INVITED ARTICLE Oleander and Datura Poisoning: An Update Vijay V Pillay1, Anu Sasidharan2 ABSTRACT India has a very high incidence of poisoning. While most cases are due to chemicals or drugs or envenomation by venomous creatures, a significant proportion also results from consumption or exposure to toxic plants or plant parts or products. The exact nature of plant poisoning varies from region to region, but certain plants are almost ubiquitous in distribution, and among these, Oleander and Datura are the prime examples. These plants are commonly encountered in almost all parts of India. While one is a wild shrub (Datura) that proliferates in the countryside and by roadsides, and the other (Oleander) is a garden plant that features in many homes. Incidents of poisoning from these plants are therefore not uncommon and may be the result of accidental exposure or deliberate, suicidal ingestion of the toxic parts. An attempt has been made to review the management principles with regard to toxicity of these plants and survey the literature in order to highlight current concepts in the treatment of poisoning resulting from both plants. Keywords: Cerbera, Datura, Nerium, Oleander, Plant poison, Thevetia. Indian Journal of Critical Care Medicine (2019): 10.5005/jp-journals-10071-23302 INTRODUCTION 1Department of Forensic Medicine and Toxicology, Poison Control India being a tropical country is host to a rich and varied Centre, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, flora encompassing thousands of plants; and while most are Kochi, Kerala, India nonpoisonous, a significant few possess toxic properties of varying 2Department of Forensic Medicine and Toxicology, Forensic Pathology degree. Cases of accidental poisoning relating to these plants due Unit, Amrita School of Medicine, Amrita Vishwa Vidyapeetham, Kochi, to mistaken identity or exploratory behavior among children are Kerala, India not infrequent, while deliberate consumption in the form of suicidal Corresponding Author: Vijay V Pillay, Department of Forensic attempts are also reported.1 Some cases are related to the intake of Medicine and Toxicology, Poison Control Centre, Amrita School of herbal remedies and traditional medicines which contain toxic plant Medicine, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India, Phone: principles. In some western countries such as the United States, +91 9895282388, e-mail: [email protected] 5–10% of all human toxic exposures that get reported to the Poison How to cite this article: Pillay VV, Sasidharan A. Oleander and Datura Control Centres involve plants.2 In India, the overall percentage of Poisoning: An Update. Indian J Crit Care Med 2019;23(Suppl 4):S250–S255. plant poisoning ranges from 6% to 15%, but if the same is taken in Source of support: Nil the context of the rural population alone, the percentage can be Conflict of interest: None as high as 63%.3 Of the many species of poisonous plants in India, the toxic profiles of Oleander (a primarily cardiotoxic plant) and Datura (a primarily neurotoxic plant) will be reviewed in this paper. popular ornamental plant that is grown in gardens as well as on the dividers of national and state highways across India. OLEANDER All parts of the plant are poisonous, especially the leaves, stem, seeds, and root. The following active toxins are present—oleandrin, The two types of oleander commonly encountered in India are pink neriin, folinerin, rosagenin, and digitoxigenin. These are cardiac oleander and yellow oleander. Both are predominantly cardiotoxic. glycosides and have digoxin-like effects, acting by inhibiting Most such cardiotoxic plants contain various cardiac glycosides the sodium–potassium adenosine triphosphatase (Na-K-ATPase) which act in similar fashion. Some of these glycosides are useful in pump.3 Leaves also contain oxalates. 