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Cleistanthus Collinus Poisoning

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Cleistanthus Collinus Poisoning QTc PROLONGATION AS A PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING DISSERTATION SUBMITTED FOR M.D GENERAL MEDICINE BRANCH – I APRIL 2020 REGISTRATION NUMBER - 201711119 THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY CHENNAI, TAMILNADU, INDIA CERTIFICATE FROM THE DEAN This is to certify that this dissertation entitled “QTc PROLONGATION AS A PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING” is the bonafide work of Dr.G.SHANTHOSH in partial fulfillment of the university regulations of the Tamil Nadu DR. M.G.R. Medical University, Chennai, for M.D General Medicine Branch I examination to be held in April 2020. Dr.K.VANITHA, MD, DCH, The Dean, Madurai Medical College, Madurai. CERTIFICATE FROM THE HOD This is to certify that this dissertation entitled “QTc PROLONGATION AS A PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING” is the bonafide work of Dr.G.SHANTHOSH in partial fulfillment of the university regulations of the Tamil Nadu DR. M.G.R. Medical University, Chennai, for M.D General Medicine Branch I examination to be held in April 2020. Dr. M. NATARAJAN, M.D., Professor and HOD, Department Of General Medicine, Government Rajaji Hospital, Madurai Medical College, Madurai. CERTIFICATE FROM THE GUIDE This is to certify that this dissertation entitled “QTc PROLONGATION AS A PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING” is the bonafide work of Dr.G.SHANTHOSH in partial fulfillment of the university regulations of the Tamil Nadu DR. M.G.R. Medical University, Chennai, for M.D., General Medicine Branch I examination to be held in April 2020. Dr. J. SANGUMANI, M.D, D.DIAB, Professor of Medicine, Department Of General Medicine, Government Rajaji Hospital, Madurai Medical College, Madurai. DECLARATION BY THE CANDIDATE I declare that, I carried out this work on “QTc PROLONGATION AS A PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING” at the Department of Medicine, Govt. Rajaji Hospital during the period FEBRUARY 2019 TO JULY 2019 under the guidance and supervision of Prof. Dr. J.SANGUMANI.M.D, D.DIAB,. I also declare that this bonafide work or a part of this work was not submitted by me or any others for any award, degree or diploma to any other University, Board either in India or abroad. This dissertation is submitted to The Tamil Nadu DR. M.G.R. Medical University, Chennai in partial fulfillment of the rules and regulations for the award of M.D Degree General Medicine Branch- I; examination to be held in April 2020. Place : Madurai Dr. G.SHANTHOSH, Date : Post Graduate student, Department of General Medicine, Madurai Medical College ACKNOWLEDGEMENT I would like to thank Dr. K. VANITHA, MD, DCH., Dean, Madurai Medical College, for permitting me to utilize the facilities of Madurai Medical College and Government Rajaji Hospital for this dissertation. I wish to express my respect and sincere gratitude to my head of department, Prof. Dr. M. NATARAJAN M.D., Professor of Medicine for his valuable guidance and encouragement during the study and also throughout my course period. I would like to express my deep sense of gratitude, respect and thanks to my beloved Unit Chief and Professor of Medicine Prof. Dr. J. SANGUMANI M.D, D.DIAB, for his valuable suggestions, guidance and support throughout the study and also throughout my course period. I am greatly indebted to my beloved Professors Dr. G. BAGHYALAKSHMI M.D., Dr. C. DHARMARAJ, M.D., Dr. DAVID PRADEEP KUMAR M.D, DGM, MRCP., Dr. S.C. VIVEKANANTHAN M.D, DTCD., and Dr.K. SENTHIL M.D., for their valuable suggestions throughout the course of study. I express my special thanks to Prof. Dr. M. NATARAJAN M.D, Professor and HOD Department of Medicine for permitting me to utilize the facilities in the Department, for the purpose of this study and guiding me with enthusiasm throughout the study period. I am thankful to my Assistant Professors: Dr. R. PALANI KUMAR M.D., Dr. P. SUDHA M.D., Dr. M. SURESH KUMAR M.D., for their valid comments and suggestions. I sincerely thank all the staffs of Department of Medicine and Department of biochemistry for their timely help rendered to me, whenever and wherever needed. I extend my love and express my gratitude to my family and friends for their constant support during my study period in times of need. Finally, I thank all the patients, who form the most vital part of my work, for their extreme patience and co-operation without whom this project would have been a distant dream and I pray God, for their speedy recovery. CONTENTS S.NO CONTENTS PAGE NO 1 INTRODUCTION 1 2 AIM OF STUDY 2 3 REVIEW OF LITERATURE 3 4 MATERIALS AND METHODS 60 5 RESULTS AND OBSERVATIONS 64 6 DISCUSSION 79 7 CONCLUSION 81 ANNEXURE BIBLIOGRAPHY PROFORMA ABBREVATIONS MASTER CHART ETHICAL COMMITTEE APPROVAL LETTER ANTI PLAGIARISM CERTIFICATE INTRODUCTION Cleistanthus collinus is a shrub that grows in