Poisoning by Plants

Background: Questions on poisoning by plants are a common reason for inquiries to poison information centers (PIC). Over the years 2011–2020, plant poisoning was the subject of 15% of all inquiries to the joint poison information center in Erfurt, Germany (Gemeinsames Giftinformationszentrum Erfurt, GGIZ) that concerned poisoning in children (2.3% in adults). In this patient collective, plant poisoning occupied third place after medical drugs (32%) and chemical substances (24%), and was a more common subject of inquiry than mushroom poisoning (1.5%).

Methods: This review is based on pertinent publications retrieved by a selective literature search in PubMed/TOXLINE on plant poisoning and on 12 epidemiologically and toxicologically relevant domestic species of poisonous plants in risk categories 2 and 3 (up to 2021).

Results: Medical personnel should have basic toxicological knowledge of the following highly poisonous plants: wolfsbane (aconitum), belladonna, angel’s trumpet, cowbane (cicuta virosa), autumn crocus, hemlock, jimson weed, henbane, castor bean (ricinus), false hellebore, foxglove (digitalis), and European yew. The intoxication is evaluated on the basis of a structured history (the “w” questions) and the clinical manifestations (e.g., toxidromes). Special analysis is generally not readily available and often expensive and time-consuming. In case of poisoning, a poison information center should be contacted for plant identification, risk assessment, and treatment recommendations. Specimens of plant components and vomit should be obtained, if possible, for further testing. Measures for the elimination of the poisonous substance may be indicated after a risk–benefit analysis. Specific antidotes are available for only a few types of plant poisoning, e.g., physostigmine for tropane alkaloid poisoning or digitalis antibodies for foxglove poisoning. The treatment is usually symptomatic and only rarely evidence-based. Individualized medical surveillance is recommended after the ingestion of large or unknown quantities of poisonous plant components.

Conclusion: The clinician should be able to recognize dangerous domestic species of poisonous plants, take appropriate initial measures, and avoid overdiagnosis and overtreatment. To improve patient care, systematic epidemiological and clinical studies are needed.

A national monitoring system for poisonings has not been implemented in Germany as yet; for this reason, epidemiological data are often incomplete. Nevertheless, the analysis of individual datasets is helpful, since questions on poisoning by plants are a common reason for inquiries to poison information centers (PIC) (1). In the period 2011–2020, 15% of all inquiries to the joint PIC (Gemeinsames Giftinformationszentrum, GGIZ) in Erfurt, Germany, concerning children related to plants (adults: 2.3%). In this patient collective, plant poisoning came third after medical drugs (32%) and chemical substances (24%), and was a more common subject of inquiry than mushrooms (1.5%) (1). Similar data are available for other European countries such as Switzerland (2020: drugs 34.8%, household products/chemicals 26.3%, plants 10%, mushrooms 1.7%—for all age groups) (2).

A recent study at the GGIZ showed that in particular children aged 1–6 years were exposed to plants with fruit-like structures (for example, berries, capsules, pods, stone fruits) in the period 2010–2019 (of a total of 7607 relevant fruit plant inquiries, 5284 [69.5%] related to young children) (3). According to the German Federal Statistical Office, a total of 263 patients were treated as inpatients in 2019 following exposure to toxic plants (ICD-10: T62.2) or berries (T62.1), of which 95 were children aged 1–4 years (4).

Although life-threatening plant poisonings are relatively rare in Germany (for example, 39 cases in 2010–19 in the GGIZ catchment area, unpublished data), there is a considerable need for information and education on the broad population level.

This review presents a selection of native poisonous plant species (3, 5, 6, 7). It also provides information relating to the diagnosis and treatment of plant poisonings.

Method and data basis

A selective literature search was carried out in PubMed/TOXLINE using the search terms (plants) AND (poisoning OR intoxication), (fruits OR berries OR seeds OR leaves OR roots) AND (poisoning OR intoxication), and regarding 12 poisonous plant species (Figure, Table 1, eTable 1) with English-language and botanical names up to publication year 2021. Selection criteria included epidemiological relevance (frequency of inquiries to the GGIZ, severe poisonings, fatalities) and high risk assessment by the German Federal Institute for Risk Assessment (Bundesinstitut für Risikobewertung, BfR) (5, 6, 7). A total of 12 poisonous plants in risk categories (RC) 2 and 3 were identified (Figure, Table 1, eTable 1).

