World J Emerg Med, Vol 8, No 4, 2017 297

Case Letter

Anticholinergic syndrome induced by toxic plants

Stergios Soulaidopoulos, Emmanouil Sinakos, Despoina Dimopoulou, Christos Vettas, Evangelos Cholongitas,
Alexandros Garyfallos
Fourth Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of
Thessaloniki, Thessaloniki, Greece
Corresponding Author: Stergios Soulaidopoulos, Email: [email protected]

World J Emerg Med 2017;8(4):297–301

DOI: 10.5847/wjem.j.1920–8642.2017.04.009

Dear editor, used in humans for medical and religious purposes.[4–6]

Plant intoxication constitutes an issue of great Intoxication can occur as a result of accidental ingestion,
interest in the literature, concerning both human and especially regarding children poisoning.[7, 8] However,
animal poisoning. Different herbs may produce multiple the majority of the reported cases, concern intoxication
effects from human organ systems, depending on specific following deliberate use of halluciniogenic substances
ingredients and metabolites that they contain. These effects or overdose in medical use.[9–12] The high concentration
may vary from gastroenteritis, hepatotoxicity, peripheral of these plants in tropane alkaloids, such as atropine,
neuropathy, psychosis, rhabdomyolysis and blood count scopolamine, and hyoscine, induces a pronounced
abnormalities to cardiotoxicity and multisystemic organ anticholinergic toxicity, characterized by both central
failure.[1,2] The ingestion of particular plants may induce and peripheral nervous system clinical manifestations.
an anticholinergic syndrome which is caused by their The onset of symptoms is dose-dependent and includes
alkaloid metabolites (Table 1). This consists of typical ataxia, disorientation, short-term memory loss, confusion,
clinical manifestations including altered mental status, hallucinations, psychosis, agitated delirium, seizures,
hallucinations, mydriasis and tachycardia.[3] The class of coma, respiratory failure and cardiovascular collapse.[13]
plants that cause anticholinergic manifestations includes Furthermore, clinical signs due to peripheral blockage
those that belong to the Solanaceae family, with Atropa of the parasympathetic postganglionic muscarinic
Belladona and Datura Stramonium being the most receptors, such as mydriasis with cycloplegia, dry mucous
common among them. membranes, hyperreflexia, flushed skin, urinary retention,
Atropa Belladona and Datura Stramonium are known diminished bowel sounds, tachycardia, and hypertension
for hundreds of years for their hallucinogenic effect. or hypotension, may also be present.[3] As these findings
They are easily found all around the world and have been can mimic several clinical entities, including severe
central nervous system damage, the early diagnosis of
plant intoxication may be crucial for the management of
Table 1. Plants inducing anticholinergic syndrome these patients.
Plants Plant-induced anticholinergic syndrome We report three cases of accidental plant intoxication
Solanaceae family Mandragora officinarum (Mandrake)
that presented with anticholinergic manifestations and we
Mandragora autumnalis (Devil's herb)
Henbanespp (Hyoscyamusniger/reticulatus) then discuss the treatment options for these conditions.
Burgmansia spp. (Angel's Trumpet )
Datura spp. (Datura inoxia ''Moonflower'', Datura
stramonium ''Jimsonweed'', Datura metel ''Devil's
trumpet'') CASES 1 and 2
Solanum erianthum An 82-year-old woman and her 86-year-old husband
Garryaceae family Garrya spp.
Bignoniaceae family Campsis grandiflora presented to the emergency department due to acute onset
Papaveraceae family Lamprocapnosspectabilis (bleeding heart) of discount consciousness, hallucinations, excitation and
Aquifoliaceae family Ilex paraguariensis (Herba mate) delirium occurring within the previous hour. Both of

