1. Plant Toxicity

2. Introduction

3. Frequency of Plant Exposure by Plant Type §Capsicum (pepper plant)(5374 exposures) §Philodendron (4061) §Holly (3441) §Euphorbia sp. (poinsettia) (3296) §Dieffenbachia (dumbcane) (2141)

4. Non Toxic Plants §African violetBegonia §Boston fernChristmas cactus §ColeusCorn plant §Crab appleDaisies §DandelionEaster Lilly §HibiscusJade plant §MagnoliaMarigold §PetuniaPrayer plant §Snake plantVelvet plant

5. Toxic Plants §One of the most frequent poisonings reported to poison control centers §69% of plant exposures reported to poison control centers involved children > 6 yrs. §15,000 people a year poisoned by plants §Account for 5-10% of calls to poison control center §Incidence is increasing §Toxicity's can also occur when plants have been treated with herbicides, insecticides or fertilizers

6. Toxic Plants, cont. §Almost any plant can cause nausea, vomiting and intestinal cramping §Not all parts of a plant are always toxic and the toxic principle may be present only during certain times of the year

7. General management of a Plant poisoned patient §Treat all cases of plant ingestion as potentially toxic until shown otherwise §First try and ID the plant, try to get actual plant if possible §Time is on the side of the patient, determine when exposure happened. §Determine how much was ingested. §Call poison control center

8. General management of a Plant poisoned patient §Demulcent therapy - ice cream, milk, egg whites §Observe patient for clinical signs §If indicated induce vomiting - syrup of Ipecac §Activated charcoal should be given §Cathartics hasten removal of remaining material

9. Common Poisonous Plants

10. Arum family §Most common toxic plant exposure reported in the US. And a very common plant in homes and public places §Members of the Arum family: l caladium l dieffenbachia - dumbcane l philodendron §Contain calcium oxalate crystals §Used for variety of purposes: punishing slaves, treating gout, impotence and frigidity

11. Signs, Symptoms and Treatment §Non soluble needle like Ca++ oxylate crystals are found in all parts of the plant, stalk produces most severe reaction §Biting into the plant causes l pain and irritation to the mucous membranes of the mouth and intense salivation l edema when they contact lips, tongue, oral mucosa l choking §Treatment l supportive care and demulcents (milk)

12. Caladium

13. Dumbcane

15. Split leafed Philodendron

16. Christmas plants §American Holly §Mistletoe §Poinsettia

17. American Holly §Berries are toxic, contain Ilicin §Clinical signs l Nausea, severe vomiting, abdominal pain, diarrhea §Treatment - Ipecac, activated charcoal

18. Jerusalem Cherry

19. Mistletoe §Berries are toxic, contain B-phenylethylamine and tyramine §Clinical signs l acute gastroenteritis, cardiovascular collapse, nausea, vomiting, respiratory difficulty, delirium, hallucinations, death §Treatment - Ipecac, activated charcoal, transport

20. Poinsettia §Non toxic §contains a latex sap which can be slightly irritating to mucous membranes §Treatment - give demulcents

21. Poinsettia

22. Cardiotoxic Plants §Contain cardiac glycosides §Oleander §Azaleas §Lilly of the valley

23. Cardiotoxic plants §First used by Egyptians as emetics and for heart aliments §Toxicity occurs usually after consuming teas or consuming parts of the plant §More than 200 naturally occurring cardiac glycosides have been Ided. §Mech of Action - bind to cell membrane and inhibit the Na/K pump.

