Datura stramonium Poisoning: Misunderstanding and Misidentification in Toxic Plant Exposures

Toxic plant exposures have increased in recent years, creating health concerns, particularly for nature adventurers and outdoor enthusiasts.1Cornara L. Smeriglio A. Frigerio J. Labra M. Di Gristina E. Denaro M. et al.The problem of misidentification between edible and poisonous wild plants: reports from the Mediterranean area.Food Chem Toxicol. 2018; 119: 112-121Crossref PubMed Scopus (12) Google Scholar Urbanization and city sprawl resulting in marginalization of human populations has caused some inhabitants to explore the surrounding environment and look for new tastes and flavors, leading to the growing popularity of camping and increased exposure to unidentified toxic plants.1Cornara L. Smeriglio A. Frigerio J. Labra M. Di Gristina E. Denaro M. et al.The problem of misidentification between edible and poisonous wild plants: reports from the Mediterranean area.Food Chem Toxicol. 2018; 119: 112-121Crossref PubMed Scopus (12) Google Scholar,2Manescu C.R. Dobrescu E. Nujnoi S. Toma F. Petra S. Toxic plant species in parks located in city centre of Bucharest.Scientific Papers. Series B, Horticulture. 2019; LXIIIGoogle Scholar Poisonous species are better known by the rural population, whereas urban inhabitants have had few opportunities to explore nature and to identify plants.2Manescu C.R. Dobrescu E. Nujnoi S. Toma F. Petra S. Toxic plant species in parks located in city centre of Bucharest.Scientific Papers. Series B, Horticulture. 2019; LXIIIGoogle Scholar Accordingly, erroneous beliefs and identification mistakes contribute to intentional or accidental clinically significant toxicity. Datura stramonium (also known as jimson weed) is regarded as an example for misunderstanding and misidentification in toxic plant exposure. It grows abundantly in temperate and subtropical regions across the world, including Europe, North America, north Africa, and eastern and southwestern Asia.3Krenzelok E.P. Aspects of Datura poisoning and treatment.Clin Toxicol (Phila). 2010; 48: 104-110Crossref PubMed Scopus (49) Google Scholar A 52-y-old male presented to our emergency department with agitation, headache, nausea, ataxia, and visual hallucinations. Family members revealed that he had ingested the seeds of an unknown plant. His vital signs were as follows: temperature 38°C, heart rate 120 beats·min-1, respiratory rate 20 breaths·min-1, and blood pressure 138/85 mm Hg. Face flushing was visible on physical examination. The patient’s wife brought the offending plant, which was identified as D stramonium (Figure 1). He was treated with sedatives (diazepam 2 mg intravenously and haloperidol 5 mg intramuscularly), rehydrated with an infusion of 3000 mL of normal saline 0.9% over 24 h, and underwent cardiac monitoring. Physostigmine was not administered because its use is reserved for seizure or combative behavior. After uneventful close observation, the patient recovered sufficiently to be alert and able to answer questions. He stated that he had ingested approximately 5 mL (1 tsp) of the seeds of the plant’s thorny fruit, which tasted bitter and prompted him to vomit a substantial amount. When asked why he ingested an unknown plant, he reported that when he sliced the green pod of the plant, he observed the diffuse tiny dark brown seeds inside the seedpod and mistook them for edible opium poppy seeds (Papaver somniferum), which his parents used to use as condiments for cookery and pastries at home (Figure 2). This scenario is just one example of toxic plant exposures encountered each year in our department. Our city encompasses a traditional community that has faced a rapid urban growth in recent years. Although the majority of plant exposures exert low toxicity and the patients are discharged with full recovery after the required treatment and observation, misinformation surrounding edible plants exists and thus deserves reporting. The present case presents misidentification leading to intoxication. We have had experience dealing with admitted cases involving misidentification of Ricinus communis and Caesalpinia gilliesii as edible beans and Amanita phalloides as edible mushrooms.4Mirakbari S.M. Shirazi M.H. Poisoning with tasty and sweet seed pods of bird of paradise plant Caesalpinia gilliessii.Wilderness Environ Med. 2019; 30: 99-100Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar However, this is the first time we have seen a confusion of D stramonium with edible opium poppy seeds. Furthermore, we could not find any cases of this in the literature. In addition, there are unfortunate misunderstandings regarding D stramonium that lead some individuals to voluntarily consume the plant’s seeds. Ingesting the seeds can result in euphoric, psychoactive, and deliriant effects, which has been used by those participating in religious ceremonies or seeking stimulation. The seeds have also been used for therapy for asthma, parkinsonism, and chronic abuse in an attempt to decrease unwanted psychiatric symptoms.5Taha S.A. Mahdi A.H. Datura intoxication in Riyadh.Trans R Soc Trop Med Hyg. 1984; 78: 134-135Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 6Bouziri A. Hamdi A. Borgi A. Hadj S.B. Fitouri Z. Menif K. et al.Datura stramonium L. poisoning in a geophagous child: a case report.Int J Emerg Med. 2011; 4: 31Crossref PubMed Scopus (17) Google Scholar, 7Amini M. Khosrojerdi H. Afshari R. Acute Datura stramonium poisoning in east of Iran—a case series.Avicenna J Phytomed. 