Acute plant poisoning: analysis of clinical features and circumstances of exposure

Current use of medicinal plants for children's diseases among mothers in Southern Romania

There is a limited number of studies focusing on ethnomedical practices in children, particularly in Eastern Europe. Romania has a rich history of using medicinal plants in ethnopediatric care, and our objective was to identify the medicinal plants currently employed in treating childhood illnesses in the southern region of the country. Material and methods Our investigation used structured interviews, focusing on respondent demographics, local names of therapeutically employed herbs, the specific plant part(s) utilized, methods of preparation and administration, and local folk indications of taxa. A total of 326 mothers with children aged 0 to 18, hospitalized in the "Grigore Alexandrescu" Children Emergency Hospital Bucharest and residing in Southern Romania, were enrolled in the study. Use Value Citation Index (UVc), Informant Consensus Factor (Fic), and Fidelity Level (FL) were calculated. Results Twenty-five plants were identified for treating children's diseases in Southern Romania. The majority of informants resided in urban areas, and mothers primarily acquired knowledge from family members and healthcare professionals. The herbs most frequently employed were Mentha spp. (UV = 0.509) for diarrhea, Matricaria spp. (UV = 0.301) for skin infections (Fic = 0.99) and digestive diseases (Fic = 0.98), and Calendula officinalis L. (UV = 0.365) for skin diseases (Fic = 0.99). Less utilized were Raphanus raphanistrum subsp. sativus (L.) Domin in respiratory diseases, Prunus avium (L.) L. stalks in urinary tract ailments, Helianthus annuus L. in ear infections, Allium sativum L. in intestinal parasitosis, Viola tricolor L. in hives, Triticum aestivum L. in dermatitis and Allium ursinum L. as a tonic. In 184 cases herbal treatment was used in conjunction with conventional medications. Education level correlated with the number of employed plants and the variety of treated ailments, while residency (rural vs. urban) did not. Both residency and education influenced plant procurement methods: rural background and, surprisingly, higher education were linked to a preference for harvesting rather than purchasing plants. Conclusion Botanical remedies are still commonly used in the treatment of pediatric diseases in Southern Romania, although the variety of taxa seems reduced compared to the past. Further exploration is essential to unlock the maximum benefits of ethnopediatric practices.

Deliberate Self-Poisoning with Plants in Southeastern France, a Poison Center 20-Year Report

INTRODUCTION

In a few regions of the globe, deliberate botanical intoxication may induce significant rates of toxicity and fatality. The objective of this report was to describe plant self-intoxication using the experiences of the southeastern France poison control center (PCC) between 2002 and 2021.

RESULTS

During those 20 years, 262 deliberate plants poisonings were reported involving 35 various plants. In most of the cases, poisoning was caused by Nerium oleander (n = 186, 71%), followed by the Datura genus (4.2%), Ricinus communis (3.8%), Taxus baccata (1.9%), Digitalis purpurea (1.2%), Aconitum nape (1.9%), Myristica fragans (1.5%), and Pyracantha coccine (1.2%). Through the 262 plants poisonings, 19 patients among the 186 Nerium oleander poisonings received Digifab as an antidote and 1 patient received physostigmine among the 11 Datura poisonings. Only four deaths were reported for this review, each involving Nerium oleander.

DISCUSSION

The first involved species was Nerium oleander (71% of all plants poisonings), then Datura sp and Ricinus communis. It is explained by this native local species' important repartition. Most patients must be admitted to an emergency department for adapted medical care; however, only 41 of them described severe poisonings symptoms. Even fewer needed an antidote, only 20 patients. There is no protocol for the use of a specific treatment, and it might be interesting to develop one for this purpose.

MATERIAL AND METHODS

This retrospective review was realized with files managed by the southeastern France PCC based in Marseille from 2002 to 2021. Our department covers the complete French Mediterranean coast, Corsica, and tropical islands (Reunion Island, Mayotte). For every patient, toxicity was evaluated using the Poison Severity Score (PSS).

Discrimination of Camellia cultivars using iD-NA analysis

Recently, many new cultivars have been taken abroad illegally, which is now considered an international issue. Botanical evidence found at a crime scene provides valuable information about the origin of the sample. However, botanical resources for forensic evidence remain underutilized because molecular markers, such as microsatellites, are not available without a limited set of species. Multiplexed intersimple sequence repeat (ISSR) genotyping by sequencing (MIG-seq) and its analysis method, identification of not applicable (iD-NA), have been used to determine several genome-wide genetic markers, making them applicable to all plant species, including those with limited available genetic information. Camellia cultivars are popular worldwide and are often planted in many gardens and bred to make new cultivars. In this study, we aimed to analyze Camellia cultivars/species through MIG-seq. MIG-seq could discriminate similar samples, such as bud mutants and closely related samples that could not be distinguished based on morphological features. This discrimination was consistent with that of a previous study that classified cultivars based on short tandem repeat (STR) markers, indicating that MIG-seq has the same or higher discrimination ability as STR markers. Furthermore, we observed unknown phylogenetic relationships. Because MIG-seq can be applied to unlimited species and low-quality DNA, it may be useful in various scientific fields.

