Deadly nightshade (Atropa belladonna) intoxication: an analysis of 49 children

An insight into recent updates on analytical techniques for bioactive alkaloids

INTRODUCTION

Alkaloids represent a wide class of naturally existing nitrogen-containing organic compounds having diverse biological activities. They are primary bioactive substances extracted from diverse plant parts. Due to their diverse biological activities, they are frequently used as medicines. The alkaloids have diverse pharmacological impacts on the human body; alkaloids are used for prevention, treatment, and reduction of discomfort associated with chronic illnesses. As most alkaloids exist in plants in complex form, combined with numerous other natural plant components, it is essential to recognize and characterize these molecules using different analytical techniques.

OBJECTIVES

We aimed to review the literature on the methods and protocols for the analysis of naturally occurring alkaloids.

METHODS

We carried out a literature survey using the PubMed, Scopus, and Google Scholar databases and other relevant published materials. The keywords used in the searches were "alkaloids," "analytical methods," "HPLC method," "GC method," "electrochemical methods," and "bioanalytical methods," in various combinations.

RESULTS

In this article, several classes of alkaloids are presented, along with their biological activities. Moreover, it includes a thorough explanation of chromatographic techniques, hyphenated techniques, electrochemical techniques, and current trending analytical methods utilized for the isolation, identification, and comprehensive characterization of alkaloids.

CONCLUSIONS

The various analytical techniques play an important role in the identification as well as the characterization of various alkaloids from plants, plasma samples, and urine samples. The hyphenation of various chromatographic techniques with mass spectrometry and NMR spectroscopy plays a crucial role in the characterization of unknown compounds.

Safety profile of herbal medicines submitted for marketing authorization in Tanzania: a cross-sectional retrospective study

BACKGROUND

The popular use of herbal medicines necessitates national regulatory authorities to have efficient mechanisms for the control of these products including marketing authorization (MA) and safety follow-up. Herbal medicines like conventional medicines require assessment of efficacy, safety and quality information before MA can be granted. However, the complete proof of safety is mainly based on the history of the long-term traditional use. Herbal medicines can cause adverse reactions due to various factors and thus require clinical trials to ensure their safety. Herbal medicines treatment practices involve combinations of different plants to achieve the desired effect while multiple herbal components have been known to cause herbal-herbal toxicity and interactions due to variety of complex active ingredients in plants. Compliance with regulatory requirements on herbal medicines has been shown to be difficult for manufacturers since different countries have different regulatory requirements with wide variations which results in the MA of very few herbal medicines. Limited studies on dossiers of marketing authorization of herbal medicines have been performed in other countries, with no studies in African regulatory system settings. The aim of this study is to determine the type of safety documentation that is submitted on herbal medicines application dossiers to support MA in Tanzania.

METHODS

A cross-sectional retrospective study of herbal medicines dossiers submitted at the Tanzania Medicines and Medical Devices Authority from 2009 to 2020 was conducted.

RESULTS

As many as 75% of the herbal products applications were combination products made by more than one herbal substance or plant. Out of 84 dossiers subjected to analysis the majority did not provide evidence of preclinical (55%) and clinical safety data (68%). Evidence of safety data in humans was mostly from the literature (70%) and not manufacturers' clinical studies. Quality parameters with safety implications were not included in 48% and 23% of the active herbal substance and finished product specifications, respectively.

CONCLUSION

Analysis of the herbal medicine dossiers submitted showed major deficiencies of safety data to support MA. Manufactures need to provide evidence to support the safety of their products for evidence-based regulatory decisions and to avoid multiple reviews of the applications.

The powerful Solanaceae: Food and nutraceutical applications in a sustainable world

The Solanaceae family is considered one of the most important families among plant species because, on one hand encompasses many staple food crops of the human diet while, on the other hand, it includes species rich in powerful secondary metabolites that could be valorized in medicine or drug formulation as well as nutraceuticals and food supplements. The main genera are Solanum, Capsicum, Physalis, and Lycium which comprise several important cultivated crops (e.g., tomato, pepper, eggplant, tomatillo, and goji berry), as well as genera notable for species with several pharmaceutical properties (e.g., Datura, Nicotiana, Atropa, Mandragora, etc.). This chapter discusses the nutritional value of the most important Solanaceae species commonly used for their edible fruit, as well as those used in the development of functional foods, food supplements, and nutraceuticals due to their bioactive constituents. The toxic and poisonous effects are also discussed aiming to highlight possible detrimental consequences due to irrational use. Finally, considering the high amount of waste and by-products generated through the value chain of the main crops, the sustainable management practices implemented so far are presented with the aim to increase the added-value of these crops.

