Role of anthraquinones in Cassia occidentalis induced hepato-myo-encephalopathy

ETHNOPHARMACOLOGICAL RELEVANCE

The different plant parts of Cassia occidentalis Linn, (CO) such as root, leaves, seeds and pods have traditionally been used in multifarious medicines for the treatment of dysentery, diarrhea, constipation, fever, eczema, cancer and venereal diseases.

MATERIALS AND METHODS

A systematic search of literature has been done in books and scientific databases like Science Direct, Pubmed, Google Scholar and Scopus etc. These sources were used to compile, analyze and review the information regarding the phytochemistry, toxicology and mechanism of toxicity of CO. The various references on this subject are cited in our review ranging from 1956 to 2019.

RESULTS

Unintentional exposure of CO causes serious pathological condition in children, known as hepato-myo-encephalopathy (HME). The toxicity after CO consumption is associated with the presence of anthraquinones (AQs), a class of secondary plant metabolites. These AQs at high concentrations are known to cause detrimental effects on essential vital organs such as liver, kidney, spleen, brain, muscle and reproductive organs. The animal studies in rodent models as well as clinical investigations have clearly revealed that CO toxicity is associated with enhanced hepatotoxicity serum markers (ALT, AST, and LDH) and presence of necrotic lesions in liver. Furthermore, CO also causes vacuolization in muscle tissue and increases the level of CPK which is a prominent muscle damage marker. Apart from these target organs, CO consumption also causes neuronal damage via disturbing the levels of different proteins such as (GFAP and b-tubulin III). The mechanistic studies show that AQs present in CO have the potential to disturb the cellular homeostasis via binding to DNA, increasing the production ROS and showing inhibitory effects on essential enzymes etc. Therefore, AQs have been observed to be the primary culprit agents contributing to the toxicity of CO in children and animals.

CONCLUSION

Despite its therapeutic potential, CO consumption can be detrimental if consumed in high amounts. A thorough analysis of literature reveals that AQs are the primary factors contributing to toxicity of CO seeds. Exposure to CO seeds causes HME, which is a serious life threatening condition for the malnourished children from lower strata. Multiple mechanisms are involved in the CO induced HME in patients. Lack of appropriate diagnostic measures and a poor understanding of the CO toxicity mechanism in humans and animals complicate the clinical management of CO poisoning subjects. Therefore, development of point of care diagnostic kits shall help in early diagnosis & suitable management of CO poisoning.

Near-fatal poisoning after ricin injection

OBJECTIVE

To report a near-fatal poisoning after intentional injection of ricin from a castor bean (Ricinus communis) extract.

CASE REPORT

A 21 year-old man self-injected ∼3 mL of a castor bean extract intramuscularly and subcutaneously in the left antecubital fossa. Upon admission to our ED (1 h post-exposure; day 1, D1) he was awake and alert, but complained of mild local pain and showed slight local edema and erythema. He evolved to refractory shock (∼24 h post-exposure) that required the administration of a large volume of fluids and high doses of norepinephrine and vasopressin, mainly from D2 to D4. During this period, he developed clinical and laboratory features compatible with systemic inflammatory response syndrome, multiple organ dysfunction, capillary leak syndrome, rhabdomyolysis, necrotizing fasciitis and possible compartment syndrome. The patient underwent forearm fasciotomy on D4 and there was progressive improvement of the hemodynamic status from D7 onwards. Wound management involved several debridements, broad-spectrum antibiotics and two skin grafts. Major laboratory findings within 12 days post-exposure revealed hypoalbuminemia, proteinuria, thrombocytopenia, leukocytosis and increases in cytokines (IL-6, IL-10 and TNF-α), troponin and creatine kinase. Ricin A-chain (ELISA) was detected in serum up to D3 (peak at 24 h post-exposure), with ∼79% being excreted in the urine within 64 h post-exposure. Ricinine was detected in serum and urine by LC-MS up to D5. A ricin A-chain concentration of 246 µg/mL was found in the seed extract, corresponding to the injection of ∼738 µg of ricin A-chain (∼10.5 µg/kg). The patient was discharged on D71, with limited range of motion and function of the left forearm and hand.

CONCLUSION

Ricin injection resulted in a near-fatal poisoning that evolved with septic shock-like syndrome, multiple organ dysfunction and necrotizing fasciitis, all of which were successfully treated with supportive care.

Raising antibodies against epoxyscillirosidine, the toxic principle contained in Moraea pallida Bak. (Iridaceae), in rabbits

Moraea pallida Bak. (yellow tulp) poisoning is the most important plant cardiac glycoside toxicosis in South Africa. The toxic principle, a bufadienolide, is 1α, 2α-epoxyscillirosidine. The aim was to investigate the potential to develop a vaccine against epoxyscillirosidine. Epoxyscillirosidine, proscillaridin and bufalin, were successfully conjugated to hen ovalbumin (OVA), bovine serum albumin (BSA) and keyhole limpet haemocyanin (KLH). There was a low immune response following vaccination of adult male New Zealand White rabbits with epoxyscillirosidine-OVA (n = 3) and OVA (n = 3) using Freund's adjuvant in Trial (T) 1. The immune response improved significantly in T2 following doubling of the dose to 0.8 mg/rabbit and changing the adjuvant to Montanide. In T3, the rabbits (n = 15), allocated into 5 equal groups, vaccinated with proscillaridin-BSA, bufalin-BSA, epoxyscillirosidine-KLH, epoxyscillirosidine-BSA and BSA respectively, using Montanide adjuvant, developed antibodies against the administered immunogens, with epoxyscillirosidine-KLH inducing the highest immune response. Proscillaridin and bufalin antibodies cross-reacted with epoxyscillirosidine in an enzyme linked immunosorbent assay. The conjugation methodology will be adjusted in the future to target optimal conjugation efficiency. Additional vaccination will be conducted in search of neutralizing antibodies against the yellow tulp toxin. The cross-reactivity of proscillaridin and bufalin antibodies with epoxyscillirosidine could be studied in future to explore the potential to prevent yellow tulp poisoning.