Characteristics of emergency department presentations following ingestion of Taxus baccata (yew)

OBJECTIVE

Presentations of Taxus baccata (yew) poisoning can range between asymptomatic cases and life-threatening cardiotoxicity - depending on the amount ingested. This study aimed to describe emergency department (ED) presentations after yew exposure, and covers their clinical presentation, diagnostic and specific treatment, to contribute to optimising intreatment and prophylaxis.

METHODS

Retrospective observational study of cases (≥ 16 years of age) presenting at the ED of the University Hospital of Bern, Switzerland, from 1 May 2012 to 31 May 2020 following reported yew exposure. Cases were retrieved from the electronic patient database using full-text terms.

RESULTS

During the study period, 55 presentations (11 patients) of the 350,381 ED attendances were included. All patients were female and the median age on first presentation was 22 years (range 16-48). All 10 patients with intentional intake had previous diagnoses of psychiatric disorders. Commonly reported symptoms on presentation were gastrointestinal disturbances (31 presentations, 56%), neurological (six presentations, 11%) and subjective cardiovascular symptoms (five presentations, 9%). The most frequent clinical findings on presentation were tachycardia (15 presentations, 27%) and hypotension (11 presentations, 20%). In 52 presentations (95%), gastroscopic extraction of the leaves was performed, activated charcoal was administered in 25 cases (45%), and there were no fatalities. In the majority of the cases (40, 73%), the patient was admitted to psychiatric care and in 10 (18%) the patient was discharged home.

CONCLUSION

ED presentations after yew exposure appear to be rare, but potentially life-threatening and commonly observed in this study in young female patients with underlying psychiatric diseases. In this case series, gastroscopic extraction and activated charcoal application were commonly performed and there were no fatalities.

Plant poisonings in Australia: a retrospective series of calls to the Queensland Poisons Information Centre

INTRODUCTION

There is little research to characterise plant poisoning in Australia. The aim of this project is to investigate plant exposures reported to a state poisons information centre.

METHODS

This is a retrospective review of plant exposures reported to the Queensland Poison Information Centre (QPIC) between January 2019 and December 2021. Main outcome measures included patient demographics, plant exposure details, symptomatology, and management advice.

RESULTS

QPIC received calls regarding 2766 plant exposures over the study period. Children aged 1-4 years were the commonest group exposed, accounting for 1295 (46.8%) exposures. The caller was usually a family member/caregiver (2036 [73.6%]) calling from home (2257 [81.6%]). Exposures were unintentional in 2722 (98.4%) cases, with the oral route being most common, occurring in 2264 (81.9%) cases.Plant groups most responsible for exposures included gastrointestinal irritants (536 [19.4%]), oxalates (522 [18.9%]), and non-toxic plants (442 [16.0%]). The plant involved was known in 2366 (85.5%) exposures, most commonly Euphorbiaceae (257 [9.3%]). Patients were asymptomatic (1644 [59.4%]) or had mild toxicity (1033 [37.3%]) in most exposures. Only 18 (0.6%) cases had moderate/severe toxicity, and this was most often due to recreational exposures by adults (9[0.3%]). Referral for medical review was advised in 407 (14.7%) cases, most commonly following exposures to Euphorbiaceae (140/407 [34.4%]), gastrointestinal irritants (52/407 [12.7%]), and oxalates (38/407 [9.3%]).

CONCLUSIONS

The majority of plant exposures reported to QPIC are unintentional paediatric exposures. Most are asymptomatic or have mild toxicity. More severe toxicity is seen in adults with recreational plant exposures.

Natural Taxanes: From Plant Composition to Human Pharmacology and Toxicity

Biologically active taxanes, present in small- to medium-sized evergreen conifers of various Taxus species, are widely used for their antioxidant, antimicrobial and anti-inflammatory effects, but mostly for their antitumour effects used in the treatment of solid tumours of the breast, ovary, lung, bladder, prostate, oesophagus and melanoma. More of the substances found in Taxus plant extracts have medical potential. Therefore, at the beginning of this review, we describe the methods of isolation, identification and determination of taxanes in different plant parts. One of the most important taxanes is paclitaxel, for which we summarize the pharmacokinetic parameters of its different formulations. We also describe toxicological risks during clinical therapy such as hypersensitivity, neurotoxicity, gastrointestinal, cardiovascular, haematological, skin and renal toxicity and toxicity to the respiratory system. Since the effect of the drug-form PTX is enhanced by various Taxus spp. extracts, we summarize published clinical intoxications and all fatal poisonings for the Taxus baccata plant. This showed that, despite their significant use in anticancer treatment, attention should also be focused on the risk of fatal intoxication due to ingestion of extracts from these plants, which are commonly found in our surroundings.

Five new species of Inosperma from China: Morphological characteristics, phylogenetic analyses, and toxin detection

Many species of Inosperma cause neurotoxic poisoning in humans after consumption around the world. However, the toxic species of Inosperma and its toxin content remain unclear. In the present study, we proposed five new Inosperma species from China, namely, I. longisporum, I. nivalellum, I. sphaerobulbosum, I. squamulosobrunneum, and I. squamulosohinnuleum. Morphological and molecular phylogenetic analyses based on three genes (ITS, nrLSU, rpb2) revealed that these taxa are independent species. A key to 17 species of Inosperma in China is provided. In addition, targeted screening for the most notorious mushroom neurotoxins, muscarine, psilocybin, ibotenic acid, and muscimol, in these five new species was performed by using ultrahigh-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). Our results show that the neurotoxin contents in these five species varied: I. sphaerobulbosum contains none of the tested neurotoxins; I. nivalellum is muscarine positive; I. longisporum and I. squamulosohinnuleum contain both ibotenic acid and muscimol, and I. squamulosobrunneum only contains muscimol; psilocybin was not detected in these five new species.

