Poisonous delicacy: Market-oriented surveys of the consumption of Rhododendron flowers in Yunnan, China

ETHNOPHARMACOLOGICAL RELEVANCE

Plants from the family Ericaceae, and in particular those in the genus Rhododendron are frequently reported to contain grayanotoxins. Plant products such as honey and herbal medicines made from these plants occasionally contain grayanotoxins, and in turn may lead to intoxication. The balance between the benefits and risk of poisoning from Rhododendrons is of concerns. This study explores the ethnobotanical knowledge of the people in Yunnan, China as regards the consumption of Rhododendron flowers, and gives special focus to their assessment of the benefit-risk balance.

MATERIALS AND METHODS

An ethnobotanical survey was conducted across 14 county-level local markets in north and central Yunnan province, during which a total of 82 stalls selling Rhododendron flowers were visited and 204 people were interviewed. Voucher specimens were obtained under the guidance of collectors, and details about local practices and knowledge were recorded using semi-structured interviews and participatory observations.

RESULTS

The consumption of the corollas of Rhododendron decorum Franch. Flowers (RDf) or Rhododendron pachypodum Balf. f. & W.W. Sm. Flowers (RPf) as a seasonal delicacy is a long-standing tradition in the study area. RDf are widely consumed in northwest and northeast Yunnan, while RPf are more prevalent in the central regions of Yunnan, and there is a high consistency in the knowledge of the process for detoxification or palatability for each species. The main reasons for eating the flowers were listed as health benefits (mostly clear heat), wild collected, tradition and good flavor. All RPf consumers stated that the corolla from this species is not toxic, while 67.4% of the RDf consumers claim that the corolla from RDf is toxic. We compared the two species and analyzed their process intensities, poisoning cases and cautions, market trade forms and existing toxicity studies, which agreed well and consistently that the corolla of RDf deserve more toxicity attention than RPf.

CONCLUSION

Our study provides a window to look into the ways, beyond honey and herbal medicine, by which Rhododendron species have influenced human wellbeing. The local culture can justify eating Rhododendron flowers, and meanwhile, has developed a series of skills to avoid the side effects of eating them, and therefore the study also provides a good case to answer more general questions about the rationality of eating any plant products by assessing the trade-off between benefits and side effects.

An Increase in Dietary Supplement Exposures Reported to US Poison Control Centers

INTRODUCTION

The objective of this study was to investigate the epidemiology of dietary supplement exposures in the USA.

METHODS

A retrospective analysis was conducted of out-of-hospital dietary supplement exposures reported to the National Poison Data System from 2000 through 2012.

RESULTS

There were 274,998 dietary supplement exposures from 2000 through 2012. The annual rate of dietary supplement exposures per 100,000 population increased by 46.1% during 2000-2002, decreased 8.8% during 2002-2005, and then increased again by 49.3% from 2005 to 2012. These trends were influenced by the decrease in ma huang exposures starting in 2002. Miscellaneous dietary supplements accounted for 43.9% of all exposures, followed by botanicals (31.9%), hormonal products (15.1%), and other supplements (5.1%). The majority of dietary supplement exposures (70.0%) occurred among children younger than 6 years old and were acute (94.0%) and unintentional (82.9%). Serious medical outcomes accounted for 4.5% of exposures and most (95.0%) occurred among individuals 6 years and older. Ma huang products, yohimbe, and energy products were the categories associated with the greatest toxicity.

CONCLUSIONS

There was an overall increase in the rate of dietary supplement exposures from 2000 through 2012. Although the majority of these exposures did not require treatment at a health care facility or result in serious medical outcomes, exposures to yohimbe and energy products were associated with considerable toxicity. Our results demonstrate the success of the FDA ban on ma huang products and the need for FDA regulation of yohimbe and energy products in the USA.

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.