Poisoning by Plants

BACKGROUND

Questions on poisoning by plants are a common reason for inquiries to poison information centers (PIC). Over the years 2011-2020, plant poisoning was the subject of 15% of all inquiries to the joint poison information center in Erfurt, Germany (Gemeinsames Giftinformationszentrum Erfurt, GGIZ) that concerned poisoning in children (2.3% in adults). In this patient collective, plant poisoning occupied third place after medical drugs (32%) and chemical substances (24%), and was a more common subject of inquiry than mushroom poisoning (1.5%).

METHODS

This review is based on pertinent publications retrieved by a selective literature search in PubMed/TOXLINE on plant poisoning and on 12 epidemiologically and toxicologically relevant domestic species of poisonous plants in risk categories 2 and 3 (up to 2021).

RESULTS

Medical personnel should have basic toxicological knowledge of the following highly poisonous plants: wolfsbane (aconitum), belladonna, angel's trumpet, cowbane (cicuta virosa), autumn crocus, hemlock, jimson weed, henbane, castor bean (ricinus), false hellebore, foxglove (digitalis), and European yew. The intoxication is evaluated on the basis of a structured history (the "w" questions) and the clinical manifestations (e.g., toxidromes). Special analysis is generally not readily available and often expensive and time-consuming. In case of poisoning, a poison information center should be contacted for plant identification, risk assessment, and treatment recommendations. Specimens of plant components and vomit should be obtained, if possible, for further testing. Measures for the elimination of the poisonous substance may be indicated after a risk-benefit analysis. Specific antidotes are available for only a few types of plant poisoning, e.g., physostigmine for tropane alkaloid poisoning or digitalis antibodies for foxglove poisoning. The treatment is usually symptomatic and only rarely evidence-based. Individualized medical surveillance is recommended after the ingestion of large or unknown quantities of poisonous plant components.

CONCLUSION

The clinician should be able to recognize dangerous domestic species of poisonous plants, take appropriate initial measures, and avoid overdiagnosis and overtreatment. To improve patient care, systematic epidemiological and clinical studies are needed.

A sabbath in the emergency room or a case of anticholinergic toxicity?

We report the case of a 32-year-old Italian man admitted to our emergency room for visual disturbances with blurred vision, anisocoria and temporal headache suddenly occurred in absence of other neurological symptoms. A diagnosis of Datura stramoniuminduced anticholinergic toxicity was done. With our work, we want to highlight the importance of a meticulous clinical examination, including papillary diameter and reflexes, combined with a detailed history of the patient in the emergency room. Anticholinergic toxicity is a medical emergency. The diagnosis is always clinical, and it can represent a challenge for the emergency clinicians because it can mimic several neurological diseases, including acute stroke and seizures, but early diagnosis is crucial to avoid severe complications and management errors.

Dark Classics in Chemical Neuroscience: An Evidence-Based Systematic Review of Belladonna

Belladonna has diverse pharmacotherapeutic properties with a shadowy history of beauty, life, and death. Alkaloids present in belladonna have anti-inflammatory, anticholinergic, antispasmodic, mydriatic, analgesic, anticonvulsant, and antimicrobial activities, which makes it widely applicable for the treatment of various diseases. However, because of its associated toxicity, the medicinal use of belladonna is debatable. Therefore, an evidence-based systematic review was planned to elucidate the pharmacotherapeutic potential of belladonna. A comprehensive literature search was performed in PubMed, MEDLINE, the Cochrane database, Embase, and ClinicalTrials.gov using the keywords "belladonna", "belladonna and clinical trials", and "safety and efficacy of belladonna". Articles published from 1965 to 2020 showing the efficacy of belladonna in diverse clinical conditions are included. The quality of evidence was generated using the GRADE approach, and 20 studies involving 2302 patients were included for the systematic review. Our analyses suggest that belladonna treatment appears to be safe and effective in various disease conditions, including acute encephalitis syndrome, urethral stent pain, myocardial ischemia injury, airway obstructions during sleep in infants, climacteric complaints, irritable bowel syndrome, and throbbing headache. However, better understanding of the dosage and the toxicity of tropane alkaloids of belladonna could make it an efficient remedy for treating diverse medical conditions.

