FORENSIC SCI SEM F Flesch. Toxic plants: the dangers of returning to nature. FORENSIC SCI SEM, 2015, 5(3): 84-89. 2157118X.5.3.R2 Peer Reviewed Received 7 September 2015 Received in revised form 17 November 2015 Accepted 21 November 2015 Available online 31 December 2015

Toxic Plants: The Dangers of Returning to Nature F Flesch *, a a Center of Poison and Toxicity, New Civil Hospital, F-67091 Strasbourg, France. * Corresponding Author: F. Flesch. E-mail : fl [email protected].

Abstract In France, the plants are involved in about 5% of cases resulting in a call to a poison control center and toxicity (CAPTV). Poisoning plants are mainly children and are usually benign. In adults, they are rare and occur either suicidal context or by confusion with an edible plant or by use of the plant in an addictive or therapeutic purposes. Such poisoning can be serious and be life threatening. This article presents the plants where severe poisoning or death have been reported and whose toxicity is mainly cardiac and / or neurological. After a brief description of each of the following plants: aconite, belladonna, colchicum, datura, foxglove, yew, oleander, redoul and hellebore, the clinical, therapeutic and analytical corresponding poisoning will be treated. Keywords: Plants toxic poisoning, Alkaloids antidote, Forensic science.

1 Introduction 2 Aconite (Aconitum napellus L., to repolarization, with the consequence, Fig. 1) premature excitation. The aconitine is In France, the plants are involved exciting and paralyzing nerve centers in about 5% of cases resulting in a call The aconite, also called helmet of of the medulla and peripheral nerve to a poison control center and toxicity Jupiter, Wolfsbane, Venus chariot or endings. Its toxic action resulting in (CAPTV) [1,2]. Poisoning plants are peacekeeper (wolfsbane or monkshood, neurological and cardiac disorders. [4] mainly children and are usually benign. in English) is a perennial herb Poisonings are rare in Europe. In adults, they are rare and occur either belonging to the family Ranunculaceae. They may be suicidal [5], consecutive to suicidal context or by confusion with It is a plant from 50 to 180 cm high that a consumption of herbal preparations or an edible plant or by use of the plant in grows mainly in mountainous areas of confusion with root vegetables (turnip, an addictive or therapeutic purposes. Western Europe. It blooms from June horseradish, celery) and exceptionally Such poisoning can be serious and be to August; the fl owers are purplish criminal. [6] Poisonings are common life threatening. blue, grouped in clusters. The root is in Asia due to the use of aconitine in In this article, we present a dozen napiforme, pointed, often surmounted Chinese medicine for its antirheumatic toxic plants, in alphabetical order of by a radical of the rod. properties and antineuralgic [7]. Severe vernacular name for which severe All organs of the plant, but poisoning can occur after ingestion of 1 poisoning or death have been reported. especially the roots and seeds contain mg aconitine or 2 to 4 g of fresh roots. These are mainly plants in cardiac diterpene alkaloids, the main one The symptoms appear soon toxicity and / or neurological. After aconitine. The aconitine acts at the after ingestion (from ten minutes a brief description of the plant [3], we level of voltage-gated sodium channels to two hours) and are characterized discuss the clinical, therapeutic and infarction, nerves and muscles. It by paresthesia oral, pharyngeal and analytical. causes persistent activation of these labial and extremities, gastrointestinal channels thus making them refractory disturbances (salivation, nausea,

