Regaliz americano

Hospital de Manacor Servicio de Urgencias

IDEACIÓN AUTOLÍTICA CON “ABRUS PRECATORIUS”

A PROPÓSITO DE UN CASO CLÍNICO

Dra. Ana Loras R2, MFyC, urg H Manacor 25-Nov-2016

Triage III: P- 10 (17:30h) ◦ Mujer de 20 años derivada del CS por dolor abdominal tras intento autolítico con ingesta de semillas de regaliz Americano.

Antecedentes personales ◦  Natural de Marruecos. ◦  Sin alergias medicamentosas, ni hábitos tóxicos. ◦  Antecedentes patológicos:

�  Hiperprolactinemia. �  Cefaleas habituales. �  Hirsutismo.

◦  No antecedentes quirúrgicos. ◦  No viajes al extranjero. ◦  No cambios alimenticios. ◦  No tratamiento farmacológico habitual.

Enfermedad actual

�  Motivo de consulta: �  Acude por dolor abdominal, sin vómitos, naúseas,

ni alteración del hábito deposicional. �  Refiere ingesta de 3-5 semillas compradas por

“Ebay” con ideación autolítica.

�  Exploración física: �  TA: 114/82mmHG; TºC: 36,5ºC; FC 99lpm. �  Leve molestia a nivel epigátrico. �  Resto: Anodino.

Exploraciones complementarias

�  Analítica sanguínea: Nº Història:

HADDOUTI SI MARIA GAYA FLORIT

HOSPITAL DE MANACORURGENCIAS

Edat: 20 años (20/04/1996)

DADES SOL·LICITANT

Sexe: M

Centre:Servei: Nº Mostra:

30056831723027

MALIYA

Ubicació: Box 2 P

Metge:

C. extern: 1144981CIP: 38477403216

DADES PACIENT

DATA 20/06/2016

Origen: FHM URGENCIAS

www.hmanacor.org

DADES LABORATORI

HORA 18:03:35

LABORATORI

Resultat Valor de referència

HEMATOLOGIAHEMATIMETRIA

HEMOGRAMA4,35 x10^6/µLHEMATIES 4,10 - 5,2012,6 g/dLHEMOGLOBINA 12,0 - 15,537,9 %HEMATÒCRIT 37,0 - 47,087,2 flVOLUM CORPUSCULAR MITJÀ 80,00 - 99,0029,0 pgHb CORPUSCULAR MITJANA 27,00 - 33,0033,2 g/dLCONCENTRACIÓ Hb CORPUSCULAR MITJANA 33,0 - 36,014,3 %RDW 12,0 - 16,06,57 x10^3/µLLEUCÒCITS 3,60 - 9,0067,3 %NEUTRÒFILS 55,0 - 75,04,42 x10^3/µLNEUTRÒFILS ABSOLUTS 2,20 - 8,2025,9 %LIMFÒCITS 25,0 - 41,01,70 x10^3/µLLIMFÒCITS ABSOLUTS 1,00 - 4,504,6 %MONÒCITS 2,0 - 8,00,30 x10^3/µLMONÒCITS ABSOLUTS 0,20 - 0,801,6 %EOSINÒFILS 1,0 - 4,50,11 x10^3/µLEOSINÒFILS ABSOLUTS 0,05 - 0,500,6 %BASÒFILS 0,2 - 1,20,04 x10^3/µLBASÒFILS ABSOLUTS 0,01 - 0,15191 x10^3/µLPLAQUETES 150 - 3500,145 %PLAQUETÒCRIT 0,12 - 0,3617,0 flPDW 13,0 - 20,0

COAGULACIÓ85 - 125TEMPS PROTROMBINA (%) 70* %

TEMPS PROTROMBINA (SEGONS) 14,2 s

0,85 - 1,15INR 1,30*

Página 1 de 2DUPLICADOData primera impresió: 21/06/2016 8:28:26

Maria Inmaculada Pastor Garcia,Irene Aguilar PerezValidat per:

Carretera Manacor-Alcúdia, s/n Manacor Telf.: (+34) 971 847 044 Fax: (+34) 971 847 047

Nº Història:

HADDOUTI SI MARIA GAYA FLORIT


Edat: 20 años (20/04/1996)

DADES SOL·LICITANT

Sexe: M


30056831723027

MALIYA

Ubicació: Box 2 P

Metge:

C. extern: 1144981CIP: 38477403216

DADES PACIENT

DATA 20/06/2016


www.hmanacor.org

DADES LABORATORI

HORA 18:03:35

LABORATORI

BIOQUIMICAGASOMETRIA VENOSA

7,40PH V 7,33 - 7,4341,1 mmHgPCO2 V 38 - 5041 mmHgPO2 V 30 - 5024,9 mmol/LHCO3 V 23 - 2726,2 mmol/LcTCO2 V 25 - 290,6 mmol/LABE-BE V -2,7 - 2,50,6 mmol/LSBE V24,4 mmol/LSBC V77,6 %SATURACIÓ O2 V 60 - 856,6 mmol/LcTO2 V