Atropine eye-drop-induced acute delirium: a case report

Atropine is an anticholinergic drug which is used in both parental and topical routes. Topical eye-drops of atropine sulfate are used as mydriatic and cycloplegics. Parental atropine-induced delirium is well known but topical atropine eye-drop-induced delirium cases are very limited in literature. In this case report, an elderly man underwent cataract surgery and developed delirium after the use of 1% atropine sulfate eye-drops as prescribed. This case supports the notion that even atropine eye-drops can cause delirium in patients at therapeutic doses in elderly.

Closing the Gap Between Therapeutic Use and Mode of Action in Remedial Herbs

The ancient tradition of taking parts of a plant or preparing plant extracts for treating certain discomforts and maladies has long been lacking a scientific rationale to support its preparation and still widespread use in several parts of the world. In an attempt to address this challenge, we collected and integrated data connecting metabolites, plants, diseases, and proteins. A mechanistic hypothesis is generated when a metabolite is known to be present in a given plant, that plant is known to be used to treat a certain disease, that disease is known to be linked to the function of a given protein, and that protein is finally known or predicted to interact with the original metabolite. The construction of plant–protein networks from mutually connected metabolites and diseases facilitated the identification of plausible mechanisms of action for plants being used to treat analgesia, hypercholesterolemia, diarrhea, catarrh, and cough. Additional concrete examples using both experimentally known and computationally predicted, and subsequently experimentally confirmed, metabolite–protein interactions to close the connection circle between metabolites, plants, diseases, and proteins offered further proof of concept for the validity and scope of the approach to generate mode of action hypotheses for some of the therapeutic uses of remedial herbs.

Atropa belladonna Expresses a microRNA (aba-miRNA-9497) Highly Homologous to Homo sapiens miRNA-378 (hsa-miRNA-378); both miRNAs target the 3'-Untranslated Region (3'-UTR) of the mRNA Encoding the Neurologically Relevant, Zinc-Finger Transcription Factor ZNF-691

Recent advances in ethnobotanical and neurological research indicate that ingested plants from our diet may not only be a source of nutrition but also a source of biologically relevant nucleic-acid-encoded genetic information. A major source of RNA-encoded information from plants has been shown to be derived from small non-coding RNAs (sncRNAs) such as microRNAs (miRNAs) that can transfer information horizontally between plants and humans. In human hosts, the 3'-untranslated region (3'-UTR) of messenger RNAs (mRNAs) is targeted by these miRNAs to effectively down-regulate expression of that mRNA target in the host CNS. In this paper, we provide evidence that the Atropa belladonna aba-miRNA-9497 (miRBase conserved ID: bdi-miRNA-9497) is highly homologous to the CNS-abundant Homo sapiens miRNA-378 (hsa-miRNA-378) and both target the zinc-finger transcription factor ZNF-691 mRNA 3'-UTR to down-regulate ZNF-691 mRNA abundance. We speculate that the potent neurotoxic actions of the multiple tropane alkaloids of Atropa belladonna may be supplemented by the neuroregulatory actions of aba-miRNA-9497 on ZNF-691, and this may be followed by the modulation in the expression of ZNF-691-sensitive genes. This is the first example of a human brain-enriched transcription factor, ZNF-691, targeted and down-regulated by a naturally occurring plant microRNA, with potential to modulate gene expression in the human CNS and thus contribute to the neurotoxicological-and-psychoactive properties of the Atropa belladonna species of the deadly nightshade Solanaceae family.

Efficacy of treatment with belladonna in children with severe pallid breath-holding spells

IntroductionPallid breath-holding spells are common and dramatic forms of recurrent syncope in infancy. They are very stressful despite their harmless nature and sometimes require treatment.

OBJECTIVE

The objective of this study was to evaluate the efficacy of belladonna in severe breath-holding spells.

METHODS

This is a multicentric, retrospective series involving 84 children with severe pallid breath-holding spells. Inclusion criteria were >1 pallid breath-holding spell with loss of consciousness, paediatric cardiology evaluation, and follow-up >6 months. In total, 45 patients received belladonna and 39 patients did not receive treatment, according to physician preference.