Figure

A selection of 12 native poisonous plants with flowers or fruits/seeds in risk categories 2 and 3 in relation to which a high number of inquiries were made or severe poisonings reported to the joint PIC in Erfurt, Germany, in the period 2010–2019. Since the phenotypic characteristics of these plants (for example, color, flower shape) can vary depending on the season and location, the classification and identification of comparative plants from nature on the basis of illustrations or photos alone is to be regarded as unreliable. For reliable determination—especially in the case of poisoning—trained specialists (for example, botanists, toxicologists, the poison control helpline) should be consulted.

Table 1

Synoptic presentation of the toxicology of native poisonous plants in risk category 2 or 3 in relation to which a high number of inquiries were made or severe poisonings were reported to the joint PIC in Erfurt (GGIZ), Germany, in the period 2010–19

eTable 1

Detailed presentation of the toxicology of native poisonous plants in risk category 2 or 3 in relation to which a high number of inquiries were made or severe poisonings occurred in the period 2010–19 at the joint PIC in Erfurt, Germany

In addition, a selective search was conducted in PubMed for publications on specific toxidromes and treatment measures, as well as in TOXLINE on plant constituents up to publication year 2021. The literature selection focused on oral forms of poisoning. In those cases where there is a lack of evidence or no basis in the literature, the measures recommended here should be seen as an expert opinion based on the experience of the authors or on established clinical practice.

Initial measures and determining the severity of poisoning

Experience has shown that the level of risk is usually unclear (for example, a questionably symptomatic child that has ingested an unknown number of unknown berries). For this reason, the situation should be assessed in a structured manner by means of (third-party) history (“w” questions):

• What (which plant parts from which species of plant) and how much was ingested when, how, and why?
• Which other individuals are affected and how?
• What are the leading symptoms (Table 2), syndromes (toxidromes), preexisting diseases, and medications?

Table 2

Clinically and toxicologically relevant organ findings and cardinal symptoms in plant poisonings according to (18)

In the case of unconscious patients or children, plant remnants in the oral cavity or in vomit may indicate that poisonous plant exposure has occurred.

Even in the case of asymptomatic individuals and ingestion of small amounts of plants, it is advisable to first inquire at the control center of the local PIC for a risk assessment. Likewise, the PIC provides patients and lay persons with appropriate advice in the event of poisoning, for example regarding initial measures or clarifying whether a medical consultation is needed.

In order to make a risk assessment, the risk must be estimated on the basis of all available information (“estimated risk”). The prediction of the risk or course of poisoning depends on numerous factors. The amount of relevant constituents can vary strongly depending on the part of the plant. Some plants contain the highest concentrations of toxic agents in their fruits (e.g., belladonna) or seeds (e.g., castor bean [ricinus], autumn crocus), in their leaves or needles (e.g., yew), or even in their roots (e.g., false hellebore). The severity of poisoning also depends on the amount ingested and the degree of crushing or chewing. Crushed plant parts release more toxic agents due to the increased surface area, or ingredients are better absorbed from them. The toxic effect may also depend on the following factors (8, 9, 10, 11, 12, 13, 14):

• Age (children and the elderly are often particularly vulnerable)
• Comorbidities (for example, kidney or liver failure)
• Enzyme make-up (toxicogenetics, for example, cytochrome status of the liver)
• Route of exposure (for example, oral, inhalation, dermal, ocular)
• Duration of exposure (chronic versus acute).

Overall, due to multiple variables, there is a high degree of uncertainty in prognostic statements regarding human intoxications.

If non-toxic or low-toxic plants/plant parts (risk categories [RC] 0, 1) or clearly non-relevant quantities have been ingested, further measures are usually not required (15). In the case of potentially relevant plant poisoning (high risk assessment), the first priority is to monitor and support vital functions (the ABCDE approach) (15, 16, 17). Medical lay persons should undertake initial measures at the scene according to instructions given by the emergency department or in consultation with the PIC (Box). These include preventing exposure to toxic agents (for example, manually removing plant residues from the oral cavity) and administering fluids in the form of water, tea, or juice to individuals that are awake.