Lethal Injection of a Castor Bean Extract: Ricinine Quantification as a Marker for Ricin Exposure Using a Validated LC-MS/MS Method

Ricin is a highly toxic agent derived from the castor bean plant (Ricinus communis). Poisoning occurs commonly by oral ingestion of the beans. Injection of ricin is believed to be more lethal. Ricin is a large glycosylated protein difficult to detect in clinical samples. Instead, ricinine, a small alkaloid found in the same beans, is used as surrogate marker for ricin exposure. We describe a simple LC-MS/MS method for the detection of ricinine in serum, blood and urine, validated according to EMA guidelines and successfully applied to patient samples of a suicidal death after injection of a castor bean extract. A 26-year-old man self-presented to the emergency department with severe abdominal cramps and nausea after injection of a castor bean extract. Due to rapid deterioration of his hemodynamic function despite early aggressive fluid resuscitation, he was transferred to ICU. Abdominal cramps worsened and a fulminant diarrhea developed, resulting in hypovolemic shock and cardiorespiratory collapse. Despite full supportive therapy, the patient died approximately 10 hours after injection due to multiple organ failure. Ricinine was quantified by LC-MS/MS after LLE with diethyl ether using ricinine-D3 as internal standard. Six hours after injection, ricinine concentrations in serum and blood were 16.5 and 12.9 ng/mL, respectively, which decreased to 12.4 and 10.6 ng/mL, 4 hours later. The urinary concentration was 81.1 ng/mL 7 hours after injection, which amply exceeded the levels previously reported in similar cases with lethal outcome. Concentrations of ricinine, compatible with a lethal exposure to castor beans, were detected in serum, blood and urine. Ricinine was also found in bile and liver tissue.

Pattern of Poisoning in a Tertiary Care Center with Special Reference to Odollam Poisoning

INTRODUCTION

Suicide is a major public health challenge in Kerala. Majority of adult poisoning is intentional. Most of those who attempt 'deliberate self harm' are young adults and many a time the reason is trivial.

OBJECTIVES

To find out the pattern of poisoning, prognostic factors in different type of poisoning, precipitating factors for deliberate self harm and to suggest preventive measures.

METHODOLOGY

This was a prospective observational study conducted among patients admitted with history of poisoning in a tertiary care centre in Kerala. Detailed history, physical examination, relevant lab investigations were done in all the patients. Psychiatric assessment and counselling was done in all survivors.

RESULTS

A total of 195 patients were included in this study-109 males and 86 females. The intention of poisoning was suicidal in 98.82% of cases. The mortality rate was 13.33%. Common poisons consumed were odollam, drugs, pesticides and rodenticides. Majority of deaths were due to organophosphorous compounds (42.31%) followed by odollam (38.46%). The common precipitating factors were family problems, personal stressors and marital discord in both sexes. Psychiatric assessment showed adjustment disorder as the commonest problem followed by impulsive act.

CONCLUSION

The common poisons ingested are organophosphorous compounds, drugs and odollam. Organophosphorous and odollam carries higher mortality. Pesticide regulation, use of less toxic pesticides in agriculture, early management and quick referral to well equipped hospitals will help in reducing mortality. Suicide prevention programmes like psychosocial support and counselling, raising public awareness about deliberate self harm and alcohol de-addiction programmes will help in reducing the incidence of deliberate self harm.

Cade oil poisoning: about a case

Throughout Morocco, cade oil is used in folk medicine for many purposes, in particular for atopic dermatosis. It is also used as a wormer. Cade oil poisoning of newborns and infants thus often has an iatrogenic origin, resulting especially from the ingestion of a significant amount or from a prolonged and extensive cutaneous application. Thus, this oil, used for therapeutic purposes, is responsible for a non-negligible number of cases of poisoning, some fatal. We report a case of poisoning after cutaneous application of cade oil in a 2-month-old infant. The outcome was fatal. This report calls attention to the real possibility of this event and emphasizes the interest of preventing it by promoting information to families in Morocco.

Rare tradition of the folk medicinal use of Aconitum spp. is kept alive in Solčavsko, Slovenia

BACKGROUND

Aconitum species are poisonous plants that have been used in Western medicine for centuries. In the nineteenth century, these plants were part of official and folk medicine in the Slovenian territory. According to current ethnobotanical studies, folk use of Aconitum species is rarely reported in Europe. The purpose of this study was to research the folk medicinal use of Aconitum species in Solčavsko, Slovenia; to collect recipes for the preparation of Aconitum spp., indications for use, and dosing; and to investigate whether the folk use of aconite was connected to poisoning incidents.

METHODS

In Solčavsko, a remote alpine area in northern Slovenia, we performed semi-structured interviews with 19 informants in Solčavsko, 3 informants in Luče, and two retired physicians who worked in that area. Three samples of homemade ethanolic extracts were obtained from informants, and the concentration of aconitine was measured. In addition, four extracts were prepared according to reported recipes.

RESULTS

All 22 informants knew of Aconitum spp. and their therapeutic use, and 5 of them provided a detailed description of the preparation and use of "voukuc", an ethanolic extract made from aconite roots. Seven informants were unable to describe the preparation in detail, since they knew of the extract only from the narration of others or they remembered it from childhood. Most likely, the roots of Aconitum tauricum and Aconitum napellus were used for the preparation of the extract, and the solvent was homemade spirits. Four informants kept the extract at home; two extracts were prepared recently (1998 and 2015). Three extracts were analyzed, and 2 contained aconitine. Informants reported many indications for the use of the extract; it was used internally and, in some cases, externally as well. The extract was also used in animals. The extract was measured in drops, but the number of drops differed among the informants. The informants reported nine poisonings with Aconitum spp., but none of them occurred as a result of medicinal use of the extract.

CONCLUSIONS

In this study, we determined that folk knowledge of the medicinal use of Aconitum spp. is still present in Solčavsko, but Aconitum preparations are used only infrequently.