RESULTS

Mean age was 11 months, ranging from 4 to 18 months, with 54% of males. Mean spell duration was 30 seconds (interquartile range 15, 60), and the frequency was four episodes per month (interquartile range 0.5, 6.5). Comparison of baseline characteristics between groups showed similar demographics, with the single difference in the severity of the spells, being more severe in the treated group. When comparing the treated and non-treated groups at 3 months, only two (5%) patients had a complete remission in the first group, whereas 20 (44%) had remission in the belladonna group (p<0.01). When considering the characteristics of the spells before and after the initiation of treatment with belladonna, 75% of the patients presented a positive response, with 44% of the patients presenting with complete resolution of the spells (p<0.01). No major adverse reaction was reported, with only 5% minor adverse events.

CONCLUSIONS

Belladonna is highly effective to alleviate severe breath-holding spells in young children, without any major adverse effects.

Comprehensive review of cardiovascular toxicity of drugs and related agents

Cardiovascular diseases are a leading cause of morbidity and mortality in most developed countries of the world. Pharmaceuticals, illicit drugs, and toxins can significantly contribute to the overall cardiovascular burden and thus deserve attention. The present article is a systematic overview of drugs that may induce distinct cardiovascular toxicity. The compounds are classified into agents that have significant effects on the heart, blood vessels, or both. The mechanism(s) of toxic action are discussed and treatment modalities are briefly mentioned in relevant cases. Due to the large number of clinically relevant compounds discussed, this article could be of interest to a broad audience including pharmacologists and toxicologists, pharmacists, physicians, and medicinal chemists. Particular emphasis is given to clinically relevant topics including the cardiovascular toxicity of illicit sympathomimetic drugs (e.g., cocaine, amphetamines, cathinones), drugs that prolong the QT interval, antidysrhythmic drugs, digoxin and other cardioactive steroids, beta-blockers, calcium channel blockers, female hormones, nonsteroidal anti-inflammatory, and anticancer compounds encompassing anthracyclines and novel targeted therapy interfering with the HER2 or the vascular endothelial growth factor pathway.

Plant toxins and acute medicinal plant poisoning in children: A systematic literature review

BACKGROUND

For many years, medicinal plants and herbal therapy have been widely used in different societies for the treatment of various diseases. Besides their therapeutic potency, some of the medicinal plants have strong toxicity in human, especially in children and elderly. Despite common beliefs that natural products are safe, there have been few reports on their toxicities.

MATERIALS AND METHODS

In the present study, we aimed to systematically review the literature wherein acute plant poisoning and herbal intoxication have been reported in pediatric patients. After literature search and selection of the appropriate documents, the desired data were extracted and described qualitatively.

RESULTS

A total of 127 articles with overall 1453 intoxicated cases were collected. The results of this study showed that some medicinal plants can cause acute poisoning and complications such as hepatic and renal failure in children.

CONCLUSION

The findings of this survey showed that acute plant poisoning can be life?threatening in children, and since a single?ingested dose of toxic plants can cause acute poisoning, parents should be aware of these toxic effects and compare the side effects of self?medication with its potential benefits.

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.

Poisonous or non-poisonous plants? DNA-based tools and applications for accurate identification

Plant exposures are among the most frequently reported cases to poison control centres worldwide. This is a growing condition due to recent societal trends oriented towards the consumption of wild plants as food, cosmetics, or medicine. At least three general causes of plant poisoning can be identified: plant misidentification, introduction of new plant-based supplements and medicines with no controls about their safety, and the lack of regulation for the trading of herbal and phytochemical products. Moreover, an efficient screening for the occurrence of plants poisonous to humans is also desirable at the different stages of the food supply chain: from the raw material to the final transformed product. A rapid diagnosis of intoxication cases is necessary in order to provide the most reliable treatment. However, a precise taxonomic characterization of the ingested species is often challenging. In this review, we provide an overview of the emerging DNA-based tools and technologies to address the issue of poisonous plant identification. Specifically, classic DNA barcoding and its applications using High Resolution Melting (Bar-HRM) ensure high universality and rapid response respectively, whereas High Throughput Sequencing techniques (HTS) provide a complete characterization of plant residues in complex matrices. The pros and cons of each approach have been evaluated with the final aim of proposing a general user's guide to molecular identification directed to different stakeholder categories interested in the diagnostics of poisonous plants.

The effect of atropine on rhythm and conduction disturbances during 322 critical care intubations

OBJECTIVES

Our objectives were to describe the prevalence of arrhythmia and conduction abnormalities before critical care intubation and to test the hypothesis that atropine had no effect on their prevalence during intubation.

DESIGN

Prospective, observational study.

SETTING

PICU and pediatric/neonatal intensive care transport.

