TOXIC PLANTS

1. TOXIC PLANTS Christopher Holstege, MD Associate Professor Departments of Emergency Medicine& Pediatrics Blue Ridge Poison Center University of Virginia

2. Substances Most Frequently Involved in Human Exposures 1. Analgesics 10.5% 2. Cleaning Substances 9.5% 3. Cosmetics 9.4% 4. Plants 4.9% 5. Cough/Cold Products 4.5% 5. Bites and envenomations 4.2% 2000 annual report of the AAPCC TESS Am J Emerg Med 2004;19(5):337-395.

3. Toxic Plant Ingestions • Most commonly affected: • Children (>75,000), hikers, abuse • consumption as food or herbs by adults • Total exposures for 2004: 106,385 • Total major outcomes: 94 • Total deaths: 6

4. Most Common Plant Exposures • Pepper 4,984 • Philodendron 4,378 • Poinsettia 2,952 • Holly 2,871 • Dumbcane 2,648 • Peace lily 2,632 • Pokeweed 2,207 • Jade plant 1,715 • Poison ivy 1,478

5. Vet Hum Tox 2001;43(1):35-7 • 14 y/o native boy was harvesting with his family plants in a swampy area of northern Saskatchewan on Thanksgiving weekend. • He ate root material from a presumed edible plant. • Within minutes he began seizing, became cyanotic, and was found in cardiac arrest. • EMS arrives and 22 min of resuscitation revises him. • He continued with intermittent seizures. • Declared brain dead 20 hours after eating it.

6. Hint: plant

7. Hint: plant often misidentified as water parsnip

8. Hint: plant final often misidentified as water parsnip

9. Water Hemlock

10. Water Hemlock What is the Latin name?

11. Cicuta maculata • Heath KB. A fatal case of apparent water hemlock poisoning. Vet Hum Toxicol. 2001 Feb;43(1):35-6. • From the Centers for Disease Control and Prevention. Water hemlock poisoning--Maine, 1992. JAMA. 1994 May 18;271(19):1475. • Landers D. Seizures and death on a white river float trip. Report of water hemlock poisoning. West J Med. 1985 May;142(5):637-40. • Mack RB. Keats, Socrates and fool's parsley--water hemlock poisoning. N C Med J. 1985 Mar;46(3):163-4. • Carlton BE. Water hemlock poisoning complicated by rhabdomyolysis and renal failure. Clin Toxicol. 1979;14(1):87-92.

12. GABA Cl- + + Extracellular space + + Intracellular space

13. GABA Cl- Picrotoxin + + Extracellular space + + Intracellular space

14. OH HOCH2(CH2)2-(C C)2-(CH CH)3-CHCH2CH2CH3 Cicutoxin • Agonist activity at the picrotoxin site • GABA receptor inhibition • Symptoms • GI distress, diaphoresis, seizures, mydriasis, rhabdomyolysis, renal failure • Treatment • charcoal • observation for 4 hours • benzodiazepines & barbituates

15. WJM 1995;163(6):573-4 • 4 y/o boy and his father ingest the green tops of “wild carrots” growing in their backyard. • Within 30 minutes, the child became sleepy and takes a nap, which is unusual for him. • 2 hours later the father cannot wake him and there is emesis in the bed of green material. • EMS is contacted.

16. WJM 1995;163(6):573-4 • P 100; RR 26 • Pupils miotic • Disconjugate gaze • Neck supple • Withdraws from painful stimuli, + gag • Labs are all normal • Toxicology screen is negative • CXR neg • Lavage and activated charcoal.

17. Hint: grow taller than a carrot

18. Hint: leaves are like a carrot

19. Hint: stem is hallow

20. Hint: stem is red speckled

21. Hint: used to kill Socrates

22. Coniine N H Poison Hemlock

23. Coniine N H Poison Hemlock What is the Latin name?

24. Coniine N H Conium maculatum

25. Coniine N H Conium maculatum What three other plants have similar clinical effects?

26. Hints: plant 1

27. Hints: plant 1

28. Hints: plant 1 final

29. Nicotine H N N CH3 Tobacco

30. Nicotine H N N CH3 Tobacco What is the Latin name?

31. Nicotine H N N CH3 Nicotiana tabacum

32. Hint: plant 2 misidentified as colored greens

33. Hint: plant 2 final

34. Tree tobacco • Streenkamp PA. Accidental fatal poisoning by Nicotiana glauca: identification of anabasine by high performance liquid chromatography/photodiode array/mass spectrometry. Forensic Sci Int. 2002 Jul 17;127(3):208-17. • Mizrachi N. Fatal poisoning from Nicotiana glauca leaves: identification of anabasine by gas-chromatography/mass spectrometry. J Forensic Sci. 2000 May;45(3):736-41. • Mellick LB. Neuromuscular blockade after ingestion of tree tobacco (Nicotiana glauca). Ann Emerg Med. 1999 Jul;34(1):101-4. • Sims DM. Another death due to ingestion of Nicotiana glauca. J Forensic Sci. 1999 Mar;44(2):447-9. • Castorena JL. A fatal poisoning from Nicotiana glauca. J Toxicol Clin Toxicol. 1987;25(5):429-35.

35. Tree tobacco • Streenkamp PA. Accidental fatal poisoning by Nicotiana glauca: identification of anabasine by high performance liquid chromatography/photodiode array/mass spectrometry. Forensic Sci Int. 2002 Jul 17;127(3):208-17. • Mizrachi N. Fatal poisoning from Nicotiana glauca leaves: identification of anabasine by gas-chromatography/mass spectrometry. J Forensic Sci. 2000 May;45(3):736-41. • Mellick LB. Neuromuscular blockade after ingestion of tree tobacco (Nicotiana glauca). Ann Emerg Med. 1999 Jul;34(1):101-4. • Sims DM. Another death due to ingestion of Nicotiana glauca. J Forensic Sci. 1999 Mar;44(2):447-9. • Castorena JL. A fatal poisoning from Nicotiana glauca. J Toxicol Clin Toxicol. 1987;25(5):429-35. What is the Latin name?

36. Nicotiana glauca

37. Hint:plant 3 final Used by herbalist to help smokers quit

38. Lobelia inflata

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45. nicotine/conine/lobeline • Mechanism • stimulation of nicotinic acetylcholine receptors • Signs/Symptoms Seizures • cortex, thalamus, interpeduncular nucleus stimulation Autonomic Ganglia Stimulation • sympathetic and parasympathetic stimulation Neuromuscular Depolarizion • Treatment • Atropine • Benzodiazepines/Barbituates

46. Case

47. Hint: history • Bulgarian dissident Georgi Markov was killed by poison dart filled with this agent and fired from an umbrella in London in 1978. • Markov, a communist defector working for the BBC World Service, left his office at Bush House in the UK capital on September 11 and walked across Waterloo Bridge to take the train home to Clapham in south-west London. • As he waited at a bus stop moments into his journey home, he felt a sharp jab in his thigh and saw a man picking up an umbrella. • He developed a high temperature and in four days was dead.

48. Hint: history final • A post mortem, conducted with the help of scientists from the UK government's germ warfare centre at Porton Down, established that he had been killed by a 1.7 mm pellet containing a 0.2 milligram dose of this poison. • No toxin was isolated. Because of the small volume and rapid demise of the patient, ricin was believed to be the only capable inciting agent. • The coroner recreated the scenario by injecting a pig with a similar dose of ricin. The pig died in a similar manner 26 hours later. • Markov's assassination was detected only because the pellet carrying the poison had not dissolved as expected.

49. Hint: history final

50. Castor Bean