A Comprehensive Study of Easter Lily Poisoning in Cats

This study was conducted with 3 objectives in mind: first, to identify the toxic fraction (aqueous or organic) in leaves and flowers; second, to identify diagnostic marker(s) of toxicosis in cats; and, third, to evaluate the morphologic effects of intoxication. The study was conducted in 2 phases. Phase 1 was to identify which extract, organic or aqueous, was nephrotoxic and also to determine the appropriate dose for use in the phase 2 studies. Results indicated that only the aqueous extracts of leaves and flowers were nephrotoxic and pancreotoxic. To identify the proximate toxic compound, cats in the phase 2 study were orally exposed to subfractions of the aqueous flower extract, 1 subfraction per cat. Results confirmed vomiting, depression, polyuria, polydipsia, azotemia, glucosuria, proteinuria, and isosthenuria as toxic effects of the Easter lily plant. Another significant finding in serum was elevated creatinine kinase. Significant histologic kidney changes included acute necrosis of proximal convoluted tubules and degeneration of pancreatic acinar cells. Renal ultrastructural changes included swollen mitochondria, megamitochondria, edema, and lipidosis. Subfraction IIa3 of the aqueous floral extract contained most of the toxic compound(s). These studies reproduced the clinical disease, identified the most toxic fraction of the Easter lily, and helped characterize the clinical pathology, histopathology, and ultrastructural pathology associated with the disease.

Acute caffeine poisoning resulting in atrial fibrillation after guarana extract overdose

Guarana (Paullinia cupana) is the climbing vine native to Amazon Basin, characterized by high caffeine content in its seeds. Guarana extract is a common ingredient of energy drinks used in order to boost energy and physical endurance and increase alertness. Severe caffeine intoxication is rare, but may be life-threatening mostly due to supraventricular and ventricular dysrhythmias.

OBJECTIVES

We present the case of intentional caffeine poisoning after ingestion of tablets containing guarana extract, complicated by atrial fibrillation.

CASE REPORT

A44-year-old man with no significant medical history was admitted to hospital about 21 h after ingestion of guarana extract containing 1.6 g of caffeine. Typical symptoms of caffeine toxicity, i.e. nausea, vomiting, anxiety and palpitaions, occurred shortly after ingestion. On admission, he was conscious, with blood pressure of 136/86 mmHg, heart rate of 106-113 beats per minute, fever of 37.8 °C, and symmetrically increased deep tendon reflexes. QTc interval in electrocardiogram was prolonged to 0.542 s. Laboratory tests revealed hypokalemia, hyperglycemia, leukocytosis, as well as elevated creatinine and creatine phosphokinase levels. Approximately 45 h post ingestion, the patient developed atrial fibrillation with fast ventricular rhythm. Tachydysrythmia subsided after infusion of amiodarone and restoration of electrolyte balance. Echocardiogram revealed presence of asymmetrical hypertrophy of the left ventricle with the systolic anterior motion of the mitral valve and normal left ventricular outflow tract gradient suggesting non-obstructive hypertrophic cardiomyopathy.

CONCLUSION

Acute caffeine poisoning may result in atrial fibrillation, especially in predisposed patients with underlying hypertrophic cardiomyopathy.

[Pathological changes in rats with acute Dysosma versipellis poisoning]

OBJECTIVE

To observe the pathological changes of major organs in rats with acute Dysosma versipellis poisoning and investigate the toxic mechanism and the injuries of target tissues and organs.

METHODS

Forty Sprague-Dawley (SD) rats were randomly divided into three experimental groups, which were given the gavage with 0.5, 1.0 and 2.0 LDo doses of Dysosma versipellis decoction, and one control group, which was given the gavage with 1.0 LD0 dose of normal saline. The rats were sacrificed 14 days after Dysosma versipellis poisoning and samples including brain, heart, liver, lung, and kidney were taken. After pathological process, the pathological changes of the major organs and tissues were observed by light microscope and electron microscope. The experimental data were statistical analyzed by chi2 test.

RESULTS

The observations of light microscopy: loose cytoplasm of neurons with loss of most Nissl bodies; swelling of myocardial cells with disappearance of intercalated disk and striations; hepatocellular edema with ballooning degeneration; and swelling epithelial cells of renal proximal convoluted tubule with red light coloring protein-like substances in the tube. The observations of electron microscopy: the structures of cell membrane and nuclear membrane of neurons were destroyed; cytoplasm of neurons, obvious edema; and most organelles, destroyed and disappeared. The mortalities of rats after acute poisoning of the four groups increased with doses (P < 0.05).

CONCLUSION

Acute Dysosma versipellis poisoning can cause multi-organ pathological changes. There is a positive correlation between the toxic effect and the dosage. The target tissues and organs are brain (neurons), heart, liver and kidney.

Gastric lavage guided by ultrathin transnasal esophagogastroduodenoscopy in a life-threatening case of tobacco extract poisoning: a case report

Nicotine, which is found in tobacco, is one of the most toxic of all known poisons. A 31-year-old woman was brought to our emergency department 2 hours after ingesting a usually fatal dose of a tobacco extract. Although gastric lavage was once commonly used to treat poisoning cases of this type, lavage can lead to such complications as aspiration, hypoxia, oropharyngeal and gastric trauma, and electrolyte disturbances. Recent guidelines have suggested less-aggressive gastric-emptying procedures as initial treatments. Currently, there are no absolute indications for gastric lavage use. The present patient had a history of depressive episodes and had attempted suicide by ingesting an extract derived from 20 cigarettes mixed with alcohol. There was no evidence of vomiting or seizures occurring before arrival of the ambulance. Physical examination revealed no signs of sweating, although the patient appeared to be confused, which is often seen with nicotine intoxication. She admitted using 2 kinds of cigarette, each of which typically contain 11.2 mg of nicotine. The patient's nicotine level was suspected to be higher than 40 to 60 mg, which is normally fatal. To determine whether gastric lavage was indicated in this case, we performed ultrathin transnasal esophagogastroduodenoscopy, which neither requires sedation nor compromises the airways. Although 2 hours had passed since ingestion, the tobacco extract and food were directly visualized within the stomach. Subsequently, gastric lavage was performed with 2,000 mL of water administered through a nasogastric tube. Ultrathin esophagogastroduodenoscopy made it possible to directly observe the gastric lavage and to ensure the stomach contents had been completely removed. No changes were noted in the vital signs, and no obstruction of the airways was observed. The patient recovered quickly and was discharged the following day. Ultrathin esophagogastroduodenoscopy helped determine the diagnosis and ensure that gastric lavage had been performed without complications.

[Acute poisoning with weight-loss dietary supplement falsely suggesting the use of amphetamine]

OBJECTIVE

We report a case of abuse of weight-loss dietary supplement in 27-year-old man, with characteristic for amphetamine sympathomimetic symptoms and positive analysis of this drug in the urine by immunoassay method (FPIA; Axsym, Abbott). However positive result was not confirmed by liquid chromatography coupled with tandem mass spectrometry (LC-MS-MS).

