion. Effective decontamination and therapies directed at the toxins generally are ineffective, and supportive care, including liver transplant if necessary, is the mainstay of therapy. Other species of mushrooms can cause hallucinations, muscarinic toxicity, or general gastrointestinal irritation. Although most mushroom species are nontoxic, caretakers of a child who has eaten or who is suspected of eating any wild mushroom should call the PCC for guidance.The PCC can be an important aid in medical decision making, particularly with symptomatic patients for whom the identity of the plant is unknown. Electronic transmission of digital images may allow the PCC and expert botanists to identify the offending plant quickly and confidently and provide data on managing the exposure.Management of a potentially lethal exposure always should include communication with a toxicologist. In these situations, establishing control of airway, breathing, and circulation should be priorities. Aggressive decontamination, with gastric emptying, activated charcoal, and possibly whole bowel irrigation, may be warranted.Parents should be aware of the types of plants kept inside the home as well as in any landscaping in the yard or neighborhood. Unknown plants or shrubs, especially those that have bright colors or other features that might seem inviting to the curious child, can be identified with the help of a local nursery.Comment: Although pediatricians may consider drug ingestion readily in the differential diagnosis for certain signs and symptoms, I dare say we do not consider toxic plant exposures as often as we should, especially in younger children. Plant exposures in children 6 years of age and younger accounted for 4.6% of calls to PCCs, and this figure only represents instances when exposure was considered. The prevalence, therefore, is probably underestimated. Another important aspect to consider is the overlap of presentations between herbal remedies and plant exposures, another area where we need to expand our questioning. Consideration of toxic plant exposures in our patients reinforces the importance and value to parents and pediatricians of PCCs and the vast knowledge of diagnosis and treatment their staff impart. The website http://www.aapcc.org contains useful information about poison centers.Janet R. Serwint, MDConsulting Editor, In Brief

The management of Elephant's Ear poisoning.

The Araceae family of plants is the major cause of symptomatic plant ingestions in some developed countries (Dieffenbachia and Philodendron) and in Zimbabwe (Elephant's Ear), especially in children. A retrospective case series was carried out to evaluate the management of poisoning due to Elephant's Ear at the largest referral hospital in Zimbabwe for the period January 1995-December 1999. The study revealed inappropriate use of antibiotics, atropine, and antihistamines in the treatment of Elephant's Ear poisoning. This article also reviews the management of poisoning due to the Araceae family of plants as exemplified by Elephant's Ear. There is a need to educate health care workers on the clinical management of Elephant's Ear poisoning especially in developing countries where there are limited resources.

Poisoning in small animals from commonly ingested plants

POISONING or suspected poisoning as a result of plant ingestions is a relatively common occurrence. Some 12 per cent of inquiries received by the Veterinary Poisons Information Service (VPIS) concern...

Poisonous Plants: When They Are a Threat to Children

Poisonous Plants: When They Are a Threat to Children

Toxicity of nightshade berries (solanum dulcamara) in mice1,2

Ripened nightshade berries (Solanum dulcamara) are among the most commonly reported plant ingestions in Minnesota. Because of the lack of adequate information regarding the toxic qualities of S. dulcamara berries, the ingestion of even small quantities by children is usually treated conservatively with syrup of ipecac. The toxicity of S. dulcamara berries was studied by gavaging mice with a preparation of lyophilized berries, ripened and unripened, collected at various times of the year. Mice receiving unripened fruit from early in the season had gastrointestinal tissue changes consistent with solanine toxicity. Animals dosed with unripened fruit from the latter part of the year showed behavioral signs suggestive of solanine toxicity, however gastrointestinal lesions were not observed. In no case did the ripened fruit produce behavioral or histologic toxicity. Aggressive treatment of children ingesting limited amounts of ripened S. dulcamara berries appears to be unnecessary.

Common Toxic Plant Ingestions

This article focuses on some of the more common dangerous plant and mushroom ingestions, discussing toxic components, early symptoms, and treatment. Among the plants considered are oleander, foxglove, hemlock, dieffenbachia, and Amanita phalloides. Details concerning recognition of toxic species are intentionally omitted in an effort to avoid potentially dangerous errors in identification.

Management of Wilderness and Environmental Emergencies

Interest and participation in wilderness sports have notably increased in recent years, and, not surprisingly, there has also been a concomitant increased incidence of environment-related injuries and illnesses. Therefore, this book should be a most welcome addition to the libraries of physicians and other health professionals who treat or advise mountaineers, trekkers, skiers, scuba divers, and other outdoors enthusiasts. The book consists of 21 chapters and an appendix that address the major problems common to wilderness sports—hypothermia, heat illness, lightning injuries, burns, solar dermatitis, submersion injuries, hazardous marine life, toxic plant ingestions and dermatitis, mammalian bites, arthropod envenomations, and venomous snake bites. In addition, some specific activities are discussed—alpine and nordic skiing injuries, diving and barotrauma, mountain sickness and other high-altitude illnesses, aerospace medicine, and problems encountered in wildland fire fighters. The chapters are by persons knowledgeable in the clinical and practical aspects of these conditions, especially with regard to

Evaluating Exposures to Plants

Exposures to plants generate an exceptional amount of public concern, especially plant ingestions by children. Most clinical problems, however, involve older age groups as a result of experimentation with or overt abuse of plant parts and extracts. Of mounting concern is the sometimes uninformed and massive use of herbal preparations, currently widely available and in popular vogue. Plant exposures, from whatever source, may present as complex pharmacologic problems that may challenge the diagnostic and therapeutic skills of the physician. Although specific physiologic antagonists (antidotes) may exist for specific intoxications, basic decontamination and supportive techniques are many times all that may be offered.

459 INCREASED PLANT INGESTIONS 1963–1977: A PROBLEM OF HOME SAFETY ASSOCIATED WITH THE BACK TO NATURE MOVEMENT

This study examines if the “back to nature” movement which started in the 1960s has resulted in increased buying of plants by the American public and if there has been a concomitant increase in plant ingestions. Sales of retail nursery stores for 1963,67,72, and 77 for the United States (US) recorded by the US Dept of Commerce census of retail trade are: (Amounts in thousands and corrected for inflation to 1967 constant $): For the same years the incidence of plant ingestions (except mushrooms) in children < 5 years old recorded by National Clearing House for Poison Control Centers is: These data indicate that the US public has been buying more plants which has altered the home environment. This fact, very likely has resulted in increased plant ingestions by young children. Improved public education regarding safe and poisonous plants may reduce the incidence of poisonous plant ingestions.

Oleander poisoning.

The two common oleanders, Thevetia peruviana and Nerium oleander, contain a mixture of poisons including cardiac glycosides, and are extremely toxic. They are cultivated universally throughout Australia, and rank equally with mushrooms as the major cause of children's admission to hospital after accidental plant ingestions. A seven-year total population survey from south-east Queensland has revealed that, in practice, the rate of clinical poisoning due to oleander is inconsequential, and mortality is negligible. The annual age-specific admission rate for children (aged from birth to 12 years of age), for all plant ingestions is 2.33 per 100 000, and 0.62 per 100 000 specifically for oleander. Oleander ingestion causes a syndrome of combine cardiac and gastrointestinal symptoms and signs. A case series of 13 children is described, and the clinical features summarized. After accidental oleander ingestion, current experience indicates that the prognosis is excellent.