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INTERNATIONAL JOURNAL OF MODERN RESEARCH AND REVIEWS

IJMRR Int. J. Modn. Res. Revs. Volume 3, Issue 3, pp 627-629, March, 2015 ISSN: 2347-8314 ORIGINAL ARTICLE

ODUVAN THALAI POISONING -A CASE REPORT.

1Dr.M.Senthilvelan,2Dr.Res veen,2Dr.Santhosh 2S.J,DR.D.Johny Abraham and 2Dr.P.Praveen Kumar Reddy

1Professor, Department of General Medicine,Rajah Muthiah Medical College,Chidambram. 2Post Graduate, Department of General Medicine,Rajah Muthiah Medical College,Chidambram.

Article History: Received 2nd March,2015, Accepted March, 30th 2015, Published 31st March,2015

ABSTRACT

Cleistanthus collinus, a toxic shrub, is used for deliberate self-harm in rural South India. The toxic principles in the leaf include arylnaphthalene lignan lactones — Diphyllin and its glycoside derivatives Cleistanthin A and B. Human toxicity results in renal tubular dysfunction, commonly dRTA, with resultant hypokalemia and normal anion gap . Acute respiratory distress syndrome (ARDS) is seen in severe cases. Cardiac rhythm abnormalities have been demonstrated in a number of clinical studies, QTc CHANGES and non specific ST-T changes are noted.Consumption of decoctions of C. collinus leaves, hypokalemia, renal failure, severe metabolic acidosis, ARDS and cardiac arrhythmias occur in severe poisonings and predict mortality.We have got a case of oduvan thalai( collinus) in our hospital probably for the first time in this part of tamilnadu,hence we report this case.

Keywords: C. collinus, ODUVAN THALAI

1.INDRODUCTION principles in the leaves are arylnaphthalene lignan lactones — Diphyllin and its glycoside derivatives Cleistanthin A and The Euphorbiaceae (spurge family) are a family of flowering Cleistanthin B; and Collinusin. Diphyllin, Cleistanthin A and with 300 genera and around 7,500 species. Most are B were collectively known as ―Oduvin‖ in the past. In herbs, but some, especially in the tropics, are also shrubs or addition, the lignans Cleistanthin C, Cleistanthin D and trees. The genus Cleistanthus, belonging to the family Cleistanone, are present. The toxicity of the has been Euphorbiaceae, comprises 140 species native to the region attributed primarily to Cleistanthin A and B. between Africa and the Pacific islands. C. collinus is a toxic deciduous shrub that grows in hilly deciduous forests of Clinical Profile; Central and South India, Malaysia and Africa. C. collinus in India is popularly known in: Hindi as Garari; Tamil, as Clinical profile of C. collinus toxicity in humans Oduvanthalai; Telugu, as Vadise; , as Nilapala; and Bengali, as Karlajuri.

All parts of the plant are potentially toxic. The leaves are commonly used for poisoning humans (suicide or homicide) and animals (cattle and fish poison) and as an abortifacient, especially in rural South India. Extracts of leaves, roots and fruits have been used in acute gastrointestinal disorders. The method of ingestion of the plant for deliberate self-harm includes swallowing the crushed plant parts;, chewing the leaves; consuming a paste/juice of the leaves or a decoction prepared by boiling the leaves in water.

Toxic constituents

Analyses of extracts from the plant, including the leaves, reveal a complex group of compounds. The toxic active Clinical studies have described in detail the clinical profile of patients presenting with C. collinus poisoning .Patients may *Corresponding author: Dr.Resveen, Post Graduate, Department of General Medicine,Rajah Muthiah Medical College,Chidambram be asymptomatic or present with common gastrointestinal

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Dr.M.Senthilvelan et al., 2015 symptoms of vomiting, nausea and abdominal pain; and, R/E,CHEST XRAY)were within normal limits occasionally, diarrhea, constipation, dysphagia, salivation, throughout,except for electrolytes and ABG. abdominal distension and decreased bowel sounds. Cardio- respiratory presentations include chest pain, dyspnea, .ABG; Showed mild metabolic acidosis (normal anion gap) tachypnea or bradypnea, tachycardia or bradycardia, with hypoxemia.after correction from day two to till day of hypotension and cyanosis. Documented clinical neurological discharge. abnormalities are mydriasis with visual disturbances, muscle 2D ECHO-normal LV systolic function.No RWMA.EF 64%. cramps and weakness, altered sensorium, giddiness, headache, altered speech, tremors and ptosis TREATMENT.Initially treated with stomach wash with plain NS and then charcoal wash.inj soda.bicorb given for Laboratory Findings; acidosis(three times given till the abg became normal).Inj N Ingestion of the poison as a decoction prepared from the ACETYLCYSTEIN (150mgper kg started) and stopped leaves and ingestion of a large number of leaves otherwise immediately (patient developed breathlessness).Patient was were associated with a poor outcome. While survivors treated with oral potassium syrup from fourth day.patient started with oral diet from third day onwards. remained relatively asymptomatic, fatally poisoned patients presented with significant clinical signs and symptoms, INVEST 1st day 4th day 5th 6th day 7th however, laboratory abnormalities such as hypokalaemia, day day hyponatremia, an elevated AST/LDH/CPK/CPK-MB, UREA 35mg|dl 30 CREAT 1.1mg|dl 1.0 nonspecific ST-T changes and QTc prolongation on ECG, SODIUM 139mmol|l 145 136 137 135 metabolic acidosis and hypoxia with widened alveolar- POTASSIUM 4.9mmol|l 4.3 2.3 3.2 4.2 arterial oxygen difference (A-aDO2) were seen in both CHLORIDE 103mmol|l 99 99 98 99 groups. Management;