CASE REPORT

The patient ate nine tablets of the Thermal Pro with declared composition of caffeine (250 mg), bitter orange (200 mg), beta-phenylethylamine (100 mg), willow bark (75 mg), Cayenne pepper (40 mg), 1,3-dimethyloamyloamine (DMAA, 35 mg), gooseberry extract (20 mg), bergamot orange (20 mg), black pepper (5 mg), after two-month period of regular consumption at dose of 2-3 capsules per day. After 4 hours, during admission to the Department of Toxicology, patient manifested typical sympathomimetic symptoms: anxiety, agitation, pale skin, sweats, tachycardia 120/min, mydriasis. Following the outcome of detecting amphetamine/methamphetamine in the patient's urine at 2377 ng/mL concentration using FPIA method, drug intoxication was suspected. It was considered that the ingestion was intentional or unconscious of adulterated dietary supplement. In view of the strong opposition of the patient, who denied any use of psychoactive substances, it was decided to re-examine collected speciments. The liquid chromatography coupled to tandem mass spectrometry (LC-MS-MS) method did not confirm the presence of amphetamine in the patient's blood and urine. Based on the composition of dietary supplements for substances which could be responsible for the positive amphetamine result in urine by FPIA method and available literature data, it was concluded that the substances that may react in the immunoassay could be dimethylamyloamine (DMAA, geranamine) or bitter orange components.

CONCLUSION

False positive urinalysis towards amphetamine/methamphetamine by immunoassay and presence of sympathomimetic effects may contribute to a false diagnosis of this drug poisoning. Definitive confirmation of such intoxication requires the use of the reference methods.

Grayanotoxin poisoning: 'mad honey disease' and beyond

Many plants of the Ericaceae family, Rhododendron, Pieris, Agarista and Kalmia, contain diterpene grayanotoxins. Consumption of grayanotoxin containing leaves, flowers or secondary products as honey may result in intoxication specifically characterized by dizziness, hypotension and atrial-ventricular block. Symptoms are caused by an inability to inactivate neural sodium ion channels resulting in continuous increased vagal tone. Grayanotoxin containing products are currently sold online, which may pose an increasing risk. In humans, intoxication is rarely lethal, in contrast to cattle and pet poisoning cases. Scientific evidence for the medicinal properties of grayanotoxin containing preparations, such as honey or herbal preparation in use in folk medicine, is scarce, and such use may even be harmful.

Upper urinary tract urothelial cancers: where it is A:T

Despite a ban on the use of plants of the Aristolochia genus in herbal medicine, as they contain known carcinogens, urothelial carcinoma attributable to the use of this plant seems to be more common than previously thought.

Evaluation of sub-chronic oral toxicity of Joloo: a traditional medicinal decoction

CONTEXT

Joloo is a Nigerian herbal decoction used for managing breast tumor, ulcer, pain, fever and general malaise in southwestern Nigeria.

OBJECTIVE

The evaluation of the sub-chronic toxicity of Joloo, a Nigerian herbal decoction, is done by investigating its effects on biochemical, antioxidant, histopathologic and hematologic indices in normal albino rats.

MATERIALS AND METHODS

Albino rats of either sex weighing between 128 and 160 g were divided into 4 groups of 10 rats each. Three test groups were orally administered 400, 800 and 1600 mg kg(-1) body weight (b. wt.) doses of Joloo while control animals received distilled water over 28 days. Animal were weighed weekly and sacrificed after day 28. Organs were harvested, weighed and subjected to histopathologic assessment. Liver and blood samples were used for biochemical, antioxidant and hematological studies.

RESULTS

Mortality and signs of toxicity were absent in animals treated with 400 and 800 mg kg(-1) doses of Joloo. At 1600 mg kg(-1) dose, 20% mortality occurred. Decreased body weight and red blood cells (P < 0.05) observed at 1600 mg kg(-1) differed significantly from control animals. No significant changes in body and organ weights presented. Significant increases in biochemical analytes and histopathologic parameters were unobserved. Rather, Joloo increased leukopoiesis and exhibited antioxidant activities at all doses.

DISCUSSION

Joloo proved safe at lower doses. The mortality at 1600 mg kg(-1) could be due to disturbances in the physiology of the animals. The significant reduction in erythropoiesis could indicate early signs of toxicity. However, the unremarkable increases in hepatic and antioxidant enzymes may suggest that Joloo modulated oxidative status in the animals.

CONCLUSION

Joloo seems safe at lower doses, but caution is advised at higher doses.

Norsesquiterpene glycosides in bracken ferns (Pteridium esculentum and Pteridium aquilinum subsp. wightianum) from Eastern Australia: reassessed poisoning risk to animals

Austral bracken Pteridium esculentum contains three unstable norsesquiterpene glycosides: ptaquiloside, ptesculentoside, and caudatoside, in variable proportions. The concentration of each of the glycosides was determined in this study as their respective degradation products, pterosin B, pterosin G and pterosin A, by HPLC-UV analysis. Samples of P. esculentum collected from six sites in eastern Australia contained up to 17 mg of total glycoside/g DW, with both ptaquiloside and ptesculentoside present as major components accompanied by smaller amounts of caudatoside. Ratios of ptaquiloside to ptesculentoside varied from 1:3 to 4:3, but in all Australian samples ptesculentoside was a significant component. This profile differed substantially from that of P. esculentum from New Zealand, which contained only small amounts of both ptesculentoside and caudatoside, with ptaquiloside as the dominant component. A similar profile with ptaquiloside as the dominant glycoside was obtained for Pteridium aquilinum subsp. wightianum (previously P. revolutum ) from northern Queensland and also P. aquilinum from European sources. Ptesculentoside has chemical reactivity similar to that of ptaquiloside and presumably biological activity similar to that of this potent carcinogen. The presence of this additional reactive glycoside in Australian P. esculentum implies greater toxicity for consuming animals than previously estimated from ptaquiloside content alone.

