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).