EVALUATION OF TOXIC HEAVY METALS IN AYURVEDIC SYRUPS SOLD IN LOCAL MARKETS OF HAZARA, PAKISTAN

BACKGROUND

Herbal and Ayurvedic preparations, widely used in Pakistan and the developing world, present serious risk of heavy metal toxicity related to their medicinal content and prolonged use by patients. The objective of this study was to find out the concentration of heavy metals in Herbal & Ayurvedic liquid preparations commonly used for treatment of different diseases, from local markets of Hazara.

METHODS

The cross sectional survey of traditional herbal & Ayurvedic medicine shops included ten liquid preparations selected from local shops of Mansehra and Abbottabad after interviewing the shopkeepers; so as to select the most commonly sold preparations along with their indications. All samples were analysed on standard Atomic Absorption Spectroscopy for qualitative and quantitative study of toxic heavy metals (Mercury, Iron, Zinc, Lead, Manganese and Arsenic).

RESULTS

Toxic levels of Mercury were present in seven syrups, i.e., (Kashneeze, Akseer e Pachas, Tankar, Sharbat e folad, Urosinal, Akseer e Jigar and Amrat dhara) while Arsenic was present only in Urosinal. Iron, Zinc, Manganese and Lead were present in permissible limits in all syrups.

CONCLUSION

Mercury and Arsenic are present in local Herbal & Ayurvedic liquid preparations far beyond the permissible limits as proposed by the International Regulatory Authorities for health drugs while the rest of metals, i.e., Zinc, Manganese, and Iron are within the therapeutic limits.

From arrow poison to herbal medicine--the ethnobotanical, phytochemical and pharmacological significance of Cissampelos (Menispermaceae)

ETHNOPHARMACOLOGICAL RELEVANCE

Cissampelos species have a rich history of traditional use, being used for both therapeutic and toxic properties. It is traditionally applied therapeutically in a diverse range of conditions and diseases including asthma, cough, fever, arthritis, obesity, dysentery, snakebite, jaundice and heart, blood pressure and skin-related problems. Conversely, it was traditionally included in preparations of curare applied as arrow poison during hunting to cause death of animals by asphyxiation. This review unites the ethnobotanical knowledge on Cissampelos with the phytochemistry and pharmacological activity which has been explored thus far. In addition, it identifies knowledge gaps and suggests further research opportunities.

METHODS

The available electronic literature on the genus Cissampelos was collected using database searches including Scopus, Google Scholar, Pubmed, Web of Science, etc. The searches were limited to peer-reviewed English journals with the exception of books and a few articles in foreign languages which were included.

RESULTS

The literature revealed that pharmacological activity including analgesic and antipyretic, anti-inflammatory, anti-allergic, bronchodilator, immunomodulatory, memory-enhancing, antidepressant, neuroprotective, antimicrobial, antimalarial, antiparasitic, anti-ulcer, anticancer, anti-oxidant, cardiovascular, muscle-relaxant, hepatoprotective, antidiabetic, antidiarrhoeal, antifertility, and antivenom activity have been confirmed in vitro and/or in vivo for various Cissampelos species. Cissampelos pareira L. and Cissampelos sympodialis Eichl. are the most explored species of this genus and the smallest number of studies have been conducted on Cissampelos laxiflora Moldenke and Cissampelos tenuipes Engl. Many alkaloids isolated from Cissampelos such as warifteine, methylwarifteine, berberine, hayatin and hayatidin showed promising anti-allergic, immunosuppressive, antidepressant, anticancer, vasodilatory and muscle-relaxant activities.

CONCLUSION

The plants of this genus are used in traditional medicine for the treatment of various ailments. These plants are a rich source of bioactive bisbenzylisoquinoline and aporphine alkaloids together with other minor constituents. Although these plants are reputable and revered in various traditional medicine systems, many have not yet been screened chemically or pharmacologically and so there is a vast amount of research still to be conducted to validate their traditional use.

[Accidental poisoning with peach seeds used as anticancer therapy--report of two cases]

We described two cases of poisoning with amygdalin. Clinical signs presented by two females were mild and lasted up to 5 hours.