70 - 110GLUCOSA 90 mg/dL

0,60 - 1,10CREATININA 0,59* mg/dL

13 - 43UREA 15 mg/dL

136 - 145SODI 140 mmol/L

3,5 - 5,1POTASSI 3,6 mmol/L

0,7 - 2,1ÀCID LÀCTIC/LACTAT 0,87 mmol/L

< 360LDH 140 U/L

< 34ALT/ GPT 12 U/L

< 31AST/ GOT 17 U/L

9 - 36GGT 17 U/L

28 - 100AMILASA 42 U/L

0,2 - 1,2BILIRRUBINA TOTAL 0,7 mg/dL

< 0.5PROTEÏNA C REACTIVA 0,03 mg/dL

17/11/2016 Página 2 de 2DUPLICADO Data informe:Data primera impresió: 21/06/2016 8:28:26

Maria Inmaculada Pastor Garcia,Irene Aguilar PerezValidat per:


Día llegada.


�  Radiología

Abdomen

Tórax

Evolución clínica: Primeras horas de incertidumbre

�  Se contacta con servicio de Toxicología de Madridà Potencial letal de las semillas à Críticos/UCI.

◦  Monitorización contínua. ◦  Constantes por hora. ◦  Sonda vesical y orogástrica. ◦  Carbón activado 50gr, 25gr a las 4 h y a las 8h. ◦  Lavado intestinal 1.5 l de SF 0,9%/hora por sonda. ◦  Dieta absoluta. ◦  Sueroterapia: 1500SG 5%/24h iv + 1500SF 0,9%/24h

iv + ClK 40mEq /24h iv. ◦  Metoclopramida 10mg/8horas iv. ◦  Lactulosa sobres: 1 sobre vo cada 8h.

�  19:35h: Expulsión fecal de 1ª semilla.

�  20:24h: Deposiciones diarréicas.

�  Noche: Hemodinámicamente estable. Sin cambios sintomáticos.

�  07: 57h (día 21): Expulsión 2ª y 3ª semilla. Mantenemos medidas adoptadas.

�  13:13h: Expulsión rama verdosa (desconocemos origen) y analítica.

.

Evolución clínica: Manteniendo la calma


�  Analítica sanguínea: Día siguiente: turno mañana.

Nº Història:

HADDOUTI SI Dr. JUAN MARTINEZ GOMEZ

HOSPITAL DE MANACORMEDICINA INTERNA HOSPITALIZACION

Edat: 20 años (20/04/1996)

DADES SOL·LICITANT

Sexe: M


30056831733051

MALIYA

Ubicació: HCRI-2

Metge:

C. extern: 1145899CIP: 38477403216

DADES PACIENT

DATA 21/06/2016


www.hmanacor.org

DADES LABORATORI

HORA 13:21:25

LABORATORI



HEMOGRAMA3,94 x10^6/µL*HEMATIES 4,10 - 5,2011,2 g/dL*HEMOGLOBINA 12,0 - 15,534,9 %*HEMATÒCRIT 37,0 - 47,088,5 flVOLUM CORPUSCULAR MITJÀ 80,00 - 99,0028,5 pgHb CORPUSCULAR MITJANA 27,00 - 33,0032,2 g/dL*CONCENTRACIÓ Hb CORPUSCULAR MITJANA 33,0 - 36,014,3 %RDW 12,0 - 16,07,52 x10^3/µLLEUCÒCITS 3,60 - 9,0076,3 %*NEUTRÒFILS 55,0 - 75,05,74 x10^3/µLNEUTRÒFILS ABSOLUTS 2,20 - 8,2017,7 %*LIMFÒCITS 25,0 - 41,01,34 x10^3/µLLIMFÒCITS ABSOLUTS 1,00 - 4,505,1 %MONÒCITS 2,0 - 8,00,39 x10^3/µLMONÒCITS ABSOLUTS 0,20 - 0,800,7 %*EOSINÒFILS 1,0 - 4,50,05 x10^3/µLEOSINÒFILS ABSOLUTS 0,05 - 0,500,2 %BASÒFILS 0,2 - 1,20,02 x10^3/µLBASÒFILS ABSOLUTS 0,01 - 0,15179 x10^3/µLPLAQUETES 150 - 3500,143 %PLAQUETÒCRIT 0,12 - 0,3616,3 flPDW 13,0 - 20,0



0,85 - 1,15INR 1,49*23,0 - 36,0TEMPS TROMBOPLASTINA PARCIAL ACT. (SEG.) 34,1 s

0,75 - 1,25TEMPS TROMBOPLASTINA PARCIAL ACT. (RÀTIO) 1,18

BIOQUIMICABIOQUIMICA EN SANG

70 - 110GLUCOSA 111* mg/dL


13 - 43UREA <4* mg/dL


Maria Inmaculada Pastor Garcia,Ana Garcia Fernandez de CastilloValidat per:


Nº Història:

HADDOUTI SI Dr. JUAN MARTINEZ GOMEZ

HOSPITAL DE MANACORMEDICINA INTERNA HOSPITALIZACION

Edat: 20 años (20/04/1996)