Box

Initial measures in oral plant poisonings. Measures modified from (e26)

To estimate the initial severity of poisoning and the clinical course, it is helpful to ascertain, for example, the modified Poisoning Severity Score (PSS) (eTable 2) (16, 18).

eTable 2

Modified Poisoning Severity Score (PSS) according to Persson et al. for the grading of poisoning severity (modified from [18])

Plant identification

For a reliable risk assessment in plant poisonings, it is important to determine the species of the plant. Species identification and toxicological evaluation often present difficulties. Therefore—even if identification and risk assessment appear to be reliable—additional expert advice should be sought. Local experts such as horticulturists, botanists, toxicologists, pharmacists, and PIC staff may be able to assist in species identification. For example, the “Vergiftungsunfälle bei Kindern” (poisoning accidents in children) app released by the German Federal Institute for Risk Assessment (Bundesinstitut für Risikobewertung, BfR) (19) provides information on plant poisoning, including photos to aid identification. Commercial apps can also help in the identification of species. Identification results—often presented as probability data with a ranking—should always be critically scrutinized and compared with other sources of information.

It is always advisable to preserve fruits and other plant parts (stems, leaves, but preferably the whole plant), as well as vomit, for the purposes of species identification at a later time. If this is not possible (for example, in the case of trees), the plant and parts of the plant that have been consumed should be photographed.

In the case of syndromic poisoning (toxidrome), the clinical picture may be able to narrow down the group of toxic agents (20, 21). In plant poisonings, the anticholinergic syndrome that occurs in the setting of tropane alkaloid intoxication (for example, atropine, scopolamine) is particularly relevant. Typical symptoms include (22, 23): tachycardia, hyperthermia, tachypnea, mydriasis, warm/dry skin, dry mucous membranes, urinary retention, tremor, intestinal atony, as well as agitation and hallucinations. Usually, only partial symptoms become manifest (22, 23).

Primary detoxification

Primary detoxification comprises measures to prevent absorption of the poison (16, 24, 25). Once the indication has been established from a critical perspective, the following measures should preferentially be used in routine clinical toxicological practice (16, 25, 26):

• administration of activated charcoal;
• where appropriate, gastric lavage or endoscopic removal.

However, the evidence is overall weak. The recommendations are based primarily on individual case reports, expert opinions, and position papers, as well as on clinical experimental studies with small numbers of voluntary subjects. Randomized controlled studies on the treatment of specific plant poisonings are not available to date.

Administration of activated charcoal

Activated charcoal, due to its large surface area and high adsorption capacity, is able to bind plant substances and reduce absorption of the poison. Its administration is liberally recommended even in cases of moderate poisoning (PSS > 1) or in cases of poisoning by unknown plants in which there is a possibility of severe poisoning but no increased risk of aspiration (25). Emergency medical services generally carry the drug, which has been declared by the WHO as “indispensable” (compare with the “Bremer Liste”). It should be administered as soon as possible, at best within 30–60 min of ingestion, together with plenty of fluids (water, tea, fruit juice) (25, 27). The selected dose should exceed the toxic agent 10–40 fold or be equivalent to 0.5–1 g/kg body weight in children or 50 g orally in adults (where appropriate, via gastric tube) (25). More detailed recommendations on establishing the indication as well as on evidence-based dosages for plant poisoning, not to mention data on clinical outcome, are not available. Experimental inhibition of absorption using 50 g of activated charcoal in adults is 40–47% after 30–60 min and 17–21% after 120–180 min (27).

Protracted, repetitive, or delayed administration of activated charcoal can possibly still be effective in poisoning by plants containing constituents that are subject to pronounced enterohepatic and/or enteroenteric circulation (for example, colchicine, digitalis glycosides). The mechanisms at work here include, on the one hand, the primary removal of active substances even from distal sections of the gastrointestinal tract and, on the other, secondary detoxification via what is referred to as gastrointestinal dialysis. The latter describes an effect in the enteroenteric circulation whereby the intestinal wall serves as a semipermeable membrane, and substances diffuse from the blood into the activated charcoal in the intestine (25, 28). The indication for activated charcoal administration should likewise be established liberally in cases of poisoning by highly toxic (for example, castor bean [ricinus], wolfsbane), difficult-to-digest (for example, yew needles), or anticholinergic poisonous plants (for example, belladonna, angel’s trumpet) (25, 28). Informative clinical studies are lacking. The cumulative dose should not exceed 300 g in adults (25).

Activated charcoal is administered for mild intoxications (PSS 0–1) only in exceptional cases: when it is readily available and can prevent the onset of symptoms of poisoning (25).

Contraindications include clouding of consciousness (and unprotected airways), recurrent vomiting, noncompliance, bleeding (for example, in ricin intoxication), and gastrointestinal tract injury. Plant-based alcohols, glycols, and oxalic acid are not adsorbed due to their physical properties (25). A combination of laxatives is not recommended (25, 27, 28, 29). As a general rule, activated charcoal (for example, from pharmacies) can also be administered by lay persons after consultation with a physician (25).

