An unusual case of baboon syndrome due to mercury present in a homeopathic medicine

Quantitative Analysis of Metal Contents in Korean Herbs and Herbal Products to Give Advice for Metal Allergic Patient

Background

Herbs have been used worldwide as complementary and alternative medicines. In Korea, herbs for medical purpose are strictly controlled by the Korea Food and Drug Administration (KFDA). But it does not provide standards for metal antigens.

Objective

This study conducted to identify the metal contents of Korean herbs and herbal products and to give information on counselling metal allergic patient.

Methods

The concentration of three metal allergens with high antigenicity, cobalt (Co), chromium (Cr), nickel (Ni) was quantitatively determined using inductively coupled plasma with a mass spectrometer after nitric acid (HNO₃) digestion. The herbal objects are as follows: 1) ten kinds of herb plants, 2) ten herbal products sold in Korean drugstores, and 3) ten herbal extracts prescribed by Korean herbal doctors.

Results

In 30 samples, Ni and Cr were detected in all items. Co was not detected in two drugstore products.

Conclusion

Although the levels of metal detected in this study were very low relative to international guidelines and KFDA regulations, the herbal preparations contained similar or higher metal levels than known metal-rich foods. It can cause problems when it added to the daily diet and cause deterioration of skin lesions of metal sensitized person.

Herbal Product Contamination and Toxicity

Herbal poisoning exposures reported to poison centers increased by 344% after passage of the Dietary Supplement Health and Education Act, with 24412 exposures reported in 2003. Increased toxicity is speculated to be related to lack of child-resistant packaging, new issues of contamination, proliferation of multiple ingredient products, excessive concentration of active ingredients, and discovery of new drug-herb interactions. This review addresses contamination issues such as heavy metals, pharmaceuticals, homeopathic remedies, microbes, insects, environmental chemicals, and mis-identification of one plant for another. Toxicity issues covered include carcinogenicity, delay in seeking medical treatment when using herbs to treat serious illness, toxic components, hypersensitivity reactions, hepatotoxins, nephrotoxins, epileptogenic compounds, cardiac toxins, gastrointestinal toxins, and hematologic toxins. Common drug-herb interactions are discussed. The pharmacist plays an important role in patient education and evaluation of potential toxicities related to herbal supplements.

Adverse effects of homeopathy: a systematic review of published case reports and case series

AIM

The aim of this systematic review was to critically evaluate the evidence regarding the adverse effects (AEs) of homeopathy.

METHOD

Five electronic databases were searched to identify all relevant case reports and case series.

RESULTS

In total, 38 primary reports met our inclusion criteria. Of those, 30 pertained to direct AEs of homeopathic remedies; and eight were related to AEs caused by the substitution of conventional medicine with homeopathy. The total number of patients who experienced AEs of homeopathy amounted to 1159. Overall, AEs ranged from mild-to-severe and included four fatalities. The most common AEs were allergic reactions and intoxications. Rhus toxidendron was the most frequently implicated homeopathic remedy.

CONCLUSION

Homeopathy has the potential to harm patients and consumers in both direct and indirect ways. Clinicians should be aware of its risks and advise their patients accordingly.

Systemic contact dermatitis in children: how an avoidance diet can make a difference

Systemic contact dermatitis is an under-recognized skin reaction that occurs secondary to systemic (oral, intravenous, intramuscular, inhaled, or subcutaneous) exposure to a hapten in a previously sensitized individual. Medicaments are the most common cause of SCD in the adult population, but other chemicals like nickel, cobalt, balsam of Peru, and formaldehyde have been implicated as well. Few reports in children exist to date. Dietary restriction has shown to be of some benefit in managing some adult patients. We present a case series of 8 pediatric patients diagnosed with SCD from the contact dermatology clinic, who showed marked improvement of their dermatitis after adequate dietary avoidance. We review common presentations of chemicals causing SCD in children and potential dietary modifications.

First case of symmetric drug-related intertriginous and flexural exanthema (sdrife) due to rivastigmine?

The term 'baboon syndrome' was introduced in 1984 to describe a special form of systemic, contact-type dermatitis that occurs after ingestion or systemic absorption of a contact allergen in individuals previously sensitized by topical exposure to the same allergen in the same areas. Its clinical picture presents as an erythema of the buttocks and upper inner thighs resembling the red bottom of baboons. This reaction was originally observed with mercury, nickel, and ampicillin. In 2004, some authors proposed the acronym SDRIFE standing for 'symmetric drug-related intertriginous and flexural exanthema' specifically for cases elicited by systemically administered drugs. Since 1984, about 100 cases have been reported in the literature; for most of the concerned drugs, previous skin sensitization or possible cross-sensitization has not been shown. We report the first case of SDRIFE due to rivastigmine, with the exception of an erythematous maculopapular eruption due to rivastigmine that was previously reported. Rivastigmine is a reversible and noncompetitive acetylcholinesterase inhibitor used for the treatment of Alzheimer disease. SDRIFE is an important condition to keep in mind in order to avoid a misdiagnosis when dealing with other exanthematous disorders and to prevent re-exposure to the responsible allergen in the future.