2012; 2: 86-89PubMed Google Scholar, 8Khanra S. Khess C.R. Srivastava N. Chronic nonfatal Datura abuse in a patient of paranoid schizophrenia: a case report.Addict Behav. 2015; 43: 39-41Crossref PubMed Scopus (8) Google Scholar D stramonium poisoning may also occur accidentally in curious children who consume it.2Manescu C.R. Dobrescu E. Nujnoi S. Toma F. Petra S. Toxic plant species in parks located in city centre of Bucharest.Scientific Papers. Series B, Horticulture. 2019; LXIIIGoogle Scholar,7Amini M. Khosrojerdi H. Afshari R. Acute Datura stramonium poisoning in east of Iran—a case series.Avicenna J Phytomed. 2012; 2: 86-89PubMed Google Scholar One case report presented a family in which 3 members were accidentally intoxicated after eating a Turkish meal of dolma made with D stramonium flowers misidentified as food ingredients.9Disel N.R. Yilmaz M. Kekec Z. Karanlik M. Poisoned after dinner: dolma with Datura stramonium.Turk J Emerg Med. 2016; 15: 51-55Crossref PubMed Scopus (11) Google Scholar Anticholinergic toxicity may occur after consuming any part of the D stramonium owing to the presence of up to 28 belladonna alkaloids, including atropine, scopolamine, and hyoscyamine.3Krenzelok E.P. Aspects of Datura poisoning and treatment.Clin Toxicol (Phila). 2010; 48: 104-110Crossref PubMed Scopus (49) Google Scholar,7Amini M. Khosrojerdi H. Afshari R. Acute Datura stramonium poisoning in east of Iran—a case series.Avicenna J Phytomed. 2012; 2: 86-89PubMed Google Scholar Patients with agitated behavior should seek medical help.10Glatstein M.M. Alabdulrazzaq F. Garcia-Bournissen F. Scolnik D. Use of physostigmine for hallucinogenic plant poisoning in a teenager: case report and review of the literature.Am J Ther. 2012; 19: 384-388Crossref PubMed Scopus (20) Google Scholar Supportive care and hydration may be necessary. Benzodiazepines are recommended to manage minor toxicity issues.3Krenzelok E.P. Aspects of Datura poisoning and treatment.Clin Toxicol (Phila). 2010; 48: 104-110Crossref PubMed Scopus (49) Google Scholar,11Rodgers Jr., G.C. Von Kanel R.L. Conservative treatment of jimsonweed ingestion.Vet Hum Toxicol. 1993; 35: 32-33PubMed Google Scholar Haloperidol is usually well tolerated and is used for sedation.11Rodgers Jr., G.C. Von Kanel R.L. Conservative treatment of jimsonweed ingestion.Vet Hum Toxicol. 1993; 35: 32-33PubMed Google Scholar Physostigmine, a short-acting anticholinesterase inhibitor, is indicated for cases with seizures, severe hypertension, severe hallucinations, and life-threatening arrhythmias.10Glatstein M.M. Alabdulrazzaq F. Garcia-Bournissen F. Scolnik D. Use of physostigmine for hallucinogenic plant poisoning in a teenager: case report and review of the literature.Am J Ther. 2012; 19: 384-388Crossref PubMed Scopus (20) Google Scholar A 10-y retrospective cohort study demonstrated that physostigmine improves anticholinergic delirium owing to different causative anticholinergic agents in a majority of patients and has few adverse events if doses <2 mg are used; however, intoxication from anticholinergic plants may be less responsive to physostigmine therapy.12Arens A.M. Shah K. Al-Abri S. Olson K.R. Kearney T. Safety and effectiveness of physostigmine: a 10-year retrospective review.Clin Toxicol (Phila). 2018; 56: 101-107Crossref PubMed Scopus (17) Google Scholar Many clinicians would consider the use of physostigmine for severe agitated delirium in the context of anticholinergic toxicity that would necessitate high-acuity care.13Dawson A.H. Buckley N.A. Pharmacological management of anticholinergic delirium—theory, evidence and practice.Br J Clin Pharmacol. 2016; 81: 516-524Crossref PubMed Scopus (46) Google Scholar We think that in urban and highly populated areas, where people have little information about the nature of toxic plants, municipal officials should limit the availability of the plants by taking various actions, such as pruning toxic plants, cleaning fallen fruits, and using nontoxic flowers and shrubs for beds, unless sufficient warnings and notice are provided. Furthermore, prior to ingestion or exposure, a digital picture of a potentially toxic plant should be taken and sent to the regional poison control center for proper identification.