DADES SOL·LICITANT

Sexe: M


30056831733051

MALIYA

Ubicació: HCRI-2

Metge:

C. extern: 1145899CIP: 38477403216

DADES PACIENT

DATA 21/06/2016


www.hmanacor.org

DADES LABORATORI

HORA 13:21:25

LABORATORI

136 - 145SODI 141 mmol/L

3,5 - 5,1POTASSI 3,3* mmol/L

34 - 145CK 41 U/L

< 360LDH 134 U/L

< 34ALT/ GPT 9 U/L

< 31AST/ GOT 14 U/L

9 - 36GGT 14 U/L

35 - 104FOSFATASA ALCALINA 31* U/L


3,5 - 5,2ALBÚMINA 3,7 g/dL

< 0.5PROTEÏNA C REACTIVA 0,03 mg/dL


Maria Inmaculada Pastor Garcia,Ana Garcia Fernandez de CastilloValidat per:


Pasadas las 24 horas: Búsqueda bibliográfica exhaustiva.

�  18:30h: ◦  Hemodinámicamente estable. ◦  Diuresis conservada. ◦  Heces líquidas. ◦  Exploración anodina. ◦  Se reduce sueroterapia. ◦  Permanece en dieta absoluta. ◦  Nuevo control analítico y gasometría

venosa.


�  Analítica sanguínea: Día siguiente: turno tarde. Nº Història:

HADDOUTI SI MARIA EUGENIA IGLESIAS BEDRINA


Edat: 20 años (20/04/1996)

DADES SOL·LICITANT

Sexe: M


30056831733038

MALIYA

Ubicació: HCRI-2

Metge:

C. extern: 1146222CIP: 38477403216

DADES PACIENT

DATA 21/06/2016


www.hmanacor.org

DADES LABORATORI

HORA 18:37:16

LABORATORI



HEMOGRAMA3,94 x10^6/µL*HEMATIES 4,10 - 5,2011,3 g/dL*HEMOGLOBINA 12,0 - 15,534,6 %*HEMATÒCRIT 37,0 - 47,088,0 flVOLUM CORPUSCULAR MITJÀ 80,00 - 99,0028,8 pgHb CORPUSCULAR MITJANA 27,00 - 33,0032,7 g/dL*CONCENTRACIÓ Hb CORPUSCULAR MITJANA 33,0 - 36,014,0 %RDW 12,0 - 16,07,82 x10^3/µLLEUCÒCITS 3,60 - 9,0067,3 %NEUTRÒFILS 55,0 - 75,05,26 x10^3/µLNEUTRÒFILS ABSOLUTS 2,20 - 8,2024,8 %*LIMFÒCITS 25,0 - 41,01,94 x10^3/µLLIMFÒCITS ABSOLUTS 1,00 - 4,506,8 %MONÒCITS 2,0 - 8,00,53 x10^3/µLMONÒCITS ABSOLUTS 0,20 - 0,800,7 %*EOSINÒFILS 1,0 - 4,50,06 x10^3/µLEOSINÒFILS ABSOLUTS 0,05 - 0,500,3 %BASÒFILS 0,2 - 1,20,03 x10^3/µLBASÒFILS ABSOLUTS 0,01 - 0,15187 x10^3/µLPLAQUETES 150 - 3500,142 %PLAQUETÒCRIT 0,12 - 0,3616,9 flPDW 13,0 - 20,0



0,85 - 1,15INR 1,47*


Maria Inmaculada Pastor Garcia,Irene Aguilar Perez,Ana Garcia Fernandez de CastilloValidat per:


Nº Història:

HADDOUTI SI MARIA EUGENIA IGLESIAS BEDRINA


Edat: 20 años (20/04/1996)

DADES SOL·LICITANT

Sexe: M


30056831733038

MALIYA

Ubicació: HCRI-2

Metge:

C. extern: 1146222CIP: 38477403216

DADES PACIENT

DATA 21/06/2016


www.hmanacor.org

DADES LABORATORI

HORA 18:37:16

LABORATORI

BIOQUIMICAGASOMETRIA VENOSA

7,44*PH V 7,33 - 7,4334,0 mmHg*PCO2 V 38 - 5071 mmHg*PO2 V 30 - 5022,0 mmol/L*HCO3 V 23 - 2724,0 mmol/L*cTCO2 V 25 - 29-1,0 mmol/LABE-BE V -2,7 - 2,5-1,0 mmol/LSBE V24,0 mmol/LSBC V95,0 %*SATURACIÓ O2 V 60 - 85

70 - 110GLUCOSA 112* mg/dL


13 - 43UREA <4* mg/dL

136 - 145SODI 140 mmol/L

3,5 - 5,1POTASSI 3,4* mmol/L

0,7 - 2,1ÀCID LÀCTIC/LACTAT 0,59* mmol/L

< 360LDH 110 U/L

< 34ALT/ GPT 9 U/L

< 31AST/ GOT 13 U/L

9 - 36GGT 13 U/L

28 - 100AMILASA 39 U/L



Maria Inmaculada Pastor Garcia,Irene Aguilar Perez,Ana Garcia Fernandez de CastilloValidat per:


Búsqueda bibliográfica exhaustiva. 20 artículos, 7 de los cuales hablaban de potencial letalidad.

