ANGEL’S TRUMPET (BRUGMANSIA ARBOREA) AND MYDRIASIS IN A CHILD - A CASE REPORT

VAN DER DONCK I.*, MULLIEZ E.**, BLANCKAERT J.*,**

ABSTRACT rologique était normal, nous avons supposé que la cause de la mydriase était le contact accidentel avec We report a case of anisocoria in a 6-year old child la Brugmansia arborea. La fiabilité du test à la pilo- who felt out of an inflatable swimming pool in the carpine dans notre cas peut être mis en question à garden. After instillation of pilocarpine 1% the di- cause du temps écoulé entre le contact et la présen- lated pupil constricted, which is an important clini- tation aux urgences, le volume d’extrait de plante cal sign associated with intracranial trauma. There probablement limité dans l’œil, et une concentra- was evidence of exposure to angel’s trumpet (Brug- tion imprévisible des alkaloides dans la plante. mansia arborea), a plant known to contain anticho- linergic substances. As the results of further neuro- logical examination turned out to be normal, we be- lieve the mydriasis was due to an accidental expo- SAMENVATTING sure to angel’s trumpet. The time lag between expo- Een 6 jarig meisje vertoonde anisocorie na een val sure and presentation at the emergency room, the uit een opblaasbaar zwembadje in de tuin. De gedi- probably low volume of the plant extract in the eye lateerde pupil ging in miosis na indruppeling met pi- and the unpredictable concentration of alkaloids in locarpine 1%, wat wijst op een mogelijk intracra- the plant, can influence and question the reliability niëel trauma. Het meisje was zeer waarschijnlijk of the pilocarpine test in this case. blootgesteld geweest aan Brugmansia arborea (en- gelentrompet), een plant die anticholinergische stof- fen bevat. Omdat verder neurologisch onderzoek nor- RÉSUMÉ maal bleek, was de mydriasis volgens ons te wijten Une fillette de 6 ans a présenté une anisocorie après aan een accidenteel contact met Brugmansia arbo- une chute hors d’une piscine gonflable dans le jar- rea. De tijdsduur tussen de blootstelling en het on- din. Après instillation de pilocarpine 1% la pupille derzoek op spoedgevallen, het vermoedelijk laag vo- dilatée allait en miosis, ce qui suggère un trauma- lume van plantenextract in het oog en de onvoor- tisme crânien. La fillette avait probablement été en spelbare concentratie van alkaloïden in de plant, contact avec la Brugmansia arborea (trompette des kunnen de betrouwbaarheid van de pilocarpine test anges, stramoine en arbre), une plante contenant des in deze casus in twijfel trekken. substances anticholinergiques. Comme l’examen neu- KEY WORDS zzzzzz Anisocoria, Brugmansia arborea (angel’s trumpet), pilocarpine * Department of Ophthalmology, University Hospitals K.U. Leuven, Leuven, Belgium ** Department of Ophthalmology, R.Z. Jan Yperman, Ieper, Belgium MOTS-CLÉS

received: 19.12.03 Anisocorie, Brugmansia arborea (trompette accepted: 02.03.04 des anges, stramoine en arbre), pilocarpine

