Plant Poisoning

Dr. Ravi Nanayakkara

Objectives

• Introduction, classification and identification of poisonous plants.

• Circumstances, route of entry, metabolism and excretion of plant poisons.

• Mechanism of action, target organs, clinical features(early and late phase) and principles of management.

• Autopsy features(external and internal) and sample collection.

Plant poisoning

More than 300 poisonous plants.

Some are edible.

Act on more than one organ, but act principally on one organ system.

Classification

• Neurotoxins• Cardiac toxins• Gastrointestinal irritants• Cellular poisons

Neurotoxins

• Datura stramonium• Substances of abuse

Canabis sativaErythrocylon cocaPapaver somniferum

• Strychnos Nux vomika

Cardiac toxins

• Nerium odorum

• Thevetia peruviana

Gastro intestinal irritants

• Gloria superba

• Ricinus communis

Cellular poisons

• Manihot utilissma

• Adenia palmeta

Datura stramonium

• Attana• CNS

Toxic substances

Atropine Hyoscine HyocyamineScopolamine

All are alkaloids

Circumstances

Accidental –Children eat the seed or fruit

Eating the leaves (mistakenly)Intentional – for revenge, confuse an enemy to robbery – mix with thalaguli

during long distance bus travels

Suicidal ingestion rare.

Absorption

• GIT

• Skin

• Mucous membranes

Target Organs - Atropine

• brain, heart, smooth muscles, glands

• Excretion - Kidney

Clinical features

• Shown in the table.

Organs Pathophysiology Clinical Features

CNS Stimulation Followed by depression Euphoria, delirium aggression, terrifying hallucinations,bizarre behaviour, confusion, convulsions, increased muscle tone,Unconsciousness

Heart Parasympathetic block — > stimulation Tachycardia, hypertension, Tachyarrythmias rarely

Skin Inhibition of sweat glands, Dilatation of blood vessels

Dry, hot Flushes

Eyes Relaxation of radial muscles of pupils, Inhibition of lachrymal glands

Mydriasis and blurring of vision, photophobia, Dry eyes

Alimentary tract Inhibition of salivary glands ,Inhibition of intestinal musculature leading to relaxation

Dry mouth, Reduced gut motility

GUT Relaxation of detrusor muscle Urinary retention

Principles of Management

• Eliminate the poison

• Phytostigmine to reverse the action

• Diazepam to control fits

• Manage complications accordingly

Mode of death

• Respiratory paralysis Asphyxia

Postmortem finding

• Non specific• Seeds or fragments of the plant may be found

in the stomach.stomach may show slight inflmmation.

• Lungs : pulmonary oedema. • Other organs will show sings of asphyxia.

Specimen collection

• Stomach and contents

• Intestine

• Urine

• Blood

Canabis sativa

• Ganja – flower

• Marijuana – flowery tops / cut leaves

• Hashish – dried resin

• H oil – oily extract

Toxic substances

• Alkaloids• Cannabinol• Cannabidiol• Cannabidiolic acid

Circumstances

• Smoking

• Beverage

• With datura

Clinical features

• Inhibitions removed – like alcohol• Confusion• Restlessness• Hallucinations• Narcosis• Nausea• Depression

Principles of management

• Symptomatic

Autopsy

• Non specific• Features of addiction

Erythrocylon coca

• Grows in Central/South America• Toxic Substances

• Alkaloid – cocaine• Leaves• Synthetic • Action – stimulates CNS and CVS

similarly to adrenalin

Clinical features

Shown in the table.

