472 A hemlock water dropwort curry: a case of multiple poisoning C Downs, J Phillips, A Ranger, L Farrell ......

Emerg Med J 2002;19:472–473

emlock water dropwort (Oenanthe crocata) is perhaps the most poisonous indigenous in Britain.1 It is a Hmember of the Umbellifer family and is found in ditches, damp meadows, in steams, by riverbanks, and in marshes. It is a large, stout plant between three and five feet high that flowers in July. The lower stem is usually thick and joins to clusters of fleshy tubers that gives rise to the popular name “dead man’s fingers”. The entire plant is poisonous. The tubers, stems, and contain oenanthotoxin, a highly unsaturated higher , which is known to be poisonous and a powerful .2 The majority of the umbellifer family are harmless. These include species of celery, parsley, , and carrots. The poi- sonous members are hemlock ( maculatum), cowbane 3 ( virosa), and hemlock water dropwort. Figure 1 Digital image of the plant recovered from the stream. Poisoning by hemlock water droplet is an infrequent event. A number of human fatalities have occurred over the years, DISCUSSION although animals are its usual victims. Hemlock water dropwort poisoning is rare in humans and the CASE HISTORY number of people in this case report is very unusual. The main A group of eight young adults who were on holiday in Argyll toxic constituent of hemlock water dropwort is oenantho- collected what they thought were water from a small . The concentration of this poison in the plant is highest in winter and spring and ingestion of very small stream. The roots were cleaned, chopped, and added to a curry. 2 All consumed the curry, but the majority of the group only had amounts may prove fatal. These events occurred in April when the concentration of toxin is still high. Oenanthotoxin a small amount of the , which was easily identifiable in the 4 curry, partly because there was some doubt regarding its is, however unstable, and the boiling involved in making the nature and partly because of its bitter taste. curry resulted in an amelioration of the toxic effects, both in Early the next morning, 10 hours after ingestion one of the the severity of symptoms, and in the time delay until presen- group had a witnessed grand mal seizure lasting about five tation. minutes. He was taken to the community hospital and was in Accidental ingestion of water hemlock most commonly a post-ictal state. No connection at this point was made with occurs by mistaken identification, particularly differentiation from water parsnip as in this case. The majority of cases the ingestion of the plant root the night before. 4–8 Gradually over the course of the next four hours a number reported have involved children and young adults. The mor- tality rate is quantity dependent, but has been reported as of the group became unwell and nauseated. During this time 28 four of the group consumed the left overs for lunch. One of between 30%–70%. these individuals, subsequently become increasingly unwell, The clinical features that have been previously reported nauseated, and began to vomit. He had a witnessed grand mal include nausea, increased salivation, and vomiting. There may seizures lasting about three minutes. On arrival at the be tremor, abdominal cramps, and diarrhoea. Grand mal emergency department this person was conscious but vomit- seizures and opisthotonus can rapidly develop, which may be ing and experiencing visual hallucinations. The patient was attributable to antagonism of an inhibitory transmitter in the agitated, tachycardic, but blood pressure and oxygen satura- brain stem. Blood pressure falls, pupils normally dilate, and tion were within normal limits. He was hyper-reflexive with electrolyte imbalances occur. The latter includes high sodium dilated pupils, but there were no focal neurological signs. He and potassium and creatinine, a lymphocytosis and very low had one further subsequent grand mal seizure controlled with sodium bicarbonate levels. Increased muscular activity and 68 intravenous diazemuls. damage results in a metabolic acidosis. Acute renal failure 89 The other patients all had varying degrees of nausea, vom- secondary to has been reported. iting, lethargy, sweating, and low grade fever. Treatment is symptomatic. If vomiting has not occurred Initially it was uncertain from the description as to the before seeking medical advice, which is unlikely, then the identity of the poisonous plant. The community hospital that stomach should be emptied. Control of seizures is best they were admitted to serves a rural area of Argyll. The police performed using intravenous diazemules.10 11 would were able to take an asymptomatic member of the group to the be the second line drug of choice. Thiopentone sodium has stream to recover a further plant. The police knew of a local been recommended for seizure control because of its faster botanist in the area who was able to positively identify the action. Treatment for resistant seizures may necessitate specimen (fig l). intubation and ventilation. Four of the group required admission to the hospital. The This episode highlighted some difficulties that can relate to person who had required intravenous diazemules, was plant poisoning. In this case the cause of the poisoning was observed over the next 48 hours. Biochemical and haemato- not readily apparent, but with the assistance of the local police logical parameters were all within normal limits, and his we were able to locate a plant specimen, and use a local bota- symptoms settled rapidly. The other three were discharged nist to aid identification. This facilitated an appropriate man- after 24 hours. agement strategy, although in this case the treatment was

www.emjonline.com A hemlock water dropwort curry 473 supportive. As a result of this the hospital has now invested in REFERENCES specific resources that relate to plant poisoning, and people in the community who have expertise in plant identification 1 Cooper MR, Johnson AW. Poisonous and fungi. An illustrated guide. Ministry of Agriculture, Fisheries and Food. London: The Stationery have been identified, and have agreed to be contacted in the Office, 1998. event of suspected poisoning. A copy of this list has been dis- 2 Ball MJ, Flather ML, Forfar JC. Hemlock water dropwort poisoning. tributed to local general practitioners and the police. Postgrad Med J 1987;63:363–5. It is possible that with increasing interest in “natural” foods 3 TG. Umbellifers of the British Isles. Handbook Number 2. London: Botanical Society of the British Isles, 1980. accidental poisoning of this nature may become more 4 O’Mahony S, Fitzgerald P, Whelton MJ. Poisoning by hemlock water frequent. These cases illustrate the potential dangers of this, dropwort. Ir J Med Sci 1987;156:241. but highlight the fact that even in small communities exper- 5 Lavar M, Cole FR, Nelson RB. Water-hemlock poisoning. [Letter]. N Engl tise is available and if accessed appropriately can be JMed1969;281:566–7. invaluable. 6 Heath KB. A fatal case of apparent water hemlock poisoning. Yet Human Toxicol 2001;43:35–6. 7 Mitchell MI, Routledge PA. Poisoning by hemlock water dropwort...... [Letter]. Lancet 1977;1:423–4. Authors’ affiliations 8 Knutsen OH, Paszkowski P. New aspects in the treatment of water 22 C Downs, J Phillips, A Ranger, The Mid Argyll Hospital, Lochgilphead, hemlock poisoning. Clin Toxicol 1984; :157–66. Argyll PA31 8LU, UK 9 Carlton BE, Tufts E, Girard DE. Water hemlock poisoning complicated L Farrell, Scottish Natural Hertitage, Lochgilphead, Argyll by rhabdomyolysis and renal failure. Clin Toxicol 1979;14:87–92. 10 Mack RB. Keats, Socrates and fool’s parsley—water hemlock poisoning. Correspondence to: Dr C Downs; [email protected] N Carolina Med J 1985;3:163–4. 11 Mational Poisons Information Service. The primary clinical toxicology Accepted for publication 31 January 2002 database of the National Poisons Information Service.

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