Maté consumption and risk of cancer: a multi-site case-control study in Uruguay

In the time period 1990-2004 we conducted a multisite case-control study in order to examine the relationship of mate consumption and risk of 13 cancer sites in Montevideo, Uruguay. The study included 13,201 participants (8,875 cases and 4,326 controls) drawn from the four major public hospitals in the city of Montevideo. Newly diagnosed and microscopically confirmed cases of cancers of the mouth, pharynx, esophagus, stomach, colon, rectum, larynx, lung, female breast, cervix uteri, prostate, bladder and kidney were included in the study. Controls were drawn from the same hospitals and in the same time period and were afflicted by non-neoplastic conditions not related with tobacco smoking or alcohol drinking and without recent changes in their diets. Odds ratios for mate consumption was directly associated with cancers of the upper aerodigestive tract (UADT), esophagus, stomach, larynx, lung, cervix uteri, prostate, bladder, and kidney. In conclusion these results suggest that chemicals, like benzo[a]pyrene, could be responsible of the carcinogenic effect of mate in the above mentioned cancer sites.

Seizure and coma following Kratom (Mitragynina speciosa Korth) exposure

Reports of toxicity secondary to Kratom are rare and lack of diagnostic testing in human specimens has prevented confirmatory explanation of observed clinical effects. We present a novel case of serious human toxicity following Kratom use confirmed via quantitative analysis of urine by high performance liquid chromatography coupled to electrospray tandem mass spectrometry. A 64 year-old male was witnessed to have a seizure at home following kratom consumption. Upon arrival to the emergency department (ED), the patient was unresponsive. While in the ED, the patient sustained a second seizure. He was intubated to protect his airway. The remainder of his hospital course was uneventful. A urine specimen was collected shortly after admission and sent for analysis. The mitragynine concentration in the urine was 167 ± 15 ng/ml. We report a rare case of Kratom toxicity characterized by a seizure and coma confirmed by urinary analysis of mitragynine by high performance liquid chromatography coupled to electrospray tandem mass spectrometry. The proposed mechanism for this reaction is unclear but suggested mechanisms include adenosine binding or stimulation of adrenergic and/or serotonergic receptors similar to tramadol.

Tremetone and structurally related compounds in white snakeroot ( Ageratina altissima ): a plant associated with trembles and milk sickness

Ingestion of white snakeroot ( Ageratina altissima ) can cause trembles in livestock and milk sickness in humans. The toxicity has been associated with tremetol, a relatively crude, multicomponent lipophilic extract of the plant. In this study, 11 different compounds were isolated from white snakeroot-derived lipophilic extracts from 18 collections. Six of the isolated compounds have not been previously reported to be found in white snakeroot. High-performance liquid chromatography (HPLC) analysis indicated that there are three different chemotypes of white snakeroot from the plant samples analyzed. Elucidation of these chemotypes may explain the sporadic and unpredictable toxicity of white snakeroot to livestock and humans.

Internet suicide guidelines: report of a life-threatening poisoning using tobacco extract

BACKGROUND

Severe nicotine intoxication occurred in a patient after ingestion of a tobacco extract made from a recipe found on a freely available Internet site.

OBJECTIVES

To determine the levels of nicotine and cotinine in the plasma of a patient who tried to commit suicide by drinking a highly concentrated tobacco extract.

CASE REPORT

A 67-year-old man tried to commit suicide by following guidelines found on an Internet site. He soaked 300 grams of tobacco for 3 days in water, evaporated most of the extract, and drank the rest of it. He felt sick immediately, with the following signs: respiratory depression, hypothermia, hypersalivation, bradycardia, and myoclonic jerks. Soon after the ingestion he vomited most of the extract. Toxicological analysis revealed potentially life-threatening nicotine and cotinine serum concentrations. Surprisingly, nicotine peak levels (322 microg/L) and cotinine peak levels (9092 microg/L) were reached more than 3 h after ingestion of the extract. Estimated nicotine and cotinine half-lives were 200 min and 1185 min, respectively. Treatment consisted of gastric lavage, ventilation, and monitoring of vital functions. The patient recovered and was discharged from the Emergency Department 4 days later without sequelae.

CONCLUSION

Nicotinergic intoxication is not always easy to recognize, and without clues from the patient and the toxicologic analysis, might well have been missed in the present case.

Nicotine poisoning due to intravenous injection of cigarette soakage

A 27-year-old female nurse intravenously injected 5 mL of cigarette soakage solution that contained approximately 5.7 mg nicotine, in a suicidal attempt. Clinical manifestations consisted of nausea, palpitation, abdominal pain, repeated vomiting, and diarrhea. She remained fully conscious during this episode. About 7 hours later, she visited emergency department on foot and received fluid infusion for dehydration. She fully recovered at night of the day. This is the first documented report of acute nicotine poisoning due to intravenous injection of cigarette soakage in humans. Signs and symptoms appeared immediately after the injection, but this case seemed to be relatively mild in terms of clinical manifestation. The elimination half-life of nicotine seems to be short, that is, less than 1 hour. Therefore, if initial treatment is appropriate and the patient can survive acute phase of nicotine poisoning, prognosis is good.

Atractylis gummifera and Centaurea ornata in the Province of Badajoz (Extremadura, Spain)-Ethnopharmacological importance and toxicological risk

ETHNOPHARMACOLOGICAL RELEVANCE

Atractylis gummifera L. and Centaurea ornata Willd. are locally marketed herbal remedies, even though in Spain it is forbidden to sell toxic plants like Atractylis gummifera. Intoxications in Spain are mainly due to accidental substitution of Centaurea ornata with Atractylis gummifera which may be fatal.

AIM OF STUDY

The aim of this article is to analyse the current use and marketing of Atractylis gummifera and Centaurea ornata in Badajoz and analyse the ethnopharmacological relevance of two recent cases of Atractylis gummifera poisoning.

BACKGROUND AND METHODS

An ethnopharmacological survey was conducted in the area where one of the poisoned patients lives and in Guadiana del Caudillo. The use, knowledge and naming of the species involved in the poisoning was assessed. This information was complemented with an exhaustive search in Spanish ethnobotanical works on the ethnopharmacological uses of both species.

RESULTS

Intoxications are due to species' substitutions. The two species are similar in name and use in the area, and both are locally marketed. AG is mainly used to heal wounds and calcaneal spurs, and CO to treat gastric ulcers and wounds.

