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A Poisoning Outbreak Caused by Millettia Pachycarpa — Chongqing Municipality, December 2020

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A Poisoning Outbreak Caused by Millettia Pachycarpa — Chongqing Municipality, December 2020 China CDC Weekly Outbreak Reports A Poisoning Outbreak Caused by Millettia Pachycarpa — Chongqing Municipality, December 2020 Qian He1; Xun Tang2; Shisong Wang3; Maolin Zhang3; Hongshun Zhang4,# lavage samples were analyzed. Summary What is already known about this topic? INVESTIGATION AND FINDINGS Millettia pachycarpa belongs to the Fabaceae family and is widely distributed in the southern China. It is toxic Around 11∶30 on December 18, 2020, 2 workers for the rotenone contained in its roots and seeds, and picked fruits thinking they were edible on the hillside ingesting its seeds could result in poisoning. besides their workplace in a village in Fengdu County, What is added by this report? Chongqing Municipality. Subsequently, they grilled In December, 2020, a poisoning from plant seeds the fruits and shared several fruits with another worker, occurred in Chongqing Municipality. The etiological and all the three workers ate the seeds after peeling the association was confirmed based on epidemiological pericarp. They developed discomfort a few minutes investigation, clinical manifestation, plant species after ingesting the seeds. Two of the workers spit out identification, and rotenone analysis. The patient most of the seeds due to poor taste and experienced rapidly developed central nervous and respiratory slightly transient nausea and dizziness but recovered depression with metabolic acidosis. The plant was relatively quickly. In contrast, the other 32-year-old identified as Millettia pachycarpa, and toxin analysis male worker who swallowed a whole seed indicated that the rotenone content contained in the unsuccessfully tried to induce vomiting for himself. He seeds was high enough to cause intoxication. underwent limb weakness and dizziness and rapidly What are the implications for public health lost consciousness and progressed to coma about ten practice? minutes later. He was then sent to Fengdu County Millettia pachycarpa poisoning is rare but could be fatal. People’s Hospital immediately. The patient was Efforts should be made to educate and communicate unconsciousness on the way to the hospital and with the public, doctors, and public health practitioners admitted to hospital in about fifty minutes. that the toxic effects the seeds could be life-threating The patient experienced central nervous system when swallowed, both accidentally or intentionally. depression and respiratory failure when arriving at the hospital. He presented deep coma, mydriasis, and had On December 18, 2020, the National Poison no light reflection. His breath was slow, averaging 6 Control Center received notification that a poisoning breaths per minute, and the blood oxygen saturation accident occurred due to ingestion of plant seeds, and was 67%. Physical examination showed breathing the patients were admitted to Fengdu County People’s sounds were rough and that wet rales (crackling Hospital of Chongqing Municipality. The plant sounds) were present in both lower lungs. The patient seemed to stem from the Millettia genus based on the was intubated and treated with ventilator-assisted pictures provided by one patient’s wife. To further ventilation to stabilize the vital signs immediately, clarify the causality of the intoxication outbreak and during which scarlet foam was ejected from the provide control measures, an investigation into the trachea, and gastric lavage was performed to decrease outbreak was conducted in collaboration with toxin absorption. Chest computed tomography (CT) Chongqing Poison Control Center. The plants with showed patchy shadows and pleural effusion in both fruits were collected at the site where the poisoning lower lungs. Blood gas analysis indicated metabolic occurred, and the doctors and patients were acidosis with pH: 7.09; lactic acid: 11.76 mmol/L. The interviewed to obtain the clinical course and patient was admitted to the intensive care unit after treatments. Then, the species of plants was identified, emergency treatment, underwent hemoperfusion and the rotenone contents of the seeds and gastric therapy once, and was administrated intravenous 298 CCDC Weekly / Vol. 3 / No. 14 Chinese Center for Disease Control and Prevention China CDC Weekly sodium bicarbonate to maintain electrolyte balance. how this poisoning occurred. This outbreak was The patient took off the ventilator 28 hours after exactly attributed to the ingestion of Millettia admission and resumed spontaneous breathing, and his pachycarpa seeds, and the etiological association was consciousness recovered. He was treated and observed confirmed based on the evidence in epidemiological in the hospital until his