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Home , Datura metel, Datura stramonium

Rom J Leg Med [24] 308-311 [2016] DOI: 10.4323/rjlm.2016.308 © 2016 Romanian Society of Legal Medicine

Datura poisoning, clinical and laboratory findings. Report of five cases

Mohammad Arefi1, Nasrin Barzegari1, Mahboubeh Asgari2, Siamak Soltani3, Naeimeh Farhidnia3, Fardin Fallah3,*

______Abstract: Introduction. of species contain belladonna that can cause central and peripheral effects. Abuse of Datura plants for their hallucinogenic effects is growing among adolescents and young adults. Datura poisoning has caused a diagnostic challenge in medical emergency wards. In this article we report 5 cases of Datura toxicity at Clinical Toxicology Emergency of Baharloo Hospital, Tehran, Iran during Summer-Fall 2015, and discuss their clinical presentations and laboratory findings. Cases. All 5 cases with Datura toxicity were young males and had intentionally used the plants. Mean duration of hospitalization was 3.2 days. Three cases were multiple-drug abusers. , , tachypnea and flushing alongside with psychotic-like signs and symptoms were observed in all cases. Elevation of liver enzymes was present in three of cases but without clinical significance. Raised LDH or CPK in four patients were without myoglobinuria and evidence of rhabdomyolysis and these biomarkers returned to normal levels by supportive care. All patients discharged with complete recovery and there was no need to ICU admission. Discussion. With the absence of routine laboratory diagnostic tests for alkaloids and complex and confusing presentations of Datura intoxication, diagnosis of such cases is difficult. Physicians' clinical suspicion and sufficient knowledge play the mainstay roles in appropriate and timely diagnosis and management of cases with Datura toxicity. Since regulatory legislation wouldn't be successful in halting the availability of natural plants, the best strategy to prevent Datura abuse is informing people about the adverse effects of these plants. Key Words: , poisoning, abuse, anticholinergic, laboratory findings, liver function tests, rhabdomyolysis.

ew features of drug abuse and addiction called "Jimson Weed" or "Angel's trumpet" - comprises Nare emerging rapidly. Many alternatives of plants that are being abused as herbal psychoactive for traditional drugs are being introduced, based on substances, usually by adolescents or youth [3]. Datura demands of abusers [1]. Besides chemicals, some of plants contain belladonna alkaloids (like , natural substances like plants are also being used as and ), which cause central alternatives for illicit drugs with similar desired effects and peripheral anticholinergic effects [4-6]. Diagnosis like hallucinogenic, sedative or stimulating effects [2]. and management of Datura poisoning is a challenge for The abuse of some of these herbals are welcomed by emergency wards due to its confusing clinical picture, consumers because of their availability, low prices, lack of unavailability of routine laboratory diagnostic tests and regulatory legislation and the commonly accepted idea of physicians' unfamiliarity with this form of drug abuse their higher safety compared to man-made or chemical [2]. preparations [2]. "Datura stramonium" species - also In this article we report 5 cases of intentional

1) Tehran University of Medical Sciences, Baharloo Hospital, Department of Clinical Toxicology, Tehran, Iran 2) Forensic Pathology Organization, Tehran, Iran 3) Iran University of Medical Sciences, Department of Forensic Medicine and Toxicology, Tehran, Iran * Corresponding author: Email: [email protected]

308 Romanian Journal of Legal Medicine Vol. XXIV, No 4(2016)

Datura poisoning, admitted to Baharloo Hospital - a received 10mg of intravenous Diazepam at Emergency referral center of toxicology in Tehran, Iran - during Room for sedation and hospitalized at Clinical Summer-Fall 2015. We describe their presentation, Toxicology Ward for supportive care. After 48 hours, he clinical course and laboratory findings. discharged with recovery of symptoms. His raised LDH had been steadily declining at repeated laboratory tests. Case Descriptions Mild elevation of Liver Function Tests was persistent and he was advised on further outpatient follow-up for Case 1 underlying liver diseases. A 29-year-old man developed , vomiting and diarrhea two hours after drinking a cup Case 2 of herbal tea containing “Datura flower” taken from A 23-year-old male patient was referred to his friend for breakfast. At admission, he had mydriatic General Emergency Ward with nausea and vomiting, pupils, flushing, persecutory delusions, vomiting and disorientation, delusions, agitation, tachycardia and dry mouth. Vital signs at admission are available in mydriasis. He was first admitted at Psychiatric Emergency Table 1. There was no previous history of any substance Ward but after hours, referred to Clinical Toxicology abuse. Findings of our routine laboratory studies (CBC, Emergency with suspicion of substance poisoning. In Ionograms, Liver Function Tests, Renal Function Tests, detailed history, his friends reported ingestion of powder Lactate Dehydrogenase or LDH, Creatine Phosphokinase of Datura seeds for stimulation effects, before the onset or CPK and Urine Screening Test for common toxins) of symptoms. There was no previous history of drug are available in Table 2. Due to evident history of Datura abuse or addiction. Vital signs and important laboratory intoxication, there was no diagnostic challenge. He findings are summarized in Tables 1 and 2. He received

