University Health Network Emergency Medicine Conference 2019 Don’t Eat These Greens!
Dr. Emily Austin St. Michael’s Hospital, Ontario Poison Centre November 12, 2019 Disclosures
None Most exposures lead to minimal toxicity.
Pediatrics: Adults: Larger exposures Smaller, exploratory ingestions Intentional, foraging Plant toxicology is complex.
Different parts of the Multiple toxic Taxonomy ≠ Toxicity plant can be toxic. compounds in a given plant Yew (Taxus spp.)
img1.southernliving.timeinc.net Taxines in the Yew plant block the Sodium Channel
Red aril Leaves, stems, roots contain toxin. does not contain toxins.
Taxine A Taxine B Taxine I
Seizures Arrhythmias Cardiovascular Death Collapse Yew (Taxus spp.)
The vast majority of plant exposures are asymptomatic.
img1.southernliving.timeinc.net There are exceptions…
Janssen CMAJ 2016. Case 1
67 year old female
Nausea & vomiting, generalized weakness, abdominal cramping
Heart Rate 53 BPM
Janssen CMAJ 2016. Wide complex Ventricular Tachycardia
Awaiting ICD placement…
Janssen CMAJ 2016. …. Day 3, her husband presents to the ED
Nausea & vomiting, visual complaints
Heart Rate 30 BPM 1’ AV Block on ECG
Janssen CMAJ 2016. A salad of harvested “kale” from the garden…
Foxglove (Digitalis purpurea)
Janssen CMAJ 2016. Foxglove contains Digitoxin, a cardiac glycoside A salad of harvested “kale” from the garden…
Serum Digoxin level Serum Digoxin level 0.3 nmol/L 0.4 nmol/L
DigiFab Antibody DigiFab Antibody 12 vials total 12 vials total
Discharged home. Many plants contain cardiac glycoside molecules
Yellow Oleander Milkweed (Cascabela thevetia) (Asclepias syriaca) Lily of the valley (Convallaria majalis) Identical to digoxin toxicity
Cardiac arrythmias Lethargy Delirium Visual changes Nausea Vomiting Diarrhea Abdominal pain The diagnosis is mainly clinical
Serum Digoxin Concentration:
Test may cross react with the digitoxin molecule
Useful for qualitative reasons Not useful to guide treatment (i.e. can’t determine # DigiFab vials) DigiFab is effective for treatment.*
Empirically dose based on clinical assessment. Many plants contain cardiac glycosides!
GI symptoms + cardiac conduction abnormalities + CNS changes
Digoxin serum level for qualitative diagnosis
Treatment with Antidote Digifab effective Case 2
48 year old female
Ate a salad made of foraged vegetables.
+++ Vomiting
GCS 3 at 11 AM “Wild Leeks” “Dandelions” “Green mushroom-like plant” Afebrile HR 76 BP 126/70 RR 12 SpO2 96%
Pupils- 3mm, sluggish GCS 3 No icterus Unresponsive to voice, touch Supple neck
Skin: dry, well perfused, warm Heart, lungs, abdomen: Benign exam
No clonus, no tremor ?Bilaterally up-going Babinski Intubation
ICU admission
ECG, CXR, CT head, MRI, EEG, Bloodwork
Day 1 Day 2 Day 3 Day 4 Day 5 Hgb 14.3 12.9 .. 9.4 9.1 WBC 15.2 11.9 … 0.3 0.2 Platelets 149 51 … 11 9
Bone marrow biopsy: ”severe trilineage hypoplasia” “Wild Leeks” “Dandelions” “Green mushroom-like plant”
Day 5: Multi-organ failure
Care is withdrawn. Mayapple (Podophyllum peltatum) Mayapple contains Podophyllotoxin
Spindle formation Potent microtubule poison
Axonal transport
Structural integrity Symptoms of podophyllotoxin poisoning
GI irritant: Nausea, Vomiting Neurotoxicity Hematologic toxicity Renal toxicity Hepatotoxicity
Support Care. ?G-CSF Overall Summary
Plant toxicology is complex.
Most exposures are not concerning.
Correct identification of plant is important.
Yew Foxglove Mayapple (Taxus spp.) (Digitalis purpurea) (Podophyllum peltatum)