Herbal poisoning cases in Turkey: a narrative review

3.1 Rhododendron ponticum (mad honey) poisoning

Rhododendron ponticum and Rhododendron luteum (Ericaceae) are two species indigenous to the Black Sea region of Turkey. These species contain a toxic compound called grayanotoxin (andromedatoxin). Honey made from the nectar of these plants is poisonous as well. Although, this honey is traditionally used to treat various diseases such as hypertension, it may cause cardiac and cholinergic poisoning, and effective treatments for such poisoning include intravenous fluids, atropine sulfate and vasopressors [9, 10]. In a study, a family consumed mad honey for breakfast and later sought medical attention due to symptoms such as nausea, vomiting, abdominal pain and dizziness. They were treated with 0.9% Sodium chloride (NaCl) infusion, and atropine was administered to the parents due to bradycardia. The parents and their children were subsequently discharged after recovery [11]. In another case report, a 21-year-old male patient presented to the hospital’s emergency department with symptoms of nausea, blackout, dizziness, cold sweats, weakness, drowsiness, bradycardia and tremors after eating two spoons of honey. He received treatment with 1 mg of atropine along with intravenous administration of 0.9% NaCl and 5% dextrose. The patient fully recovered and was discharged from the hospital [12]. In a separate report by Aksoy et al. [13], a 72-year-old male patient was admitted to the emergency department with complaints of dizziness, weakness, nausea, vomiting, cold sweats and fainting after eating two spoons of mad honey. As treatment, 2 mg of atropine, intravenous dopamine and saline infusion were administered and the patient was discharged after his complaints improved.

3.2 Atropa belladonna poisoning

Atropa belladonna (A. belladonna, Solanaceae) is a perennial herbaceous plant known for its striking purple flowers, alternately leaves, purple and semi-spherical fruits. This plant contains important alkaloids such as atropine, scopolamine and hyoscyamine [14]. A. belladonna causes poisoning in both adults and children, where in cases of poisoning, symptoms such as meaningless speech, mydriasis, tachycardia and flushing are observed [15]. Gastric lavage and the antidote physostigmine are commonly used to treat such poisoning [16]. A study investigated nine patients who experienced poisoning from A. belladonna with the majority consuming the fruit of the plant, mistaking it for another fruit. One of them deliberately swallowed the fruit. The most commonly reported symptoms were dry mouth and slurred speech, followed by other symptoms such as paresthesia of the lips, nausea, bilateral lower extremity weakness, agitation and temporary loss of consciousness. Eight of the cases were admitted to the intensive care unit and one was discharged as an outpatient [17]. In another case report, three geriatric cases were admitted to the emergency department in five days with A. belladonna poisoning. These patients exhibited confusion, hallucinations and meaningless speech. The first two cases involved individuals who accidentally ingested the fruit because they thought it would cure their diabetes, while the third patient mistook it for a different fruit. Due to the unavailability of therapeutic physostigmine, conservative treatment was implemented. They were all discharged from the hospital a few days later [18]. In a different case, a 64-year-old male patient was admitted to the emergency department due to poisoning from A. belladonna. He presented with symptoms of nausea, vomiting, headache, incoherent speech, palpitations, flushing of the body and face, and inability to urinate. He was discharged on the 4th day after gastric lavage, application of activated charcoal, urinary catheterization, and benzodiazepine treatment [19]. Additionally, a 49-year-old female patient was admitted to the emergency department with complaints of restlessness and aggression after consuming A. belladonna fruit. A nasogastric tube was inserted, gastric irrigation was performed, and 1 mg/kg dose of activated charcoal was administered. After the urinary catheter was inserted, 1000 cc of urine was drained, and ventilatory support treatment was applied. After 24 hours, the symptoms completely disappeared [20].