Table 1. Important clinical and paraclincial findings of five cases of Datura poisoning at Clinical Toxicology Emergency of Baharloo Hospital, Tehran, Iran, during Summer-Fall 2015. Case Pulse Rates/ Axillary Respiratory Blood ABG Findings EKG Findings O Saturation Number min Temperature (°C) Rates/min pressure(mmHg) 2 at admission Sinus 1 108 37.8 17 121/70 98% Normal tachycardia Sinus Respiratory 2 120 38.4 23 150/80 97% tachycardia acidosis Sinus Respiratory 3 119 38 19 120/80 98% tachycardia acidosis Sinus Respiratory 4 110 38.2 18 143/70 98% tachycardia acidosis Sinus 5 105 37.5 15 130/75 97% Normal tachycardia All findings have been documented at the time of admission to Clinical Toxicology Emergency. Table 2. Laboratory findings of five cases of Datura poisoning at Clinical Toxicology Emergency of Baharloo Hospital, Tehran, Iran, during Summer-Fall 2015. Rhabdomyolysis Blood Kidney Liver Function Tests Case Indicators Sugar Function Ionogram CBC Findings Urine Screening Test Number AST ALT ALKP LDH CPK (mg/dL) Tests (U/L) (U/L) (IU/L) (U/L) (U/L) WBC=10200/ Negative 119 ٭501 137 ٭48 ٭Normal Normal 64 122 1 mcl (PMN=88%) Normal Negative 73 ٭523 188 ٭Normal Normal 36 69 100 2

WBC=12200/ THC and ٭233 ٭Normal Normal 30 27 285 560 93 3 mcl (PMN=86%)

4 97 Normal Normal 38 54 217 180 220 Normal THC and Tramadol

Normal THC and Tramadol ٭1204 ٭488 310 48 ٭Normal Normal 44 102 5

All tests have been applied on the blood samples of patients obtained at the time of admission to Clinical Toxicology Emergency. AST(SGOT) = Aspartate transaminase. ALT(SGPT) = Alanine transaminase. ALKP = Alkaline Phosphatase. THC = . * Points to the elevated laboratory test values, based on the age- standardized normal ranges of our tests.

