Accidental poisoning with Aconitum: Case report and review of the literature

A Narrative Review of Aconite Poisoning and Management

Aconite poisoning refers to toxicity resulting from plants belonging to the Aconitum genus, which comprises over 350 different species of perennial flowering plants that grow in temperate mountainous areas of the northern hemisphere (North America, Europe, Asia). These plants contain a group of toxins known as aconite alkaloids, which encompass numerous closely related toxic compounds. Conventional teaching from toxicology textbooks has broadly classified these alkaloids based on their mechanism of action, often simplifying them as substances that prevent sodium channel inactivation. However, this is an oversimplified and sometimes inaccurate description, as some aconite alkaloids can act as sodium channel blockers. Aconite alkaloids have a long history of use as poisonous substances and have been historically employed for hunting, assassinations, traditional medicine, and self-inflicted harm. Toxicity can occur due to the consumption of traditional medicines derived from aconitum plants or the ingestion of aconite plants and their derivatives. The clinical manifestations of aconite poisoning may encompass gastrointestinal symptoms, sensory alterations, seizures, and life-threatening dysrhythmias that may not respond to standard treatments. Treatment is primarily supportive however evaluation and management of these patients should be personalized and carried out in collaboration with a toxicologist.

Intentional intoxication with monkshood plant leading to atrioventricular dissociation and ventricular ectopy in a 17-year-old female: a case report

BACKGROUND

Monkshood, a toxic plant containing a potent cardio- and neurotoxin called aconitine, can lead to a range of symptoms, including nausea, vomiting, dizziness, seizures, and cardiac arrhythmias. Mortality associated with this intoxication are due to ventricular tachyarrhythmias which are difficult to treat and often refractory in nature.

CASE PRESENTATION

We present a case of a 17-year-old female patient who presented to the emergency department after intentionally ingesting a monkshood plant and developed atrioventricular dissociation and frequent ventricular ectopy. The patient was successfully treated with activated charcoal, supportive care, and cardiac monitoring.

CONCLUSION

This case highlights the importance of early recognition of aconitine poisoning and the need for prompt supportive care, cardiac rhythm monitoring, and preemptive antiarrhythmic treatment planning.

Accidental poisoning with aconite overdose: A case report and resuscitative emergency management in a tertiary level hospital of Bangladesh

Intoxication with aconite, a common over-the-counter herbal medicine in Asia, can result in ventricular tachycardia and cardiac arrest and requires heart rate monitoring in a critical care setting and aggressive use of antiarrhythmica. Educational efforts in the appropriate use of alternative medicine may help prevent intoxication.

The known, unknown, and the intriguing about members of a critically endangered traditional medicinal plant genus Aconitum

Humanity will always be indebted to plants. In the ongoing scientific era, the 'Herbal Revolution' has helped discover several valuable medicinal plants and associated novel secondary metabolites from the diverse unexplored ecosystems, treating several diseases via phytotherapy. The Aconitum genus comprises several economically-important poisonous mountainous medicinal plant species whose unique biodiversity is on the verge of extinction due to illegal human intervention triggered habitat loss, over-harvesting, and unrestricted trading. Owing to its vast diversity of diterpene alkaloids, most species are extensively used to treat several ailments in rural parts of the world. Irrespective of this, many unexplored and intriguing prospects exist to understand and utilize this critical plant for human benefit. This systematic review tries to fill this gap by compiling information from the sporadically available literature known for ~300 Aconitum spp. regarding its nomenclature and classification, endangerment, plant morphology, ploidy, secondary metabolites, drug pharmacokinetics, conservation, and omics-based computational studies. We also depicted the disparity in the studied model organisms for this diverse genus. The absence of genomic/metagenomic data is becoming a limiting factor in understanding its plant physiology, metabolic pathways, and plant-microbes interactions, and therefore must be promoted. Additionally, government support and public participation are crucial in establishing conservation protocols to save this plant from endangerment.

An insight into current advances on pharmacology, pharmacokinetics, toxicity and detoxification of aconitine

Aconitine is a diterpenoid alkaloid, which mainly exists in the plants of Aconitum. In the last decade, a plethora of studies on the pharmacological activities of aconitine has been conducted and demonstrated that aconitine possessed an extensive range of pharmacological activities such as anti-tumor, anti-inflammatory, analgesic, local anesthesia, and immunomodulatory effects. Pharmacokinetic studies indicated that aconitine may have the characteristics of poor bioavailability, wide distribution, and slow elimination. However, studies have also found that aconitine has toxic effects on the heart, nerves, embryos, etc. Therefore, we believe that aconitine may not be suitable for heart patients and pregnant women to treat related diseases. It is important to note that all of these pharmacological effects require further high-quality studies to determine the clinical efficacy of aconitine. This review aims to summarize the advances in pharmacological, pharmacokinetics, toxicity, and detoxification of aconitine in the last decade with an emphasis on its anti-tumor and anti-inflammatory activities, to provide researchers with the latest information and point out the limitations of relevant research at the current stage and the aspects that should be strengthened in future research.

