Ingestion of angel's trumpet: an increasingly common source of toxicity

Review on the genus Brugmansia: Traditional usage, phytochemistry, pharmacology, and toxicity

ETHNOPHARMACOLOGICAL RELEVANCE

The genus Brugmansia belongs to the Solanaceae family and contains approximately 7-8 species distributed in America, Europe, Africa, and Asia. The genus Brugmansia plants are used in the traditional medicine of different parts of the world for the treatment of inflammations, rheumatic arthritis, wounds, skin infections, headache, asthma, colic, aches, and so on.

AIM OF THE REVIEW

To the best of our knowledge, this is the first review study that focuses on the phytochemistry, pharmacology, toxicity, and traditional uses of Brugmansia species in order to understand the link between the traditional uses, phytochemistry, and modern therapeutic uses, and provide a scientific fundamental for further research in the phytochemical and pharmacological activities of their species.

MATERIALS AND METHODS

The information reported in this study was retrieved from the scientific database such as ScienceDirect, PubMed, Springer, CNKI, Wiley, Google Scholar, and Baidu Scholar, up until May 2020. The key search word was "Brugmansia." Additionally, information was derived by search on the reference lists of included articles and Ph.D. dissertations.

RESULTS

As traditional uses, Brugmansia species are used against a wide range of diseases such as body pain, inflammatory conditions, skin infection, wound, and other diseases. Also, these species are used as a hallucinogen, protection from evil, and magical rituals. Phytochemical investigations have led to reporting approximately 189 chemical compounds in this genus. Among these components, tropane alkaloids, terpenes, and flavonoids are the most representative components of Brugmansia species. The plant extracts and chemical constituents of Brugmansia species exhibit a broad spectrum of biological and pharmacological activities, including anti-inflammatory, cytotoxic, antioxidant, antibacterial, antispasmodic, anti-asthmatic, antinociceptive, antiprotozoal activities, and so on.

CONCLUSION

This review summarized and analyzed the information of traditional uses, phytochemical, pharmacological activities, and toxicity of the genus Brugmansia plants, which show their species have interesting chemical constituents with different biological activities. The traditional uses of some species from this genus have been estimated by pharmacological activities, such as the anti-inflammatory, antispasmodic, antiasthma, antinociceptive, anti-addictive, and antiprotozoal activity. However, the traditional uses of many species have not been confirmed, also the secondary metabolites of the many species have not yet been determined and have never been pharmacologically estimated. Considerably more research is needed to assert the ethnopharmacological uses, determine the chemical constituents, toxicity, and pharmacological activities of the genus Brugmansia species. The present review will be helpful for further research in the phytochemistry and pharmacology of Brugmansia species.

Ischemic Stroke and Provoked Seizure as a Manifestation of Brugmansia suaveolens (Angel's Trumpet) Acute Intoxication: A Detailed Clinical, Electroencephalogram, and Magnetic Resonance Imaging Description and 5-Month Follow-up

METHODS

We present a detailed clinical, laboratory, electroencephalogram/magnetic resonance imaging description and a 4-month follow-up of a case of stroke and provoked seizures as manifestation of angel's trumpet intoxication.

RESULTS/DISCUSSION

A 76-year-old woman presented with stuporous state evolving in 48 hours in bilateral mydriasis, vomiting, global aphasia, confusion, and stereotyped movement. An interictal electroencephalogram, performed 72 hours later, showed frequent generalized epileptiform discharges, and a brain magnetic resonance imaging revealed 2 small subcortical lesions in the right frontal lobe on diffusion weighted imaging sequences. When completely recovered, she could tell that she had mistaken angel's trumpet flowers for pumpkin flowers, so she had eaten them.

CONCLUSIONS

Angel's trumpet intoxication is a neurological emergency that deserves attention of both the media in matter of plant poisoning and the scientific forums because of the high lethal potential to better choose the diagnostic and therapeutic process.

The Anesthesiologist's Armamentarium: From Recreation to Medication and Back

For millennia, mankind has sought a means of altering consciousness, often aided by naturally occurring elements. Psychotropic substances have been an integral part of spiritual, medicinal, and recreational aspects of life. The origin of anesthesiology stems directly from the use of recreational drugs; early inhaled anesthetics were first used as a means of entertainment. Hence, it is no surprise that many medications in the anesthesiologist's armamentarium are diverted for recreational use. In the 172 years following the first successful public demonstration of ether anesthesia, many drugs with abuse potential have been introduced to the practice of anesthesia. Although anesthesiologists are aware of the abuse potential of these drugs, how these drugs are obtained and used for recreational purposes is worthy of discussion. There are articles describing the historical and recreational use of specific drug classes. However, to the best of our knowledge, this is the first comprehensive review focusing on the breadth of drugs used by anesthesiologists.