Bull. Soc. belge Ophtalmol., 292, 53-56, 2004. 53 INTRODUCTION DISCUSSION Solanaceae are often used as ornamental plants. Mydriasis after accidental instillation of plant Angel’s trumpet is a frequently found kind in components of the Solanaceae family into the gardens. It is known to contain alkaloids such eye has been reported previously. Flowers that as scopolamine and atropine. Accidental my- can induce parasympatholytic effects in the eye driasis from exposure to plant components in are deadly nightshade (Atropa belladonna), an- humans and animals has been reported (4, 5). gel’s trumpet (Brugmansia arborea), thorn ap- To distinguish atropine-like intoxication caus- ple or jimsonweed (Datura stramonium), and ing anisocoria from a potentially dangerous in- black henbane (Hyoscyamus niger) (4, 5, 9, tracerebral process, the pilocarpine 1% test is 10, 11). There is considerable confusion in used. In this case, however, the pilocarpine test medical literature about the names in this group did not reveal previous contact with an atro- of plants. Angel’s trumpet was originally part pine-like substance. of the genus Datura, but is now placed in a sepa- rate genus called Brugmansia (6). CASE REPORT Alkaloids are nitrogen-containing bases of a vegetable origin. The alkaloids found in the A 6-year old girl was brought into the emer- Solanaceae which cause mydriasis are prima- gency unit at 10.00 pm because of a sudden rily the tropanes atropine and scopolamine. Tro- onset anisocoria which had started at 4.00 pm. panes form an important subdivision of the al- Earlier that day, she had fallen several times kaloids, with as common property a methylat- while playing in an inflatable swimming pool ed nitrogen atom at one end of a ring struc- in the garden. No relevant drug history nor ac- ture. They are anticholinergics and block the cidental intoxication was present. The parents acetylcholine receptors of the muscarinic sub- denied the presence of poisonous plants near type (the other subtype, nicotinic receptors, is the pool. On examination we noticed mydria- not affected by tropanes). They prevent acetyl- sis with absence of the pupillary light reflex and choline to enter the effector cells, resulting in the consensual pupillary light response in the paralysis of smooth muscles, such as the ciliary left eye. The consensual pupillary light reflex muscle and the sphincter pupillae. Absorption of the right eye was normal. The anterior cham- from the conjunctiva bypasses the first-pass of bers were normal without inflammatory chang- the liver and can cause systemic effects like es, both irises were normal. The fundus exami- tachycardia, dry mouth, confusion, visual and nation was normal. Extraocular movements were auditory hallucinations. Scopolamine produces intact. mydriasis and cycloplegia of rapid onset, last- At this moment an intracranial trauma or tu- ing 4 to 6 days, with a peak after 15 minutes. moral mass could not be excluded, neither an After the instillation of atropine, mydriasis is accidental inoculation of the left eye with an maximal at 30 minutes and lasts for 7 to 12 atropine-like substance. Pilocarpine 1% instil- days (6,9). lation induced constriction of the left pupil. A The Brugmansia genus (angel’s trumpet) con- CT-scan of the brains was performed, but showed tains a concentration of tropane alkaloids rang- no evidence of a subdural hematoma. Besides ing from 2,5 mg/g to 7 mg/g. Per blossom, one the anisocoria, no abnormal neurological signs found 0.20 mg of atropine and 0.65 mg of sco- were noticed. The next day, both pupils were polamine (3). In Datura (thorn apple), the seeds normalized with normal light responses. The have the highest alkaloid content of the plant: parents found a flower called angel’s trumpet 2.71 mg/g of atropine and 0.66 mg/g of sco- in the garden. The girl confirmed touching it polamine. Leaves of the thorn apple contain 0.2 while falling out of the inflatable swimming to 0.45 mg/g of total alkaloids (8). The alka- pool. This plant belongs to the family Sola- loid concentration in the leaves, stem, flowers naceae (genus Brugmansia or Datura) and is and seeds of an individual plant differ marked- known to cause eye dilation due to anticholin- ly. It even changes with season and hydration, ergic substances when the juice from the plant so it is almost impossible to determine the ex- comes into contact with the eye. act dose of the alkaloids in the plant compo-