Fatal ingestion of Taxus baccata: English yew

Poisoning from consumption of foraged alternative medicine products is an uncommon yet recognized occurrence. Here, presented is the case of a 40-year-old woman who was witnessed to collapse with labored breathing and subsequently died despite emergency medical personnel attendance and resuscitation efforts. Autopsy revealed the presence of plant matter that was visually identified as leaves from Taxus baccata - the English Yew. Isolation of alkaloids from the plant material and subsequent identification of the same alkaloids in the decedent's blood by liquid chromatography-tandem mass spectrometry indicated a toxicological cause of death. This case illustrates a collaborative team approach among subject matter experts to unexpectedly discover and then confirm the sudden death of this woman from T. baccata toxicity.

Lectin Activity in Commonly Consumed Plant-Based Foods: Calling for Method Harmonization and Risk Assessment

Lectins are ubiquitous proteins characterized through their ability to bind different types of carbohydrates. It is well known that active lectins from insufficiently prepared legumes can cause adverse human health effects. The objective of this study was to determine the activity of lectins in samples across plant families representing commercially available edible plants, and the feasibility of inactivating lectins through soaking and boiling. Lectins were extracted from the plant families Adoxaceae, Amaranthaceae, Cannabaceae, Fabaceae, Gramineae, Lamiaceae, Linaceae, Pedaliaceae, and Solanaceae. A hemagglutination assay based on non-treated or trypsin treated rabbit erythrocytes was used to measure the lectin activity. The results showed the highest lectin activity in species from the Fabaceae family and demonstrated that soaking and boiling have an effect on the levels of active lectins. This is the first large study that combines lectin activity obtained from two different assays with raw and processed edible plants. In addition, we examined the current risk assessment, and regulations necessary for an adequate official reporting of results. We encourage the scientific community to further explore this field and agree on harmonized methods for analysis and interpretation, and hope that our methodology can initiate this development.

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.

Toxic plants-Detection of colchicine in a fast systematic clinical toxicology screening using liquid chromatography-mass spectrometry

Colchicum autumnale, which can be mistaken for Allium ursinum, contains the alkaloid colchicine potentially leading to life-threatening up to fatal intoxications. We report two cases of acute intoxications with unexplained circumstances. Using the authors' systematic screening approaches, colchicine could be detected in blood plasma and urine samples using liquid chromatography coupled to linear ion trap mass spectrometry (LC-ITMSⁿ ) and high-resolution tandem mass spectrometry (LC-HRMS/MS). Metabolites of colchicine could be identified in urine for confirmation of screening results. Gas chromatography-mass spectrometry (GC-MS) analysis was also conducted, but colchicine could not be detected. Furthermore, colchicine concentration was estimated via LC-HRMS/MS in plasma samples. Results of the systematic screening indicated the ingestion of colchicine from both subjects. In both cases, the parent compound was detected in blood plasma and urine using the LC-HRMS/MS and LC-ITMSⁿ system. An O-demethylation metabolite was identified in urine samples of both subjects using LC-HRMS/MS; the N-deacetylation product was also found in urine samples of both cases via LC-HRMS/MS and LC-ITMSⁿ . The use of LC-ITMSⁿ resulted only in the detection of the O-demethylation product in case 2. Plasma concentrations were estimated at 2.5 ng/ml and 4.7 ng/ml for cases 1 and 2, respectively. We demonstrated the detection of this highly toxic alkaloid in blood plasma and urine using a time-saving and reliable clinical systematic screening. Furthermore, we identified metabolites of colchicine being rarely discussed in literature, which can be used as additional screening targets.

Rapid Identification of Common Poisonous Plants in China Using DNA Barcodes

Toxic plants have been a major threat to public health in China. However, identification and tracing of poisoned species with traditional methods are unreliable due to the destruction of plant morphology by cooking and chewing. DNA barcoding is independent of environmental factors and morphological limitations, making it a powerful tool to accurately identify species. In our study, a total of 83 materials from 26 genera and 31 species of 13 families were collected and 13 plant materials were subjected to simulated gastric fluid digestion. Four markers (rbcL, trnH-psbA, matK, and ITS) were amplified and sequenced for all untreated and mock-digested samples. The effectiveness of DNA barcoding for the identification of toxic plants was assessed using Basic Local Alignment Search Tool (BLAST) method, PWG-Distance method, and Tree-Building (NJ) method. Except for the matK region, the amplification success rate of the remaining three regions was high, but the sequencing of trnH-psbA and ITS was less satisfactory. Meanwhile, matK was prone to be more difficult to amplify and sequence because of simulated gastric fluid. Among the three methods applied, BLAST method showed lower recognition rates, while PWG-Distance and Tree-Building methods showed little difference in recognition rates. Overall, ITS had the highest recognition rate among individual loci. Among the combined loci, rbcL + ITS had the highest species recognition rate. However, the ITS region may not be suitable for DNA analysis of gastric contents and the combination of loci does not significantly improve species resolution. In addition, identification of species to the genus level is sufficient to aid in the clinical management of most poisoning events. Considering primer versatility, DNA sequence quality, species identification ability, experimental cost and speed of analysis, we recommend rbcL as the best single marker for clinical identification and also suggest the BLAST method for analysis. Our current results suggest that DNA barcoding can rapidly identify and trace toxic species and has great potential for clinical applications. In addition, we suggest the creation of a proprietary database containing morphological, toxicological and molecular information to better apply DNA barcoding technology in clinical diagnostics.