Unknowing ingestion of Brugmansia suaveolens leaves presenting with signs of anticholinergic toxicity: a case report

Background

Brugmansia suaveolens is the commonest species under the Solanacea (“Angels Trumpet” in English; “Attana” in Sinhalese) plant family in Sri Lanka. It contains alkaloids like scopolamine, atropine and hyoscyamine which can cause an anticholinergic toxindrome. There have been a few reported cases of accidental ingestion of Brugmansia seeds among children, seeds being the most toxic part, but no such reported cases of Brugmansia leaves poisoning among adults.

Case presentation

A 60-year-old-female Sinhalese presented with acute confusion, delirium, and agitation. She had ingested a herbal drink made from leaves of an unknown plant from her garden prior to onset of symptoms. She had urinary retention, mydriasis and sinus tachycardia. She was managed supportively with activated charcoal and hydration and the delirium completely resolved within 15 hours. The presented unkown plant leaves were identified as Brugmansia suaveolens.

Conclusion

Although seeds are the most toxic plant part in most cases of Brugmansia poisoning, leaves also have a significant degree of toxicity. It is important that medical professionals promptly recognize the features of anticholinergic syndrome, and have a high index to suspect Brugmansia poisoning and start prompt treatment. It is also important to improve awareness of toxic plants among the general community to prevent toxicities and fatalities.

[Hypertensive crisis and anticholinergic toxidrome secondary to accidental consumption of datura stramonium in two children]

OBJECTIVE

To identify a hypertensive clinical form of atropine or anticholinergic toxidrome secondary to accidental consumption of Datura seeds.

PATIENTS AND METHODS

We report two cases of Datura intoxication in two children who presented marked anticholinergic syndrome whose diagnosis was made by the anamnesis and the clinic.

RESULT

Patient 1: A 5-year-old boy, returns home agitated with balance disorders. He was admitted to pediatric resuscitation unit. His Glasgow score was 11/15. The child made inconsistent remarks. The neurological examination revealed mydriasis. Hemodynamically, the blood pressure was 145/91mmHg, the heart rate was 145 bpm. The rest of the examination noted a temperature of 37.5°, a bladder globe. Standard biological tests were normal. ECG found sinus tachycardia. Urine analysis revealed a positive alkaloid reaction with the presence of atropine. The evolution was favorable after 48hours. Patient 2: 45-month-old boy admitted to a state of severe agitation of toxic origin. The clinical examination showed a central and peripheral anticholinergic symptomatology with severe hallucinations, severe hypertension, and a heart rate at 190 bpm. The rest of the examination found erythema in the thorax and upper limbs, bilateral mydriasis. The toxicological report confirmed the presence of alkaloids. The evolution was favorable.

CONCLUSION

Hypertension crisis and other anticholinergic clinical signs of Datura stramonium intoxication achieve favorable outcomes in children.

[Acute encephalopathy due to angel's trumpet intoxication: A case report and literature review]

We report two cases (a married couple) of intoxication due to angel's trumpet ingestion. Case 1: A 71-year-old woman was found lying unconscious on the sofa at home and was brought to our hospital by ambulance. She showed mydriatic anisocoria, and an intracerebral lesion was suspected. However, the brain magnetic resonance imaging showed no abnormal lesion and acute encephalopathy of unknown cause was diagnosed. Case 2: A 68-year-old man (husband of the patient of Case 1) showed alteration of consciousness with agitation and was admitted to our hospital on the next day. He also had slight mydriasis. As his manifestations were similar to those of his wife, we studied their medical history again. We found that they mistook the roots of angel's trumpet for burdock and cooked and ate them. This intoxication causes characteristic encephalopathy with altered consciousness and mydriasis. In the case of anisocoria or mild mydriasis, the diagnosis is difficult sometimes. The intoxication occurred within a family; this was a clue to the correct diagnosis. Severe cases exhibit pyramidal signs and symptoms or convulsion, and deaths have been reported. Angel's trumpet intoxication is an important neurological emergency.