CONCLUSIONS

The usage of amygdalin may be connected with serious side effects. The cyanide and prussic acid which are deliberated in digestive system are responsible for toxicity in such cases. The rarity of poisoning with amygdalin as well as high cost of analysis are responsible for the reason that most labs are not prepare for such procedure.

[A rare case of exposure to natural psychoactive substances, and difficulties with medicolegal assessment]

An unusual case of exposure to natural psychoactive substances deriving from Datura stramonium (jimsonweed, thorn-apple) is presented in this article. It may be of interest in this case that a hallucinogenic substance was intentionally administered by a third party. An initial assessment in this criminal case was questionable, and resulted from a lack of consideration of toxicological exposure and its possible aftermath. The above-mentioned case demonstrates the necessity of considering all toxicological aspects of the case, even though initial findings seemed to indicate something else.

Potentially hazardous environmental factors for poisoning in rural Vietnam: a community-based survey

Poisoning represents one of the most common threats against public health. This population-based study was undertaken to identify potentially hazardous environmental factors for poisoning in Vietnam, and thereby to improve the background information needed to take adequate preventive measures. The study population comprised 3814 individuals from 942 randomly selected households in Phu Tho Province. Their mean age was 32.7 years, 50.4% were male. Data collection methods included face-to-face interviews using a structured questionnaire, and reality observations following a structured checklist. Of the study population, 438 individuals (11.5%) recalled having suffered from at least one episode of symptomatic poisoning. The toxic agents most commonly involved in these incidents were pesticides (68.7%). Hazardous exposure to toxins was reported to occur frequently and pesticides were again the agents most commonly involved. The presence of insecticides and other pesticides in the home were common (39%) and 21.7% of studied households kept poisonous chemicals in places easily accessible to children. Nearly half the households kept medications at home, often without any medical safe-box. Fifty-six point two percent reported prescriptions were not necessary for purchasing pharmaceuticals. Common habits among household members put them at risk for poisoning by natural toxins. Among these, frequent use of unusual herbs, and the practice of raising and eating poisonous animals were most important. In conclusion, the widespread use of pesticides, risk for exposure to natural toxins and self medication constitute major hazards for poisoning in Vietnam. Effective control regulations and safe strategies are lacking.

Toxic plants: a chemist's perspective

Chemistry has long been an integral part of toxicology, as the two fields originated in much the same way: the investigation of plants with interesting properties. In this chapter I review the role that chemistry has played in understanding toxic and medicinal plants. After some introductory remarks, three broad areas are addressed: the role of natural products in understanding plant taxonomy and evolution, recent developments in chemical synthesis, especially efforts to discover and efficiently synthesize novel structures based upon naturally occurring toxins, and finally, developments in the new field of systems toxicology, which seeks to integrate all aspects of an organism's response to toxic insult.

Severe Acute Poisoning with HomemadeAconitum napellusCapsules: Toxicokinetic and Clinical Data

Aconitum napellus is an extremely dangerous plant that contains various toxic diterpenoid alkaloids, mainly aconitine primarily concentrated in the roots. We report a case of acute intoxication of a 21-year-old man admitted to our Emergency Department after the ingestion, in order to sleep, of three homemade Aconitum napellus capsules. Capsules were measured to contain 237 mg of root and 19 microg of aconitine. The patient experienced the first symptoms on wakening 5 hours later with generalized paresthesia, nausea, diarrhea, vertigo, thoracic pain dyspnea, and dyschromatopsia. At admission, 7 hours after intake electrocardiographic analysis showed a sinusal bradycardia with polymorphic and bigeminal ventricular extrasystolia. Cardiovascular and neurological symptoms disappeared, respectively within 11 and 13 hours of ingestion. The patient was discharged from the ICU on day 2. Plasmatic concentrations at H7, H9, H14 H19, and after ingestion were, respectively, of 1.75, 0.75, 0.35, and 0.02 ng/mL. The calculated half-life of aconitine was 3 hours. To our knowledge, this is the first reported case with an aconitine toxicokinetic-effect relationship. The authors stress that clinicians must be aware of possible occurrence of acute poisoning with Aconitum napellus in European countries and in the United States as herbal medicine is becoming increasingly popular.

