Anticholinergic toxicity from nightshade berry poisoning responsive to physostigmine

Acute Anticholinergic Syndrome from Atropa Belladonna Mistaken for Blueberries

Purpose

To report the first case in the ophthalmic literature of acute anticholinergic syndrome after ingestion of Atropa belladonna mistaken for blueberries.

Methods

A 36-year-old woman presented to our ophthalmic emergency department with complaints of blurry vision, lightning flashes, disorientation, loss of balance, agitation, and anxiety for 24 hours. Ophthalmic examination revealed bilateral pupillary dilatation and paresis of accommodation. Additional symptoms of the anticholinergic syndrome were elicited on further questioning.

Results

Anticholinergic intoxication was suspected and the patient admitted to have eaten six “blueberries” found in the forest the previous day. The patient identified Atropa belladonna as the source of the berries she had eaten when shown photographs of the plant and its fruit. The recommendations of the Swiss Toxicological Information Centre were followed and physostigmine, the antidote for severe poisoning when 10 or more berries are ingested, was not administered.

Conclusions

Accidental ingestion of Atropa belladonna berries may cause patients to first consult an ophthalmologist. It is important to recognize the anticholinergic syndrome caused by such intoxication in order to make a proper diagnosis, avoid unnecessary testing, and provide expedient appropriate treatment when required.

Prolonged Antimuscarinic Delirium in a Child Due to Benztropine Exposure Treated With Multiple Doses of Physostigmine

An 11-year-old boy presented with an antimuscarinic toxidrome due to benztropine and risperidone ingestion. His delirium was prolonged and difficult to treat with benzodiazepines. Multiple doses of physostigmine successfully treated it. Benztropine is a potent antimuscarinic agent, whereas risperidone has not been reported to cause antimuscarinic toxicity. The use of physostigmine to treat benztropine intoxication in a pediatric patient has not previously been described. In this case, multiple doses were used and were well tolerated.

Exploring Hallucinogen Pharmacology and Psychedelic Medicine with Zebrafish Models

After decades of sociopolitical obstacles, the field of psychiatry is experiencing a revived interest in the use of hallucinogenic agents to treat brain disorders. Along with the use of ketamine for depression, recent pilot studies have highlighted the efficacy of classic serotonergic hallucinogens, such as lysergic acid diethylamide and psilocybin, in treating addiction, post-traumatic stress disorder, and anxiety. However, many basic pharmacological and toxicological questions remain unanswered with regard to these compounds. In this study, we discuss psychedelic medicine as well as the behavioral and toxicological effects of hallucinogenic drugs in zebrafish. We emphasize this aquatic organism as a model ideally suited to assess both the potential toxic and therapeutic effects of major known classes of hallucinogenic compounds. In addition, novel drugs with hallucinogenic properties can be efficiently screened using zebrafish models. Well-designed preclinical studies utilizing zebrafish can contribute to the reemerging treatment paradigm of psychedelic medicine, leading to new avenues of clinical exploration for psychiatric disorders.

Accidental overdose in the deep shade of night: a warning on the assumed safety of 'natural substances'

There is an increasing use of herbal remedies and medicines, with a commonly held belief that natural substances are safe. We present the case of a 50-year-old woman who was a trained herbalist and had purchased an 'Atropa belladonna (deadly nightshade) preparation'. Attempting to combat her insomnia, late one evening she deliberately ingested a small portion of this, approximately 50 mL. Unintentionally, this was equivalent to a very large (15 mg) dose of atropine and she presented in an acute anticholinergic syndrome (confused, tachycardic and hypertensive) to our accident and emergency department. She received supportive management in our intensive treatment unit including mechanical ventilation. Fortunately, there were no long-term sequelae from this episode. However, this dramatic clinical presentation does highlight the potential dangers posed by herbal remedies. Furthermore, this case provides clinicians with an important insight into potentially dangerous products available legally within the UK. To help clinicians' understanding of this our discussion explains the manufacture and 'dosing' of the A. belladonna preparation.

Atropa acuminata Royle Ex Lindl. blunts production of pro-inflammatory mediators eicosanoids., leukotrienes, cytokines in vitro and in vivo models of acute inflammatory responses

ETHNOPHARMACOLOGICAL RELEVANCE

Atropa acuminata Royle Ex Lindl. has been widely used in folk medicine for several inflammatory disorders such as arthritis, asthma, conjunctivitis, encephalitis, pancreatitis, peritonitis, acute infections and neuroinflammatory disorders.