!!"# ! !""# $%&'()*%% +',*-'* ./0

!"#$ %$&'%(

&)*+),*,- ./0 1) !"#$% &#'()*+#,$% 2304/*5*16 708,9

!" #$%&'&()

!"#$%&'(#' )#(*$'+*',$'- .*#*/(& 0"$1,'(& 23*(4+,#56- 7(#89- :/, ;(#<(

!"##$%&!"# $%&%'#$#&( )* % +%(,#&( -,(" +),.)&,&' /0# () ,&'#.(,)& )* ("# 1#20,3,(4 5#%& 6)=/%$ 1/*4('"/,%$7,. +3#.#&(#/8 !"# 9:,&,9%: *#%(03#. )* (",. 9%.# ,&9:0/#/ +0:$)&%34 )#/#$% %&/ "4+#3(#&.,)&; (",. "%.&)( 5##& 3#9)3/#/ +3#<,)0.:4 ,& ("# :,(#3%(03# %..)9,%(#/ -,(" 1#20,3,(4 5#%& +),.)&,&'8

'(&)*%+, 3">,4,'98 !"?1&,4(',"#$= "4+#3(#&.,)&8

8888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888888!"//*$1"#8*#4* '"@ !A B*/#(#8"CD?(,&@ 8,/5+<E$&'A&<)44*1'*8@ FG H%#* FIIJ

> ?@A4#%3A):/ 5)4 -%. %/$,((#/ () ("# ,&(#&.,<# 9%3# 0&,(3#20,3,&' ,&(#3$,((#&( +).,(,<# +3#..03# <#&(,:%(,)& 6BCCD7*)3 /30'A3#.,.(%&( +0:$)&%34 )#/#$%8

E# "%/ +3#<,)0.:4 5##& %/$,((#/ () % $#/,9%: -%3/ F "#%3:,#3 -,(" <)$,(,&'G -%(#34 /,%33")#% %&/ 9):,9H4%5/)$,&%: +%,& )* @ " /03%(,)&8 >( ("%( (,$#G "# "%/ %.,&0. (%9"49%3/,% ?FI 5#%(8$,&!?G %3(#3,%: 5:))/ +3#..03#)* ?FJKLJ $$E'G %&/ 5,:%(#3%: 93#+,(%(,)&. %&/ 3")&9",,& ",. :0&' *,#:/.8 E# -%. (3#%(#/ -,(" *30.#$,/# IJ $',&(3%<#&)0.:4G )M4'#& -%. %/$,&,.(#3#/ 0.,&' % :)- *:)-$%.H %&/ &#50:,.#/ .%:50(%$): -%. ',<#& %. "# "%/ %",.()34 )* 9",:/"))/ %.("$%8

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

V& %/$,..,)& () ("# BTUG "# -%. /3)-.4 %&/ .:)- ()3#.+)&/ () 9)$$%&/.8 E,. 3#.+,3%()34 3%(# -%. IJ

53#%("8$,&!?G % "#%3( 3%(# )* ?SJ 5#%(8$,&!?G %3(#3,%:5:))/ +3#..03# %( (",. .(%'# "%/ /#93#%.#/ () WJKIJ $$E'8 VM4'#& .%(03%(,)& 6:%!O7 -%. WOX8 E# -%.,&(05%(#/ 0.,&' % FA$$ (3%9"#%: (05# %&/ <#&(,:%(#/ -,("% (,/%: <):0$# )* @JJ $:G 3#.+,3%()34 3%(# ?O 53#%("8A$,&!? %&/ BB!O -%. J8S8 !"# :%!O ,&93#%.#/ -,("<#&(,:%(,)&G %&/ .")3(:4 %*(#3-%3/. 3#%9"#/ LFX8 R30.#A$,/# ? $'8$,&!? %&/ &,*#/,+,&# J8?S !'8H'!?8$,&!?

-#3# %/$,&,.(#3#/8 B& %//,(,)&G %& ,&*0.,)& )* /)50(%A$,&# -%. 9)$$#&9#/8 B&<#.(,'%(,)&. 3#<#%:#/ % .#30$+)(%..,0$ F8J $$):8:!? %&/ 5:))/ 03#% ?O8F $$):8:!?8Y:))/ '%. %&%:4.,. .")-#/ %& 0&9)$+#&.%(#/ $#(%5):,9%9,/).,. -,(" +E )* W8?LLG 5,9%35)&%(# ?@8S $$):8:!?