Ruta Graveolensintoxication

We describe a case of unintentional poisoning from Ruta Graveolens, a medicinal herb that is used for heart protection in Taiwan. A 78-year-old woman developed bradycardia, acute renal failure with hyperkalemia, and coagulopathy after three days of consuming a decoction made from Ruta Graveolens for the treatment of palpitations and heart protection. She was treated with hemodialysis in the emergency department for hyperkalemia. Her bradycardia and hypotension improved gradually three days later. Ruta use might cause multi-organ toxicity. We believe this case report helps in the recognition of the systemic toxicity of Ruta Graveolens.

Transient blindness due to posterior reversible encephalopathy syndrome following ephedra overdose

Posterior reversible encephalopathy syndrome (PRES), also known as reversible posterior leukoencephalopathy syndrome (RPLS), is most often associated with hypertensive emergencies and is characterized by seizures, mental status changes and visual disturbances. We report a case of a previously healthy young man who developed multiorgan failure and transient cortical blindness following ingestion of a performance-enhancing ephedra-based supplement. Neuroimaging findings confirmed the clinical suspicion of PRES. Radiographic abnormalities and neurologic dysfunction subsequently resolved with correction of his systolic blood pressure. This case emphasizes the need for prompt treatment and consideration of toxic ingestions in patients presenting with hypertension-related end-organ dysfunction.

Hepatotoxicity associated with herbal products

A significant number of herbal products have been associated with hepatotoxicity. Attribution of liver injury to a specific herbal pro-duct may be difficult. There are few clinical or laboratory manifestations that specifically suggest that liver injury is the result of aspecific herbal. Compounding this difficulty is that the patient may have liver disease from another cause, may be consuming other potentially hepatotoxic products, or may be using a contaminated herbal product. The most important clue often is the temporal relationship between initiation of the herbal product and the appearance of liver injury; of equal importance is the resolution of the injury following withdrawal of the herbal product.

Anticholinergic syndrome due to 'Devil's herb': when risks come from the ancient time

We describe a case of Mandragora autumnalis poisoning which occurred in a 72-year-old female patient who had eaten the venenous M. Autumnalis, picked near her home, mistaking it for the edible Borago Officinalis. M. Autumnalis is a solanaceous plant, common in the Sicilian countryside, which contains a variable concentration of solanum alkaloids, causing gastrointestinal irritation, and tropane alkaloids, with anticholinergic properties. Unluckily, M. Autumnalis is often mistaken for the edible B. Officinalis, likewise widespread in Sicilian countryside. The diagnosis of Mandragora poisoning was made on the basis of clinical symptoms and signs of anticholinergic syndrome associated with a history of vegetable meal of uncontrolled origin, moreover analysing the vegetable obtained from gastric lavage. Decontamination and symptomatic treatment were useful in our patient to control acute poisoning.

A review of the clinical and toxicological aspects of 'traditional' (herbal) medicines adulterated with heavy metals

The popularity of traditional remedies has greatly increased in westernised countries over recent years. Although many of these remedies are used safely, there have recently been an increasing number of case reports being published of heavy metal poisoning after the use of traditional remedies, in particular, Indian Ayurvedic remedies. This study reviews the data on published cases, along with the history of Ayurvedic medicine in an attempt to provide an insight into why heavy metals, in particular lead, mercury and arsenic are added in such large concentrations to these remedies.

Poisonings and overdoses in the intensive care unit: General and specific management issues

OBJECTIVE

To provide current information on general and specific interventions for overdoses likely to require intensive care.

DESIGN

Review of literature relevant to selected interventions for general management of overdoses and specific poisons.

RESULTS

The benefit of interventions to decrease absorption or enhance elimination of toxins is limited to a relatively small number of specific agents. Antidotes and certain interventions may be helpful in preventing or treating toxicity in specific poisonings when used appropriately. Intensive supportive care is also necessary to achieve good outcomes.