24. Cardiotoxic plants §Clinical signs: l tachycardia l V fib §Toxic exposure is rare §AAPCC reports in 1998 - 2,553 exposures (out of 2.24 million exposures to toxic substances) §Mortality is rare - 1998 AAPCC reported one death §Most common age of exposure is children under the age of 6 years (72.5% of exposures)

25. Oleander §Very toxic plant, common ornamental §Clinical signs l GIT irritation, vomiting, abdominal pain, diarrhea, hyperkalemia, AV block, cardiogenic shock §Treatment - Ipecac, activated charcoal, transport

26. Oleander

30. Azaleas §Rhododendron, Bird of paradise §contain andromedotoxin §Treatment - Ipecac, activated charcoal, transport

31. Azaleas

33. Castor Bean

34. Castor bean §Contain phytotoxins - ricin - inactivated by heat during the production of castor oil §seeds are the most toxic part of the plant, 2-4 seeds could be fatal in adult §Clinical signs l nausea, violent vomiting and diarrhea, burning sensation in the mouth, hemolysis, renal failure, death §Treatment - Ipecac, activated charcoal, transport

35. Castor bean

36. Castor Bean

37. Castor Bean

38. Rhubarb

39. §Leaves are toxic, contain oxalic acid, heating does not destroy the toxic principle §Stems are edible §Clinical signs l abdominal pain, vomiting, diarrhea, headache, muscle cramps, tetany, renal failure §Treatment - Ipecac, activated charcoal, transport

40. Rhubarb

41. Rhubarb, stem

42. Rhubarb

43. Rhubarb, flowers

44. Jimsonweed Datura stramonium

45. Jimsonweed Toxicity §Plant alkaloids are metabolites that have a nitrogen containing chemical ring §This plant has a history of hallucinogenic use and has been connected to sorcery, witchcraft and native medicine dating back to 1500 BC §Marc Anthony’s military troops were neutralized and defeated after ingesting this plant §318 cases reported to AAPCC with 2 deaths §Toxicity manifests as classic anticholinergic posioning

46. Jimsonweed Toxicity §toxic agents - solanaceous alkaloids, atropine, hyoscyamine and scopolamine §highest concentration of active agents is in the seeds (0.1 mg atropine per seed) §As little as 1/2 tsp. of seeds has caused death from pulmonary arrest §handling the seeds or leaves and rubbing the eyes can cause mydriasis §Seeds can be made into a tea §Reports of smoking the leaves of the plant

47. Jimsonweed toxicity, cont. §Clinical features: l tachycardia, dry flushed skin, dry mucous membranes, mydriasis, blurred vision, hyperpyrexia, urinary retention, confusion, disorientation, loss of short term memory, ataxia, visual and auditory hallucinations, psychosis, death

48. Jimsonweed toxicity, cont. §“Mad as a hatter, red as a beet, dry as a bone, blind as a bat and hot as a hare” §Treatment l maintain airway l transport l do not induce vomiting and defer administration of activated charcoal unless prolonged transport time is anticipated

49. Jimsonweed, thorn apple, angel’s trumpet

50. Jimsonweed, flowers

51. Jimsonweed, seed pod

52. Pokeweed

53. §AKA Inkberry, pigeonberry §Roots and leaves are the most toxic, fruit is mildly toxic §Toxic principle is a resinous material and a water soluble saponin

54. Poke weed §Clinical signs l produces a burning sensation in the mouth, GI cramps, vomiting, diarrhea, visual disturbances, diaphoresis, salivation, prostration, can be fatal §To prepare pokeweed your must boil the leaves twice to remove the toxic principle §Treatment - Ipecac, activated charcoal, transport

55. Pokeweed, Ink berries

57. Pokeweed

59. Toxicodendron

60. Poison Ivy §All portions of the plant, even the smoke from burning leaves §Toxic principle - an oily oleoresin called urushiol §Urushiol can be transmitted from person to person or other vehicles by direct contact

61. Poison Ivy §50-70% of US population is susceptible §Poison ivy east of the Rockies, poison oak west and poison sumac in the south east. §Clinical signs l severe allergic contact dermatitis 12-24 hours post exposure, blistering, inflammation, and vesicle formation l Urushiol penetrates skin and binds to membrane lipids within 10-20 minutes of exposure

62. Poison Ivy, cont. §Treatment: l avoid contact, wash affected area with soap and rinse with alcohol, repeat l 2 tbsp. Epsom’s salt/cup of water, sponge onto the affected area and allow to dry, 2-3 times/day l Electronic itch stopper l Tecnu cleanser l corticosteroids, topically and orally l histamine blockers

