Food Poisoning From Fruits in Germany

Accidental exposures are common, but rarely symptomatic

Since 1994, the Joint Poison Information Center (Gemeinsame Giftinformationszentrum, GGIZ) in Erfurt, Germany, has been available around the clock to the public in the German federal states of Saxony, Saxony-Anhalt, Thuringia, and Mecklenburg-West Pomerania as a poison emergency helpline (Tel.: [phone]). The center processes approximately 27,000 inquiries each year (1). Advice on plant exposures ranks highest alongside queries regarding household products and medicines (1).

Children constitute a special at-risk group when it comes to the ingestion of certain plant parts. For example, fruits (berries, seeds, beans, pods, hulls, cones, nuts, dupes, and apple fruits) are visually attractive and appealing, resemble well-known everyday food plants, and are often easily accessible (playgrounds, gardens).

In order to determine the actual risk of fruit plant ingestions and identify preventive measures, an analysis of real exposure data was carried out at the GGIZ (“risk assessment”).

Methods

The core data set of the GGIZ from the period 2010–2019 for plant poisonings was statistically analyzed according to plant type, frequency of inquiries, poisoning severity, and patient age.

Symptom severity was determined using the Poisoning Severity Score and, as a general rule, in the context of a standardized telephone consultation (2). Maximum severity and need for treatment relate to fruit plants as single toxins (causal approach without defined follow-up). Classification into risk categories (RC) from 0 to 3 is in line with the re-evaluation of poisonous plants undertaken by the “Toxicity of Plants” Committee at the German Federal Institute for Risk Assessment (Bundesinstitut für Risikobewertung, BfR) (BfR)(3, 4):

• RC 0  = Non-toxic (no symptoms expected)
• RC 1  = Mildly toxic (mild symptoms expected)
• RC 2  = Moderately toxic (moderate symptoms expected)
• RC 3  = Highly toxic (severe symptoms expected).

In order to identify fruit plants with a high real risk of poisoning, a modified Litovitz risk factor was additionally calculated (number of severe and moderate poisonings per 100 exposures). Relevant fruit plants are defined by a cut-off of ≥ 30 inquiries per analysis period, and highly relevant fruit plants by ≥ 300 inquiries per analysis period.

Results

Of the 7607 inquiries regarding 45 relevant and six highly relevant fruit plants, there were:

• 459 (6%) Inquiries regarding plants in RC 0
• 3645 (47.9%) Inquiries regarding plants in RC 1
• 2986 (39.3%) Inquiries regarding plants in RC 2
• 517 (6.8%) Inquiries regarding plants in RC 3.

Young children (1 to < 6 years) accounted for 5284 (69.5%) single exposures, adults (18 years and older) for 1091 exposures (14.3%), school children (6 to < 14 years) for 727 (9.6%) exposures, babies (up to 1 year) for 265 (3.5%), and adolescents (14 to < 18 years) for 83 exposures.

Single exposures (n = 7229) remained asymptomatic in 80% (5746) of all cases, with mild symptoms seen in 13% (908), moderate symptoms in 2% (170), and severe symptoms in 0.28% (20).

Severe poisonings were caused by seven fruit plants (Table): European yew (n = 9), autumn crocus (n = 4), castor-oil plant (n = 3), angel’s trumpet (n = 3), belladonna (n = 3), jimson weed (n = 1), and arborvitae (n = 1). The highest real risk of poisoning (Litovitz risk factor) was seen for castor bean, belladonna, jimson weed, and angel’s trumpet (Table).

Table

Fruit plants that led to severe poisoning upon exposure in the period 2010–2019, in descending order of number of inquiries to the Joint Poison Information Center in Erfurt, Germany

Overall, five fatalities, all of which were suicides, were caused by three plant species: autumn crocus, castor bean, and European yew (n = 3). These were also the species most frequently associated with suicide (n = 121).

Discussion

Approximately 150 of the 3000 native plant species have relevant poisoning potential (5). During the study’s analysis period, inquiries regarding plant poisoning were the third most frequent in children (15%), whereas in terms of numbers they were comparatively negligible among adults (2%). The risk of ingestion is per se higher in children: children are usually not able to judge plants and their toxic potential. Many of the plants that were most commonly involved in poisoning have attractive fruits (53.7%) that are appealing to children.