Drug allergy: an updated practice parameter

Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient

Surveillance of suspected adverse reactions to natural health products in Italy

PURPOSE

Natural health products are promoted to the public as equally or more effective and less toxic than conventional drugs. However, some 'natural' medicines, and in particular some herbal medicines, are known to have adverse effects. The Italian Pharmacovigilance System, in charge of the Italian Medicines Agency, collects spontaneous reports only for registered drugs. The awareness of the need of surveillance of the safety of natural health products has stimulated the implementation of a suspected adverse reaction reporting system in Italy. The system has been set up by the Italian National Institute of Health.

METHODS

An ad hoc reporting form can be downloaded from different institutional web sites. Voluntary reports of suspected adverse reactions are sent to the National Institute of Health and are evaluated by a multidisciplinary group of experts.

RESULTS

From April 2002 to March 2007, 233 spontaneous reports of suspected adverse reactions to natural health products were collected. A large proportion of suspected adverse reactions were serious: hospitalization was reported in 35% of forms; 6% reported life threatening clinical events and two fatal events were notified. About 50% of suspected adverse reactions were related to gastrointestinal, skin, psychiatric and nervous system disorders. Mainly herbal products (66%) were involved. Twenty-one cases of hepatitis of various seriousness were reported. Twenty-one reports were associated with 27 homeopathic preparations, mostly preparations containing mixtures of substances. Fourteen reports regarded suspected reactions to products containing propolis.

CONCLUSION

Safety and efficacy of 'natural' medicines have not been thoroughly investigated. It is important to improve communication with the public on safety issues. Encouraging spontaneous reporting can contribute to improve awareness among health personnel and patients about the benefit-harm profile of these remedies.

Systemically induced allergic exanthem from mercury

Cutaneous reactions to mercury can manifest themselves in different forms. Apart from contact dermatitis, flare-up reactions, disseminated exanthem as well as skin symptoms in previously unaffected skin are known. Regarding systemic allergen application, 2 separate clinical patterns, namely acute generalized exanthematous pustulosis (AGEP) and symmetric flexural exanthem 'baboon syndrome' have been described. Systemic allergic reactions to mercury are most commonly provoked by the inhalation of metallic mercury vapours from a broken thermometer, often after previous sensitization to mercury compounds, e.g. Mercurochrome. Patch testing with mercurials yields positive reactions in approximately 80% of patients. We report 3 patients, 2 with flexural exanthem, and 1 presenting with AGEP, respectively. Positive patch tests to mercury derivatives could be demonstrated in all of them. Furthermore, non-toxic serum mercury levels were detected in 2 of the patients. The present review provides a survey of the literature on systemic allergic exanthem to mercury. However, plausible explanations for the distribution pattern of the skin manifestations in AGEP and flexural exanthem are still lacking.

Cutaneous side effects of alternative therapy

Unconventional, complementary, and alternative therapies have become very popular forms of therapy and the predictions are that their popularity will continue to soar in the future. They are often perceived as being "natural" and therefore harmless, devoid of side effects, and without unpleasant consequences. The fact is that although their risks might be less than those of conventional drugs, side effects of this therapy can and do occur and must be considered as being a relevant factor in using such methods. It is to be expected that their numbers will increase in the future because of their growing popularity and because of continuing efforts to intensify their activity and therapeutic efficacy. Therefore, now more than ever, dermatologists should be familiar with all possible side effects, risks, and toxic, allergic, and possible mutagenic reactions. This article provides fundamental and vital information for practicing dermatologists.

Homeopathy in dermatology

Alternative methods are commonly used in patients with dermatologic diseases, with homeopathy being one of the most common. Homeopathy was developed by Samuel Hahnemann (1755-1843) and is based on the law of similars and the law of infinitesimals. It is a regulatory therapy where high dilutions of particular compounds are thought to induce a counterreaction in the organism. In dermatology, homeopathy is often used in atopic dermatitis, other forms of eczema, psoriasis, and many other conditions. To date, however, there is no convincing evidence for a therapeutic effect. There are only a few controlled trials, most of them with negative results. The few studies with positive results have not been reproduced. Acceptance by the patient seems largely based on counseling and emotional care rather than on objective responses to the homeopathic drugs.

Side-effects of complementary and alternative medicine

Complementary and alternative medicine are increasingly used to diagnose or treat allergic diseases, and numerous studies have reported benefits of this type of medicine. This article presents a review of the literature on risks of these methods. The potential sensitizing capacity of numerous herbal remedies may lead to allergic contact dermatitis and more rarely to IgE-mediated clinical symptoms. Mechanical injuries may be observed following acupuncture leading to pneumothorax, cardiac tamponade or spinal injury. Infectious complications after acupuncture include hepatitis and bacterial endocariditis. Organ toxicity has been observed associated with various herbal preparations involving the liver, kidneys, and the heart. Some herbs may have cancerogenic properties. Severe nutritional deficiencies can occur in infants and small children given strict alternative diets, resembling 'kwashiorkor'. Finally, among other miscellaneous adverse effects, adulteration with steroids, and herbal and drug interactions are discussed. The pattern of side-effects is similar to that observed by the use of conventional medicine. Therefore, caution may be justified using both conventional and unconventional methods. Only if the benefit is proven and the side-effects are established, should a given method be chosen.