Airway, breathing and circulation should be assessed and appropriately stabilized. Mechanical ventilation may be required in the setting of respiratory failure.Initial lab investigations should include serum electrolytes (potassium, sodium, bicarbonate and magnesium), creatinine, arterial blood gas and a chest radiograph.Activated charcoal was administered every 6 hours for 4 days.In patients who have taken decoctions, it is unlikely that gastric lavage beyond 1-2 hours post-ingestion is of benefit.The mainstay of C. collinus poisoning management is monitoring and correction of electrolyte imbalances, namely, hypokalemia and metabolic acidosis. The mainstay of C. collinus poisoning management is monitoring and correction of electrolyte imbalances, namely, hypokalemia and metabolic acidosis(with inj.sodium bicarbonate).N-ACETYLCYSTEINE 150 mg per kg over 1 hour,followed by 50 mg per kg over next 4 hours,followed by 100 mg per kg over 16 hours has been suggested. 2.CASE

A 23 yr old female patient came with alleged history of consumption of oduvan thalai leaf (10 leaves by boiling and drank the decotion) by night 8 pm,but presented only next day afternoon to our casualty with complaints of abdominal pain (+).no other specific complaints.o|e-patient general condition was normal,conscious ,oriented,BP-110|70 mmHg,PR-76|min(regular).RR-18|MIN.SYSTEMIN EXAMINATION-CVS-S1S2+,no murmurs,RS-nvbs+,no added sounds,P|A soft,non tender,CNS-NFND. Course in the hospital. Patient had complaints of vomiting on and off,with c/o ECG showing T wave inversions in II,III,avf,v1 to v6 intermittent chest pain. Patient developed metabolic acidosis and hypokalemia(though not developed any weakness ) from fourth day of hospital stay.Patient also had chestpain with 3.DISCUSSION ecg changes(T wave inversion in II,III,avf,V1 to V6).patients A case of oduvan thalai poisoning(cleistanthus collinus) blood investigations (CBC,RBS,RFT,LFT,BT,CT,URINR came for the first time to our hospital.patient initially had only gastrointestinal symptoms like vomiting and loose

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Volume 3, Issue 3, pp 627-629, March, 2015 stools,later from fourth day onwards patient had chest 5.REFERENCES. pain,and later developed metabolic acidosis and hypokalemeia,patient was treated symptomatically.Patient 1. Hawton K, Heeringen K. Suicide. Lancet. 2009;373:1372–81. responded well to the treatment and got discharged.Patient [PubMed] came for review after one weak.patient was asymptomatic 2. Eddleston M, Phillips MR. Self poisoning with pesticides. with normal ecg and with normal electrolytes report.Since it BMJ. 2004;328:42–4. 3. Eddleston M. Patterns and problems of deliberate self- is first case of oduvan thalai poison we got in our hospital,we poisoning in the developing world. QJM. 2000;93:715–31. took an initiative to report this case.If we treat the patient 4. Jeyaratnam J. Acute pesticide poisoning: A major global symptomatically,patient has a good prognosis. health problem. World Health Stat Q. 1990;43:139–44. 4.CONCLUSION 5. Bose A, Sandal Sejbaek C, Suganthy P, Raghava V, Alex R, Muliyil J, et al. Self-harm and self-poisoning in southern India: Cleistanthus collinus, a toxic shrub, is used for deliberate Choice of poisoning agents and treatment. Trop Med Int Health. self-harm in rural South India. The toxic principles in the leaf 2009;14:761–5. include arylnaphthalene lignan lactones- Diphyllin and its 6. Joseph A, Abraham S, Muliyil JP, George K, Prasad J, Minz glycoside derivatives Cleistanthin A and B. Human toxicity S, et al. Evaluation of suicide rates in rural India using verbal results in renal tubular dysfunction, commonly dRTA, with autopsies, 1994-1999. BMJ. 2003;326:1121–2. 7. Aaron R, Joseph A, Abraham A, Muliyil J, George K, Prasad resultant hypokalemia and normal anion gap metabolic J, et al. Suicides in young people in rural southern India. Lancet. acidosis. Acute respiratory distress syndrome (ARDS) is seen 2004;363:1117–8. in severe cases. Cardiac rhythm abnormalities have been 8. Eddleston M, Ariaratnam CA, Meyer WP, Perera G, demonstrated in a number of clinical studies, QTc Kularatne AM, Attapattu S, et al. Epidemic of self-poisoning CHANGES and non specific ST-T changes are with seeds of the yellow oleander tree (Thevetia Peruviana) in noted.Consumption of decoctions of C. collinus leaves, northern Sri Lanka. Trop Med Int Health. 1999;4:266–73. hypokalemia, renal failure, severe metabolic acidosis, ARDS 9. Eddleston M, Juszczak E, Buckley NA, Senarathna L, and cardiac arrhythmias occur in severe poisonings and Mohamed F, Dissanayake W, et al. Multiple-dose activated predict mortality.We have got a case of oduvan charcoal in acute self-poisoning: A randomised controlled trial. thalai(Cleistanthus collinus) in our hospital probably for the Lancet. 2008;371:579–87. first time in this part of tamilnadu.Hence we report the case. 10. Aleem MA, Paramasivam M. Spectrum of acute poisoning in villagers. J Assoc Physicians India. 1993;43:859.

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