Pathophysiology Clinical features

CNS - Initial stimulation

Late - depression

Excitement, hallucinations, euphoria, hyperkinesis, headache, nausea, vomiting, twitching of small facial muscles, stereotype behaviour, hypereflexia, tonic-clonic seizures Hyporeflexia, coma, respiratory and cardiovascular depression

CVS - Initial stimulation –

Late – depression

Tachycardia, hypertension, ventricular dysrhythmias Weak, slow pulse; low blood pressure

Respiratory system - Initial stimulation – Late depression

Tachypnoea, slow shallow breathing, cyanosis

Vasoconstriction, Hyperactivity (psycho-motor) Pyrogenic action on thermoregulatory centre pallor, hyperthermia

Sympathomimetic action on intestinal wall Diarrhoea, abdominal cramps

Constriction of radial muscles of the pupil Dilatation of pupil

Discussed in drugs of abuse

Papaver somniferum(Opium / Heroin)

• Unriped capsule of poppy plant

• Alkaloids – morphine codeine narcolin papavarin ……

Circumstances

• Ingestion

• Inhalation

• Injections

Clinical features

• Excitement – euphoria

• Depression of brain stem

• Narcosis and death

Discussed in drugs of abuse

Strychnos Nux vomikaGoda/Divi kaduru

• Spinal stimulant• Commonly found in Southern costal area.• Toxin is mainly found in seeds.• Poison – Strychnine ( an alkaloid)

Circumstances

• Accidental – Children eat fruit• Suicidal rare due to bitter• Homicidal rare due to bitter• Abstract of seeds(strychnine) is used to as a

rodenticide, kill stray dogs by injecting with a long stick

• Homicidal injection - rare

Absorption

• All mucosal surfaces• Rapidly absorbed via GIT and spread

throughout body

Target organ

• Spinal cord and brain

Action

• Strychnine stimulate the brain and spinal cord by inhibiting the inhibitory pathways.

• Hyperexcitation of brain stem and spinal cord.• Slightest stimulation can cause convulsions.

Clinical features

• Bitter taste in mouth• Muscle stiffness• Tremors• Twitching• Convulsions• Concious till death

Differential diagnosisFeature Strychnine Tetanus

History Of poisoning (may be) Injury (usually available)

Onset of symptoms Sudden Gradual

Early symptoms Uneasiness, Restlessness Lock jaw

Relaxation in between spasms

Complete Never complete

Fatal period Few hours Several days

Chemical analysis Poison + No poison

Management

• Maintain airway, breathing, circulation• Control fits• Minimum stimulation

Gastric lavarge and vomiting can precipitate convulsion.

• Management of complications

Mode of death

• Hypoxia to brain stem

Respiratory paralysis

Asphyxia

Autopsy

• Non specific• Asphyxia• Muscle haemorrhages

Cardio vascular system

• Thevetia peruviana – Yellow oliander• Nerium oleander – Pink oliander

Circumstances

• Suicide-consume fruits

• Accidental – any part of the plant (children)

• Homicidal-rare

Toxic substance

• Cardiac glycosides – digitalis like action• Inhibit Na+/K+ ATPase• Alteration of membrane potential in

myocardium and neurones• Increse cardiac

ExcitabilityContractilityAutomaticity

Route of absorption

• GIT-injestion

Target organs

• Heart (mainly) - Arrhythmias

• CNS - Neuronal excitability depression

• GIT-irritant

Clinical features

• Faintishness,papitation, irregular pulse,hypotensoin• Yellow vision,blurred vision,dilated pupils, muscular twiching,tetanic spasms,anxiety, confusion• Nausea,vomiting• Pain in throat and numbness in tongue and

lips,abdominal pain,profuse salivation

Principles of management

• Emesis• Activated charcoal• Antidote-Kaneru tab

(Antibody against cardiac glycosides)• Management of complications

Mode of death

• Circulatory failure

• Arrhythmias

Lethal dose : 8-10 seeds, 15-20g root

Autopsy

• Non specific

• GIT irritation

• Fragments of seed in stomach

• Poisonous part – Fruit seeds

• Poison - Cardiogenic glycosides • Circumstances - Accidental, suicidal

• Clinical features - Cardiac arrhythmias

Gloriosa superba (Niyangala)

• Main suicidal poison before availability of pesticides

• Grows throughout the island

Toxic substances• Colchicine- Cellular poison• Choline• Salicylic acid

Mode of action

• Colchicine-cellular poison

Mitosis arrested.