many areas in south India. The shrub is also grows in Malaysia and Africa. It is called as Oduvanthalai in Tamil Nadu. Any part of the plant is toxic. It is commonly used as a homicidal agent and abortifacient. It can be ingestion by swallowing the crushed plant parts, chewing leaves or a decoction of the boiled leaves. The toxic compounds are arylnaphthalene lignan compounds like Cleistanthin A; B which are responsible for most of the clinical features. The other toxic compounds are Diphyllin and cleistanthin C and D. In the kidneys, it causes distal Renal Tubular Acidosis resulting in hypokalemia and also normal anion gap metabolic acidosis. Cardiac involvement results in arrhythmias. Plant poisoning is a common method of self-harm in rural young women in South India. The most common plant poisons consumed in South India are Cleistanthus collinus and Thevetia peruviana. Women consume plant poisons because of easy availability or free access. Though the plant grows in other parts of the country, poisoning is confined mainly to the southern parts of the India. 1 AIM OF THE STUDY TO STUDY THE INCIDENCE OF QTc PROLONGATION IN CLEISTANTHUS COLLINUS POISONING. TO STUDY THE USEFULNESS OF QTc PROLONGATION AS A PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING. 2 REVIEW OF LITERATURE India is a tropical country, and so, it is host to a rich array of thousands of plants, some of them are extremely poisonous. Most people in rural areas depend for their food, on plants grown in their own farms. Cases of accidental poisoning occur frequently due to careless ingestion of toxic plant products or contamination of food items. Some cases are due to, consumption of harmful home remedies or traditional treatment. A substantial number of patients are children, for whom plants are accessible easily. In few Western population, most of the human exposures reported to poison, are involving plants. In India, if rural population is taken in isolation, the percentage of consumption of plant poisons will be very high. 3 Cleistanthus collinus poisoning The shrub is also called, Oduvanthalai or Nillipalai in Tamilnadu and Pondicherry, Kadishe in Andhra Pradesh, Karlajuri in West Bengal, Garari in northern states of India Its botanical name is Cleistanthus collinus. Cleistanthus collinus belongs to family Phyllanthaceae and grows wild in dry hills of India from Himachal Pradesh to Bihar and also in southern parts, upto peninsular India. It is a small, deciduous tree with spreading and smooth branches. Leaves are orbicular or broadly oval or elliptical and has rounded tips. Flowers look like borne in small axillary clusters. The fruit capsule is large, looks trigonous, woody, dark- brown and appears shiny and wrinkled when dried. Seeds look globose and chestnut to brown in colour. 4 Toxic parts of the plant include all parts of the plant, which are equally poisonous. Extract of the various parts of the plant yield a number of compounds. Of these, glycosides, arylnaphthalene lignan lactones are highly toxic. The lignan lactones including cleistanthin A and B, collinusin and diphyllin, are called collectively as “oduvin”. Clinical features include 1. Vomiting 2. epigastric pain 3. breathlessness 5 4. visual disturbances, giddiness and drowsiness 5. fever, tachycardia, hypotension or 6. respiratory arrest 7. survivors are usually asymptomatic or transiently symptomatic with abdominal pain, giddiness or visual symptoms. Neuromuscular weakness may be documented. Distal renal tubular acidosis and shock occurs due to inappropriate vasodilatation. Diagnosed by 1. ECG changes like QTc prolongation and non-specific ST-T changes. 2. Blood investigations may reveal hypo-kalaemia, hypo-natraemia, hyper- bilirubinaemia, hypo-calcemia and elevated urea levels. 3. Arterial blood analysis, may show metabolic acidosis, hypoxia with a widened alveolar- arterial O2 gradient, especially in those with respiratory failure. Treatment can be given by, 1. Correction of metabolic acidosis with soda bicarbonate. 2. Correction of hypokalaemia with intra-venous potassium chloride. 3. N-acetylcysteine in the form of i.v., given as 150 mg/kg i.v. over 1 hour, followed by 50 mg/kg i.v. over 4 hours and 100mg/kg i.v. over the next 16 hours. 6 7 8 Castor poisoning It is commonly known as, mole bean or moy bean or palma christi. Its botanical name is Ricinus communis. The plant belonging to family Euphorbiaceae, which is a perennial, erect, branched plant, native to India. It is also encountered even in temperate and tropical climates. Dwarf forms of the plant are typically 2 metres in height, however most plants become tree-like with stout roots and soft stems reaching a height of 7 to 8 metres. Stems and branches are red or maroon. Leaves have long, green or reddish stalks and are quite large, which are generally notched into several palmate lobes with toothed margins. Clusters of greenish-white coloured flowers form at the end of the branches, on long upright stems.
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