According to older reports, the polystyrene derivative cholestyramine is also able to inhibit absorption of lipophilic poison/toxic agents (for example, digitalis glycosides) by interrupting enterohepatic circulation (30, 31, 32, 33). In the early phase of poisoning, however, activated charcoal should be preferred due to its high capacity to rapidly absorb poison (25).

Gastric lavage and endoscopic removal

According to a clinical toxicology position paper, there is insufficient evidence as yet to justify the routine use of gastric lavage (34). In selected individual cases (for example, life-threatening situations), the measure can by all means be effective (34).

Endoscopic removal of plant residues is the preferred option, since the effectiveness of elimination can be better assessed and guided due to direct visualization. Comparative studies on gastric lavage in plant poisonings are lacking.

Both measures can be recommended even some time after ingestion (> 60 min), for example after ingestion of difficult-to-digest plant parts such as yew needles—much like pharmacobezoar formation in tablet intoxication. Also, both methods can be performed in unconscious patients while preventing aspiration.

Obsolete measures

Due to the significant side effects (for example, cardiotoxicity), poor evidence, and practicability of ipecac syrup, gastric lavage and endoscopic removal should always be preferred. This holds true even though, according to an older experimental study from 1993 with 19 participants, iatrogenic emesis induced by ipecac syrup was significantly superior to gastric lavage in terms of retrieval rate of 30 technetium capsules (54.1 ± 21.3% standard deviation [SD] capsules vomited versus 30.3 ± 17.4% SD capsules recovered by gastric lavage, p = 0.0021) (35). Vomiting induced using apomorphine or mechanical stimulation is also obsolete due to its low practicability (availability, controllability), patchy evidence, and potential side effects (for example, respiratory depression with apomorphine) (36, 37, 38, 39).

The gastric clearance rate is incomplete when such measures are taken (59% after 30 min, 44% after 60 min; study with 20 voluntary subjects) (40). The administration of saltwater, for example, by lay persons in the context of first aid, is also contraindicated, since this may lead to patients requiring treatment for hypernatremia (e1, e2).

Further measures

Diagnostic work-up

Laboratory diagnostics are performed in a problem-oriented manner and include, at a minimum, obtaining a blood count as well as measuring blood glucose, serum electrolytes, blood gases, retention values (creatinine, urea), muscle parameters (creatine kinase, myoglobin), liver count (aspartate aminotransferase [ASAT], alanine aminotransferase [ALAT], gamma-glutamyl transferase [GGT]), blood coagulation, and, where appropriate, a pregnancy test.

Although the diagnosis of plant poisoning usually has to be made on the basis of history, symptoms/toxidromes, and the poisoning scenario (e.g., plant species/part, amount ingested) due to the relative unavailability of laboratory analysis, blood, urine, and vomit samples should be taken early on as a matter of course and for forensic purposes. Molecular biological analysis for the identification of poisonous plants is gaining in importance (e3). Special investigations are generally time- and cost-intensive and should not delay treatment measures.

Commercially available diagnostic digoxin immunoassays are often cross-reactive in plant poisonings with plant-derived cardiac glycosides. Due to a lack of validation, they are not suitable for treatment monitoring following the administration of a digitalis antidote, but they may be able to provide qualitative information where required (e4, e5, e6).

Secondary detoxification

In individual cases, secondary detoxification procedures can be used to attempt the removal of toxic agents that have already been absorbed (24, e7). In addition to the abovementioned administration of activated charcoal (gastrointestinal dialysis), these include hemodialysis if the toxic agents are dialyzable and the poisoning scenario is life-threatening (Table 1, eTable 1) (e8). These procedures also serve to eliminate myoglobin in the context of toxic rhabdomyolysis (for example, in poisoning with hemlock) or to eliminate lactate in the case of subsequent lactic acidosis in intensive care patients (e9, e10, e11).

Owing to significant advances in dialysis technology involving the use of biocompatible high-flux membranes, hemoperfusion with activated charcoal or exchange resins has been used less and less in recent years and is reserved for specialized centers.

Individual case reports on the benefits of forced diuresis (for example, using loop diuretics) or urine alkalinization (for example, using sodium bicarbonate) are available for only a handful of plant poisons (e12, e13). These methods should not be routinely used (e12).