AIM OF THE STUDY

Our aim was to evaluate Atropa acuminata for its anti-inflammatory properties and to delineate its possible mechanism of action on the modulation of the inflammatory mediators.

MATERIALS AND METHODS

We investigated the inhibitory action of ethanolic extract of Atropa acuminata (AAEE) on production of NO, TNF-α and IL-1β in lipopolysaccharide (LPS)-stimulated RAW264.7 cells and also assayed it for COX 1/2 and 5-LOX inhibitory activities. Next AAEE was tested in acute inflammatory animal models., carragenean induced rat paw edema, carragenean induce pleurisy in rats and vascular permeability in mice and the effects on NO, PGE2 and LTB4 production in the pleural fluid and paw exudates were evaluated. In addition the effects on leukocyte migration and exudation and vascular permeability were also observed.

RESULTS

Our findings summarized novel anti-inflammatory mechanisms for Atropa acuminata based on dual in vitro cyclooxygenase 1/2/ and 5-Lipoxygenase inhibitory activities and also significant downregulation of nitric oxide (NO) and pro-inflammatory cytokin (TNF-α and Il-1 β) release in LPS-stimulated RAW 246.7 macrophage cell line. In acute inflammatory models in vivo (carragenean induced edema, carragenean induced pleurisy in rats and vascular permeability in mice), AAEE exhibited an extensive diverse mechanism for anti-inflammatory properties. This was indicated on the basis of dose dependent suppression of multi targeted inflammatory mediators., NO, TNF-α and IL-1β, eicosanoids., PGE2 and leukotrienes., LTB4 along with significantly decreased leucocyte migration, exudation and decreased vascular permeability. These effects were more potent and prolonged than traditional NSAIDS, thereby indicating fewer side effects. AAEE was found to be safe for long term administration, as confirmed by the results of acute toxicity studies and MTT assay. The complex mode of action of the herbs was attributed possibly due to the high polyphenolic, flavanol and flavonoid content present in the extracts as observed by means of quantitative screening for phytochemicals.

CONCLUSION

Our study provides scientific evidence to support the traditional anti-inflammatory uses of Atropa acuminata and is probably due to inhibitory effects on multiple inflammatory mediators which indicates a promising potential for the development of a strong anti-inflammatory agent from this plant.

Holiday plants with toxic misconceptions

Several plants are used for their decorative effect during winter holidays. This review explores the toxic reputation and proposed management for exposures to several of those, namely poinsettia (Euphorbia pulcherrima), English holly (Ilex aquifolium), American holly (Ilex opaca), bittersweet (Solanum dulcamara), Jerusalem cherry (Solanum pseudocapsicum), American mistletoe (Phoradendron serotinum), and European mistletoe (Viscum album).

Brunfelsia australis (Yesterday, Today, and Tomorrow tree) and Solanum poisoning in a dog

A 2.5 yr old female beagle presented for acute abdominal pain and vomiting after consuming limited offerings of green potato skins. Progressive complications associated with suspected ingestion of a higher potency toxin followed within 5 hr. Subsequent investigations revealed a significant ingestion of an Australian shrub commonly called a "Yesterday, Today, and Tomorrow" tree (Brunfelsia australis). The toxic principle for this emerging toxicity is referred to as "strychnine-like" and is potentially lethal with gastrointestinal, central nervous system, and cardiac pathology. This plant is currently being aggressively promoted by United States nurserymen for its dramatic tri-colored blooms and drought resistance.

An Atropa belladonna L. poisoning with acute subdural hematoma

Atropa belladonna L. is a plant long known to cause poisoning. But no cases of acute subdural hematoma resulting from such poisoning have been reported so far. Care must also be taken in terms of acute pancreatitis and rhabdomyolysis in cases of such poisoning. The plant may sometimes be mistaken for the Caucasian blueberry, V. arctostaphylos L. At least one anti-cholinesterase toxidrome finding was determined in all the nine cases of belladonna poisoning in this series. No elevated creatine kinase was reported in one case with acute subdural hematoma and hyperamylasemia.

Atropine autoinjector use as a suicidal gesture

Atropine autoinjectors are used by the U.S. military as pre-hospital first-line therapy for nerve agent exposure. This case report examines the misuse of these devices in a suicide attempt. An anticholinergic toxidrome resulted from this misuse. The patient was successfully treated.

