PLANT POISONINGin Critical Care林秉熙 醫師新光醫院腎臟科主治醫師國立陽明大學醫學系講師Lin B.S.1Key Points (1)There are a large variety of plant poisons in nature with only few specific antidotes.Acute gastroenteritis is a feature of most plant poisonings. Organic brain syndromes are common.Supportive care and decontamination (gastro-intestinal tract and others) are the mainstays of treatment. Lin B.S.2Key Points (2)Identification of the plant is important for anticipating clinical events.In plant-related cardiac glycoside toxicity, antidigoxin Fab fragments may be of use.Mucosal irritation, renal failure, and hypo-calcemia characterize plant-related oxalate toxicity.Lin B.S.3Key Points (3)Life-threatening mushroom poisonings tend to have a delay of at least 6 h prior to the onset of symptoms. Hepatic, renal, or central nervous system complications may develop, depending on the type of mushroom ingestedLin B.S.4Hindered plant toxicologyPaucity of acutely ill patients, prospective clinical trials, and good clinical series in plant toxicology Immense number of uncharacterized potential toxins in the plant kingdom Imprecise identification of the offending speciesIdentification of the toxin or quantitative blood levels rarely obtainedLin B.S.5Benign plants with acute illnessSimultaneous ingestion of pesticidesAllergic responseLin B.S.6Common clinical syndromesAcute gastroenteritisAlmost universal, even the only feature of poisonings Organic brain syndromethe second most common manifestationoften seen along with, or following the gastroenteritisalteration in mental status manifested by delirium, coma, or seizuresLin B.S.7General ManagementStablized airway, breathing & circulationNaloxone & dextrose for altered mentationGastrointestinal decontamination with lavage and activated charcoalIdentifying the plantConsultation with regional poison control centerSpecific antidote if availableLin B.S.8Specific Plant Syndromes (1)ANTICHOLINERGIC SYNDROMEPYRROLIZIDINE ALKALOIDSCARDIAC GLYCOSIDEOXALATE SYNDROMESOLANINE ALKALOIDSNICOTINE ALKALOIDCYANOGENIC PLANTSLin B.S.9Specific Plant Syndromes (2)TOXALBUMIN-CONTAINING PLANTSCOLCHINE POISONINGMISTLETOE (槲寄生槲寄生) TOXICOLOGYPODOPHYLLUM (鬼臼樹脂鬼臼樹脂) POISONINGPENNYROYAL (薄荷薄荷) OILEUCALYPTUS (桉樹桉樹) OILHALLUCINOGENIC PLANTSLin B.S.10Specific Plant Syndromes (3)AKEE FRUIT POISONINGTAXINE (YEW) POISONINGFAVA BEAN POISONINGWATER HEMLOCK (毒水芹毒水芹) POISONINGRHODODENDRON (杜鵑花杜鵑花) POISONINGDAPHNE (月桂月桂) POISONINGGASTROENTERITIS SYNDROMEMUSHROOM POISONINGLin B.S.11Anticholinergic SyndromeDeadly nightshade (Atropa belladonna 顛茄)Angels trumpet (Datura suaveolens 曼陀羅)Jimson weed (D. stramonium)Matrimony vine (Lycium halimifolium)Henbane (Hyoscyamus niger 茛菪)Lin B.S.12Anticholinergic syndrome (ACS)Tropane alkaloidsatropine (顛茄鹼)scopolamine (茛菪鹼)The most common plant causesDatura stramonium (jimson weed, 曼陀羅)Atropa belladonna (deadly nightshade,茛菪)Lin B.S.13Anticholinergic syndrome (ACS)The most frequent cause of intoxication by these plants is from teas. Anticholinergic plant poisoning is occasionally induced purposefully in an attempt to capture the hallucinogenic anticholinergic effects.Lin B.S.14Anticholinergic syndrome (ACS)Toxicities: competitive antagonist at the cholinergic-muscarinic receptor. Cross the blood-brain barrier, cause central effectsClinical pictures: mad as a hatter, hot as a bare, dry as a bone, red as a beet, and blind as a bat Lin B.S.15Anticholinergic syndrome (ACS)Tachycardia:usually sinussupraventricular