CONCLUSION

Knowledge of the indications and limitations of current interventions for poisonings and overdoses is important for care of the critically ill poisoned patient.

Analysis of lead content in herbal preparations in Malaysia

In Malaysia, the phase 3 registration for traditional medicines was implemented on 1 January 1992 under the Control of Drugs and Cosmetics Regulation 1984, emphasizing quality, efficacy and safety (including the detection of the presence of heavy metals) in all pharmaceutical dosage forms of traditional medicine preparations. Therefore, a total of 100 products in various pharmaceutical dosage forms of a herbal preparation, were analysed for lead content using atomic absorption spectrophotometer. Results showed that 8% (eight products) possessed 10.64-20.72 ppm of lead, and therefore, do not comply with the quality requirement for traditional medicines in Malaysia. One of these products, M-Tongkat Ali (exhibited 10.64 +/-0.37 ppm of lead), was in fact already registered with the DCA Malaysia. The rest, Sukarno Tongkat Ali, Eurycoma Madu, Super Pill Tongkat Ali, Force Pill Tongkat Ali, Tender Pill Tongkat Ali, Super Pill Tongkat Ali Plus and Great Pill Tongkat Ali Plus have not registered with the DCA Malaysia and exhibited 12.24-20.72 ppm of lead. Although this study showed that only 92% of the products complied with the quality requirement for traditional medicines in Malaysia, however, they cannot be assumed safe from lead contamination because of batch-to-batch inconsistency.

Herbal infusions used for induced abortion

Plants and herbs have been used to induce abortions but there is very little published information describing the commonly used ones. The purpose of this report is to describe the herbal products used to induce abortions, and to enhance awareness and understanding of their toxic effects. A descriptive retrospective survey was conducted on the calls received by the Montevideo Poison Centre between 1986 and 1999 concerning the ingestion of herbal infusions with abortive intent. A total of 86 cases involving 30 different plant species were identified. The species most frequently involved were ruda (Ruta chalepensis/graveolens), cola de quirquincho (Lycopodium saururus), parsley (Petroselinum hortense), and an over-the-counter herbal product named Carachipita. The components of Carachipita are pennyroyal (Mentha pulegium), yerba de la perdiz (Margiricarpus pinnatus), oregano (Origanum vulgare), and guaycuri (Statice brasiliensis). Abortion occurred in 23 cases after the ingestion of parsley, ruda, Carachipita, celery, Cedron, francisco alvarez, floripon, espina colorada. Out of the 23 cases, 15 involved the only the ingestion of plants, 4 cases used injected drugs (presumably hormones), and in 4 cases there was associated self-inflicted instrumental manipulation. Multiple organ system failure occurred in those patients who had ingested ruda (alone or in combination with parsley or fennel), Carachipita, arnica, or bardana. Deaths occurred in one case of Carachipita ingestion and in 4 cases of ruda ingestion (2 cases of ruda alone, 2 cases of ruda with parsley and fennel). Self-inflicted instrumental manipulations were found in 4 of the patients with multiple organ system failure and in one of those who died. The results of this report are not conclusive, but it appears that the ingestion of plants to induce abortion involves the risk of severe morbidity and mortality.

[Star anise poisoning in infants]

Star anise is used as herbal tea, for the treatment of colicky pain in infants. It may cause neurological troubles.

CASE REPORTS

We report 2 cases of star anise poisoning in infants before 6 months of age. Star anise herbal tea was given by parents. Tremors or spasms, hypertonia, hyperexcitability with crying, nystagmus, and vomiting were observed. Contamination or adulteration of Chinese star anise (Illicium verum Hook), with Japanese star anise (Illicium religiosum) was proved in one child.

CONCLUSION

Confusion or blending between Chinese and Japanese star anise may cause poisoning. Japanese star anise is a neurotoxic plant indeed, because it contains sesquiterpenic lactones. From November 2001, star anise products are theoretically prohibited in France, but they may be still available in some small groceries, or imported by families themselves.