Spasmogenic effect of a Solanummelongena leaf extract on guinea pig tracheal chains and its possible mechanism(s)

The methanol extract of fresh leaves of Solanum melongena L. (Solanaceae) was evaluated for its capacity to alter the tone of isolated, pre-contracted guinea pig tracheal chains, as well as for its possible mechanism(s) of action. Using serial dilutions between 0.0025 and 2.5 mg/mL, the extract was found to cause a dose-dependent increase in the force of muscle contraction. The EC(50) value was 0.46 +/- 0.01 mg/mL. The concomitant use of acetylcholine 10(-5) M did not significantly affect the force of contraction induced by the extract. Histamine 10(-5) M added at about 40% to, and salbutamol 10(-6) M antagonized by about 30% its constrictive effect. Chlorpheniramine 10(-6) M, propanolol 10(-5) M, and nifedipine 10(-6) M did not significantly influence the extract-induced force of contraction, but atropine 3 x 10(-7) M reduced it by approximately 60%. These data suggest that the Solanum melongena extract exerted a bronchospasmogenic rather than a bronchospasmolytic effect, probably through muscarinic receptor stimulation.

A female with central anticholinergic syndrome responsive to neostigmine

Central anticholinergic syndrome is a rarely observed condition in children. The occurrence of this syndrome after ingestion of Solanum pseudocapsicum is infrequent because findings tend to be milder and localized to the gastrointestinal system, without central nervous system involvement. Most patients do not present with diagnostic problems because their relatives can usually report any ingestion of poisonous agents; however, when drug poisoning or plant ingestion is uncertain, a differential diagnosis with encephalitis must be considered. Physostigmine salicylate is the specific antidote because it crosses the blood-brain barrier because of its tertiary ammonium group. Neostigmine methylsulfate has a quaternary ammonium group, which prevents its penetration through the blood-brain barrier; hence its primary influence is believed to be due to its action on the peripheral nervous system. We describe a female with central anticholinergic syndrome caused by ingestion of Solanum pseudocapsicum. A slow intravenous infusion of neostigmine methylsulfate (0.03 mg/kg) immediately resolved the clinical picture. To our knowledge, this case is the first reported of central anticholinergic syndrome occurring after ingestion of Solanum pseudocapsicum in a child and the first report of a complete and rapid remission after intravenous neostigmine methylsulfate administration.

Poisonous Plants: Perils in Nature

Poisonous plants are of great concern to any parent or health care practitioner. Household and landscape plants account for 7.1 % of all poisonous exposures in children. Many parents and health care professionals are aware of other potential poisons in the house; however, many times plants are overlooked as a potential poison. Though most plants are associated with only minor symptoms from dermal contact or ingestion, there are some that are associated with significant toxic effects that can be fatal. Poisonous plants are classified as anticholinergic, cardiac glycoside, cyanogenic, central nervous system stimulant/hallucinogens and severe gastrointestinal irritants. Many times these toxic plants produce a multitude of symptoms called a toxidrome. It is important for health care professionals to recognize these toxidromes and be knowledgeable about the proper treatment modalities.

Poisoning by plant material: review of human cases and analytical determination of main toxins by high-performance liquid chromatography-(tandem) mass spectrometry

The authors have reviewed the main toxic plants responsible for human deaths throughout the world. Forty plants (genera or species) were listed in order to establish an inventory of the active molecules that could be identified, the already published analytical methods and the reported human fatal cases. In a second step, the authors have developed a general method for the detection of various toxins in whole blood by high-performance liquid chromatography coupled to mass spectrometry or tandem mass spectrometry. Sample preparation was realized by liquid-liquid extraction at pH 9.5 for oleandrine, taxol and the alkaloids. These latter compounds were divided into two groups following their chemical properties and could be subsequently purified by acid/base clean up. Cyanogenic compounds and atractyloside were isolated by precipitation of the protein content with acetone and purified for atractyloside by washing with chloroform. Separation of the drugs occurred under reversed-phase conditions on a C18 analytical column 150x2 mm I.D. (5 microm particle size) using two different mobile phases. The first one, formiate buffer 2 mM acidified at pH 3.0, was used for the separation of atractyloside, oleandrine, taxol, the cyanogenic molecules and some alkaloids. The second mobile phase, formiate buffer 10 mM made basic at pH 8.2 was used for the majority of other alkaloids. A gradient elution mode was chosen using acetonitrile or acetonitrile-methanol (50:50, v/v) as the eluting solvent. Detection under positive ionization mode was the mode of choice for all compounds except for atractyloside (negative ions) and for taxol (mixed mode available). Application to real forensic cases has been demonstrated.