Classification of the mechanisms by which cardiotoxic plant poisons exert their effects

Episodes of poisoning due to plant-based toxins are an unusual presentation to the emergency department. Plant poisons may be ingested if the source plant is misidentified as benign (eg, Lily of the Valley being mistaken for wild garlic and water hemlock being mistaken for wild celery), or taken as part of a complementary medicine regime or otherwise for psychotropic effect. Numerous plant poisons demonstrate cardiotoxic effects resulting from action against cardiac myocyte ion channels, or other cardiac receptor targets. These mechanisms will produce stereotyped symptoms and including electrocardiogram (ECG) changes dependent on which ion channels or receptors are targeted. These mechanisms are stereotyped and may be grouped by toxidromic effect. This article proposes a novel classification of cardiotoxic plant poisons based on these actions. Given that these mechanisms mirror the Vaughan Williams classification used to categorise therapeutic antiarrhythmic agents, it is felt that this will serve as a mnemonic and diagnostic aid in clinical situations of cardiotoxic plant ingestion.

Accidental poisoning with autumn crocus (Colchicum autumnale): a case series

INTRODUCTION

Colchicum autumnale (autumn crocus) is a plant that contains highly toxic alkaloid colchicine. The aim was to evaluate accidental C autumnale poisoning and assess serum troponin as a prognostic parameter.

METHODS

In this study, we retrospectively included all adult patients with a history of accidental C autumnale ingestion and serum colchicine confirmation during the study period from 2000 to 2019. The medical files of enrolled patients were reviewed. Literature search of accidental ingestions of C autumnale was done.

RESULTS

Over the study period of 20 years, 16 adult patients were admitted to the University Medical Centre Ljubljana due to acute colchicine poisoning after ingestion of C autumnale. They all mistakenly ingested C autumnale's leaves instead of Allium ursinum in the spring and had confirmed colchicine in serum by GC-MS or LC-MS/MS (15.5 µg/L (0.5-80 µg/L)). They developed vomiting and diarrhoea within 1-9 h after the meal. Vomiting within 2 h was associated with lethality (p=.04). Bone marrow suppression developed in 15 patients (94%). Acute myocardial injury with positive troponin I (>0.10 µg/L) developed in five patients; lethal cardiogenic shock with decreased cardiac output and hypotension occurred in four of these patients despite supportive therapy. Positive troponin I ultra (>0.10 µg/L) was associated with need for intensive support therapy (p=.01), decreased cardiac output (p=.01) and death (p=.01). The mortality was 4/16 (25%). On review, we found 58 cases; 95% cases accidently ingested leaves of C autumnale instead of A ursinum. Troponin I was reported in 3% cases. The lethality of this and reviewed cases was 35% (26/74).

CONCLUSIONS

In unexplained gastroenterocolitis after ingestion of wild plants as a salad or spice in the spring, especially when wild garlic is mentioned, we should always consider C autumnale poisoning. Cardiogenic shock can be predicted by a positive serum troponin I measurement.

Fatal Yellow Oleander Poisoning Masquerading as Benign Candlenut Ingestion Taken for Weight Loss

BACKGROUND

Candlenuts (Aleurites moluccana) and yellow oleander seeds (Thevetia peruviana) bear a physical resemblance to one another. Candlenuts are benign and marketed as weight loss supplements. Yellow oleander seeds, however, contain toxic cardioactive steroids; as few as 2 seeds may cause fatal poisoning. Because of their physical similarities, the potential for a lethal substitution exists.

CASE REPORT

A 63-year-old woman presented to the emergency department with vomiting after ingesting 5 of what she believed to be candlenuts that were ordered online under the colloquial name "Nuez de la India" for the purpose of weight loss. She was bradycardic (nadir pulse of 30 beats/min) and hyperkalemic (serum potassium 7.3 mEq/L). Within hours of presentation she suffered a ventricular fibrillation arrest, followed by a terminal asystolic arrest. Postmortem analyses of liver tissue and the seeds were consistent with fatal T. peruviana poisoning. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: T. peruviana seeds contain toxic cardioactive steroids; their physical resemblance to candlenuts poses a risk of potentially fatal substitution. Therapy with high-dose digoxin specific immune fragments (20-30 vials) may be helpful.