SUBJECTS

All children of age less than 8 years intubated September 2007-2009. Subgroups of intubations with and without atropine were analyzed.

INTERVENTION

None.

MEASUREMENT AND MAIN RESULTS

A total of 414 intubations were performed in the study period of which 327 were available for analysis (79%). Five children (1.5%) had arrhythmias prior to intubation and were excluded from the atropine analysis. Atropine was used in 47% (152/322) of intubations and resulted in significant acceleration of heart rate without provoking ventricular arrhythmias. New arrhythmias during intubation were related to bradycardia and were less common with atropine use (odds ratio, 0.14 [95% CI, 0.06-0.35], p < 0.001). The most common new arrhythmia was junctional rhythm. Acute bundle branch block was observed during three intubations; one Mobitz type 2 rhythm and five ventricular escape rhythms occurred in the no-atropine group (n = 170). Only one ventricular escape rhythm occurred in the atropine group (n = 152) in a child with an abnormal heart. One child died during intubation who had not received atropine.

CONCLUSIONS

Atropine significantly reduced the prevalence of new arrhythmias during intubation particularly for children over 1 month of age, did not convert sinus tachycardia to ventricular tachycardia or fibrillation, and may contribute to the safety of intubation.

Anticholinergic Toxic Syndrome Caused by Atropa Belladonna Fruit (Deadly Nightshade): A Case Report

Atropa Belladonna poisoning may lead to anticholinergic syndrome. Ingestion of high amounts of the plant may cause lethargy, coma, and even a serious clinical picture leading to death. In this case report, we aimed to present a case with anticholinergic syndrome that developed after ingestion of the fruit called "Deadly Nightshade" in our country.

Ethnobotanical study in the Madonie Regional Park (Central Sicily, Italy)--medicinal use of wild shrub and herbaceous plant species

ETHNOPHARMACOLOGICAL RELEVANCE

This paper illustrates the results of an ethnobotanical study carried out in the Madonie Regional Park (Central Sicily, Italy). It specifies the medicinal uses of plants in the study area and contains the results of a quantitative analysis carried out for the first time in an area noted for its high degree of biodiversity. It also introduces 28 species not previously accounted for in the area of study for their medicinal uses, highlighting Silene flos-cuculi L. Greuter & Burdet, little known as medicinal in the Mediterranean area.

AIM OF THE STUDY

To understand to what extent current knowledge on medicinal-use plants is still an element of the culture within the elderly population of the Madonie Regional Park.

METHODOLOGY

The information was obtained using a semi-structured interview format performed on 150 informants over the age of 60 who were considered experts in plants and rural traditions. The taxa were identified and the results were analysed also using a range of quantitative ethnobotanical indices.

RESULTS

A census was made of 174 wild plant species, 100 of which with medicinal and veterinary uses, belonging to 49 botanical families. Of the 170 endemic species found in the Madonie Regional Park, only 2 species were cited in this study for medicinal purposes. Most of the species were used against dermatological diseases, general health and metabolic disorders. The leaves were the most-used parts of the plant and the most common preparation methods were decoction and infusion. The level of knowledge on medicinal uses of the plants was not found to be high within the elderly population, demonstrating an ongoing process of cultural erosion.

CONCLUSIONS

Only very few medicinal uses are widely known by all the informants and, on many occasions, a specific medicinal use was cited by only very few people. Further study is required in order to find out to what extent knowledge on the medicinal use of plants is still present in the younger generations in this area of Sicily, and what methods might be adopted in order to halt this gradual loss in knowledge.

Toxicology in the ICU: part 3: natural toxins

This is the third article of a three-part series that reviews the care of poisoned patients in the ICU. This article focuses on natural toxins, such as heavy metals and those produced by plants, mushrooms, arthropods, and snakes. The first article discussed the general approach to the patient, including laboratory testing; the second article focused on specific toxic agents, grouped into categories.

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.

[Deadly nightshade (Atropa belladonna) intoxication in a 2-year-old child]

Plant intoxications account for 5% of all intoxication cases according to French anti-poison centers. We report an uncommon case of intoxication with deadly nightshade (Atropa belladonna) in a 2-year-old child. The child presented at the ER with an atropinic syndrome, both central and peripheral, after ingestion of wild berries a few hours before. The fruit and leaves brought in by the mother allowed the anti-poison center to identify belladonna, in agreement with clinical findings. The child was kept in the intensive care unit for 48 h and progression was favorable with symptomatic treatment.