3.3 Conium maculatum (hemlock) poisoning

Conium maculatum (C. maculatum, Apiaceae) is a very poisonous species that contains piperidine alkaloids. All parts of the plant including fruits, flowers, leaves, seeds and roots are toxic [21]. General symptoms of hemlock poisoning, which contains alkaloids such as coniine, include tremors, vomiting, movement problems, pulse changes, rapid breathing, urination, salivation, nausea, convulsions, nervous system paralysis, coma and death [22]. In one case, a 42-year-old woman consumed C. maculatum which she collected from the garden, mistaking it for another plant. She was hospitalized with complaints of dry mouth, weakness and feeling ill. Despite receiving treatment, including gastric lavage, ventilatory support, activated charcoal and anticonvulsants, the patient died. The autopsy revealed damage to the brain and other organs [23]. Accidental ingestion of hemlock can lead to central nervous system depression, respiratory failure, acute rhabdomyolysis, acute renal failure and even death. Treatment for this type of poisoning is primarily supportive.

In another incident, a 3-year-old girl accidentally consumed this plant and began vomiting two hours later, eventually losing consciousness. She was discharged after 10 days following therapeutic plasma exchange, golytely-based stool passage and antibiotic treatment [24]. Additionally, a 6-year-old girl accidentally ate C. maculatum and presented at the emergency department with symptoms of burning in the mouth, increased salivation, trembling hands and gait instability. Gastric lavage was performed and activated charcoal, intravenous crystalloid infusion and fresh frozen plasma were administered. The patient recovered 3 days later [25].

3.4 Apple oil poisoning

Salvia is a genus belonging to the Lamiaceae family. Salvia triloba (Salvia fruticosa, sage) is a species that grows in Turkey, and the essential oil obtained by steam distillation from the leaves of this plant is called Apple oil, which is rich in 1,8-cineole and camphor. Gall nuts are formed on the branches of this shrub and their resemblance to apples is the reason behind the name “apple oil” [26]. Apple oil is traditionally used to treat of infantile colic, characterized by restlessness, agitation and crying crisis which can be seen in the first 4–5 months of babies. The apple oil is recommended to be used by massaging 1–2 drops externally onto the soles of the feet and the abdominal area. However, incorrect application such as oral use or overdose can sometimes lead to poisoning. Apple oil poisoning may affect the central nervous system, resulting in sedation, confusion, vertigo, delirium, hallucination, tremor and seizure, or respiratory system symptoms such as pneumonia and respiratory failure.

In a study, four cases related to the misuse of bitter apple oil were admitted to the hospital and treated. It has been stated that poisonings were caused by parents’ insomnia and fatigue, lack of knowledge, mixing with other oral drops, and insufficient information given by doctors [27].

3.5 Apricot seed poisoning

Certain plant species contain cyanogenic compounds that can break down into hydrogen cyanide (HCN), an extremely toxic substance. For instance, the seeds of Prunus armeniaca (apricot) contain cyanogenic substances [28]. Hydroxycobalamin, amyl nitrite and sodium nitrite are antidotes used in the treatment of cyanide poisoning [29]. Several pediatric patients have been admitted to hospitals with symptoms such as vomiting, loss of consciousness and convulsions following ingestion of apricot seeds. Patients were treated with methods such as oxygen support, activated charcoal and antidote application [30, 31]. Four children poisoned with apricot seeds were admitted to the hospital with complaints such as nausea, vomiting, abdominal pain, and weakness, etc. A 3-year-old boy and a 2.5-year-old girl were treated with nasal Continious Positive Airway Pressure (CPAP), intravenous fluid therapy and hydroxocobalamin (70 mg/kg). A 2-year-old girl with respiratory distress and loss of consciousness was intubated and given intravenous fluid therapy, dopamine (5 mcg/kg/min) and hydroxocobalamin (70 mg/kg). A 3.5-year-old girl recovered without requiring antidote treatment. All patients were discharged [32].

One other notable case involved a 3-year-old male patient who sought emergency care due to seizures after consuming apricot seeds. He was treated with Midazolam (0.1 mg/kg) and hydroxycobalamin (70 mg/kg) administered intravenously, and was discharged after 24 hours of monitoring [33].