%&/ 5%.# #M9#.. )*!?@8I8 V&# "0&/3#/ $,::,:,(3#. )* N8IX.)/,0$ 5,9%35)&%(# -%. %/$,&,.(#3#/G %&/ .05.#20#&(5:))/ '%. %&%:4.,. .")-#/ % +E )* W8ING 5,9%35)&%(# )*OO8@ $$):8:!? %&/ % 5%.# #M9#.. )* J8F8 >:(")0'" % 9"#.(ZA3%4 -%. 3#20#.(#/G ("#3# -%. % /#:%4 %&/ ,( -%. (%H#&N " :%(#3G 54 -",9" (,$# ",. :0&'. -#3# 9:#%38

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

1-&*2/3*2,&4 !""#4 *+4 5&6*2 ##789##8"::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::

© 2015 Rajeshkumar Ganesan and Rajalakshmi Ettiyan. This open access article is distributed under a Creative Commons

Attribution (CC-BY) 3.0 license.

American Journal of Pharmacology and Toxicology

!

Case Reports

Abrus Precatorius Induced Hemorrhagic Colitis

1

Rajeshkumar Ganesan and 2

Rajalakshmi Ettiyan

1

Gastroenterology, Sri Venkateswara Medical College and Research Centre, India

2

Internal Medicine, Indira Gandhi Medical College and Research Institute, India

Article history

Received: 02-07-2015

Revised: 15-07-2015

Accepted: 11-08-2015

Corresponding Author:

Rajeshkumar Ganesan

Gastroenterology, Sri

Venkateswara Medical College

and Research Centre, India

E-mail: [email protected]

Abstract: Abrus Precatorius commonly known as Rosary bead or

Kundumani (Arena, 1986) is an irritant poison affecting almost all major

systems of the body with more damage to the gastrointestinal system. The

mortality rate is 10 to 15% for a lethal dose of just 1-2 crushed seeds.

Following is the case report of hemorrhagic colitis due to the ingestion of a

toxic dose of ABRUS seeds (Reedman et al., 2008). Sigmoidoscopy was

done to document the hemorrhagic colitis. Client was treated as severe

colitis with intra venous antibiotics, intravenous steroids; Oral Mesalamine,

Intra venous Pantaprazole and IV fluids. Despite consuming a large amount

of the toxin, our client survived.

Keywords: Abrus Precatorius, Hemorrhagic Colitis, Severe Colitis

Introduction

abrus Precatorius commonly known as Rosary bead

or Kundumani (Arena, 1986) is an irritant poison

affecting almost all major systems of the body with more

damage to the gastrointestinal system. Oral ingestion of

whole seeds often does not produce serious illness since

the shell protects the toxin from digestion (Shih and

Goldfrank, 1998). The mortality rate is 10 to 15% for a

lethal dose of just 1-2 crushed seeds. The damage is

done by a Toxalbumin called ABRIN concentrated more

in the seeds and released on crushing (Reedman et al.,

2008). Following is the case report of hemorrhagic colitis

due to the ingestion of a toxic dose of ABRUS seeds

(Reedman et al., 2008). Sigmoidoscopy was done to

document the hemorrhagic colitis. Client was treated as

severe colitis with intra venous antibiotics, intravenous

steroids; Oral Mesalamine, Intra venous Pantaprazole

and IV fluids. Despite consuming a large amount of the

toxin, our client survived.

Case Report

A 25 year old female was brought to our casualty

with alleged history of consuming a handful of

crushed Kundumani seeds (Abrus Precatorius) mixed

with water as single intake with suicidal intention

about 10 h back.

On day 1, she had a history of multiple episodes of

vomiting after 3-4 h of ingestion which was not blood

stained. No history of abdominal pain, fever, dyspnoea,

melena and bleeding per rectum at the time of admission.

There was no significant history of any ailments,

substance abuse or medications in the past.

On general examination, she was conscious and

oriented and there were no pallor, Icterus, Cyanosis,

Clubbing, Lymphadenopathy and Pedal edema. Her

vitals were blood pressure-100/70 mm/Hg, Pulse -

62/min which was regular and normal in volume,

Respiratory rate -20 breaths/min and afebrile. On

systemic examination, per abdomen- soft, no tenderness

and normal bowel sounds were heard. Other system

examination was normal.

Stomach wash was given in the casualty till clear

fluid was obtained. Activated charcoal (50 gm) was

given through Ryles tube. Blood sample was taken and

sent for routine investigation. She was started on intra

venous fluids and inj. Pantaprazole and shifted to

intensive care unit for monitoring.

Routine investigation revealed Hemoglobin-12 g%,

Total count-6700 cells/cu.mm, DC -Neutrophils: 77%,

Lymphocytes: 20%, Eosinophils: 03%, Monocytes: 0%,

Basophils: 0%, Hematocrit -34%, Platelet count -1.84

lakhs/cu.mm, Blood group –B-positive, Prothrombin

time -15.2 sec ( control -13.5 s) INR -1.2 sec. Blood

glucose (R) -111 mg dL−1

. Serum Bilirubin: Total -1.0

mg dL−1

, Direct -0.7 mg dL−1

, Indirect -0.3 mg dL−1

,

Total protein -6.0 g%, Albumin -3.7 g%, Globulin -2.3

g%, AST(SGOT) -34 IU/L, ALT (SGPT) -17 IU/L,

ALP- 61 IU/L, Urea-16 mg dL−1

, S. Creatinine -0.6 mg

dL−1

, Sodium (mmol/L)- 137, Potassium(mmol/L)- 3.6,

Chloride (mmol/L)- 106. Urine routine was within

normal limits. Figure 1 showed the Electro cardiogram at

the time of admission.