The potential toxicity of individual plants depends on their actual constituents and/or plant age, genetics, the ripeness of the fruit, the location in which they grow, as well as the weather and climate. The amount ingested (dose) and individual factors, such as the sensitivity of the organism (for example, enzyme make-up, compensatory mechanisms, age), routes of exposure (oral, dermal, inhalation, ocular, intravascular), and duration of exposure (acute, chronic) also play a significant role in the severity of poisoning following exposure.

In view of the high number of inquiries (highly relevant fruit plants), there is considerable demand for information on the yew, privet, bladder cherry, cherry laurel, lily of the valley, and mahonia—although, remarkably, none of these plants are in RC 3. The extent of the need for information clearly does not correlate with the actual risk of poisoning, reflecting instead a lack of botanical/toxicological knowledge and, in some cases, the visual appeal of individual fruits. However, one cannot rule out the possibility that some fruit plant species are overrepresented (or underrepresented), given that they are found with varying frequencies in the four federal states as a result of particular geobotanical/bioclimactic characteristics. Also, not all poisonings can always be verified in terms of plant species and severity within the context of a telephone call.

Our analysis shows that the risk posed to the public by potentially poisonous fruit plants should be considered not only in terms of plant constituents (hazard identification). In order to realistically evaluate and establish preventive measures, the actual risk needs to be assessed taking valid exposure data into consideration. From this viewpoint, it was possible to identify 45 fruit plants of high and six of the highest relevance for Germany. Young children constitute an especially at-risk group.

Although life-threatening cases of poisoning by fruit plants are comparatively rare in Germany, there is a considerable need for information and education on a broad population level regarding the relevant species and their toxicological potential.

Sebastian Wendt, Dagmar Prasa, Christoph Lübbert, Kathrin Begemann, Heike Franke

Division of Infectious Diseases and Tropical Medicine, Department of Oncology, Gastroenterology, Hepatology, Pneumology and Infectiology, University of Leipzig Medical Center, Leipzig (Wendt, Lübbert) [e-mail]

Interdisciplinary Centre for Infectious Diseases (ZINF), Leipzig University Hospital; (Wendt, Lübbert)

Postgraduate Study of Toxicology and Environmental Protection, University of Leipzig (Wendt, Franke)

Poison Information Center for the states of Mecklenburg-Western Pomerania, Saxony, Saxony-Anhalt and Thuringia, c/o HELIOS Klinikum Erfurt (Prasa))

Department of Infectious Diseases, Nephrology and Rheumatology, St. Georg Hospital, Leipzig (Lübbert)

German Federal Institute for Risk Assessment (BfR), Department Exposure, Berlin (Begemann)

Rudolf-Boehm-Institute of Pharmacology and Toxicology, University of Leipzig Medical Center, Leipzig (Franke)

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

Manuscript received on 22 October 2021, revised version accepted on 13 January 2022.

Translated from the original German by Christine Rye.

Cite this as:
Wendt S, Prasa D, Lübbert C, Begemann K, Franke H: Food poisoning from fruits in Germany—accidental exposures are common, but rarely symptomatic.
Dtsch Arztebl Int 2022; 119: 333–4. DOI: 10.3238/arztebl.m2022.0108

References

1. Gemeinsames Giftinformationszentrum Erfurt (GGIZ): Anfragestatistik: Informationen zu Anfragen an das GGIZ. www.ggiz-erfurt.de/anfragestatistik.html (last accessed on 19 October 2021).

2. Persson HE, Sjöberg GK, Haines JA, Pronczuk de Garbino J: Poisoning severity score. Grading of acute poisoning. J Toxicol Clin Toxicol 1998; 36: 205–13

3. Hermanns-Clausen M, Andresen-Streichert H, Pietsch J, Acquarone D, Fuchs J, Begemann K: Risiko Pflanze – Ein neuer Ansatz zur Einschätzung des Vergiftungsrisikos für Kleinkinder. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62: 1336–45

4. Bundesinstitut für Risikobewertung (BfR): Bekanntmachung einer Liste besonders giftiger Gartenpflanzen und einheimischer Pflanzen in der freien Natur. www.bundesanzeiger.de/pub/publication/cb9rFDxrsetJdU4RBZu/content/cb9rFDxrsetJdU4RBZu/BAnz%20AT%2002.07.2021%20B4.pdf?inline (last accessed on 17 August 2021).

5. Haerkötter G, Haerkötter M: Giftpflanzen: Beschreibung, Wirkung, Geschichten. Köln: Anaconda 2018.