Chemical Compounds, Pharmacological and Toxicological Activity of Brugmansia suaveolens: A Review

This study investigates updated information in different search engines on the distribution, phytochemistry, pharmacology, and toxicology of Brugmansia suaveolens (Solanaceae) using the extracts or chemical compounds at present. This plant has been used in traditional medicine in different cultures as a hallucinatory, analgesic, aphrodisiac, nematicide, sleep inducer, and muscle relaxant, as well as a treatment for rheumatism, asthma, and inflammation. The flowers, fruits, stems, and roots of the plant are used, and different chemical compounds have been identified, such as alkaloids, volatile compounds (mainly terpenes), coumarins, flavonoids, steroids, and hydrocarbons. The concentration of the different compounds varies according to the biotic and abiotic factors to which the plant is exposed. The toxic effect of the plant is mainly attributed to atropine and scopolamine, their averages in the flowers are 0.79 ± 0.03 and 0.72 ± 0.05 mg/g of dry plant, respectively. Pharmacological studies have shown that an aqueous extract exhibits the antinociceptive effect, at doses of 100 and 300 mg/kg i.p. in mice. On the other hand, the ethanolic extract at 1000 mg/L, showed a nematocidal activity in vitro of 64% against Meloidogyne incognita in 72 h. Likewise, it showed a 100% larvicidal activity at 12.5 mg/L against Ancylostoma spp. In another study, the lethal activity of shrimp in brine from an ethanolic extract showed an LC₅₀ of 106 µg/mL at double serial concentrations of 1000-0 (µg/mL). Although there are pharmacological and phytochemical studies in the plant, they are still scarce, which has potential for the examination of the biological activity of the more than one hundred compounds that have been reported, many of which have not been evaluated.

Swipe Right: a Comparison of Accuracy of Plant Identification Apps for Toxic Plants

INTRODUCTION

Plant identification applications for use on smartphones have been increasing in availability, accuracy, and utilization. We aimed to perform an introductory study to determine if a plant identification application (ID app) used on a smartphone could identify toxic plants, and to compare apps to determine which is most reliable.

METHODS

We compared three popular iPhone plant ID apps, PictureThis (PT), PlantSnap (PS), and Pl@ntNet (PN), used to identify 17 commonly encountered toxic plants. Apps were used to photograph the entire plant, leaves, and flowers of ≥ 10 different plants for each species. Two toxicologists performed plant identification with confirmation of identification performed by a botanist, and inter-researcher agreement was confirmed. For each plant species, scores for accuracy of app identification of leaves, flowers, and whole plant were combined to create an overall composite score used to compare accuracy of each app (95% C.I.).

RESULTS

PictureThis had the best performance with 10/17 (59% [36 to 78]) plant species identified 100% correctly, as opposed to 8/17 (47% [26 to 69]) for Pl@ntNet and 1/17 for PlantSnap (5.8% [1.1 to 27]).

CONCLUSION

A plant identification app may be a useful tool to assist healthcare providers and the public in identifying toxic plants.

[Poisonous plants-a new approach for assessing the risk of poisoning in small children]

BACKGROUND

Plant poisoning in small children (from 0.5 to <6 years of age) is the third most frequent cause for phone contact with a poison center. For prevention of poisonings, a list of poisonous plants that should not be planted close to playgrounds or other places frequently visited by children was published in 2000 by the Bundesanzeiger. This list has been reevaluated and updated by the "Toxicity of Plants" working group of the Committee of the Assessment of Intoxications at the Federal Institute of Risk Assessment (BfR).

MATERIALS AND METHODS

Relevant plants were taken from a recent publication. A literature search was conducted in PubMed concerning all plant poisonings in children and the toxic ingredients of plants. Also, monographs and the database POISINDEX were integrated in the evaluation. A classification was made for plants that after oral, dermal, or ocular contact of small quantities could cause severe, moderate, mild, or no intoxications in small children.

RESULTS

Based on data of exposure and potentially toxic ingredients of the involved plants, a risk assessment was executed, which diverges from other publications because it concerns the actual basic risk of an intoxication. In total, 251 plants were reevaluated. For 11 plants, there was a high risk, for 32 a moderate, for 115 a mild, and for 93 plants no risk of intoxication could be determined.

CONCLUSION

The new assessment of evaluating a toxicity risk for small children on the basis of exposure data and including the toxicity of ingredients allows for a more realistic assessment of the risk of poisoning with outdoor plants. In this way, infant exposure carrying a high risk of intoxication can be identified.

Two fatal intoxications by colchicine taken for saffron. Clinical, medico-legal and forensic toxicological implications

Although fatal colchicine intoxications are rare and mostly related to suicidal intake or accidental overdose, other hypotheses should be considered when dealing with colchicine poisoning. We present a case of double, acute, and subacute, fatal colchicine intoxication in a married couple. The 70-year-old male victim suddenly died after vomiting and diarrhea. The next day his wife showed aggravating gastrointestinal symptoms and was hospitalized with a diagnosis of septic shock. A complete postmortem examination on the man was performed, together with histopathological analysis. Toxicological examination performed through liquid chromatography coupled to mass spectrometry revealed a colchicine blood peripheral concentration of 33 ng/mL. A few days after hospitalization, the woman showed a colchicine plasma concentration of 32 ng/mL. Despite veno-venous hemofiltration, she ultimately died of septic shock and multi-organ failure. Death scene investigation revealed that, a few days before the death of the male victim, the couple had collected wild saffron and had eaten a presumed saffron risotto. The integrated analysis of circumstantial, clinical, postmortem and toxicological data allowed to establish that the couple had died of a fatal accidental intoxication due to the ingestion of natural colchicine, mistaken for saffron. The death of the male was deemed caused by acute cardiovascular collapse induced by acute intoxication, while the female had suffered a subacute poisoning by antimitotic agent, resulting in immunosuppression and systemic infection. Toxicological analyses, promptly performed on the man for forensic purposes, directed the investigations and suggested the clinical diagnosis on the woman.