Poisoning by Herbs and Plants: Rapid Toxidromic Classification and Diagnosis

The American Association of Poison Control Centers has continued to report approximately 50,000 telephone calls or 8% of incoming calls annually related to plant exposures, mostly in children. Although the frequency of plant ingestions in children is related to the presence of popular species in households, adolescents may experiment with hallucinogenic plants; and trekkers and foragers may misidentify poisonous plants as edible. Since plant exposures have continued at a constant rate, the objectives of this review were (1) to review the epidemiology of plant poisonings; and (2) to propose a rapid toxidromic classification system for highly toxic plant ingestions for field use by first responders in comparison to current classification systems. Internet search engines were queried to identify and select peer-reviewed articles on plant poisonings using the key words in order to classify plant poisonings into four specific toxidromes: cardiotoxic, neurotoxic, cytotoxic, and gastrointestinal-hepatotoxic. A simple toxidromic classification system of plant poisonings may permit rapid diagnoses of highly toxic versus less toxic and nontoxic plant ingestions both in households and outdoors; direct earlier management of potentially serious poisonings; and reduce costly inpatient evaluations for inconsequential plant ingestions. The current textbook classification schemes for plant poisonings were complex in comparison to the rapid classification system; and were based on chemical nomenclatures and pharmacological effects, and not on clearly presenting toxidromes. Validation of the rapid toxidromic classification system as compared to existing chemical classification systems for plant poisonings will require future adoption and implementation of the toxidromic system by its intended users.

Poisoned after Dinner: Dolma with Datura Stramonium

Datura stramonium, which is also known as Thorn Apple or Jimson Weed, is an alkaloid containing plant that is entirely toxic. The active toxic constituents of the plant are atropine, scopolamine and hyoscyamine. It has been abused worldwide for hundreds of years because of its hallucinogenic properties. Previous reports have shown that herbal medication overdose and accidental food contamination are ways it can cause poisoning. Herein we present a family that had three of its members poisoned after eating a traditional meal “dolma” made of datura flowers. None had fatal complications and all were discharged healthy. Datura stromonium may be used accidentally as a food ingredient. Since its poisonous effects are not known, people should be informed and warned about the effects of this plant.

Intoxication by angel's trumpet: case report and literature review

Background

Brugmansia, commonly referred to as angel’s trumpet (AT), has been become popular in Korea as an ornamental shrub. However, it is not generally known by the public that this plant contains tropane alkaloids, and that ingestion of AT can lead to anticholinergic poisoning.

Case presentation

A 64-year-old Korean female presented with acute mental changes caused by inadvertent ingestion of the petals of AT flowers used as a garnish in a traditional Korean food (bibimbop). She regained her usual level of awareness after 10 hours.

Conclusion

Considering its easy availability, the toxicity of AT should be addressed to prevent accidental and intentional poisoning by this ornamental plant.

Toxicology in the ICU: part 3: natural toxins

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

Anticholinergic delirium following Datura stramonium ingestion: Implications for the Internet age

Recreational use of Datura to deliberately induce an anticholinergic delirium is not uncommon. We present a case of Datura intoxication in a young adult who learned about the recreational use of Datura on the Internet and subsequently purchased Datura stramonium seeds from an online vendor. Using the Google search engine, we conducted searches for "Datura," "jimson weed" and "Datura seeds" and reviewed the first 200 search results for each search term. We found 16 websites recommending the recreational use of Datura, 12 vendors selling seeds of genus Datura and one website that both promoted the recreational use of Datura and also sold Datura stramonium leaves. The promotion of recreational use of Datura on the Internet represents a danger to public health and the ability to purchase Datura seeds from Internet vendors may increase the prevalence of Datura abuse.

An unusual cause of fulminant Guillain-Barré syndrome: angel's trumpet

A 5-year-old previously healthy boy presented with typical findings of Guillain-Barré syndrome and unilateral tonic pupil. He was placed on mechanical ventilation for 35 days for respiratory failure. Plasmapheresis and two courses of intravenous immunoglobulin therapy were given to the patient, and he experienced stepwise recovery from his illness. This case of acute motor axonal neuropathy type Guillain-Barré syndrome is novel in that the cause was established as ingestion of a toxic solanaceous plant, angel's trumpet (Brugmansia suaveolens; syn. Datura suaveolens). Understanding the signs and symptoms of angel's trumpet toxicity can allow for early diagnosis and proper case management.

Presumed Angel's trumpet (Brugmansia) poisoning: clinical effects and epidemiology

OBJECTIVE

To investigate the pattern and epidemiology of anticholinergic plant poisoning, and to characterize its time course and clinical features.

METHODS

We reviewed all anticholinergic plant poisonings using a prospective database of all poisonings admitted to a major toxicology unit in Australia. All patients that presented with anticholinergic plant poisoning between July 1990 and June 2000 were included. Patient demographics, details of poisoning, diagnostic clinical features, adverse effects (seizures, arrhythmias, hypotension, accidental injury), and treatments required were obtained. Important diagnostic features were analysed and compared to previous studies.