Cardioactive steroid poisoning from an herbal cleansing preparation

We describe a case of unintentional poisoning from a cardioactive steroid and the subsequent analytic investigation. A 36-year-old woman with no past medical history and taking no conventional medications ingested an herbal preparation marketed for "internal cleansing." Its ingredients were neither known to the patient nor listed on the accompanying literature. The next morning, nausea, vomiting, and weakness developed. In the emergency department, her blood pressure was 110/60 mm Hg, and her pulse rate was 30 beats/min. Her ECG revealed a junctional rhythm at a rate of 30 beats/min and a digitalis effect on the ST segments. After empiric therapy with 10 vials of digoxin-specific Fab (Digibind), her symptoms resolved, and she reverted to a sinus rhythm at a rate of 68 beats/min. Her serum digoxin concentration measured by means of the fluorescence polarization immunoassay (Abbott TDx) was 1.7 ng/mL. Further serum analysis with the Tina Quant digoxin assay, a more digoxin-specific immunoassay, found a concentration of 0.34 ng/mL, and an enzyme immunoassay for digitoxin revealed a concentration of 20 ng/mL (therapeutic range 10 to 30 ng/mL). Serum analysis by means of high-performance liquid chromatography revealed the presence of active digitoxin metabolites; the parent compound was not present. When the diagnosis of cardioactive steroid poisoning is suspected clinically, laboratory analysis can confirm the presence of cardioactive steroids by using immunoassays of varying specificity. An empiric dose of 10 vials of digoxin-specific Fab might be beneficial in patients poisoned with an unknown cardioactive steroid.

[Cases of neurological symptoms associated with star anise consumption used as a carminative]

BACKGROUND

Since March 2000, a series of infants with serious gastrointestinal and neurological symptoms have been observed in Spain. These symptoms were suspected to be associated with the use of star anise infusion. We performed an epidemiological study to determine the characteristics of these patients and to evaluate the association between the symptoms and anise consumption.

METHOD

From February to September 2001, a matched case-control study (1:2) was performed among infants aged less than 3 months admitted to the pediatric emergency departments of two hospitals in Madrid. Mantel-Haenszel and conditional logistic regression odds ratios (OR) were calculated to quantify the association and the dose-response relationship. Laboratory analyses of the implicated substances were performed.

RESULTS

Twenty-three cases were studied. The mean age was 29.2 days (SD: 25.5). The symptoms observed were irritability, abnormal movements, vomiting and nystagmus. Eighteen cases and 36 controls were included in the case-control study. Nine controls (25 %) consumed anis infusion (consumption was high in five and low in four). The Mantel-Haenszel OR was 18.0 (2.03-631) and the OR for the dose-response relationship was 11.7 (95 % CI: 1.3-188.5) for low levels of consumption and 18.2 (95 % CI: 1.8-183.5) for high levels. Laboratory analyses revealed contamination of Illicium verum by Illicium anisatum.

CONCLUSIONS

This study confirms the association between the symptoms described and the use of anise infusion. The dose response analyses provide further evidence for the association. Cross-contamination was found between the product and other anise species. We recommend destruction of the contaminated products, avoidance of anise infusions among infants, and dissemination of the results among pediatricians.

[Convulsive status secondary to star anise poisoning in a neonate]

Despite its potential toxicity, the use of star anise infusions for the treatment of infant colic is firmly rooted in our culture. In the last year, several cases of infants with acute neurological and gastrointestinal symptoms related to the ingestion of large quantities of star-shaped anise have been reported in Spain. We report a 1-month old girl who was admitted to our emergency room with convulsive status after ingesting a considerable amount of star anis administered to relieve possible infant colic. The patient required three repeat doses of diazepam to control the seizures. Because no abnormalities were found and outcome was favorable without anticonvulsant therapy, the clinical symptoms can be attributed to star anise ingestion, which contains potent neurotoxins such as veranisatins. The etiopathogenesis of this process and star anise toxicity are discussed and the need for the regulation of natural products with pharmacological effects which are freely dispensed from drug stores is stressed. Finally, the regulations of the Ministry of Health and Consumption for 2001 concerning the withdrawal of all anise-containing products are presented.