Clinical Toxicology (2008) 46, 173–175 Copyright © Informa Healthcare USA, Inc.ISSN: 1556-3650 print / 1556-9519 onlineDOI: 10.1080/15563650601185134

LCLTCASE REPORT

An unusual manifestation of Abrus precatorius poisoning: A report of two cases

Abrus precatorius poisoningDHARANIPRAGADA SUBRAHMANYAN, DKS, JOMAL MATHEW, and MITHUN RAJ

Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India

Abrus precatorius seeds are highly toxic and are often ingested as a means of suicide in India. Hemorrhagic gastroenteritis with erosions,hemolysis, acute renal damage, hepatotoxicity with elevated liver enzymes, and seizures are common manifestations of toxicity. We reporttwo cases of Abrus precatorius poisoning with raised intracranial pressure (ICP) and papilledema that have not been described earlier inliterature. One patient recovered completely with conservative management to lower raised ICP while the other patient expired beforeeffective treatment could be institutedd. The cases are being reported to propose the need for routine fundus examination and brain imagingin severe abrus poisoning with CNS toxicity, as early institution of treatment for cerebral edema measures may be life saving.

Keywords Abrus precatorius; Papilledema; Altered sensorium; Seizures

Introduction

Abrus precatorius (rosary pea or jequirity pea) is common tomany tropical areas throughout the world and is sometimesused as an herbal remedy in folk medicine. All parts of theplant are poisonous and the seeds are often ingested as ameans of suicide in our country (although the exact regionalstatistics are lacking). Here we report two cases of Abrusprecatorius poisoning during a two-year period. Both hadevidence of raised intra cranial pressure (ICP) and papille-dema on presentation, which has not been reported earlier inliterature. The cases are being presented to propose the bene-fit of routine fundus examination and brain imaging in severeabrus poisoning.

Case 1

A seventeen-year-old woman presented to our hospital withhistory of eating ten crushed seeds of Abrus precatorius onAugust 11, 2004 following a family quarrel. Within fourhours of consuming the seeds, she developed multipleepisodes of vomiting and presented to our emergency depart-ment. Her vital signs were stable with a pulse rate 100 beats/minute and blood pressure 110/70 mm Hg. Physical examina-tion was unremarkable. Within six hours of consuming the

seeds she was treated with gastric lavage followed byactivated charcoal (50 grams every eight hours), and intrave-nous hydration. Gastric lavage showed crushed remnants ofthe seeds that were identified by their distinctive red outercovering. Further toxicological analysis of the gastriccontents was not done. In hospital she developed loosewatery stools on day two, six to eight episodes per day, asso-ciated with epigastric pain and tenderness that continued untilday 3. On day 4 her diarrhea turned bloody and the abdomi-nal pain worsened. Hydration was maintained and adjusted tomaintain a normal central venous pressure. Intravenousproton pump inhibitors were added to the treatment regimen.She appeared to doing well except for diarrhea, when on day6 she developed altered sensorium in the form of drowsinessand decreased speech output. There was no fever, headache,vomiting, seizures, or ear discharge. Her vitals were stableand she was maintaining adequate hydration. Central nervoussystem examination revealed grade 2 sensorium with Glas-gow coma score of 10. Both pupils were 3 mm and reactive tolight. She was moving her limbs in response to pain and deeptendon reflexes were exaggerated with bilateral extensorplantar response. Detailed motor and sensory examinationcould not be carried out in view of altered sensorium. Therewas no neck stiffness. Her biochemical parameters were nor-mal. Liver enzymes and bilirubin were normal and prothrom-bin time was 16 seconds (control 15 seconds). Anophthalmologic examination at this point revealed bilateralestablished papilledema. Computerized tomography (CT) ofthe brain showed diffuse cerebral edema and featuressuggestive of raised ICP.

Treatment consisted of mannitol, dexamethasone and ace-tazolamide to decrease cerebral edema; ceftriaxone 2 gram

Received 5 September 2006; accepted 21 December 2006.Address correspondence to Mithun Raj, Jawaharlal Institute of

Postgraduate Medical Education and Research (JIPMER),Department of Medicine, Pondicherry 605006, India. E-mail:[email protected]