as well as ventricular arrhythmias may occur. Profound alteration in mentation:including confusion, agitation, disorientation, hallucinations, and seizures. Lin B.S.16Physical examinationMydriasis, absence of perspiration, and relatively parched mucous membranes Flushed due to peripheral cutaneous dilationFever is common.Lin B.S.17Treatment of ACSObserved for cardiac dysrhythmias, hemodynamic instability, agitation, and seizures. Benzodiazepines for significant agitationPotential antagonist: Physostigminemay result in bradydysrhythmias, asystole, or seizuresrestricted to patients with life-threatening ACS, or diagnostic dilemmasLin B.S.18Administeration of physostigmineUsual dose of physostigmine: 2 mg (0.5 mg for pediatric patients) intravenously over at least 2 min.A syringe containing atropine standbyContraindications: asthma, peripheral vascular disease, bowel obstruction, urinary tract obstruction, or gangrene.Lin B.S.19CARDIAC GLYCOSIDESChristmas rose (Helleborus niger 黑藜蘆) Lily of the Valley (Convallaria majalis 歐鈴蘭) Foxglove (Digitalis purpurea 毛地黃) Common oleander (Nerium oleander 夾竹桃) Yellow oleander (Thevetia sp.)Lin B.S.20Cardiac glycosides (1)The presentation of plant cardiac glycoside poisoning is similar to medicinal glycosides.There is an initial period of gastrointestinal discomfort followed by multiple cardiac conduction abnormalities and hyperkalemia. Lin B.S.21Cardiac glycosides (2)Foxglove plant (Digitalis purpurea 毛地黃)contains predominantly digitoxinlong half-life and prolonged clinical syndromeEuropean snapdragon 金魚藻 (Digitalis lanata)contains mostly digoxincauses a more abbreviated syndromeLin B.S.22Cardiac glycosides (3)Variable degree of cross-reactivityDigoxin levels unreliable Bind to activated charcoal: Multiple doses of activated charcoal indicated Digitoxin: a true enterohepatic circulation Efficacy of antidigoxin Fab fragments: Controversy Lin B.S.23Pyrrolizidine Alkaloid SyndromeThreadleaf (Senecio longilobus 劉寄奴草)Heliotrope (Heliotropium europaeum 天芥菜)Russian comfrey (Symphytum xuplandicum 紫草)Horsefoot (Tussilage farfara 款冬)Lin B.S.24Pyrrolizidine alkaloids (1)First recognized in 1954 in Jamaicahepatic veno-occlusive disease related to drinking herbal teas or eating contaminated cereals.Endothelial edema of small and medium size hepatic veins and venules, result in sclerosis and occlusion. Lin B.S.25Pyrrolizidine alkaloids (2)Congestion of hepatic sinusoids and central veinscentrilobular hemorrhagic necrosislarge hepatic veins unaffected, distinguishing from the Budd-Chiari syndrome.Typicall presentation:RUQ abdominal pain, nausea, vomiting, diarrhea, hepatomegaly, splenomegaly, ascites, jaundice, hypoglycemia, and extremely high GOT/GPTLin B.S.26Pyrrolizidine alkaloids (3)Chronic ingestionprogressive hepatic veno-occlusive diseasecor pulmonaleNo specific antidoteTreatment: supportivemanagement of coagulopathy, hypoglycemia, pulmonary hypertension, and encephalopathyLin B.S.27Oxalate SyndromeDumbcane (Dieffenbachia sp.)Elephants ear (Colocasia antiquorum)Rhubarb (Rheum sp. 大黃)Jack-in-the-pulpit (Arisaema atrorubens 美國黃花菖蒲)Skunk cabbage (Symplocarpus foetidus 臭菘)Swiss cheese plant (Monstera sp.)Philodendron (Philodendron sp. 