Section Aims

This sections aims to cover the toxicology of the following important poisonings
1. Plants that contain cardiac glycosides
2. Plans that contain gastrointestinal and systemic toxicity
3. Anticholinergic and Hallucinogenic plants
4. Proconvulsant plants
5. Herbal products


Gastrointestinal irritants and plant dermatitis


Objectives

  • Understand the mechanism of toxicity of these plants.
  • Discuss the clinical effects of plants with systemic toxicity.
  • Detail the assessment of a patient poisoned by a systemically toxic plant.
  • Outline the management of gastrointestinal and systemic complications following ingestion of these plants

Read

Gastrointestinal irritants and
Plant dermatitis

Problems

Problems Gastrointestinal irritants and plant dermatitis

CardioToxic Plants


Objectives

  • .List plants that contain Cardiac glycosides
  • Understand the mechanism of action of cardiac glycisides on the heart
  • Detail clinical features of cardiac glycoside toxicity
  • List predictors of toxicity
  • List prognostic markers
  • Describe in detail the process of resuscitation of a patient with cardiac glycoside toxicity
  • List the investigations that should be carried out
  • Describe the management of acute poisoning and cardiac complications
  • Detail the clinical effects of nicotinic alkaloid plant poisoning.
  • Discuss the management of nicotinic alkaloid plant poisoning.

Read

  • Cardiac Toxins
  • Eddleston M, Ariaratnam CA, Sjöström L, Jayalath S, Rajakanthan K, Rajapakse S, Colbert D, Meyer WP, Perera G, Attapattu S, Kularatne SA, Sheriff MR, Warrell DA. Acute yellow oleander (Thevetia peruviana) poisoning: cardiac arrhythmias, electrolyte disturbances, and serum cardiac glycoside concentrations on presentation to hospital. Heart. 2000 Mar;83(3):301-6.
  • Eddleston M, Rajapakse S, Rajakanthan, Jayalath S, Sjöström L, Santharaj W, Thenabadu PN, Sheriff MH, Warrell DA. Anti-digoxin Fab fragments in cardiotoxicity induced by ingestion of yellow oleander: a randomised controlled trial. Lancet. 2000 Mar 18;355(9208):967-72.
  • Eddleston M, Juszczak E, Buckley NA, Senarathna L, Mohamed F, Dissanayake W, Hittarage A, Azher S, Jeganathan K, Jayamanne S, Sheriff MR, Warrell DA; Ox-Col Poisoning Study collaborators. Multiple-dose activated charcoal in acute self-poisoning: a randomised controlled trial. Lancet. 2008 Feb 16;371(9612):579-87.
  • Roberts DM, Southcott E, Potter JM, Roberts MS, Eddleston M, Buckley NA.Pharmacokinetics of digoxin cross-reacting substances in patients with acute yellow Oleander (Thevetia peruviana) poisoning, including the effect of activated charcoal. Ther Drug Monit. 2006 Dec;28(6):784-92.
  • Ozhan H, Akdemir R, Yazici M, Gündüz H, Duran S, Uyan C.Cardiac emergencies caused by honey ingestion: a single centre experience.Emerg Med J. 2004 Nov;21(6):742-4 (fulltext)

Problem

Problem Cardiac Toxins and Proconvulsant Plants

Proconvulsant plants

Plants containing nicotinic alkaloids lead to sympathetic over stimulation. In severe cases these patients can develop coma, seizures, cardiovascular collapse followed by respiratory paralysis. Tobacco and Poison Hemlock are well known plants that contain nicotinic alkaloids.

Objectives:

  • List plants that contain nicotinic alkaloids
  • Describe the mechanism of action of nicotinic alkaloids
  • Identify clinical features of nicotinic alkaloid plant poisoning
  • Outline the management of nicotinic plant toxicity

Read:

  • Proconvulsant Plants
  • P Davies, S Levy, A Pahari, D Martinez Acute nicotine poisoning associated with a traditional remedy for eczema Arch Dis Child. 2001 Dec;85(6):500-2.
  • McKnight RH, Spiller HA Green tobacco sickness in children and adolescents.Public Health Rep. 2005 Nov-Dec;120(6):602-5 (fulltext)
  • Arcury TA, Quandt SA, Preisser JS.Predictors of incidence and prevalence of green tobacco sickness among Latino farmworkers in North Carolina, USA.J Epidemiol Community Health. 2001 Nov;55(11):818-24. (fulltext)
  • Ingestion of cigarettes and cigarette butts by children--Rhode Island, January 1994-July 1996 .MMWR Morb Mortal Wkly Rep. 1997 Feb 14;46(6):125-8 (fulltext)
Problem Proconvulsant plants

Anticholinergic and other hallucinogenic plants


Objectives

  • Understand the mechanisms of hallucinogenic plants.
  • Understand the usual patterns of abuse of hallucinogenic plants.
  • List the most common clinical manifestations of hallucinogenic plant poisoning.
  • Understand how this helps differentiate the likely agent in a suspected hallucinogenic plant ingestion.
  • Recognise situations where the use of antidotes may be indicated.
  • Know the supportive treatment for anxiety with severe visual hallucinations.