54 nent that comes in contact with the eye (6). In- carpine may be related to volume and concen- gestion of 10 to 50 mg of atropine appears to tration of the drug. Pupillary constriction in- be toxic for adults, 4 to 5 mg may be fatal to creases in proportion to the volume and con- small children. centration of pilocarpine. Constriction is great- The duration of the mydriasis after exposure to er in darkness or dim light than in bright light a plant component varies from 24 hours to 1 (2,7). week. The presentation of the mydriasis can dif- In this case, pilocarpine 1% caused miosis of fer from a maximally dilated and non-respon- the dilated pupil. Because of the negative neu- sive pupil to variable light responses. These dif- rological and neuroradiological examinations ferences are probably related to the various and the very high chance of exposure to an- ways of contact with the plants. The quantity gel’s trumpet, we believe the pilocarpine test of sap and the length of its exposure has a big failed in making the right diagnosis. This can influence on the clinical expression. For in- be explained either by a low volume of plant stance, rubbing the eye right after contact with extract, by the unpredictable concentration of a leaf or flower can give dilation of one day’s alkaloids or by involuntary instillation of a high- duration, while a broken stalk exuding sap in er volume of pilocarpine. Moreover, the patient the eye can give a fully dilated pupil for several came to the emergency room 6 hours after ex- days (4, 5). Ingestion of a part of a plant caus- posure, which is a long time after the maximal es mydriasis in 100% of the cases with a me- effect of the alkaloids. All these factors can in- dian duration of 31 hours (6). fluence the predictive value of the pilocarpine When dealing with anisocoria in a child, the test. first step is to confirm that no ocular condition like iris atrophy, optic nerve coloboma or hy- CONCLUSION poplasia, glaucoma, lens displacement or pos- terior synechiae is present. Secondly, the con- Suspicion of an accidental intoxication should sensual pupillary reflex of the right eye indi- always arise when unilateral mydriasis is found cates that the afferent pathway is functional. in patients without evidence of a retrobulbar or In the next step, one has to distinguish a para- intracerebral process. Questions about playing sympathetic pathway lesion from a iris muscle or working in the garden should always be asked. sphincter impairment, like posttraumatic iri- Because of the variability of the concentration doplegia, or from the presence of an atropine- of alkaloids in plants of the same species, it is like substance in the eye. Young children with difficult to determine the amount of alkaloids blond hair or blue eyes may be especially sen- that came into contact with the eye. A time lag sitive to the effects of tropanes. of several hours between the first symptoms Pilocarpine stimulates the acetylcholine recep- and the pilocarpine test, makes the predictive tors on the smooth muscle of the iris sphinc- value of the test disputable. The pilocarpine 1% ter. Atropine and scopolamine competitively in- test is very useful in determining the cause of hibit the action of acetylcholine on the musca- mydriasis of sudden onset, but it should be rine receptors. If there is a pharmacologic block- pointed out that this test is probably not al- age of the receptors, the pupil stays in mydria- ways completely reliable. sis when one drop of pilocarpine 1% is given. In lesions of the cranial nerve III the pupil con- REFERENCES stricts rapidly (1). In a normal eye the pupil constricts within 15 minutes after instillation (1) BURDE R.M., SAVINO P.J.,TROBE J.D. − Cli- of pilocarpine, peaking at 30 to 60 minutes. nical decisions in neuro-ophthalmology. 2nd The effect of pilocarpine drops is individual, but ed. St. Louis: Mosby. Textbook: 1985; 221- is unrelated to the subject’s age or sex. It is not 239. (2) DRUMMOND P.D. − The effect of light inten- significantly different between eyes with differ- sity and dose of dilute pilocarpine eyedrops on ent iris colours. Factors known to affect drug pupillary constriction in healthy subjects. Am penetration into the anterior chamber are not J Ophthalmol 1991; 112: 195-199. responsible for the differences in drug effect on (3) GREENE G.S., PATTERSON S.G., WARNER E. pupil size. Pupil variability in response to pilo- − Ingestion of angel’s trumpet: an increasingly

55 common source of toxicity. South Med J 1996; scopolamine in Datura stramonium. Fitoterapia 89: 365-369. 2001; 72: 644-648. (4) HANSEN P., CLERC B. − Anisocoria in the dog (9) ROEMER H.C., BOTH H.V., FOELMANN W., provoked by a toxic contact with an ornamen- GOLKA K. − Angel’s trumpet and the eye. JR tal plant: Datura stramonium. Vet Ophthal- Soc Med 2000; 93: 319. mol 2002; 5: 277-279. (10) SAVITT D.L., ROBERTS J.R., SIEGEL E.G. − (5) HAVELIUS U., ASMAN P. − Accidental mydria- Anisocoria from Jimsonweed. JAMA 1986; 255: sis from exposure to angel’s trumpet (Datura 1439-1440. suaveolens). Acta Ophthalmol Scand 2002; (11) VOLTZ R., HOHLFELD R., LIEBLER M., HER- 80: 332-335. TEL H. − Gardener’s mydriasis. Lancet 1992; (6) ISBISTER G.K., OAKLEY P., DAWSON A.H., 339: 752. WHYTE I.M. − Presumed angel’s trumpet (Brug- mansia) poisoning: clinical effects and epide- miology. Emerg Med 2003; 15: 376-382. (7) LEAVITT J.A., WAYMAN L.L., HODGE D.O., BRUBAKER R.F. − Pupillary respons to four concentrations of pilocarpine in normal sub- zzzzzz jects: application to testing for Adie tonic pu- Correspondence: pil. Am J Ophthalmol 2002; 133: 333-336. Dr. I. Van der Donck, (8) MIRALDI E., MASTI A., FERRI S., BARNI COM- P. Ceulemansstraat 6, B-2330 Merksplas PARINI I. − Distribution of hyoscyamine and email: [email protected]

56