84 Forensic Science Seminar Volume 5 number 3 F Flesch. Toxic plants: the dangers of returning to nature. FORENSIC SCI SEM, 2015, 5(3): 84-89. FORENSIC SCI SEM vomiting, sometimes diarrhea), L., Fig. 2) anticholinergic symptoms and devices. dizziness and asthenia . In severe cases It is available in France under the name occur in cardiac disorders (ventricular Belladonna also called beautiful of Anticholium® and is subject to the tachycardia, ventricular fi brillation, lady, black button or mandrake status of temporary authorization to cardiac dysrhythmias) and a respiratory baccifère (deadly nightshade, English) use registered (ATU 2007). The drug, paralysis. The paresthesia association is a herbaceous plant belonging to the unwieldy due to its side effects, can with muscle weakness and heart Solanaceae family. Present in Europe, problems is characteristic of poisoning it grows in clearings, preferably by aconite. limestone terrain. It bears fruit in Aconite swallowed requires August / September and produces hospitalization in an intensive care globular berries, about the size of a unit with ECG and blood pressure cherry, embedded at the center of a star monitoring. Digestive evacuation chalice. by vomiting, gastric lavage may be Poisoning can be consecutive to recommended if a short time (less accidental ingestion in children [12,13] or than one hour). The indication of this confusion with edible berries in adults. digestive evacuation will depend on [14] They rarely occur in a context the assumed dose ingested, symptoms suicidal or addictive. and delay. Treatment is mainly All parts of the plant contain symptomatic. There is no consensus tropane alkaloids, including atropine, Figure 1. Aconit on the best treatment for ventricular hyoscyamine (levorotatory isomer of arrhythmia, amiodarone, fl ecainide, atropine) and scopolamine. These three mexiletine and magnesium sulphate [8,9] alkaloids have a parasympatholytic have been used with variable success share; they inhibit competitively and depending on the case. Lidocaine was reversibly binding of acetylcholine generally ineffective. In animal studies, at peripheral and central muscarinic rats, are fl ecainide and beta-blockers receptors, resulting sympathomimetic that have proven to be most effective. [10] effects (or anticholinergic or In case of ventricular arrhythmias and antimuscarinic). refractory shock, it should be quickly Symptoms appear 30 minutes to Figure 2. Belladone put in place circulatory support. 2 hours after ingestion and include, The aconitine can be assayed depending on the amount ingested, in the blood or urine. The analytical one or more of the following clinical method that now seems most effective signs: vomiting, dry mouth, mydriasis, for the determination of aconitine is tachycardia, hyperthermia, confusion, liquid chromatography coupled with delirium, convulsions, coma and tandem mass spectrometry (LC-MS respiratory depression . / MS). A blood concentration of 3.6 Treatment is mainly symptomatic. g / l can be considered lethal in the Physostigmine (or eserine), reversible absence of treatment [9]. In a case of acetylcholinesterase inhibitor, severe intoxication with a plasma increases the level of acetylcholine concentration at 1.75 mg / l at the in the synaptic cleft and allows the seventh hour, the calculated half-life of stimulation of muscarinic and nicotinic aconitine was three hours [11]. receptors. Thanks to its tertiary amine structure, physostigmine pass the blood 3 Belladonna (Atropa belladonna brain barrier and acts on both central Figure 3. Colchique

December 2015 ISSN 2157-118X 85 FORENSIC SCI SEM F Flesch. Toxic plants: the dangers of returning to nature. FORENSIC SCI SEM, 2015, 5(3): 84-89. be used in cases of severe poisoning colchicine that inhibits microtubule thorn apple, grass to the moles (jimson resistant to symptomatic measures. It formation by binding to tubulin with weed, English). It is a herbaceous plant is to be administered at a rate of 1 to the consequence, a blocking mitosis at belonging to the Solanaceae family, 2 mg i.v. slow in adults after verifying the stage of metaphase. abundant in Europe where she likes the absence of cons-indications for its Poisonings occur mostly in spring, wasteland and roadsides; it is widely use. Physostigmine is between the 5th by confusion leaves with those of wild grown for its decorative appearance. and 20th minute after injection, and the garlic [18,19] or wild leek; they rarely It blooms from July to October (large effect persists for 45 to 60 minutes [15-17]. occur in children by consumption of white fl owers trumpet-shaped). Its seeds or adults in a suicidal frame. [20] fruit is a large thorny ovoid capsule 4 Colchique (Colchicum Colchicum poisoning are serious containing many seeds. autumnale L., Fig. 3) and bring life-threatening. The fi rst All parts of the plant contain signs are gastrointestinal and occur after alkaloids including hyoscyamine Colchicum also called meadow a delay of several hours (vomiting and (principal alkaloid), scopolamine and saffron (meadow saffron or autumn profuse diarrhea quickly responsible atropine; these alkaloids are peripheral crocus, English) is a herbaceous for dehydration). In severe cases, there and central competitive antagonists of perennial fl owering from August to is the appearance in the fi rst 24 hours acetylcholine. Datura causes, such as November. Fruits and leaves appear in of acute circulatory failure. By the third belladonna, a parasympatholytic effect the spring of the following year. The day appears myelosuppression that will but whose intensity is stronger. fruit is a large green capsule with three last two to six days and whose risk is The most common method of compartments, each containing 60-80 infection and bleeding. By the tenth intoxication for the consumption of seeds. The main compound is crocus day occurs alopecia. The blood test this plant in a goal addictive form of colchicine to confi rm the diagnosis. decoction, ingestion of seeds or use of Regarding the therapeutic cigarettes made from dried leaves. [21] management: the digestive evacuation The poisoning causes is rarely performed because of anticholinergic syndrome primarily the typically long delay between neuropsychiatric symptoms with ingestion and hospital admission. The psychomotor excitement, incoherent, administration of activated charcoal visual hallucinations, disorientation, repeated doses may be effective but is aggressiveness. Among the peripheral generally not feasible because of severe anticholinergic signs, we note the Figure 4. Datura vomiting. The volume of distribution presence of a bilateral mydriasis while of colchicine renders illusory the other anticholinergic signs are more renal replacement methods. The fi ckle: dry mouth, sinus tachycardia, anticolchicine antibodies are not, to hyperthermia, vomiting and urinary date not available. Treatment is mainly retention. In severe cases, there may supportive, guided by daily monitoring be convulsions and coma. Evolution is of electrolytes, blood counts and generally favorable in 24 to 48 hours. prothrombin. The diagnosis can be confi rmed by blood and urine assay of alkaloids by 5 Datura (Datura stramonium L., liquid chromatography coupled to a Fig. 4) dual-mass spectrometry (LC-MS / MS). [22]