15 g of the root or 5–15 pharmacotherapeutics (e.g., digitalis). Table 1 lists common plants leaves can be fatal if consumed.4 “Taste” or exploratory ingestions that contain cardiac glycosides. However, some cardiotoxic plants are unlikely to result in serious toxicity, but substantial ingestion do not contain glycosides (e.g., aconite). causes rapid onset of nausea, vomiting, and diarrhoea.5 In one case, numbness of tongue was reported immediately after consumption PINK OLEANDER (NERIUM OLEANDER) of oleander tea.6 This plant is also known by other common names such as white Gastrointestinal (GI) manifestations are followed by oleander, common oleander, rose laurel, rose bay, rosa francesca, cardiovascular features such as marked bradycardia with PR and laurier rose, and adelfa. It is a large evergreen ornamental shrub QRS prolongation. Sinus arrest, varying degrees of atrioventricular belonging to the family Apocynaceae, with long, lanceolate, (AV) block with dissociation, or escape rhythms may occur, including leathery leaves and clusters of white or pink flowers. The leaves paroxysmal atrial tachycardia with AV block, junctional tachycardia, produce a clear, thick sap. In Indian traditional medicine, the roots frequent ventricular ectopics, and bigeminy. Hypotension may and leaves are used to prepare decoctions that are said to be useful occur. In one case, atrial fibrillation with nonspecific ST segment in the treatment of various skin conditions. The root is sometimes changes and intraventricular conduction delays were seen more used as an abortifacient by rural people. Pink oleander is also a than 12 hours after ingestion.7 In another case which involved © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons. org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Oleander and Datura Poisoning: An Update Table 1: Plants containing cardiac glycosides All the parts of this plant, especially the seeds and root are Representative example poisonous. The active toxins include thevetin B, cerberin, nerifolin, thevetin A, ruvoside, and peruvoside (in ascending order of toxicity). Family Botanical name Common name The usual fatal dose comprises 15–20 g of root or 8–10 seeds. In Apocynaceae Cerbera thevetia or Yellow oleander general, yellow oleander is more toxic than pink oleander. Thevetia peruviana As in the case of pink oleander, yellow oleander is also used in Nerium oleander Common or pink traditional Indian medicine. The bark contains cardenolides, which oleander have been investigated as cytotoxic agents for the treatment of Strophanthus Dogbane cancer. In the past, yellow oleander glycosides have been used in Asclepiadaceae Asclepias Milkweed the treatment of heart failure and atrial fibrillation, but subsequently Calotropis Crown flower this was discontinued due to high toxicity. The seeds of this plant Celastraceae Euonymus europaeus Spindle tree have been used in suicidal and homicidal cases.13 Cruciferae Cheiranthus Wall flower Toxicokinetics and toxic effects are similar to those encountered Erysimum Wall flower in pink oleander. The most commonly seen manifestations in poisoning include GI distress, bradycardia with AV block, Liliaceae Convallaria majalis Lily of the valley hypotension, lethargy, and dizziness.14 Convulsions, electrolyte Urginia maritima or Squill disturbances, hypertension, and coma have been reported in severe Urginia indica poisoning. Mydriasis can occur. Numbness with a burning sensation Ranunculaceae Helleborus niger Henbane of the mouth may develop initially on chewing the seeds. In one Scrophulariaceae Digitalis purpurea Foxglove study of 300 yellow oleander seed ingestions with suicidal intent, Digitalis lanata Woolly foxglove 12% of the patients had palpitations, while 46% had some type of arrhythmia; sinus bradycardia was present in 49% of the patients, and ischemic electrocardiograph (ECG) changes were noted in 39% inhalation of smoke from a burning oleander plant, a middle- 15 aged patient suffered from sinus bradycardia (without AV block), of the patients. Subendocardial and perivascular hemorrhage with severe dizziness, and vomiting.8 Decreased QRS-T interval, T-wave focal myocardial edema were found during autopsies of some of flattening/inversion, irregular ventricular rate, and increased PR the patients who died. First-degree heart block was noted in one patient about 6 hours after the ingestion of yellow oleander seeds, interval, etc., have also been reported. Hyperkalemia is common in 16 cases of severe poisoning as a result of blockade of the Na-K-ATPase with complete heart block occurring a little later. The sap of yellow pump—potassium shift from the intracellular to the extracellular oleander may cause blistering or dermatitis on contact. With regard space. This makes it a very useful marker of toxicity and thereby to clinical diagnosis of poisoning, cardiac glycosides of this plant a rapidly available laboratory feature in severe cardiac glycoside are best identified by radioimmunoassay. poisoning.9 In suspected cases of oleander poisoning (both types), Delirium, lethargy, dizziness, drowsiness, and headache are cardiopulmonary resuscitation/resuscitation should be initiated