Herbal medicine causing likely strychnine poisoning

'Maqianzi' (the dried ripe seed of Strychnos nux-vomica L.) contains 1.0-1.4% each of strychnine and brucine. After processing to reduce its toxicity, 'maqianzi' was used as a herbal remedy for rheumatism, musculoskeletal injuries and limb paralysis. A 42-year old woman with neck pain was prescribed 15 g of 'maqianzi' to be taken in two doses at 7 hours apart, although the recommended dose was 0.3-0.6 g. She was apparently well after drinking the first of two bowls of 'maqianzi' decoction. One hour after she drank the second bowl of herbal decoction, she suddenly developed tonic contractions of all her limb muscles and carpopedal spasm lasting 5 min, difficulty in breathing, chest discomfort and perioral numbness. The second bowl of decoction probably became more concentrated because of evaporation of water during continued boiling and contained a larger amount of 'maqianzi'. On arrival in the hospital 1 hour later, she complained of muscle pain and tiredness. She was found to have hyperventilation and weakness of four limbs, with muscle power of grade 5(-)/5. All her symptoms gradually subsided over the next few hours. This case illustrated that 'maqianzi' can cause strychnine poisoning even after processing, especially when the recommended dose is greatly exceeded. In any patient with 'unexplained' muscle spasms or convulsions, strychnine poisoning should be included in the differential diagnosis and they should be asked about the use of herbal medicines.

Selected herbal hazards

One of the most important considerations in treating herbal ingestions is product quality assurance. Although most herbal companies are reputable, there are numerous reports of adulterated products (addition of substances not noted on the label). This has been particularly true of Chinese herbal products, which frequently contain pharmaceutical agents. Plant identification errors occur, and entire batches of product have been mixed using the wrong herb. In some cases, labels are written in a foreign language or only contain directions for mixing, making interpretation difficult. In cases where a known ingestion produces unexpected clinical signs, the potential for adulteration or other errors should be considered. When a product is not standardized, a consumer cannot be sure what dose of active constituents has been used or how bioavailable the product may be. Standardization also provides assurance that the actual herb is in the product [26]. Clients who use herbal products should be advised to treat them as a medication and to keep them away from pets. Specifically, ask clients if they take or use any natural or herbal products. Many people do not consider these substances drugs or assume, "If natural, it is harmless." Clients should be encouraged to learn about the herbal and neutraceutical products they are taking or giving their pets. Owners need to discuss the proper use of herbal products in pets with their veterinarian. Clients can be encouraged to discuss alternative therapies by discussing a pet's diagnosis and suggested treatments thoroughly. Discuss the client's expectations and opinions of alternative and conventional medicine. Issues of safety and efficacy must be fully explained to clients. Clients should be encouraged to report potential adverse reactions or to discuss different routes of therapy if a pet's medical condition is not improving. Clients who want to use alternative medical treatments should obtain a thorough medical workup so as to make a correct diagnosis and be referred to a veterinarian trained in alternative medicine. In choosing an alternative medicine practitioner, the same criteria would be used as for any other specialist: education, training, and professionalism [14].

Life-threatening uvular angioedema caused by Ecbalium elaterium

Ecbalium elaterium, known as the wild or squirting cucumber, is a hairy perennial herbaceous vine of the Cucurbitaceae family, endemic to the Mediterranean region. All parts of the plant are toxic, particularly the gherkin-like fruits. It is frequently used in the treatment of sinusitis by nasal aspiration in some parts of the Mediterranean. The studies regarding to Ecbalium elaterium, argue that it has an anti-inflammatory characteristic. Two cases of uvular oedema have been ascribed to the undiluted use of this substance. Since they can threaten life, similar cases arising with the improper use of herbals should not be ignored in the emergency department. In this paper we present a life-threatening uvular angioedema caused by nasal aspiration of undiluted juice of squirting cucumber.