Cell death.• Choline – action same as acetyl choline• Salicylic acid – Local irritant

Circumstances

• Accidental-yams

• Suicidal

• Homicidal

Target organs

• Gastro intestinal tract

• Bone marrow

• CNS

• Smooth muscles

Clinical features

• Shown in the table.

Patho – physiology Symptoms and signs Time of onset after ingestion

Acute inflammation of alimentary tract mucosa due to local actions of salicylic acid and benzoic acid

burning pain, numbness, itching and tingling around mouth and throat. Nausea, vomiting, dehydration, thirst, blood and mucus diarrhoea

within 6- 12 hrs

Augmentation by choline of autonomic contraction of smooth muscles throughout the body. In gastrointestinal tract , bronchi , uterus

abdominal colic, ileus, tenesmus, breathlessnessabortion

within 6- 12 hrs

Block of mitosis, by cholchicine in bone marrow→ bone marrow aplasia→ Throinbocytopenia

bleeding gums, easy bruising within 6 hrs

Acute tubular necrosis of the kidney decreased urine output, haematuria

Central nervous system stimulation, then depression. Respiratory centre depression

Restlessness, confusion, delirium, convulsions, coma Breathlessness

after 36 hrs

Arrest of cell division in hair follicles Rapid shedding of stratum corneum

Alopecia, generalized depilation Dermatitis

after 1-2 weeks

Principles of management

• Gastric lavage

• Activated charcoal

• Management of complications

Autopsy

• Features of acute dehydration and GI irriration

• Features of complication

Ricinus communis(Endaru)

• Entire plant is poisonous• Seeds most poisonous• Grows throughout the island

• AbsorptionGI mucosa

Mode of actionRicin

Blockage of protein synthesis

Cell death

Tissue necrosis

Acute inflammation

Circumstances

• Accidental –Children

• Suicidal

• Homicidal-rare

Clinical featuresPathology Clinical features

Alimentary tractAcute inflammation

Haemorrhagic gastroenteritis, erosions

Burning, sensation of mouth, throat, chest, abdomen, salivation, nausea, vomiting diarrhoea ↙ ↘Dehydration electrolyte(thirst) imbalance ↓ ↓shock muscle cramps(oliguria) (abdomen/calves) drowsiness, delirium, convulsions

abdominal pain,haematemesis,bloody diarrhoea

KidneyNephritis,Acute renal tailure

haematuria. albuminuria. oliguria. uraemia

LiverNecrosis. Inflammation

jaundice

CirculationHaemagglutinatin ->haemolysis haemoglobinuria

Management

• Gastric lavarge• Complication

Mode of death

• Circulatory failure

• Renal failure

• Respiratory failure

Autopsy

• GIT irritation

• Seeds in stomach

• Non specific (Oedema and foci of necrosis)

Specimen

• Gastric contents• Blood• Histology

LiverKidneyStomach and intestine

Manihot utilisma

• Cyanogenic glycoside

Clinical features

• Nausea• Vomiting• Abdominal pain• Diarrhoea• Respiratory failure

Management

• Complications

Autopsy

• Contents in stomach• Non specific

Poisoning ?

• National Poisons Information CentreNational Hospital of Sri Lanka Colombo.

0112686143, 0112691111 Ext 430

Summary

• CNS• GIT• CVS• Cellular toxic

Plants

• Datura stramonium• Canabies sativum• Erythrocylon cocca• Papova somniferum• Strichnus nux vomica• Nerium odorum• Gloriosa superba• Ricinus communis

For each plant• Toxic substance• Circumstances• Absorption• Actions / target organs• Clinical features• Management• Modes of death• Post mortem findings• Samples

Thank You.