Identification and poisoning diagnosis of Aconitum materials using a genus-specific nucleotide signature

Aconitum genus generally contains hypertoxic alkaloids. Poisoning incidents due to the improper ingestion of Aconitum materials frequently occur around the world. DNA barcoding is considered as a powerful tool for species identification, but complete sequences of conventional DNA barcodes are sometimes unattainable from food and highly processed products due to severe DNA degradation. Therefore, a shorter molecular marker will be more profitable for the authentication and poisoning diagnosis of Aconitum materials. In this study, 1246 psbA-trnH sequences and chloroplast genomes representing 183 taxa of Aconitum were collected, and a 23-bp nucleotide signature unique to Aconitum genus (5'-TATATGAGTCATTGAAGTTGCAG-3') was developed. The nucleotide signature was conserved and universal within Aconitum while divergent among other genera. The specific molecular signature was then successfully applied to the detection of processed Aconitum ingredients. To further evaluate the application potential of nucleotide signature in completely unknown mixture samples, boiled food mixtures, containing different ratios of Aconitum materials, were sequenced by high-throughput sequencing technology. The results showed that the nucleotide signature sequence could be directly extracted from raw sequencing data, even at a low DNA concentration of 0.2 ng/µl. Consequently, the 23-bp genus-specific nucleotide signature represents a significant step forward in the use of DNA barcoding to identify processed samples and food mixtures with degraded DNA. This study undoubtedly provides a new perspective and strong support for the identification and detection of Aconitum-containing products, which can be further introduced to the diagnosis of food poisoning.

Aconitine induces brain tissue damage by increasing the permeability of the cerebral blood-brain barrier and over-activating endoplasmic reticulum stress

OBJECTIVE

This study aimed to explore the neurotoxicity of aconitine and its underlying mechanism.

METHODS

The rats were administered with the aconitine solution intragastrically at different dosages (0.5 mg/kg, 1.5 mg/kg, and 2.5 mg/kg). Evans blue (EB) extravasation and evaluation of tight junction protein expression were performed to determine the permeability of the blood-brain barrier. Cellular damage, apoptosis, and levels of endoplasmic reticulum (ER) stress markers were determined using H&E staining, Tunnel assay, and western blotting. The effects of aconitine on cell viability, apoptosis, and activation of the ER stress signaling in PC12 cells were assessed in vitro using the MTT assay, flow cytometry, western blot, and immunofluorescence analysis.

RESULTS

Aconitine was observed to significantly increase the murine blood-brain barrier penetrability in a dose-dependent manner. The in vivo experimental results revealed that aconitine could stimulate the pathway for endoplasmic reticulum stress. The increase in the endoplasmic reticulum stress in the brain tissue promoted apoptosis, leading to brain damage. Moreover, PC12 cell proliferation was inhibited upon treatment with aconitine in a dose-dependent manner. In addition, cell apoptosis was increased upon treatment with aconitine also in a dose-dependent manner. These findings indicated that aconitine caused damage to PC12 cells via endoplasmic reticulum stress.

CONCLUSION

Aconitine induces brain tissue damage by increasing the penetrability of the blood-brain barrier in the cerebral region and over-activating the endoplasmic reticulum stress.

Diagnostic ions guided 2D-locating strategy for characterization of chemical analogues in complex herbal medicines using liquid chromatography-ion mobility-mass spectrometry

Rapid characterization of chemical analogues in potentially toxic complex matrix was essential for prevention of accidental poisoning. On the basis of the fragment ions possessed not only the same retention times (RT) but the same drift times (DT) on liquid chromatography-ion mobility-mass spectrometry (LC-IM-MS), an alternating frames (AF)-data independent acquisition (DIA) was utilized for simultaneous detection and rapid match of precursor/product ions with a fast switch of low/high collision energy (CE). A diagnostic ions guided 2D-locating strategy was developed for identification of chemical analogues in potentially toxic herbal medicines using LC-IM-MS. Firstly, the 2D-locations (RT, DT) of diagnostic ions were screened from high-fragment IM-MS frames according to their m/z. Then, the correlated precursor ions were extracted from the complex background interference in low-fragment IM-MS frames based on diagnostic ions' 2D-locations. Finally, the remained ions were characterized using double-bond equivalent analysis combined with MS/MS fragment interpretation. Totally, 236 diterpene alkaloids including eight compounds with potential new esterification types were characterized in processed lateral roots of Aconitum carmichaelii Debx. Moreover, the LC-IM-MS distribution regularities of diterpene alkaloids with various chemical structure types were further investigated and discussed. This study presented an innovative idea for revealing the chemical basis related to the toxicities of potentially poisonous herbal medicines to ensure the medication safety.

The toxicology and detoxification of Aconitum: traditional and modern views

Aconitum carmichaeli Debx.-derived herbal medicine has been used for anti-inflammation and anti-arrhythmia purpose for more than two thousand years. It is processed into Chuanwu (Radix Aconiti praeparata) and Fuzi (Radix Aconiti lateralis praeparata) in Traditional Chinese Medicine, which are two useful drugs but with toxic properties. There have been patients poisoned by accidental ingestion of Aconitum plants or misuse of the herbal drug, and this is of great concern to study in-depth. In this review, we provided the traditional and contemporary practice of using Aconitum herbs as medicine, from functions, processing methods to toxicity in ethnomedicine aspects to discuss the underlying connections of traditional and modern understanding on the toxicity of Aconitum plants. We summarized the functions and toxicology of the herbal drugs are analyzed from chemical and clinical aspects, with the help of traditional and modern knowledge of medicine. The medicinal doses and lethal doses determined by researches are summarized, and the usage and processing methods are updated and reviewed in the modern view. In addition, clinical management of poisoned cases using western medicine is discussed. This review provides insights and awareness of safety when using Aconitum-derived herbal medicine, and the application of modern scientific knowledge to optimize the detoxification processes. We suggest the possibility to renew the current standard processing method from the official Pharmacopoeia all over the world.