Read

Anticholinergic and other hallucinogenic plants

  • Richard h. Schwartz, md marijuana: a decade and a half later, still a crude drug with underappreciated toxicity pediatrics vol. 109 no. 2 february 2002, pp. 284-289
  • Fisher BA, Ghuran A, Vadamalai V, Antonios TF. Cardiovascular complications induced by cannabis smoking: a case report and review of the literature. Emerg Med J. 2005 Sep;22(9):679-80.
  • Leslie Iverse. Cannabis and the brain. Brain 2003;126(6): 1252-1270
  • J. R. Unwin.Illicit drug use among Canadian youth. II. Can Med Assoc J. 1968 March 2; 98(9): 449–454.
  • Spina SP, Taddei A Teenagers with Jimson weed (Datura stramonium) poisoning. CJEM. 2007 Nov;9(6):467-8 (fulltext)
  • A Ballantyne, P Lippiett, and J Park Herbal cigarettes for kicks. Br Med J. 1976 December 25; 2(6051): 1539–1540.

Problem

Problem Anticholinergic and other hallucinogenic plants

Poisoning with plants that can induce muscle spasm

Strychnine poisoning was a common pharmaceutical poison in the past. Plants containing strychnine give rise to similar clinical manifestations. Strychnine inhibits glycine, an important inhibitory neurotransmitter in the spinal cord. This leads to generalized muscle contractions.

Objectives:

  • List causes of muscle spasms/ muscle rigidity encountered in clinical practice
  • Describe the clinical features of strychnine poisoning
  • Describe the evaluation of a patient with strychnine for complications
  • Describe the management of strychnine poisoning

Reading

  • David Michael Wood, Emma Webster, Daniel Martinez, Paul Ivor Dargan and Alison Linda Jones Survival after deliberate strychnine self-poisoning, with toxicokinetic data Critical Care 2002, 6:456-459 (fulltext)
  • J R Lambert, R J Byrick, and M D Hammeke. Management of acute strychnine poisoning. Can Med Assoc J. 1981 May 15; 124(10): 1268–1270 (fulltext)

Problem

Problem strychnine

Miscellaneous plant poisons

Objectives:

  • Identify clinical features of ricin toxicity
  • Describe the management of ricin poisoning

Read

  • Mouser P, Filigenzi MS, Puschner B, Johnson V, Miller MA, Hooser SB. Fatal ricin toxicosis in a puppy confirmed by liquid chromatography/mass spectrometry when using ricinine as a marker.J Vet Diagn Invest. 2007 Mar;19(2):216-20.(fulltext)
  • Audi J, Belson M, Patel M, Schier J, Osterloh J JAMA. Ricin poisoning: a comprehensive review.2005 Nov 9;294(18):2342-51.(fulltext)
  • Bradberry SM, Dickers KJ, Rice P, Griffiths GD, Vale JA. Ricin poisoning. Toxicol Rev. 2003;22(1):65-70.(pubmed)

Problem

Problem Miscellaneous Plants

Mushrooms

Unintentional ingestion of mushrooms is still an important problem with deaths occurring in some parts of the world. Toxic mushrooms can present various clinical presentations due to the differing toxins present. Cyclopeptides ( e.g. Amanita phalloides), glyromitrin ( e.g. G. californica), Muscarine (Clitocybe dealbata), Coprine e.g. C. atramentarius) and Psilocybin (e.g. C. cubensis) are some of the toxins present in this group of mushrooms.

Objectives:

  • Identify clinical features of mushroom poisoning by different mushrooms
  • Describe the management of mushroom poisoning

Read

  • WikiTox Meixner Test
  • Trim GM, Lepp H, Hall MJ, McKeown RV, McCaughan GW, Duggin GG, Le Couteur DG. Poisoning by Amanita phalloides ("deathcap") mushrooms in the Australian Capital Territory. Med J Aust. 1999 Sep 6;171(5):247-9. (fulltext)
  • Pond SM, Olson KR, Woo OF, Osterloh JD, Ward RE, Kaufman DA, Moody RR Amatoxin poisoning in northern California, 1982-1983. . West J Med. 1986 Aug;145(2):204-9.(fulltext)
  • Yamada EG, Mohle-Boetani J, Olson KR, Werner SB. Mushroom poisoning due to amatoxin. Northern California, Winter 1996-1997.West J Med. 1998 Dec;169(6):380-4 (fulltext)
  • Erguven M, Yilmaz O, Deveci M, Aksu N, Dursun F, Pelit M, Cebeci N. Mushroom poisoning. Indian J Pediatr. 2007 Sep;74(9):847-52 (fulltext) IndianJPediatr749847_142720.pdf