CONCLUSIONS

New intoxications are likely since consumers often have limited knowledge of the plants they consume. Also, it is common to think that all medicinal plants are harmless. As the use of Atractylis gummifera seems to increase in the area, preventive measures need to be taken.

Suicidal death after injection of a castor bean extract (Ricinus communis L.)

The castor bean plant (Ricinus communis L.) or wonder tree is cultivated in many countries as an ornamental annual plant in gardens. The highest concentration of the lectin ricin is present in the seeds and pods. Ricin is considered as one of the most toxic natural poisons. Ricinine is a piperidine alkaloidal toxin present in castor bean and is described as a biomarker for the exposure to ricin. A case report is presented of a 49-year-old man who committed suicide by intravenous and subcutaneous injection of a castor bean extract. He was brought to the emergency department 24 h after injecting himself. On admission, the patient was conscious and he presented with a history of nausea, vomiting, diarrhoea, dyspnoea, vertigo and muscular pain. Despite symptomatic and supportive intensive care, the man died 9 h after admission due to multiorgan failure. A body external examination was performed. Blood, urine, vitreous humour and the castor bean extract were submitted to the laboratory for toxicological analysis. The identification of ricinine in the extract was performed by solid phase extraction in combination with full-scan gas chromatography/mass spectrometry, high-performance liquid chromatography with photodiode array detection and liquid chromatography/mass spectrometry operated in the full-scan mode, respectively. An extraction procedure with Oasis HLB solid phase extraction cartridges was applied. Chromatography was achieved using a Symmetry C18 column using a gradient mode with 0.15% formic acid and 0.15% formic acid in acetonitrile as mobile phase. Exposure to the castor bean extract was confirmed by identification of the biomarker ricinine in blood, urine and vitreous humour using solid phase extraction and liquid chromatography tandem mass spectrometry with electro spray source in positive ionization mode. Multiple reaction monitoring was used for specific detection. To the authors' knowledge, it is the first time that ricinine has been identified in vitreous humour in a case of castor bean poisoning. Based on the clinical symptoms and the results of the toxicological analysis, we concluded that death was caused by intoxication with plant toxins originated from R. communis L.

A rare case of brucine poisoning complicated by rhabdomyolysis and acute renal failure

Brucine is the predominant alkaloid present in the bark of the tree Strychnos nux vomica and is a weaker alkaloid when compared to strychnine. However, its toxicological property is akin to strychnine. We report a rare case of brucine poisoning complicated by acute renal failure and rhabdomyolysis. A 24-year-old male presented with a history of consumption of a decoction made from the bark of the Strychnos nux vomica tree. Soon after, he developed widespread muscle spasms and convulsions, which were promptly treated. On the fifth day of admission, he developed features of rhabdomyolysis and acute renal failure. Investigations revealed elevated creatine phosphokinase levels and elevated blood urea and serum creatinine. The patient was managed with hemodialysis and recovered gradually. There are many reports of strychnine poisoning producing rhabdomyolysis and renal failure. In this case report, attention is drawn to the fact that brucine, although a weaker alkaloid, can also produce life threatening complications like rhabdomyolysis and acute renal failure.

Acute Erycibe Henryi Prain (“Ting Kung Teng”) Poisoning

Erycibe henryi Prain ("Ting Kung Teng"), a species of Convolvulaceae, has been used in Chinese medicine to relieve pain involving the musculoskeletal system, such as arthritis, sciatica, and traumatic tissue swelling. E. henryi can be mistaken for another herbal plant, Tripterygium wilfordii Hook F, used to treat gouty arthritis. We report here three cases of E. henryi poisoning. All three cases presented with vomiting, diarrhea, salivation, diaphoresis, lacrimation, and rhinorrhea; two patients also had miosis, hypothermia, bradycardia, hypotension, and ventricular tachyarrhythmias. Laboratory abnormalities included leucocytosis, hyperglycemia, hyperamylasemia, hypocalcemia, and transiently elevated liver enzymes, creatinine and creatinine phosphokinase. The active constituents of E. henryi include several tropane alkaloids, which exhibit cholinergic activities. Gastrointestinal disturbances and ventricular tachyarrhythmias may occur with ingestion of either E. henryi or T. wilfordii, but the cholinergic symptoms can help to differentiate them.

Juniper Tar Poisoning

Juniper tar (cade oil) is distilled from the branches and wood of Juniperus oxycedrus. It contains etheric oils, triterpene and phenols, and is used for many purposes in folk medicine. A case is reported of a previously healthy man who ingested a spoonful of home-made extract of Juniperus oxycedrus. The poisoning caused fever, severe hypotension, renal failure, hepatotoxicity, and severe cutaneous burns on the face. After supportive and symptomatic treatment, the patient improved and was discharged in a good condition on the eleventh day.

Distribution of ibogaine and noribogaine in a man following a poisoning involving root bark of the Tabernanthe iboga shrub

In the present paper, we report for the first time the tissue distribution of ibogaine and noribogaine, the main metabolite of ibogaine, in a 48-year-old Caucasian male, with a history of drug abuse, found dead at his home after a poisoning involving the ingestion of root bark from the shrub Tabernanthe iboga. Ibogaine and noribogaine were quantified in tissues and fluids using a fully validated liquid chromatography-electrospray mass spectrometry method. Apart from cardiac tissue, ibogaine and noribogaine were identified in all matrices investigated. The highest concentrations were found in spleen, liver, brain, and lung. The tissue/subclavian blood concentration ratios averaged 1.78, 3.75, 1.16, and 4.64 for ibogaine and 0.83, 2.43, 0.90, and 2.69 for noribogaine for spleen, liver, brain, and lung, respectively. Very low concentrations of the two drugs were found in the prostatic tissue. Both ibogaine and noribogaine are secreted in the bile and cross the blood-brain barrier. Four other compounds were detected in most of the studied matrices. One of them was identified as ibogamine. Unfortunately, we were not able to positively identify the other three compounds because of the unavailability of reference substances. Two of them could possibly be attributed to the following oxidation products: iboluteine and desmethoxyiboluteine. The third compound could be ibogaline.