RESULTS

Thirty-three patients were presumed to have ingested Brugmansia spp. (Angel's trumpet) based on their description of the plant; median age 18 years (interquartile range 16-20); 82% males. Thirty-one ingested a brewed tea or parts of the plant (flower). Thirty-one used it recreationally. Common clinical features were: mydriasis (100%), mean duration 29 h (SD 13) and delirium (88%) with a mean duration of 18 h (SD 12). Tachycardia only occurred in 11 of the 33 patients (33%). In 24 patients where the time of ingestion was certain, 7 of 8 (88%) patients presenting within 5 h had tachycardia and only 5 out of 16 (31%) presenting after 5 h had tachycardia. There were no deaths, seizures or arrhythmias (excepting tachycardia). One patient had hypotension and two sustained accidental traumatic injuries. Nineteen patients required sedation, mainly with benzodiazepines. Physostigmine was used diagnostically in eight cases.

CONCLUSIONS

Anticholinergic plant abuse is sporadic in nature. Most cases were moderate in severity, requiring sedation only, and severe toxicity was rare. Mydriasis and delirium were the commonest features, the later having important implications for management.

Serious psychiatric and neurological adverse effects of herbal medicines -- a systematic review

OBJECTIVE

Psychiatric and neurological patients frequently try herbal medicines often under the assumption that they are safe. The aim of this systematic review was to provide a summary of recent data on severe psychiatric and neurological adverse effects of herbal remedies.

METHOD

Computerized literature searches were carried out to identify all reports of psychiatric and neurological adverse effects associated with herbal medicines. These data were subsequently extracted, validated and summarized in narrative and tabular form.

RESULTS

Numerous case reports comprise a diverse array of adverse events including cerebral arteritis, cerebral oedema, delirium, coma, confusion, encephalopathy, hallucinations, intracerebral haemorrhage, and other types of cerebrovascular accidents, movement disorders, mood disturbances, muscle weakness, paresthesiae and seizures. Several fatalities are on record. They are caused by improper use, toxicity of herbal ingredients, contamination and adulteration of preparations and herb/drug interactions.

CONCLUSION

Herbal medicines can cause serious psychiatric and neurological adverse effects.

Pica and the elephant's ear

This is a case report of an otherwise healthy 2-year-old boy with a history of pica, associated with iron deficiency anemia. This boy was referred to our department for a neurologic evaluation because of an acute episode of sialorrhea, difficulty in speaking, dysphagia, and repeated swallowing movements. An uncertain episode of a brief-duration still gaze was also reported. In addition, the history revealed that the child had earlier ingested a leaf from a poisonous houseplant called Colocasia esculenta, also known as "elephant's ear." The habit of pica subsided after treatment with iron supplements. A 9-month follow-up period was uneventful. Neurologic manifestations can accompany accidental intoxications of some non-nutrient substances. Thus, pica must be suspected in children with acute behavior alterations.

Drug information libraries on the Internet

In the past several years there has been a dramatic proliferation of drug-related sites on the Internet. This article reviews the information found at selected Internet drug information libraries, and comments on its accuracy and implications. Drug-related sites were found by initially performing an Internet search on "psychoactive drugs" and then exploring links among the sites identified. Sites were chosen on the basis of comprehensiveness of information and positive or tolerant attitude toward drug use. While all classes of drugs are discussed at these sites, the primary foci of interest are synthetic and naturally occurring hallucinogens. Many of the biological materials discussed are legal and readily available. Information surveyed at these sites was largely accurate regarding the effects of various substances and biological sources of psychoactive compounds.

CONCLUSIONS

Internet drug information libraries contain large amounts of information about a wide variety of drugs, including previously little-known biological sources of hallucinogens. The availability of this information could have significant effects on patterns of drug use.

The toxicology of African herbal remedies

Toxicity related to traditional medicines is becoming more widely recognized as these remedies become popular in developed countries. Accidental herbal toxicity occurs not only as a result of a lack of pharmaceutic quality control in harvesting and preparation but also because herbal remedies are believed to be harmless. Although there is a huge amount of data available documenting the pharmacologically active ingredients of many plants, it is seldom helpful to the toxicologist in an acute situation. Current analytic methods such as high-performance liquid chromatography, gas chromatography--mass spectrometry, and immunoassays can provide identification of the toxin in those few cases in which the history or symptoms give a clear lead, but broad screening methods remain to be developed. In most cases of plant poisoning, treatment continues to be only of symptoms, with few specific antidotes available. It is important that toxicologists in the West be alert to the possibility of encountering poisoning in patients due to traditional African remedies.