TOXICOLOGY OBSERVATION

Attempted Suicide, by Mail Order: Abrus precatorius

David H. Jang & Robert S. Hoffman & Lewis S. Nelson

Published online: 19 June 2010# American College of Medical Toxicology 2010

AbstractObjective Abrus precatorius is cultivated in many subtrop-ical areas. The seeds exist in a variety of colors such asblack, orange, and most commonly, glossy red. A blackband is found at the end of the seed. The plant containsmultiple pods which typically contain three to five Abrusseeds. The seeds contain abrin, which inhibits ribosomalfunction, halting protein synthesis and leading to cellulardeath. A unique aspect of this case is the use of the internetto order a potentially lethal poison as well as transmissionof a picture to identify the seed.Case Report A 20-year-old man presented to the emergen-cy department complaining of vomiting and watery diarrheafor 6–8 h prior to arrival. He denied any medication use,recent illness, travel, or changes in his diet. Initial vitalsigns were normal. The patient was diagnosed with viralgastroenteritis. During his evaluation, the patient admittedto feeling suicidal. While awaiting psychiatry evaluation,the patient's father arrived with a box of small hard redseeds, which he believed that his son ingested in a suicideattempt. The seeds could not be identified by the staff. Apicture of the seeds was transmitted by e-mail to the NewYork City Poison Control Center, allowing their identifica-tion as A. precatorius. The patient was reinterviewed andadmitted to chewing and swallowing 10 seeds. Given thepotential toxicity of abrin, the patient was admitted to theintensive care unit. He continued to have frequent episodesof emesis as well as diarrhea. He gradually improved over

2 days. He admitted to ordering a box of Abrus seeds onlinefrom Asia after reading on the Internet about their use insuicide. He was eventually discharged for outpatientfollow-up with no permanent sequelae.Conclusion Abrin has an estimated human fatal dose of0.1–1 μg/kg. Most cases of Abrus seed ingestions areunintentional and occur in children. Ingesting the intactseeds typically results in no clinical findings, as they passthrough the gastrointestinal tract due to their hard shell.Abrin released during chewing is poorly absorbed system-ically from the gastrointestinal tract. This causes thevomiting and diarrhea with resultant hypovolemia andelectrolyte disturbances, which can be severe and lifethreatening, particularly in areas with less advanced healthcare systems. Management is primarily supportive.

Keywords Toxalbumin . Abrus precatorius . Abrin . Ricin .

Rosary pea . Jequirity bean

Introduction

Abrin is a toxalbumin that can be found in the seeds of theAbrus precatorius plant. Abrin is similar in structure andfunction to ricin (Ricinus communis) although consideredeven more potent [1]. Abrin seeds, which are attractivelycolored and can be found in a variety of objects such asornaments and necklaces, are most commonly ingestedunintentionally by children. Occasionally, they are ingestedintentionally for suicidal purposes by people who are awareof their potential toxicity [2]. The primary mechanism ofabrin toxicity involves inhibition of ribosomal proteinsynthesis causing cellular death [9]. While the majority ofpatients with ingestion of Abrus seeds have good outcomeswith supportive care, there are deaths reported in theliterature [12]. Toxalbumins are of interest as they are

D. H. Jang (*) : R. S. Hoffman : L. S. NelsonNew York City Poison Control Center, New York University,New York, NY, USAe-mail: [email protected]

R. S. Hoffmane-mail: [email protected]

J. Med. Toxicol. (2010) 6:427–430DOI 10.1007/s13181-010-0099-1

Clinical Toxicology (2008) 46, 1071–1073 Copyright © Informa UK, Ltd.ISSN: 1556-3650 print / 1556-9519 onlineDOI: 10.1080/15563650802334671

LCLTCASE REPORT

Acute demyelinating encephalitis due to Abrus precatorius poisoning – complete recovery after steroid therapy

Recovery from demyelination due to Abrus is rareRATNAKAR SAHOO, ABDOUL HAMIDE, S. DEEPAK AMALNATH, and B. SRIKANT NARAYANA

Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry 605006, India

Introduction. Poisoning from Abrus precatorius is attributed to a toxalbumin (abrin) that acts by inhibiting protein synthesis and rarely cancause immuno-mediated demyelination. We report a case of abrin poisoning with demyelination. Case report. A 19-year-old manpresented with a history of ingesting crushed Abrus precatorius seeds following a family quarrel. He developed vomiting, abdominal pain,and bloody diarrhea, followed by a seizure and an altered sensorium. Magnetic resonance imaging (MRI) of the brain showeddemyelination in the bilateral-medial temporal lobes. The patient was treated with supportive care, and intravenous methylprednisolonefollowed by oral prednisone, and recovered fully. Discussion. Abrin is an immuno-modulator that may cause immune-mediateddemyelination. We report the clinical course of a patient with demyelination after abrin poisoning, treated with corticosteroids, anddocument his clinical recovery. Conclusion. Demyelination is a rare complication of Abrus precatorius poisoning. In our case, thedemyelination was demonstrated by MRI. Although our patient appeared to recover completely following methylprednisolone therapy, thesuggestion that methylprednisolone or other corticosteroids might be useful in treating this demyelination needs experimental verificationand clinical validation before concluding that it is a beneficial therapy.