黃蘗)Caladium (Caladium bicolor 貝母)Lin B.S.28Oxalate syndrome (1)Primary syndrome: mucosal irritationMost common cause: Dieffenbachia Chronic ingestion of rhubarb leaves (大黃)Soluble vs. insoluble (rhaphides) formLin B.S.29Oxalate syndrome (2)Rhaphides: severe mucosal irritation, even laryngeal edemaSoluble oxalate: systemic & diffuse effectMucosal irritationgastroenteritisrenal failurehypocalcemiaLin B.S.30Oxalate syndrome (3)TreatmentMaintain airwayOral fluid, preferably milk for dilutionECG & serum calcium monitoringHemodynamic monitoringAdequate fluid supply & monitor renal functionLin B.S.31Solanine Alkaloid SyndromeJerusalem cherry (Solanum pseudo-capsicum)Common potato (S. tuberosum 馬鈴薯) Eggplant (S. melongena 茄子) Woody nightshade (S. dulcamara) Horse nettle (S. carolinense 針茄) Common nightshade (S. nigrum) Tomato (Lycopersicon esculentum) Trumpet flower (Solandra sp.)Lin B.S.32Solanine alkaloid (1)Most plants of the Solanaceae family (nightshade 茄屬 or potato plants 馬鈴薯) contain the solanine alkaloids in nontoxic amounts.Severe solanine alkaloid poisoning can occur when potatoes are harvested while still green, are improperly stored, or are traumatized.Lin B.S.33Solanine alkaloid (2)Toxicities:Gastrointestinal tract irritationGastric juice hydrolyze solanine alglycon & sugarAglycone: hypotension & organic brain syndromeSolanocapsine toxicity: cardioinhibitory syndrome, with both negative inotrophic/chronotrophic effectSuperimposed ACSLin B.S.34Solanine alkaloid (3)TreatmentSupportive measuresGastrointestinal decontamination: activated charcoalTreat superimposed ACSLin B.S.35Nicotine SyndromeTobacco (Nicotiana sp. 菸草)Poison hemlock (Conium maculatum 毒人蔘)Indian tobacco (Lobelia inflata 半邊蓮)Lin B.S.36Nicotine alkaloid-containing plantsPoisoning when used as purgatives and enemasHemlock (毒芹)root: confused with wild carrotsLeaves: similar in appearance to parsley (荷蘭芹)Lin B.S.37Nicotine alkaloid-containing plantsToxicityRapid emesis due to direct effect and stimulation of medullary chemoreceptor trigger zoneStimulate postsynaptic receptors of autonomic neurons and motor end platesInitial stimulation followed by depression, either sympathomimetic or cholinergicDeath within an hour of ingestion (respiratory failure)Lin B.S.38Nicotine alkaloid-containing plantsTreatmentThorough skin decontaminationActivated charcoal in multidose fashionRespiratory and hemodynamic monitoringLin B.S.39Cyanogenic Glycosides SyndromeCommon fruit pits (Rosaceae family)Cherry laurel (Prunus laurocerasus 月桂櫻桃)Cassava (Manihot esculenta 樹薯)Bamboo (Phytostachys aurea 竹子)Elderberry (Sambcucus sp. 接骨木)Bitter almonds (Prunus dulcis 苦杏)Hydrangea (Saxifragaceae family 繡球花)Lima beans (Phaseolus lunatus 青豆)Chokecherry (Prunes airginiana 苦櫻桃)Lin B.S.40Cyanogenic plants (1)Cyanide:One of the most potent and rapid acting poisonsWidely distributed in the plant world in the form of cyanogenic glycosides (sugar compounds of cyanide)Glycosides may be hydrolyzed by either plant enzymes simultaneously ingested or endogenous enzymes to liberate hydrogen cyanideLin B.S.41Cyanogenic plants (2)Amygdalin (苦杏仁素)The most common glycoside, also found in plum, peach, apricot, bitter almond, cherry, pear, and apple The major glycoside in the product sold as LaetrileThese pits contain a complex of enzymes known as emulsin in their coats. When the pits are chewed, emulsin is liberated and metabolizes the nontoxic amygdalin to free hydrogen cyanide.Lin B.S.42Cyanogenic plants (3)Linamarin: another common cyanogenic glycoside found in lima and cassava beansTropical or Nigerian ataxic neuropathy:Chronic cassava consumption in tropical areas, particularly Nigeria, associating with chronic cyanide poisoningLin