Testing for atropine and scopolamine in hair by LC-MS-MS after Datura inoxia abuse

Datura inoxia belongs to the family of Solanaceae. This is a very common plant in New Caledonia that contains two main toxic alkaloids, l-atropine and l-scopolamine. In this study, we report the case of a 20-year-old male admitted to an Emergency Unit after consumption of 6 dried flowers in hot water for hallucinations, mydriasis, and agitation associated with tachycardia and increase of systolic blood pressure to 180. Full recovery was observed after one week. Three weeks later, a lock of about 80 hairs (200 mg) was collected from the subject in vertex posterior with scissors to be tested for both atropine and scopolamine. After decontamination with dichloromethane, a strand of hair was segmented into three parts, cut into small segments (< 1 mm), incubated overnight in 1 mL pH 8.4 phosphate buffer in the presence of 2.5 ng atropine-d(3), the internal standard, then extracted with 5 mL dichloromethane/isopropanol/n-heptane (50:17:33). The residue was reconstituted in 100 microL of methanol, from which 10 microL was injected into an XTerra MS C18 column (100 x 2.1 mm, 3.5 microm) eluted with a gradient of acetonitrile and formate buffer delivered at a flow rate of 0.2 mL/min. A Quattro Micro triple-quadrupole mass spectrometer (MS) was used for analyses. Ionization was achieved using electrospray in the positive ionization mode. For each compound, detection was related to two daughter ions (atropine: m/z 290.2 to 124.0 and 92.9; atropine-d(3): m/z 293.1 to 127.0 and 92.9; scopolamine: m/z 304.1 to 138.0 and 156.0). Although atropine was never detected (limit of detection = 2 pg/mg), scopolamine was identified in the three segments, in the range 14 to 48 pg/mg. The absence of atropine in hair is consistent with its very low dosage in the flower of Datura inoxia. Hair segmentation indicated that the subject was previously exposed on several occasions to the plant. Liquid chromatography-tandem MS appears to be a necessity for testing tropane alkaloids of the Datura group, given the low concentrations to be measured.

The use of Eucalyptus tereticornis Sm. (Myrtaceae) oil (leaf extract) as a natural larvicidal agent against the malaria vector Anopheles stephensi Liston (Diptera: Culicidae)

Secondary metabolites obtained from the indigenous plants with proven mosquito control potential can be used as an alternative to synthetic insecticides under the integrated vector control. The essential oil extract from the forest redgum, Eucalyptus tereticornis Sm. (Myrtaceae) was tested against mature and immature mosquito vector Anopheles stephensi Liston (Diptera) under laboratory condition. The extract showed strong larvicidal, pupicidal and adulticidal activity. The leaf oil extracts showed high bioactivity at high doses. Results obtained from the laboratory experiment showed that the leaf extracts suppressed the pupal and adult activity of Anopheles stephensi at higher doses. In general, first and second instar larvae were more susceptible to all treatments. Clear dose -response relationships were established with the highest dose of 160ppm plant extract evoking almost 100% mortality. The results obtained suggest that, in addition to their medicinal activities, E. tereticornis can also serve as a natural mosquitocide.

Effects of Dysoxylum malabaricum Bedd. (Meliaceae) extract on the malarial vector Anopheles stephensi Liston (Diptera: Culicidae)

In recent years, use of environmentally friendly and biodegradable natural insecticides of plant origin have received renewed attention as agents for disease vector control. Methanol extracts of leaves from the Indian white cedar Dysoxylum malabaricum Bedd. (Meliaceae) were tested against mature and immature Anopheles stephensi Liston (Diptera) mosquitoes under laboratory conditions. The extract showed strong larvicidal, pupicidal, adulticidal, and antiovipositional activity. The maximum leaf extract concentration tested in this study was 4%, which produced pronounced effects. In general, first and second instars were more susceptible to leaf extract than older insects. Clear dose-response relationships were established, with the highest dose of 4% plant extract causing 97% mortality of first instars.

Identification of atractyloside by LC-ESI-MS in alleged herbal poisonings

An LC-MS screening method was developed to detect the presence of atractyloside (ATR), the toxic principle of a commonly used medicinal plant in South Africa, Callilepis laureola, in biological matrices such as body fluids and human viscera.

Larvicidal potential of Nerium indicum and Thuja oriertelis extracts against malaria and Japanese encephalitis vector

Ethanolic and acetone extracts of Nerium indicum and Thuja orientelis have been studied against III instar larvae of Anopheles stephensi and Culex quinquefasciatus. Ethanolic extract of N. indicum is found more effective than its acetone extract against anopheline larvae with LC50 values of 185.99 and 148.05 ppm for former and 229.28 and 149.43 ppm for the later after 24 and 48 hrs of exposure. The acetone extract with LC50 values of 209.00 and 155.97 ppm is more effective in case of culicine larvae than its ethanolic extract with LC50 494.07 and 194.49 ppm after 24 and 48 hours of treatment. Ethanolic extract of T. orientelis is more effective against both the larval species with LC50 values of 13.10 and 9.02 ppm after 24 and 48 hours for anopheline and 22.74 and 16.72 ppm against culicine larvae. The acetone extract showed LC50 values of 200.87 and 127.53 ppm against anopheline and 69.03 and 51.14 ppm against culicine larvae. Thus ethanolic extract of T. orientelis is an ideal potential larvicide for both types of mosquito larvae.

Toxicity, pathophysiology and pathology in sheep following dosing of the nephrotoxic plant Nolletia gariepina (DC) Mattf

Ingestion of the plant Nolletia gariepina was confirmed as the cause of acute mortalities in cattle in the Kuruman area of the Northern Cape Province of South Africa. The aim of this trial was to investigate the toxic effects of this plant with respect to clinical signs, pathophysiology and pathology using the sheep as a model. At dosages of 1.5 g dried, milled plant material/kg body mass there were no detectable abnormal findings, while at dosages of 2.8-3.0 g/kg most of the animals died acutely. In subacutely affected sheep, depression, inappetance, teeth grinding, tachycardia, weak ruminal movements and recumbency were noticed. The most prominent pathophysiological changes observed, included a sharp rise in non-protein nitrogen substances in the plasma, remarkable decline in glomerular filtration rate, increase in sodium and potassium excretion, and a rise in urine gamma glutamyltransferase activity. Macroscopically a severe nephrosis was present in all the animals. The most important findings detected histologically were necrosis of the proximal convoluted tubular epithelium and large numbers of protein casts in the lumens.