64. Poison Ivy, cont. §Treatment: cont. l calamine lotion l zinc oxide ointment l baking soda paste (one tablespoon of baking soda to one teaspoon of water) l baths in oatmeal soap or medicated oatmeal based products like Avenno. l Zanfel - binds to urushiol l Ivy Block - a pre-exposure preventative

66. Poison Ivy, cont. §Treatment: cont. l If you were exposed to the smoke of burning poison ivy, oak or sumac and you believe you may have breathed in the fumes, you need to seek medical treatment immediately. l Some people can have life threatening reactions from inhaling urushiol vapors into their lungs. In some states, it is illegal to burn poison ivy due to the health risks it represents.

68. Toxicodendron, Poison Ivy

69. Poison Ivy “Leaflets of three, let it be”

70. Poison Ivy

74. §Other urushiol containing plants: l cashew nut shells - exposure to unroasted cashew nut shells can cause a reaction, roasting inactivates the allergen. l mango tree - mango fruit skin can cause reactions in sensitive individuals l ginkgo tree

75. Mushroom Toxicity

76. Mushroom toxicity §1999 AAPCC reported 8996 mushroom exposures, 2930 treated in a hospital and 6 fatalities §5976 of these ingestions were in children > 6 years §Amanitin phalloides accounts for 90-95% of all fatalities from mushroom poisoning in North America

77. Mushroom toxicity §Never eat any wild mushroom §Etiology - consumption of raw or cooked mushrooms/toadstools §Cooking, canning or freezing WILL NOT render toxic mushrooms non toxic §Clinical Syndromes - usually acute onset of signs and symptoms

78. Categories of Mushroom Toxicity §I) Protoplasmic poisons - destruction of cells §Signs and Symptoms l Stage I - first 6-24 hrs., severe abdominal pain, severe diarrhea l Stage II - 24-48 hrs., apparent recovery, cellular destruction is occurring in the kidney and liver l Stage III - 3-5 days post ingestion, liver and kidney failure, death can occur 4-7 days post ingestion §Treatment - induce vomiting, transport

79. Examples of Mushrooms which cause protoplasmic poisoning

80. Amanita phalloides §Contain a mixture of heat stable cyclopeptides including: l phalloidin l phalloin l amatoxin - accounts for the lethality

81. Amanita phalloides

83. Categories of Mushroom Toxicity, cont. §II) Neurotoxins l contain compounds which cause neurological signs and symptoms, convulsions, hallucinations, excitation, depression, spastic colon.

84. Examples of Mushrooms which cause Neurologic signs and symptoms

85. Amanita muscarina

86. Inocybe sp.

90. Psilocybe sp.

92. Categories of Mushroom Toxicity, cont. §III) Gastrointestinal irritants l cause nausea, vomiting, abdominal cramping, diarrhea §Examples: green gill, gray pink gill, etc.

93. Green gill §These large, common mushrooms often appear in fairy rings on suburban lawns, commonly called toadstools. §They cause violent gastrointestinal upset. §Is parasol-shaped and has a cream or tan, scaly cap, a large ring on the stem and cream-colored gills which turn dingy green with age.

94. Green gill, cont. §As its name suggests, it is the only mushroom with a greenish spore print. Size 4" to 12" tall, 2" to 12" in diameter. §This mushroom is found in summer and fall, on the ground in lawns, pastures and meadows.

95. Green gill, green spored

96. Categories of Mushroom Toxicity, cont. §IV) Disulfiram-like compounds l generally non toxic and produce no clinical signs unless alcohol is consumed within 72 hours of eating them. §Example - inky cap mushroom

97. Inky cap mushroom

98. Diagnosis of Human toxicity §Clinical testing §History §Outbreaks are not very common §Usually isolated cases - seen in people who go out picking mushrooms §Patient management - induce vomiting, give activated charcoal, seek medical help