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them had accidentally consumed the foliage of Datura to his medication to control the symptoms. Finally, all
Stramonium along with other non-cultivated plants his neurologic manifestations resolved and he was also
which they had collected from a neighboring field. The discharged in good clinical condition.
precise amount of the consumed plant was not possible
to be estimated. They were both transferred immediately
to the hospital after found fallen to the ground by their CASE 3
familiars in an estimated time of one hour after lunch. A 62-year-old man presented to the emergency
On physical examination both patients had normal vital department due to signs and symptoms of delirium,
signs except for mild tachycardia (approximately 90 memory and consciousness disorders. His weight was
pulses per minute). Glasgow Coma Scale was 9 and 10, 86 kg and his medical history was significant for arterial
respectively. Both patients were disoriented, agitated, hypertension. His symptoms began twelve hours prior
making purposeless movements with irrepressible to his admission to our hospital when he complained
speech and hallucinations. Pupils were widely dilated for nausea, weakness and headache. A clinical diagnosis
and not responding to light in both patients, as well. of stroke had been previously made in a local medical
In addition, abdominal examination revealed urinary facility. Subsequently, the patient was transferred to our
retention and lessening intestinal peristalsis without hospital due to constant deterioration of his condition.
abdominal distension, again in both of them. The 82- On clinical examination high blood pressure (180/90),
year-old woman, weighting 67 kg, had a medical history sinus node tachycardia (115 beats/minute) and fever (38 °C)
of arterial hypertension and atrial fibrillation while in her were detected. The remaining physical examination was
86-year-old hausband, weighting 81 kg, medical history normal. Of note, cervical stiffness was absent, but bilateral
was significant for heart failure due to coronary artery mydriasis was noted. The patient was confused, agitated,
disease, diabetes and benign prostatic hyperplasia. and had both memory and self-orientation disorders. He
Both patients were initially managed in the emergency presented with a confused speech having an estimated
room with gastric lavage, infusing 200 mL of normal Glasgow coma scale of 13. No signs of pyramidal
saline and aspirating back through a nasogastric tube, damage were found.
repeating it until the returning fluid showed no further A CT scan of the brain was performed to exclude
gastric contents. Subsequently, 80 g of activated charcoal ischemia, intracerebral hemorrhage and brain edema.
where administered via the nasogastric tube and a Due to the fact that disorientation was combined with
bladder catheterization was performed to avoid urinary headache and fever, a lumbar puncture was decided to
retention. After 30 minutes, they were transferred to the exclude a central nervous system infection, although
Internal Medicine ward where they stayed for a total of there were no clear signs of meningeal irritation. A
four days. Laboratory results had no major abnormalities. thorough physical examination, chest X-rays and urine
A computed tomography (CT) of the brain was performed analysis did not reveal any signs of infection. Serum
to exclude acute stroke or other brain damage. laboratory values were within normal limits, as well. He
Intravenous fluids (normal saline and dextrose 5% water was treated with intravenous fluids and paracetamol.
solution), diazepam 5 mg i.v. twice in the first 24 hours of His clinical course was uneventful with quick
hospitalization and haloperidol 5 mg i.v. three times a day improvement of his mental and physical status from the
were administered to control the patients' manifestations. second day of hospitalization, although mydriasis persisted
Symptoms resolved gradually in both patients with for a longer period of time. There was no need for antibiotic
no serious sequleae. The wife had an improvement treatment due to the non-persistent character of the fever.
in her status of consciousness, with disappearance He was discharged after seven days in apparently good
of hallucinations tachycardia and agitation on the clinical condition. Detailed history taking revealed that the
second day of hospitalization, although, she remained patient had consumed a rather small amount of unknown
disoriented. During the following days she showed fruits and herbals, ignoring the possibility of poisoning,
a gradual improvement with total restoration of during an excursion the day his symptoms began. As
consciousness. The bladder catheter was removed and samples of these herbals were available, an analysis
she was discharged home in good clinical condition. was performed to identify the exact species. Atropa
The husband had a similar clinical course although he Belladonna, a plant with known anticholinergic properties,
remained confused and disoriented for a longer period was confirmed to have been ingested and thought to be
of time. Quetiapine, 25 mg twice a day, had to be added responsible for the confronting clinical syndrome.

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DISCUSSION Stramonium, a plant that exists in abundance in Greece.