Asteraceae species as potential environmental factors of allergy

The statistics from Europe and the USA have proven a high risk for skin diseases associated with plant contact. Therefore, plant-induced dermatitis is of increasing attention in dermatology. The focus of this paper was to present the current knowledge on aspects of contact allergy related to Asteraceae (Compositae) species. The Asteraceae family is one of the largest in the world with members across all continents. The PubMed/Medline databases have been searched. The Asteraceae representatives consist of diverse secondary metabolites, which exhibit various advantageous effects in humans. In particular, sesquiterpene lactones (SLs) may cause sensitization resulting in skin irritation and inflammation. In this study, we tried to reveal the allergenic potential of several Asteraceae species. The Asteraceae-related allergy symptoms involve eczema, hay fever, asthma, or even anaphylaxis. Furthermore, the evidence of severe cross-reactivity with food and pollen allergens (PFS) in patients sensitive to Asteraceae allergens have been announced. Further identification and characterization of secondary metabolites and possible allergens in Asteraceae are necessary for the better understanding of Asteraceae-related immune response. The Asteraceae allergy screening panel (the SL mix and the Compositae mix of five plant species) is a promising tool to improve allergy diagnostics and therapy.

[Accidental intoxication by outdoor and garden plants : Data from two German poison centres]

BACKGROUND AND OBJECTIVES

Accidental exposure of children to plants occurs often and results in numerous calls to poison centres. The aim of this study was to identify outdoor plants that led to moderate or severe poisoning after accidental exposure and to identify patterns of paediatric plant exposures.

MATERIALS AND METHODS

Human exposure data on accidental exposures provided by two German poison centres were retrospectively evaluated regarding the number and the routes of exposure. Special attention was turned to the kind and severity of symptoms. Based on these data a modified Litovitz factor was calculated.

RESULTS

Out of 42,344 confirmed exposures to 227 plant species, 39,346 (93%) were asymptomatic, 2415 (5.7%) experienced minor, 580 (1.3%) moderate and 3 (0.007%) severe symptoms. Twenty-six plant genera were responsible for 70% of all exposures. Only eight of these plants (Arum spec., Laburnum anagyroides, Narcissus spec., Phaseolus vulgaris/coccineus, Prunus laurocerasus, Sambucus spec., Taxus baccata, Thuja spec.) led to at least moderate symptoms. Accidental exposure of children aged 0.5-5 years was mainly by oral ingestion (98%) and involved mostly fruits (60%).

CONCLUSIONS

Exposure data collected by poison centres are very useful for hazard identification of outdoor plants. The data give a comprehensive overview of observed symptoms, which offers valuable instruments for use in clinical practice.

Comprehensive review of cardiovascular toxicity of drugs and related agents

Cardiovascular diseases are a leading cause of morbidity and mortality in most developed countries of the world. Pharmaceuticals, illicit drugs, and toxins can significantly contribute to the overall cardiovascular burden and thus deserve attention. The present article is a systematic overview of drugs that may induce distinct cardiovascular toxicity. The compounds are classified into agents that have significant effects on the heart, blood vessels, or both. The mechanism(s) of toxic action are discussed and treatment modalities are briefly mentioned in relevant cases. Due to the large number of clinically relevant compounds discussed, this article could be of interest to a broad audience including pharmacologists and toxicologists, pharmacists, physicians, and medicinal chemists. Particular emphasis is given to clinically relevant topics including the cardiovascular toxicity of illicit sympathomimetic drugs (e.g., cocaine, amphetamines, cathinones), drugs that prolong the QT interval, antidysrhythmic drugs, digoxin and other cardioactive steroids, beta-blockers, calcium channel blockers, female hormones, nonsteroidal anti-inflammatory, and anticancer compounds encompassing anthracyclines and novel targeted therapy interfering with the HER2 or the vascular endothelial growth factor pathway.