Keywords Abrus precatorius; Poisoning; Demyelination; Methylprednisolone

Introduction

Abrus, Castor, Datura, and Oleander seeds are easily accessi-ble in the villages of India. Abrus precatorius is a perennialvine that produces seeds that are believed to have aborti-facient, anodyne, aphrodisiac, antimicrobial, diuretic, emetic,and antirheumatic properties. The seeds are also used to treatdiabetes and chronic nephritis. Abrus precatorius seeds con-tain abrin, a potent lectin, that inactivates ribosomes, inhibit-ing protein synthesis. Central nervous system effects includeraised intracranial pressure, papilledema, convulsions, andcoma. We report here an unusual case of abrin poisoning withacute demyelinating encephalitis.

Case report

A 19-year-old man was admitted to hospital with history ofingesting a handful (10–15) of crushed Abrus precatoriusseeds following an argument with his father. The left over

seeds at the site of ingestion were brought by his parents tothe hospital.

His vital signs were stable with pulse rate 96 beats/minand blood pressure 120/70 mmHg. He was treated withgastric lavage and intravenous fluids. Gastric lavageshowed crushed remnants of seeds that were identified asAbrus precatorius by their distinctive red outer covering.Toxicological analysis of gastric contents was not done.Within 5 h of consuming the seeds, he developed abdomi-nal pain and vomiting. On day 2, he developed initiallywatery diarrhea that became bloody, five to six episodesper day, associated with upper abdominal pain, and ten-derness. Hydration was adjusted to maintain a normalcentral venous pressure, and an intravenous proton pumpinhibitor was started. Clinical findings improved over thefollowing 4 days. On the day 5, he developed repeatedepisodes of generalized tonic–clonic seizures followed byan altered sensorium (drowsiness and reduced speech out-put). There was no fever, headache, or ear discharge. Hisvital signs were stable and he was maintaining goodhydration. He had a Glasgow Coma Scale score of 8. Hewas moving his limbs in response to pain but deep tendonreflexes were exaggerated with extensor planter response.Empirical treatment included intravenous phenytoin,cefotaxime, and metronidazole. There was no improve-ment in sensorium, and he was transferred to anotherhospital on the day 7. In that hospital, computerized

Received 28 April 2008; accepted 9 July 2008.Address correspondence to Ratnakar Sahoo, Department of

Medicine, Jawaharlal Institute of Postgraduate Medical Educationand Research (JIPMER), Pondicherry 605006, India.E-mail: [email protected]

Utilidad de las semillas

Búsqueda exhaustiva: Conclusiones

�  Mayoría de ingestas en adultos son con ideación AUTOLÍTICA.

�  Se encuentran en áreas subtropicales, NO en nuestro medio.

�  Fácil ACCESO de compra por Internet para bisutería. �  TODA la planta venenosa, en especial la SEMILLA. �  La toxina es la “ABRINA”, inhibe la función ribosomal,

alterando la síntesis de proteínas à muerte celular. �  Dosis letal 0.1–1 μg/kg (ínfima)à Necesario

contacto directo. �  Existe un período de latencia de 3 días, los síntomas

pueden persistir hasta 10 DÍAS. �  Existe un 5% DE MORTALIDAD, y suele ocurrir unos 14 días tras la ingesta.

�  Síntomas comunes: Naúseas, vómitos, diarreas, dolor abdominal, hematemesis, melenas.

�  Síntomas graves: IRA, hemaglutinación, hemólisis de GR, hipovolemia, hepatotoxicidad, alteración del estado neurológico, convulsiones, encefalitis aguda desmielinizante, fallo orgánico global.

�  Tratamiento SINTOMÁTICO Y DE SOPORTE: Fluidos iv, corrección electrolítica, transfusión sanguínea.

* Lavado gástrico y antieméticos deben ser utilizados con precaución, debido a la acción necrotizante de la abrina. �  NO hay ANTÍDOTO eficaz.

Búsqueda exhaustiva: Conclusiones

Reinterrogando a nuestra paciente. Ingestión de 3-5 semillas enteras, no trituradas: ◦  Tratamiento sintomático. ◦  No alteraciones analíticas en las 1ªs 30h, salvo leve

alteración de la coagulación.

INGRESO EN MEDICINA INTERNA

◦  Constantes y BMT cada 8 horas. ◦  Control y lavado de deposiciones en busca de las

semillas. ◦  Dieta absoluta. ◦  SF 0,9% 1500ml/24h iv + SG 10% 1500ml/24h iv + ClK

80mEq/24h. ◦  Metoclopramida 10mg/8h, si vómitos. ◦  Nuevo control analítico a las 7am.

Ingreso en Medicina Interna �  No síntomas evidentes. �  Tolerancia oral sin complicaciones. �  Diuresis conservada, no alteración ritmo deposicional. �  Estabilidad analítica. �  No medicación de rescate. �  Valoración por Psiquiatría: Se descarta patología

psiquiátrica. ALTA HOSPITALARIA o  Seguimiento por su médico de Atención Primaria. o  Dieta equilibrada e hidratación abundante. o  Actividad física progresiva. o  No requiere medicación específica.

Utilidad de las nuevas tecnologías.

Plantas más letales del mundo.

Aldefa Cicuta Regaliz Americano

Belladona Higuera infernal

GRÀCIES

Regaliz americano

Health & Medicine

Transcript of Regaliz americano