Solanceae family constitutes a large, widespread group Atropa belladonna, another widely known member of
of plant species with a remarkable high concentration the Solonseae family, was confirmed after chemical analysis
of alkaloids, which are secondary metabolic products as the cause of the anticholinergic intoxication in our third
that form a defense mechanism against insects, predator case. This plant is also known as "deadly nightshade" and
and disease.[14] Alkaloids are pharmacologically active, has a long history of use as a pharmaceutical cosmetic
nitrogen-containing compounds that are divided in or deleterious agent (Figure 2). Both the foliage and the
several subgroups. An important subgroup of alkaloids, berries of the plant are extremely toxic due to their high
commonly found in plants of the Solonceae family, is concentration in tropane alkaloids.[20] The risk of poisoning
tropane alkaloids. They typically have anticholinergic is important as the berries of the plant are black, globular
and anesthetic properties.[15] Atropine, hyoscyamine and and sweet and may be easily confused with other edible
scopolamine are the most important and extensively studied berries. Remarkably, Atropa Belladonna intoxication
members of tropane alkaloids. All these substances are may lead to liver function impairment besides its
found in high concentrations in both Datura Stramonium anticholinergic syndrome.[21] However, cases of Atropa
and AtropaBelladona. Their properties arise from the Belladonna intoxication are relatively infrequently
competitive binding to central nervous system and reported in the literature.
parasympathetic postganglionic muscarinic receptors In all of our cases, symptomatic treatment was
which ultimately lead to several clinical manifestations.[16] given to the patients. As soon as the diagnosis of tropane
Datura Stramonium, also known as "Jimson weed" intoxication through plant digestion was suspected,
and "Angel's trumpet", probably represents one of the nasogastric lavage was performed according to published
most commonly encountered plants containing tropane recommendations. [22] Gastric lavage and activated
alkaloids. It consists of coarse toothed leaves, trumpet charcoal may prove to be useful in the first 24 hours after
shaped flowers with white pale violet colored petals and plant digestion, as they prevent the prolonged alkaloid
fruits consisting of spiny egg-shaped capsules (Figure absorption due to decreased gastric motility. Intubation
1). Historically, Datura has been used for spiritual should be considered before performing gastric lavage,
purposes, due to its hallucinogenic properties, as well as in those cases with great loss of consciousness, unable
in traditional medicine to treat asthma and relief pain. All to protect their airway. In addition, close hemodynamic
of its parts may become toxic due to their high in tropane monitoring was performed and intravenous fluids
alkaloids. It is estimated that the average concentration were administered in order to avoid sudden circulatory
of atropine and scopolamine is 0.20 and 0.65 mg per collapse in all of our cases. There was no need to
blossom, respectively.[11] Several reports in the literature provide respiratory support. However, maintenance
describe different aspects of the anticholinergic syndrome of airway patency must be secured in the more severe
concerning adult, children and animal intoxication.[17–19] cases of anticholinergic syndrome, as these result in loss
Regarding our first two cases, Datura Stramonium was of consciousness. Finally, it must be highlighted that
confirmed as the etiology of their clinical syndrome as bladder catheterization should always be considered as a
no other causes were identified and the patients reported measure for urinary retention management.
eating plants that had similar appearance to Datura It has to be mentioned that anticholinergic syndrome,

Figure 1. Datura Stramonium. Figure 2. Atropa belladonna.

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due to its central nervous manifestations, may mimic our first two cases, physostigmine was deferred and was
other central nervous system disorders. These have to considered only as a salvage treatment. Finally, in the third
be always excluded as the diagnosis of tropane alkaloid case there was no need for physostigmine at all due to the
toxicity is usually based on medical history. Further low delirium severity and the immediate improvement of
investigation may be needed to exclude other clinical the patient's clinical situation.
entities. Therefore, a brain CT scan was performed in
all of our cases to confirm the suspected diagnosis and
exclude an alternative diagnosis that could explain the CONCLUSION
clinical syndrome of our patients. A lumbar puncture Intoxication by poisonous plants containing tropane
also excluded a central nervous system infection in case alkaloids may constitute a real medical emergency,
3. Fever was finally attributed to a rather clinically non- presenting difficulties in early diagnosis and management.
significant, short-term infection, unable to be specified Physicians should be aware of plant intoxication whenever
by laboratory and imaging methods. acute onset of consciousness alterations is combined with
Sedatives are recommended for the supportive signs of anticholinergic toxicity and a medical history of
management of tropane alkaloid intoxication,[23] whereas vegetal abuse or digestion. Finally, public education
benzodiazepine administration is recommended for those about the possibility of serious and fatal poisoning by
patients whose predominant symptom is mild to moderate hallucinogenic or unknown herbs is of great importance.
agitation.[24] However, it has to be noted that escalating doses
of benzodiazepines enhance the risk of intubation.[25] Severe
delirium or difficulty in the management of agitation could Funding: None.
also be treated with antipsychotic drugs in low doses, such as Ethical approval: Not needed.
haloperidol and droperidol. In such cases, patients should be Conflicts of interest: The authors have no financial or other conflicts
of interest related to the submitted article to declare.
always monitored for QT prolongation.[26,27] In the second Contributors: Soulaidopoulos S proposed the study and wrote the
case of our series, we added low doses of quetiapine to first draft. All authors read and approved the final version of the paper.
the patient's treatment (benzodiazepines), which proved
to be more effective in the management of his psychiatric
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