The genus Datura comprises about Treatment is symptomatic. twenty species of which the most Physostigmine, available in France common is Datura stramonium L., also under the name of Anticholium®

Figure 5. Digitale called Jimson weed, grass of the devil, and subjected to a nominative ATU,

86 Forensic Science Seminar Volume 5 number 3 F Flesch. Toxic plants: the dangers of returning to nature. FORENSIC SCI SEM, 2015, 5(3): 84-89. FORENSIC SCI SEM can be used in severe poisoning (see the dosage of digoxin that is usually very small quantities (0.01%). Belladonna). used to assess the severity of the Severe poisoning are mainly poisoning; However, given the low observed in adults and may be 6 Digitale (Fig. 5) correlation clinicobiological [23], secondary to ingestion of leaves and should be preferred clinical signs for seeds with suicidal intent or accidental The genus Digitalis includes evaluating the severity and determine ingestion in a context of herbal twenty species. This is a herbaceous the therapeutic management. A treatment. In children, accidental plant belonging to the family of measurement of specifi c glycosides poisoning are usually benign due to the Scrophulariaceae and blooming from would be helpful if the laboratory ingestion of non-toxic fl eshy part of the May to September as a long unilateral has the appropriate techniques [24]. "bay" or ingesting a small amount of cluster. In France there are three wild Regarding treatment, indicating a "bays" with a non-mache core. species: foxglove (Digitalis purpurea digestive evacuation is to discuss on The clinical signs appear two to L.) or purple foxglove in English, the time, the amount ingested and three hours after ingestion and include yellow digitalis (Digitalis lutea L.) symptoms. Repeated administration digestive, neurological signs (coma, and Digitalis grandifl ora (Digitalis of activated charcoal may be useful convulsions) and heart (ventricular grandifl ora L.). [23]. Treatment involves the careful conduction disorders, arrhythmias, The plant contains many correction of hypokalaemia and ventricular fi brillation). The dosage of compounds which qualitatively administration of atropine in case of the alkaloids in biological fl uids can and quantitatively variable cardiac bradycardia. Specifi c treatment by be performed in a laboratory with the glycosides (digitoxin, gitoxin, antidigitalis antibodies (DIGIBIND ®) correct technique [25,26]. lanatoside C digitoxigenin). These is the treatment of choice for severe Le traitement des troubles cardenolides act by inhibiting the Na poisoning. cardiaques reste mal codifi é : lidocaïne, + / K + ATPase membrane. They have phénytoïne, anticorps antidigitaliques, a positive inotropic, chronotropic and 7 If (Taxus baccata L., Fig. 6) assistance circulatoire et perfusion de dromotropic negative. They also a vasoconstrictor, diuretic and a central This is a tree (yew, English) from effect. 4 to 15 m high evergreen, often planted Poisoning can be a result of a in parks and gardens. The fruit, falsely confusion with borage leaves used to called "bay", is formed by a red aril prepare salads or teas, or voluntary sacciforme surrounding an ellipsoidal ingestion with suicidal intent. seed. Accidental poisoning in children are Except the aril, all parts of the plant Figure 6. If rare. are poisonous and contain a mixture Symptoms involve: gastrointestinal of alkaloids and complex structure disorders (nausea, vomiting), pseudoalcaloïdes. The main cardiotoxic neurosensory disorders (confusion, substances are taxines A and especially confusion, color blindness), heart B taxines, diterpene taxane core problems with conduction disturbances substances that are antagonists of the and / or automatism (sinus bradycardia, calcium and sodium channels and atrioventricular block grade 1, 2 or whose properties are similar to those of 3, sinus or junctional tachycardia, the class of antiarrhythmic 1. One gram tachycardia or ventricular fi brillation). of redwoods contain approximately These disorders may be associated with 5 mg of taxines. Taxol (paclitaxel), hyperkalemia, this intoxication gravity antimicrotubuline cytotoxic agent factor. Because of cross-reactions when originally isolated from the bark of cardenolides assays immunoassay, Taxus brevifolia Nutt., Are present in Figure 7. Laurier rose