In the case of lipophilic cardiotoxic agents (for example, taxine B) with high distribution volumes, high-dose intravenous lipid emulsion (lipid resuscitation) can be considered in the form of an individual attempt at treatment in life-threatening poisoning (e13, e14, e15, e16, e17). It is assumed that the toxicity of some poisons can be reduced by, for example, redistribution in the lipid phase, thereby reducing uptake at the site of action (e7, e18). At the same time, a redistribution of toxic agents to lipid-containing tissues occurs, accompanied by metabolic degradation (inactivation), prolonged excretion, or storage. Nonspecific organ-protective effects of lipids, for example on the myocardium, are also under debate (e18).

In (continuous) 12-lead ECG monitoring, arrhythmias, bundle branch blocks, widened QRS complexes, and prolonged QT interval can be determined at the scene in cases of poisoning by cardiotoxic plants (for example, wolfsbane, foxglove, European yew, autumn crocus). ECG monitoring for at least 24 h is indicated if cardiotoxic poisonous plants have been ingested (e13, e19).

Antidotes

Antidotes are available for only a handful of plant poisonings: physostigmine salicylate (physostigmine) is able to antagonize the anticholinergic effect of tropane alkaloids (found, for example, in angel’s trumpet, jimson weed, belladonna) and is indicated in particular for central symptoms such as delirium (e20, e21). According to case reports, digitalis antibodies (anti-digoxin Fab-fragments) can be effective in poisonings by plant-derived cardiac glycosides (cardenolides/cardenolide glycosides) from foxglove (digoxin, digitoxin, digitoxigenin) and oleander (oleandrin) (e5, e6). However, in contrast to medicinal digitalis poisoning, there is less evidence for the clinical efficacy of digitalis antibodies in plant-derived cardenolide poisoning (e5). For convallatoxin (from lily of the valley), which is also one of the cardiac glycosides, no antagonistic effect could be detected for digitalis antibodies in the laboratory—although digoxin-specific immunoassays cross-react in diagnostic tests (e4). The postulated effect of digitalis antidote in poisoning by European yew (due to immunological cross-reactivity with taxine B) is currently unclear (e13, e22, e23). Where appropriate, the administration of this antidote can be considered on a case-by-case basis in life-threatening yew poisoning.

Monitoring and further treatment

Due to delayed poison absorption or possible symptom latency, patients should be monitored medically (ideally [pre-]hospitalization) following ingestion of relevant or unknown amounts of toxic plant constituents. The duration and (instrument-based) extent of mandatory monitoring depend on, among other things, the type of plant, the amount ingested, preexisting diseases, and age, and should be determined on a case-by-case basis. For patients that have ingested non-toxic or low-toxic plants (for example, RC 0, RC 1) or clearly harmless amounts, alone the administration of fluids in the form of water, tea, or juices is adequate.

In all other cases, the treatment of plant poisonings is predominantly symptomatic: maintaining fluid and electrolyte balance, analgesic therapy, spasmolysis, and, in severe cases, intensive care measures ranging from, for example, controlled ventilation for respiratory depression (for example, in yew or hemlock poisoning) to extracorporeal membrane oxygenation (ECMO) (e24).

As a matter of principle in cases of unexplained disorders of consciousness, one should consider other causes such as (herbal) drug, medication, and alcohol intoxication, as well as hypoglycemia. Suicidal plant poisonings (for example, using European yew) in the period 2016–20 at the joint PIC comprised 10–55% mixed intoxications in which other toxins were ingested alongside the plant poison (unpublished data). Suicidal patients require appropriate monitoring and early psychiatric referral.

Summary

In order to improve patient care, systematic epidemiological studies, for example, using a national monitoring system with regular reporting, as well as clinical studies on the treatment of plant poisonings, are required.

Conflict of interest statement
The authors declare that no conflict of interests exists.

Manuscript received on 7 October 2021, revised version accepted on 26 January 2022.

Translated from the original German by Christine Rye.

Corresponding author
Dr. med. Sebastian Wendt, DTM, B.A.
Medizinische Klinik II
Bereich Infektiologie und Tropenmedizin
Universitätsklinikum Leipzig
Liebigstr. 20, 04103 Leipzig, Germany

Cite this as:
Wendt S, Lübbert C, Begemann K, Prasa D, Franke H:
Poisoning by plants. Dtsch Arztebl Int 2022; 119: 317–24.
DOI: 10.3238/arztebl.m2022.0124

►Supplementary material

eReferences, eTables:
www.aerzteblatt-international.de/m2022.0124

cme plus

This article has been certified by the North Rhine Academy for Continuing Medical Education. Participation in the CME certification program is possible only over the internet: cme.aerzteblatt.de. The deadline for submission is 5 May 2023.

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