Problem

Problem Mushroom

Colchicine containing plants

Colchicine cantained in plants such as Gloria superba and Colchicium autumnale inhibits microtubular formation within cells. This leads to interference with cellular mitosis and cell death. Interference of microtubular functions in all organs of the body can result in multi organ failure with the greatest effect manifesting in rapidly dividing cells such as the gastrointestinal tract.
Initial clinical presentation is in the gastrointestinal tract with nausea, vomiting and diarrhoea leading to volume depletion. In severe poisoning this initial clinical stage leads to multiorgan failure and finally death or recovery.

Objectives:

  • Describe the mechanism of action of colchicine
  • Describe clinical sequealae of colchicine toxicity
  • Describe predictors of toxicity
  • Outline the management of acute poisoning and resuscitation of a patient with severe colchicines toxicity
  • List the investigations that should be carried out

Read

  • WikiTox Colchicine
  • Maxwell MJ, Muthu P, Pritty PE. Accidental colchicine overdose. A case report and literature review. Emerg Med J. 2002 May;19(3):265-7 (fulltext)
  • Danel VC, Wiart JF, Hardy GA, Vincent FH, Houdret NM.Self-poisoning with Colchicum autumnale L. flowers. J Toxicol Clin Toxicol. 2001;39(4):409-11.
  • Folpini A, Furfori P.Colchicine toxicity--clinical features and treatment. Massive overdose case report. J Toxicol Clin Toxicol. 1995;33(1):71-7.
  • Brvar M, Ploj T, Kozelj G, Mozina M, Noc M, Bunc M. Case report: fatal poisoning with Colchicum autumnale.Crit Care. 2004 Feb;8(1):R56-9. Epub 2004 Jan 2.(fulltext) colchicine autumnale.pdf
  • Eddleston M, Persson H. Acute plant poisoning and antitoxin antibodies.J Toxicol Clin Toxicol. 2003;41(3):309-15. (fulltext)

Problem

Problem Colchicine Plants

Herbals

Objectives

  • Understand the spectrum of intoxication with common herbal medications.
  • List traditional medications susceptible to interact with St John’s wort and the symptoms associated with this poisoning.
  • Describe initial evaluation, stabilisation and treatment of common herbal remedies intoxication.
  • Discuss the main difficulties in dealing with herbal remedies poisonings.
  • Describe the mechanism of toxicity of Ma Huang.
  • Describe the mechanism of aconite tachyarrhythmias.
  • Discuss steps that would be useful in preventing herbal medication poisoning from a Community Health Perspective.

Read

Herbals

Problem

Problem Herbals

Volatile Oils


Objectives

  • Understand the mechanism of toxicity of individual volatile oils.
  • Understand the circumstances of volatile oil poisoning.
  • Detail the clinical manifestations of poisoning by the various volatile oils.
  • Outline the management of volatile oil poisoning.

Read

  • Volatile Oils
  • Theis JG, Koren G. Camphorated oil: still endangering the lives of Canadian children.
    CMAJ. 1995 Jun 1;152(11):1821-4 (fulltext)
  • Anderson IB, Mullen WH, Meeker JE, Khojasteh-BakhtSC, Oishi S, Nelson SD,
    Blanc PD. Pennyroyal toxicity: measurement of toxic metabolite levels in two cases and
    review of the literature.Ann Intern Med. 1996 Apr 15;124(8):726-34 (fulltext)
  • Demetriades AK, Wallman PD, McGuiness A, Gavalas MC. Low cost, high risk: accidental nutmeg intoxication.Emerg Med J. 2005 Mar;22(3):223-5. (fulltext)
  • Hartnoll G, Moore D, Douek D Near fatal ingestion of oil of cloves. Arch Dis Child. 1993 Sep;69(3):392-3 (fulltext)
  • Patel S, Wiggins J. Eucalyptus oil poisoning.Arch Dis Child. 1980 May;55(5):405-6 (fulltext)
  • Filipsson AF. Short term inhalation exposure to turpentine: toxicokinetics and acute effects in men. Occup Environ Med. 1996 Feb;53(2):100-5.(fulltext)

Problem

Problem Volatile Oil