Clinical Toxicology of Yew Poisoning

Objectives: Yew plant materials contain highly toxic taxine alkaloids. Serious ingestions can result in life-threatening toxicity. The purpose of this article is to summarize the literature on the treatment of acute yew poisoning. Data Sources: PubMed (January 1946 to November 2017) was searched using the search terms “taxus/po”. EMBASE (1980 to November 2017) was searched using the search terms “taxus/to” and “yew.mp.” Web of Science (1945 to November 2017) was searched using the text words taxus, taxine, and yew. Study Selection and Data Extraction: Available English language articles involving case reports, epidemiology, treatment, and outcomes were included. Data Synthesis: Although not uncommon, unintentional yew poisoning rarely results in significant morbidity or mortality. A total of 26 case reports of yew poisoning were evaluated along with 4 case series articles (totaling 22 additional cases). Only 4 of the 48 total cases (8%) were accidental poisonings, the rest being deliberate ingestions. In 20 patients (42%), it resulted in fatalities. Severe, acute yew poisoning results in symptomatology largely resistant to pharmacotherapy intervention. Conclusions: Most nonintentional ingestions of yew plant constituents are asymptomatic and require little intervention. Severe poisoning can result in life-threatening cardiac toxicity and require aggressive supportive care. Therapeutic interventions, such as sodium bicarbonate, digoxin immune fab, and hemodialysis that have been utilized in case studies and case series in the literature have little proven benefit. Extracorporeal life support should be considered in severe yew poisoning.

Human Plant Exposures Reported to a Regional (Southwestern) Poison Control Center Over 8 Years

BACKGROUND

There is little published data about human plant exposures reported to US poison control centers (PCCs).

METHODS

A retrospective chart review of all reported plant exposures to a single regional PCC between January 1, 2003 and December 31, 2010 was done to understand better the characteristics of plant exposure cases. Specific generic plant codes were used to identify cases. Recorded variables included patient demographics, plant involved, exposure variables, symptoms, management site, treatments, and outcome. Univariate and multivariate regression was used to identify outcome predictors.

RESULTS

A total of 6492 charts met inclusion criteria. The average age was 16.6 years (2 months-94 years); 52.4% were male. The most common exposure reason was unintentional (98%), and the majority (92.4%) occurred at the patient's home. Ingestions (58.3%) and dermal exposures (34.3%) accounted for most cases. Cactus (27.5%), oleander (12.5%), Lantana (5.7%), and Bougainvillea (3.8%) were most commonly involved. Symptoms developed in 47.1% of patients, and were more likely to occur following Datura (66.7%), and Morning Glory or Milkweed (25% each) exposures. Almost 94% of patients were managed onsite (home) and only 5.2% involved evaluation in a health care facility (HCF). Only 37 (0.6%) patients required hospital admission, and 2.9% of cases resulted in more than minimal effects. Exposures resulting in more than minimal clinical effects were predicted by several variables: abnormal vital signs (OR = 35.62), abnormal labs (OR = 14.87), and management at a HCF (OR = 7.37). Hospital admissions were increased for patients already at a HCF (OR = 54.01), abnormal vital signs (OR = 23.28), and intentional exposures (OR = 14.7).

CONCLUSION

Plant exposures reported to our poison control center were typically unintentional ingestions occurring at home. Most patients were managed onsite and few developed significant symptoms.

Activated charcoal significantly reduces the amount of colchicine released from Gloriosa superba in simulated gastric and intestinal media

BACKGROUND

Poisoning with Gloriosa superba, a plant containing colchicine, is common in Sri Lanka.

OBJECTIVES

This study was to estimate release of colchicine from 5 g of different parts of Gloriosa superba in simulated gastric and intestinal media, and examine the binding efficacy of activated charcoal (AC) to colchicine within this model.

METHODS

A USP dissolution apparatus-II was used to prepare samples for analysis of colchicine using HPLC.

RESULTS

Cumulative colchicine release from tuber in gastric media at 120 minutes was significantly higher (2883 μg/g) than in intestinal media (1015 μg/g) (p < .001). Mean ± SD cumulative colchicine concentration over 2 hours from tuber, leaves and trunk in gastric medium was 2883.15 ± 1295.63, 578.25 ± 366.26 and 345.60 ± 200.08 μg/g respectively and the release in intestinal media was 1014.75 ± 268.16, 347.40 ± 262.61 and 251.55 ± 285.72 μg/g respectively. Introduction of 50 g of AC into both media made colchicine undetectable (<0.1 μg/ml).

CONCLUSIONS

The tuber released the highest quantity of colchicine. The colchicine release and elapse time to achieve saturated, equilibrium dissolution mainly depends on physicochemical properties of plant part. Significant in vitro binding of colchicine to AC suggests that AC has a role in decontamination of patients presenting to hospital after ingestion of Gloriosa superba.

Suicide attempt with self-made Taxus baccata leaf capsules: survival following the application of extracorporeal membrane oxygenation for ventricular arrythmia and refractory cardiogenic shock

CONTEXT

Yew intoxication has been known for many years; high dose ingestion of Taxus baccata leads to cardiac toxicity mediated by calcium and sodium channel blocking properties. We present a case report of a patient who attempted suicide after T. baccata ingestion, causing refractory cardiogenic shock requiring temporary circulatory assistance by veno-arterial extra corporeal membrane oxygenation (VA ECMO).

CASE DETAILS

A 28-year-old man was admitted to the critical care unit of a university hospital for arrhythmia after ingestion of self-made T. baccata leaf capsules. He rapidly developed cardiovascular collapse requiring mechanical ventilation, high dose intravenous catecholamines and electrical cardioversion. A femoro-femoral VA ECMO was implanted due to severe biventricular dysfunction and ventricular arrhythmia, associated with continuous renal replacement therapy. Taxol A, taxol B and baccatin III were detected and measured in both blood and urine samples by high-performance liquid chromatography tandem mass spectrometry, and kinetics suggested urinary excretion. Two days after hospital admission, VA ECMO and continuous renal replacement therapy were removed with full recovery of cardiac function.