309 Arefi M. et al. Datura poisoning, clinical and laboratory findings

Physostigmine at Clinical Toxicology Emergency due to in serial tests and mild elevated AST returned to normal severity of his anticholinergic signs; sedatives also had at the time of discharge. been prescribed at Psychiatric Emergency. He stayed at Clinical Toxicology Ward for 3 days and discharged in Discussion good health condition. At discharge, his elevated ALT and LDH were in normal range. Datura plants grow spontaneously in most parts of the world and have been used in folklore and Case 3 as herbal treatments for many A 25-year-old male patient with the history medical problems [7]. Intentional use of Datura plants of multiple-drug abuse was admitted to Toxicology for their hallucinogenic and stimulating effects is growing Emergency Ward after smoking a preparation of especially among adolescents and youths [8]. Different “ and seeds of Datura”. He was very agitated Datura plants have various amounts and proportions of and showed aggressive behaviors and tried to harm alkaloids and therefore severity of symptoms in poisoned himself. Mydriasis, flushing, nausea and thirst were patients may vary [4]. In each all parts contain present. His vital signs and laboratory tests are available alkaloids, but they are greatest in ripe seeds [4, 7]. Central in Tables 1 and 2. Due to severe agitation, he received 20 effects of alkaloids are usually psychotic-like signs and mg of intravenous Diazepam in two doses, one dose of symptoms including , hallucination, confusion, Midazolam and one dose of Haloperidol at first day of disorientation, agitation, aggression, photophobia, admission. He transferred to Clinical Toxicology Ward blurred vision, seizure and even coma [3, 4, 7, 9]. after sedation and was under supportive care for 4 days. Peripheral signs of alkaloids are mydriasis, dry skin and He raised concerns about probable rhabdomyolysis mouth, flushing, tachycardia, fever, hyper or hypotension among physicians. Neither myoglobinuria, nor any and [4, 9, 10]. Treatment is usually indicative symptom or sign of rhabdomyolysis were supportive care, fluid replacement and Benzodiazepines detected during hospital stay. He discharged when his for sedation; but in severe cases may be elevated LDH and CPK returned to normal. used for the alleviation of anticholinergic symptoms [4, 9]. Patients with Datura poisoning usually recover soon, Case 4 with short duration of hospitalization [4, 5, 11]. Despite A 17-year-old student brought to Toxicology benign nature of Datura poisoning in most cases, reports Emergency by his friends due to severe agitation, of fatalities [12], coma [7], seizure [7], rhabdomyolysis hallucination, flushing and vomiting after taking a [13] and impairment of liver function tests [14] are also cup of herbal tea containing “Cannabis and Datura”. available. Tables 1 and 2 show his vital signs and laboratory tests. In this report, we described 5 cases of Datura While there was no reported history of any drug abuse, intoxication referred to Clinical Toxicology Emergency Urine Screening Test was positive for Tramadol and Ward of a toxicology referral center in Tehran, Iran. All Cannabis. He received 20 mg of intravenous Diazepam cases were hospitalized in Clinical Toxicology Ward at Emergency Room but due to uncontrollable agitation, with mean duration of 3.2 days. Mydriasis, tachycardia, Midazolam was also prescribed. He stayed at Clinical and altered mental condition were present Toxicology Ward for two days and discharged in good in all patients. Urine Screening Test showed multiple-drug condition. abuse in three of cases. Leukocytosis and mild elevation of liver function tests were observed in two and three Case 5 of patients, respectively. Elevation of rhabdomyolysis A 17-year-old boy with the history of biomarkers (LDH or CPK) were observed in four cases. abuse, smoking and previous drug poisoning was There was no need to ICU admission and all patients brought to Clinical Toxicology Emergency Ward by his treated with supportive care and sedation. Just one parents because of visual and hearing patient received Physostigmine due to severity of his and severe agitation. At admission, he presented with anticholinergic symptoms. mydriasis, flushing and other anticholinergic signs With the available reports of rhabdomyolysis (Table 1). Laboratory tests are summarized in Table 2. At following Datura poisoning [13], elevation of LDH Emergency Room he received two doses of intravenous and CPK in our patients led to physicians' concerns Diazepam and one dose of Midazolam to control his for probable rhabdomyolysis. None of these patients severe psychotic symptoms. With the elevated LDH developed myoglobinuria and they showed reduction and CPK levels, he was suspicious for rhabdomyolysis. of CPK and LDH in serial laboratory tests with He was hospitalized for 5 days and received intravenous only conservative managements. As mentioned by fluids. Fortunately, there was no myoglobinuria and Blackford et al., [15] the rise of “Creatine Kinase” is symptoms of rhabdomyolysis during hospitalization. His not uncommon in Datura ingestion but it is usually raised LDH and CPK levels had been gradually reducing without any clinical sign and neither accompanied with

310 Romanian Journal of Legal Medicine Vol. XXIV, No 4(2016) rhabdomyolysis. Few monographs in the literature have natural herbal substances as they grow spontaneously reported impaired Liver Function Tests in patients with anywhere; thus the most important measures to halt Datura poisoning [14]. Most available investigations Datura abuse is informing people with side-effects and about the hepatotoxicity of Datura are experimental consequences of abuse and dependency. With the absence studies on animal subjects and results are with of routine laboratory diagnostic tests for alkaloids controversy [16-20]. Some of these experimental studies and complex and confusing presentations of Datura show no effect of Datura on liver function and enzymes intoxication, diagnosis of such cases is difficult and [16, 17]; others report hepatic toxicity and rise of liver must be made on clinical findings and high suspicion of enzymes in prolonged or heavy Datura exposures [18- physicians. Physicians should have enough information 20]. Elevation of liver enzymes among our patients was about the physiopathology, clinical and paraclinical mild and without any clinical significance. However, features of Datura poisoning to make their best diagnosis interpretation of laboratory tests among our patients and management. In patients with anticholinergic and is not easy and accurate because there is no reliable psychiatric symptoms, Datura poisoning should always history of the duration of Datura abuse and some be considered. cases are multiple-drug abusers. Consistent with our cases, rise of WBC at acute phase of Datura toxicity Conflict of interest. The authors declare that have been reported in experimental rats [18]. Further they have no conflict of interest concerning this article. methodologically-designed studies are needed to find Ethical Considerations. Written informed the impact of Datura on different human organs and consent for this report was obtained from all described serum biomarkers. patients and also from fathers of cases 4 and 5. Legislation can't easily control availability of

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