B.S.43Cyanogenic plants (4)Diagnosis:Based primarily on a high index of suspicionHypotension, seizures, an altered mental status, or a persistent metabolic acidosis in the setting of the potential ingestion of cyanogenic plantsOdor of bitter almonds is a further clue but unreliable; cannot be detected by up to 40 % of the population. Lin B.S.44Cyanogenic plants (5)Treatment of cyanide poisoningPrompt resuscitationVentilation with 100 % oxygenSodium thiosulfate, 25 % solution, 150 mg/kg ivGastric decontamination (larvage)Activated charcoal administrationLin B.S.45Toxalbumin SyndromeCastor bean (Ricinus communis 蓖麻子)Jequirity bean (Abrus precatorius 相思子)Sandbox tree (Hura crepitans)Bellyache bush (Jatropha gossipifolia 麻風樹屬)Black locust (Robinia pseudoacacia 北美刺槐樹)Desert potato (J. macrorhiza)Lin B.S.46Toxalbumin-containing plantsAbrin, the active toxin in the jequirity bean, and ricin, found in the castor bean, are among the most potent natural toxins known when administered parenterally.Ingestion of these beans is usually not associated with toxicity unless they are chewed.Extremely antigenic, causing a hypersensitivity reaction Lin B.S.47Toxalbumin-containing plantsCastor bean toxicity: acute, severe, gastroenteritisJequirity bean contains glycyrrhizin, which may cause hyperaldosteronism.Abrin is more toxic than with ricin“as little as one jequirity bean when chewed can be lethal to a child” Lin B.S.48Toxalbumin-containing plantsToxic effects of toxalbumin ingesion:acute, persistent and severe gastroenteritisencephalopathy: stupor, seizures, and comamultiple organ system failure in some cases, with pancreatitis, hepatotoxicity, hemolysis, renal failure.In addition, a primary irritant dermatisLin B.S.49Toxalbumin-containing plantsTreatment:Standard supportive careActivated charcoal administrationTreat severe hemorrhagic gastroenteritisNo specific antidote availableLin B.S.50Colchicine SyndromeAutumn crocus (Colchicum autuminate)Glory lily (Gloriosa superba)Lin B.S.51Colchicine poisoningTrue botanical colchicine poisoning is unusual.The clinical syndrome:acute gastroenteritis, may be severe & hemorrhagicascending motor paresis, bone marrow depression, rhabdomyolysis, renal failure, DIC, and ARDS, which is usually the cause of deathOrganic brain syndrome: seizures and delirium. Lin B.S.52Colchicine poisoningAtropine: antidotal to the gastrointestinal effectsActivated charcoal should be administeredmultidoses of charcoal due to ileus in many patientsAnticipate rhabdomyolysis and renal failurecirculatory shockdirect nephrotoxic effects of the colchicineCentral venous or Swan-Ganz monitoring if neededLin B.S.53Mushroom poisoningMushroom-induced toxic syndromes: 8 groupsThree life-threatening mushroom syndromes:Hepatorenal syndrome, central nervous system abnormalities, renal failurecausative agents: cyclopeptides, monomethyl-hydrazine, orelline, and orellanineLin B.S.54Mushroom poisoningSpecific managementprolonged multiple-dose activated charcoal therapyhigh-dose penicillin G may be hepatoprotective ?transplantation for fulminant amatoxin-induced hepatic failure ?Monomethylhydrazine poisoning: administration of methylene blue for significant methemoglobinemiatreatment of seizures with pyridoxineLin B.S.55Acute GastroenteritisHolly berries (Illex sp. 冬青)Pokeweed (Phytolaccia americana )(北美商陸木) English ivy (Hedera helix 長春藤)Aloe vera 蘆薈Multiple bulbsLin B.S.56Thank You for Your Attention終於結束了 Lin B.S.57Lin B.S.58