DISCUSSION

Our experience suggests that circulatory assistance by VA ECMO and continuous renal replacement therapy seem to be effective safe second-line therapeutic options in critically ill cases of severe yew intoxication with refractory cardiogenic shock due to arrhythmia.

Species identification of white false hellebore (Veratrum album subsp. oxysepalum) using real-time PCR

Food poisoning is frequently caused by the accidental ingestion of toxic plants that possess strong morphological similarities to edible plants. False helleborine (Veratrum album) is one of the most common plants involved in such accidents. In cases of poisoning by toxic plants, rapid and accurate identification, usually based on the morphological or chemical analysis of plant parts, is required for appropriate medical treatment or forensic investigation. However, morphological examinations require experience in systematic botany because the samples are fragmentary, and chemical analysis of natural compounds can be difficult. In this study, we developed a TaqMan real-time PCR method using trnH-psbA and trnL-trnF that could be carried out in 30-60min. The lower detection limit was less than 10pg of DNA and the primer sets were specific to V. album and Veratrum stamineum. Mixed samples, cooked samples, and simulated gastric contents were successfully identified, and a multiplex assay of two regions was also possible. These results indicate that the TaqMan real-time PCR analysis is a very effective method to detect small samples of V. album and V. stamineum accurately and rapidly in poisoning cases.

Poisonous or non-poisonous plants? DNA-based tools and applications for accurate identification

Plant exposures are among the most frequently reported cases to poison control centres worldwide. This is a growing condition due to recent societal trends oriented towards the consumption of wild plants as food, cosmetics, or medicine. At least three general causes of plant poisoning can be identified: plant misidentification, introduction of new plant-based supplements and medicines with no controls about their safety, and the lack of regulation for the trading of herbal and phytochemical products. Moreover, an efficient screening for the occurrence of plants poisonous to humans is also desirable at the different stages of the food supply chain: from the raw material to the final transformed product. A rapid diagnosis of intoxication cases is necessary in order to provide the most reliable treatment. However, a precise taxonomic characterization of the ingested species is often challenging. In this review, we provide an overview of the emerging DNA-based tools and technologies to address the issue of poisonous plant identification. Specifically, classic DNA barcoding and its applications using High Resolution Melting (Bar-HRM) ensure high universality and rapid response respectively, whereas High Throughput Sequencing techniques (HTS) provide a complete characterization of plant residues in complex matrices. The pros and cons of each approach have been evaluated with the final aim of proposing a general user's guide to molecular identification directed to different stakeholder categories interested in the diagnostics of poisonous plants.

Fatal colchicine poisoning by accidental ingestion of Colchicum persicum: a case report

Colchicine poisoning can occur not only by taking dosage form but also by ingesting a plant containing colchicine. A 39-year-old man presented to the emergency room with nausea, vomiting, and diarrhea 9 hours after ingestion of wild garlic. Symptoms attributed to food poisoning, and he received supportive cares and discharged. However, he was admitted to the hospital because of severe gastrointestinal presentations 4 hours later. He received treatments based on the diagnosis of acute gastroenteritis. The patient was in a fair condition during 30 hours of hospitalization until he suddenly developed respiratory distress and unfortunately died with cardiopulmonary arrest. The deceased body referred to our legal medicine center for determining cause of death and investigating possible medical staff malpractices. Postmortem examination, autopsy, macropathology and micropathology study, and postmortem toxicological analysis were performed. All results were submitted to the medical committee office for decision. The unknown cause of death was disclosed after determination of colchicine in the plant and botanical identification as Colchicum persicum. The committee determined the most probable cause of death as acute cardiopulmonary complications induced by colchicine poisoning and the manner of death as accidental. The medical staff was acquitted of the malpractice.

Myocardial fibrosis associated with previous ingestion of yew (Taxus sp.) in a Holstein heifer

Twenty-six 5-month-old Holstein calves were accidentally exposed to discarded branches of yew bushes ( Taxus sp.). Several calves were found dead approximately 24 hr after exposure; however, a few calves died several days after exposure. One calf died 18 days after the initial exposure to Taxus sp. and was examined on the farm via necropsy. Gross lesions included ascites, and dilated and flaccid myocardial ventricles. Sections of formalin-fixed heart were submitted to the Indiana Animal Disease Diagnostic Laboratory for histopathologic examination; fresh rumen contents were submitted for toxicologic testing. Histologically, large areas of myocardium were replaced by fibrous connective tissue, suggesting previous myocardial necrosis. Taxus alkaloids were identified in the rumen contents using gas chromatography–mass spectrometry. Based on the clinical history, the gross and histologic lesions, the identification of Taxus alkaloids in the rumen contents, and lack of exposure to other known cardiotoxic agents, yew toxicity was considered the cause of death in this calf. Ingestion of taxines is known to cause acute and subacute toxicity in human beings and animals; however, a chronic clinical course and severe histologic lesions have not been previously associated with yew toxicity. Although only 1 calf was examined, this case suggests that yew toxicity can result in a prolonged clinical course in cattle and can cause histologic myocardial lesions.