December 2015 ISSN 2157-118X 87 FORENSIC SCI SEM F Flesch. Toxic plants: the dangers of returning to nature. FORENSIC SCI SEM, 2015, 5(3): 84-89. solutés alcalins ont été utilisés avec des though there is no strict correlation It is a perennial herb of the mountainous succès variables [27]. between the measured concentration regions of Europe. The fl owers form a and the severity of the poisoning. The long white cluster to the end of the rod. 8 Laurier rose (Nerium oleander effectiveness of the activated carbon is The fruits are in the form of a brown L., Fig. 7) likely, although there is no consensus ovoid capsule containing seeds. The on the mode of administration (single plant contains many alkaloids including This is a shrub (oleander, English) dose versus multiple doses) [31,32]. protovératrines A and B [35]. The main from 2 to 3 m high belonging to the Treatment includes, besides the pathophysiological mechanism of family Apocynaceae. The leaves If atropine in bradycardia and careful poisoning is related to the increase in are evergreen and fl owers, pink, correction of ionic abnormalities, the permeability of sodium channels [36]. red or white, are present from June administration of antibody antidigitalis Poisonings occur mainly in adults by to September. All parts of the plant whose indication is based on clinical, confusion with gentian (Gentiana lutea contain glycosides, the main one being electrocardiographic and laboratory L.) in the liqueur crafted from the roots, the oleandrine, whose structure is (serum potassium). the two species share the same habitat. similar to that of digitalis. Poisonings Symptoms appear after 30 minutes occur most often in adults with suicidal 9 Redo (Coriaria myrtifolia L.) to 3 hours and are characterized by context [28,29]. digestive disorders (nausea, vomiting, The symptoms of poisoning are This is a common shrub of abdominal pain), cardiovascular those of digitalis intoxication with: Mediterranean regions whose fruit disorders (bradycardia, hypotension, digestive disorders (nausea, vomiting), roughly resemble blackberries. All parts conduction disorders) and neurological neurosensory disorders (agitation, of the plant contain a sesquiterpene disorders (visual disturbances, confusion, color vision disorders), lactone (coriamyrtine) having a dizziness, paresthesia, confusion) [37,38]. cardiac disorders related to inhibition structural similarity with the picrotixine Symptoms usually resolve within 24 to of the Na + / K + ATPase membrane and anisatin. The most common cause 48 hours. Treatment is symptomatic. (bradycardia, conduction disorders of poisoning is ingestion of fruit, Atropine is effective bradycardia. and / or automatism). These disorders especially in children. may be associated with hyperkalemia, The symptoms usually occur 11 Conclusion gravity factor of this poisoning. [30] The between 30 minutes and 2 hours of dosage of oleandrine not being made in ingestion and associate: digestive A number of plants contain current practice, the dosage of digoxin (gastrointestinal pain, vomiting), cardiotoxic and neurotoxic alkaloids. which is generally used to assess neurological disorders (in order of Their use can cause serious the severity of the poisoning even frequency: convulsions, confusion, intoxications whose diagnosis may be hypertension and muscle cramps, disregarded in the absence of accurate fainting, coma, disorientation , history. It is therefore appropriate for lockjaw and opisthotonos, headache, every patient in a context of digestive agitation) and breathing problems disorders with cardiovascular disorders (rapid breathing, apnea). Treatment is and / or neurological symptoms symptomatic [33,34]. (paraesthesia, confusion, convulsions) to discuss the hypothesis of plant 10 Vératre (Veratrum album L., poisoning. A blood sample is to allow Fig. 8) the admission, if any, to provide a measurement of specifi c alkaloids The white hellebore (known in in order to confi rm the diagnosis Europe), also known as white hellebore and to advance in the study of a (white hellebore or poison lilly, clinicopathologic correlation for cases

Figure 8. Redoul English), belongs to lafamille Liliaceae. of poisoning infrequent, and caused

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