[A study on the rotation of crops among Panax quinquefolium, Perilla frutescens and Coix lacryma-jobi]

OBJECTIVE

To provide evidence for establishing an efficient method of growing Panax quinquefolium by rotation of crops.

METHOD

Four-year old P. quinquefolium was cultivated in water and soil cultures. Biological assays were conducted with the aqueous extracts of P. quinquefolius, Fructus Perillae and roots of Coix lacryma-jobi. P. quinquefolium was cultivated in the soil where purple Perilla frutesens and C. lacryma-jobi were grown previously. The effects of rotation were determined.

RESULT

The stems, leaves and fibrous roots of Panax quinquefolium contained allelopathic substances. When the concentration of the allelopathic substances exceeded 1g per kg soil, P. quinquefolius could not grow. On the other hand, when the concentration of allelopathic substances fell below 0.2 g per kg soil, the rate of seedling growth was decreased by 25%. When P. quinquefolius was cultivated in the soil in which purple Perilla frutesens had previously grown, or in the soil supplemented with Fructus Perillae, the rates of seedling growth and the yield were raised by 26.8% and 11.5% tively, in comparison with the controls.

CONCLUSION

Rotation of Panax quinquefolium and Perilla frutesens was shown to be a good way for the cultivation of the former. During the growing process, application of Fructus Perillae to the soil could further enhance the growth and of Panax quinquefolium.

Rapid Detection of Oleander Poisoning Using Digoxin Immunoassays

Oleander is an ornamental shrub that grows in the United States, Australia, India, Sri Lanka, China, and other parts of the world. All parts of the plant are poisonous because the presence of cardiac glycoside oleandrin. Despite its toxicity, oleander extract is used in folk medicines. Because of its structural similarity, oleandrin cross-reacts with the fluorescence polarization immunoassay (FPIA) for digoxin. We studied the potential of detecting oleandrin in serum using 5 common digoxin immunoassays (FPIA, MEIA, both from Abbott; Beckman digoxin assay on Synchron LX, Chemiluminescent assay, CLIA from Bayer Diagnostics) and a recently FDA-approved turbidimetric assay on the ADVIA 1650 analyzer (Bayer). Aliquots of drug-free and digoxin-like immunoreactive substances (DLIS)-free serum pools were supplemented with ethanol extract of oleander leaves or oleandrin (Sigma Chemicals) in amounts expected in vivo after severe overdose. We observed significant apparent digoxin concentration with FPIA, Beckman, and the new turbidimetric assay (1 mL drug-free serum supplemented with 5.0 microL of oleander extract: apparent digoxin 2.36 ng/mL by the FPIA, 0.32 ng/mL by the MEIA, 0.93 ng/mL by the Beckman, 0.82 ng/mL by the new turbidimetric assay). The CLIA showed no cross-reactivity. Similar observations were made when serum pools were supplemented with oleandrin. Because cross reactivity should be tested in the presence of the primary analyte, we supplemented serum pools prepared from patients receiving digoxin with oleander extract or oleandrin. The measured digoxin concentrations were falsely elevated with the FPIA, Beckman, and turbidimetric assays, the highest false elevation being observed with the FPIA. Surprisingly, apparent digoxin concentrations were falsely lowered when MEIA was used. Digibind neutralizes free apparent digoxin concentration in vitro in serum pools supplemented with oleander extract, and this effect can be measured by the FPIA. We conclude that FPIA is most sensitive to detect the presence of oleander in serum. In contrast, the CLIA (no cross-reactivity) should be used for monitoring digoxin in a patient receiving digoxin and self-medicated with a herbal remedy containing oleander.

LC-MS determination of Taxus alkaloids in biological specimens

A semi-quantitative LC-MS method was developed for the detection of the pseudo alkaloids of Taxus baccata (yew) from human body fluids and tissue samples. This method was used to examine the cause of death of a 43-year-old man who died several hours after he drank a decoction of taxus leaves. Autopsy and histology demonstrated early signs of myocardial hypoxia. Since investigation of the stomach content did not yield evidence of taxus ingestion, the taxus alkaloids were determined in blood, stomach content and tissue samples of the deceased by LC-MS. The samples were prepared by solid phase extraction on RP-18 columns. Chromatographic separation was achieved by HPLC on a RP-8 column, coupled to an ion trap mass spectrometer (Finnigan LCQ). An atmospheric pressure electrospray ionisation was performed. Spectra of the alkaloids were recorded in the single MS mode and in the MS-MS mode and compared with reference spectra obtained from an extract of yew leaves. In the stomach content, the kidneys, the liver and a heart blood sample of the deceased, alkaloids of Taxus baccata, predominantly taxine B and iso-taxine B, were identified. The semi-quantitative evaluation of the heart blood revealed a taxine concentration of 11 micro g taxine/g. As far as we know this is the first case in which a semi-quantitative analysis of taxine alkaloids has been performed.

A clinical and laboratory profile of Cleistanthus collinus poisoning

AIMS

1. To study the clinical features in patients with Cleistanthus collinus poisoning, 2. To study in them the effect of Cleistanthus collinus poisoning on the various organ systems and metabolic parameters using standard laboratory investigations.

METHODS

All patients admitted to the hospital between September 1998 and April 2000 were studied. Statistical analysis of the results was done using chi-square test, Fisher's exact test and Student's 't' test.

RESULTS

Forty six cases were studied, 15 (32%) of whom died. Eighty percent of the patients were in the second to third decade. The female:male ratio was 3:2. Ingestion of the poison as a decoction prepared from the leaves and ingestion of a large number of leaves otherwise were associated with a poor outcome. While survivors remained relatively asymptomatic, fatally poisoned patients presented with significant clinical signs and symptoms, however, laboratory abnormalities such as hypokalaemia, hyponatremia, an elevated AST/LDH/CPK/CPK-MB, nonspecific ST-T changes and QTc prolongation on ECG, metabolic acidosis and hypoxia with widened alveolar-arterial oxygen difference (A-aDO2) were seen in both groups.

CONCLUSION

It is a poisoning seen in the young with significant mortality. Cause of death appears to be mainly due to its cardiac and respiratory effects. Metabolic disturbances especially hypokalaemia was a prominent feature. Most deaths occurred on the 3rd day and all within a week. No specific antidote is available.