chest CT completely recovered correlation, clinical manifestations, plant species and was discharged. identification and rotenone toxin analysis. This work The plant specimens were collected at the scene of demonstrated that Millettia pachycarpa has potential the poisoning incident and testified as the ingested for poisoning and that the public should be warned plants by the patient. It was identified as the Millettia about the severe toxic effects and potential fatal effects. pachycarpa (Figure 1) using morphological and DNA Although ingestion of Millettia pachycarpa seeds is barcoding method, which belongs to Fabaceae family. relatively rare, it may be fatal without appropriate and The specimen was deposited in the Poisonous Plants timely treatment. This incident involved 3 persons, 2 Herbarium affiliated with the National Poison Control of whom experienced slightly transient dizziness and Center (No. 2020121801). recovered fast, while the other suffered severe central The primary toxin rotenone in Millettia pachycarpa nervous and respiratory depression, due to the seeds and biological samples were analyzed used liquid difference in intake amount. The neurological chromatography coupled to mass spectrometry symptoms of the 32-year-old male patient progressed method. The rotenone content in Millettia pachycarpa rapidly from dizziness to coma with respiratory seeds (n=2) were 1,389.46 mg/kg and 928.88 mg/kg, depression in about 10 minutes after the ingestion. and the rotenone content in gastric fluid sample was The scarlet foam ejected from the trachea and the chest 3.16 μg/mL. In addition, there were others rotenoid CT indicated aspiration pneumonia developed, which compounds found in the seeds with untargeted was accounted for the central nervous depression and screening. vomiting caused by gastrointestinal irritation. The patient was intubated and ventilated immediately after DISCUSSION admission to the emergency department, then, the gastric lavage was carried out to break off more toxin China CDC collaborated with the local poison absorption. In addition, the patient underwent control center to conduct an investigation to clarify hemoperfusion therapy and administered sodium FIGURE 1. The leaves, fruits, and seeds of Millettia pachycarpa. Chinese Center for Disease Control and Prevention CCDC Weekly / Vol. 3 / No. 14 299 China CDC Weekly bicarbonate to maintain acid-base balance. In the region where Millettia pachycarpa and other The toxicity of Millettia pachycarpa seeds is rotenone-containing plants were distributed, ingestion attributed to its rotenone and rotenoids. Rotenone and misuse of the plants should be prevented. mainly exerts toxicity to the nervous, respiratory, and Therefore, the public should be educated to distinguish gastrointestinal systems when ingested orally. There is the plants and recognize its toxic effects. Clinicians no specific antidote available for rotenone poisoning, should be aware and trained to recognize clinical and treatment mainly relies on symptomatic and toxicological characteristics and treatment of rotenone- supportive measures (1), including intubation, containing plants intoxication. In addition, the mechanically-assisted ventilation, maintenance of acid- pathophysiological, toxicokinetic, and treatment base balance, and stabilizing the vital signs. strategy of rotenone-containing plants poisoning Gastrointestinal decontamination, such as emetic and should be further reviewed and studied. gastric lavage, should be used to prevent more toxin doi: 10.46234/ccdcw2021.075 absorption even when the patient is unconsciousness. # Corresponding author: Hongshun Zhang, zhanghs@niohp. There is insufficient evidence that hemoperfusion chinacdc.cn. therapy is effective for eliminating rotenone, but it is 1 National Institute of Occupational Health and Poison Control, China one of the choices for the treatment of rotenone CDC, Beijing, China; 2 Fengdu County People’s Hospital, Chongqing, poisoning. The recognition and treatment of the China; 3 The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, China; 4 National Institute of inhalation of pneumonia should be a priority when Occupational Health and Poison Control, China CDC, Beijing, such patients are encountered. China. Millettia pachycarpa is a rotenone-containing plant Submitted: February 19, 2021; Accepted: March 19, 2021 and is widely distributed in the south of China. Reports of Millettia pachycarpa poisoning were uncommon in China, but 2 incidents occurred in REFERENCES Guizhou and Hunan provinces in 2020. Another 1. Gupta RC. Rotenone. In: Gupta RC, editor. Veterinary toxicology. 2nd rotenone-containing plant, Pachyrhizus erosus, has an ed. Oxford: Academic Press. 2012; p. 620-3. http://dx.doi.org/10. edible root and is cultivated extensively in southeastern 1016/B978-0-12-385926-6.00052-1. China, but its rotenone-containing
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