3.6 Ecballium elaterium poisoning

Ecballium elaterium (E. elaterium, Cucurbitaceae) is a herbaceous plant native to the Mediterranean area. It primarily contains cucurbitacins, and has been used traditionally to treat ailments such as sinusitis, jaundice and rheumatism. Despite previous studies showing its diverse biological activities, the fruits of E. elaterium are known to be poisonous. [34]. The juice of E. elaterium can cause mucosal irritation [35].

In one case, a 46-year-old male patient presented to the emergency department with complaints of sore throat and difficulty swallowing after administering 3–4 drops of E. elaterium extract into each nostrils to treat sinusitis. Despite being treated with nasal oxygen and intravenous methylprednisolone and diphenhydramine, the patient developed chest pain and shortness of breath 1 day later. His treatment included ipratropium bromide, salbutamol, budesonide, pheniramine maleate and methylprednisolone [36]. In another case, a 38-year-old male patient who used E. elaterium juice intranasally was admitted with shortness of breath, burning and stinging sensation in the eyes, and swelling of the eyelids. He received oxygen therapy, epinephrine (0.3 mg), intravenous methylprednisolone (80 mg), and diphenhydramine (50 mg) before being discharged [37].

In another case, a 6-year-old boy accidentally ingested E. elaterium and was admitted to the hospital complaining of vomiting. Maintenance fluid infusion and ranitidine + sucralfate (1 mg/kg) treatment were applied. The patient was monitored and later discharged [38].

3.7 Nicotiana rustica poisoning

Tobacco plants natively belong to America but are cultivated worldwide. These plants contain a variety of secondary metabolites [39]. Although tobacco is extremely harmful to human health, it is widely used today. Nicotine is an addictive alkaloid and is found in tobacco. Certain compounds in tobacco smoke are carcinogenic, making tobacco use a severe public health concern [40]. Lung cancer, heart disease, and chronic lung disease are common in smokers. It is also known to be associated with laryngeal cancer, oral cavity, pharynx, esophagus, gastrointestinal cancer, bladder cancer, pancreatic cancer, uterine cancer and breast cancer [41]. A study conducted with primary school students in Kazakhstan, revealed that using Nicotiana rustica led to symptoms such as hyperemia, swelling and white plaque formation in the oral mucosa layer [42].

3.8 Dieffenbachia poisoning

Dieffenbachia species belongs to the Araceae family and is commonly referred to as the “weeping flower”. This ornamental plant is widely favored for home cultivation due to its ease of growth, rapid development, and preference for shaded environments. It contains several potentially harmful compounds such as sapanosides, alkaloids, cyanogenetic heterosides, proteolytic enzymes, calcium oxalate crystals and oxalic acid. It is believed that the calcium oxalate crystals, oxalic acid, and protease may be responsible for its poisoning effects. These compounds cause an inflammatory reaction and cause localized irritation symptoms, particularly when the plant is ingested orally or comes in contact with the eyes.

Dieffenbachia poisoning in humans or animals may cause systemic or local effects. Symptoms may arise from chewing the stem or the leaves, leading to oropharyngeal edema, pain, hypertrophy and ulceration in the oral mucosa or tongue, increased secretions and difficulty in speaking. There is no specific treatment for this type of poisoning; however, in mild cases, supportive treatment such as cold application and topical analgesics may be sufficient. In more severe cases, treatment may involve steroids, antihistamines and nebulized epinephrine. In cases of airway obstruction, intubation and tracheostomy may be required. Cases of poisoning of children who accidentally consumed the leaves of this plant are recorded in the literature [43, 44, 45].

An 8-year-old girl who had contact with Diffenbachia was admitted to the hospital with complaints of numbness of the tongue, swelling and redness of the lower lip, slurred speech and difficulty breathing. Methyl prednisolone (1 mg/kg) and pheniramine (1 mg/kg) were administered. The patient’s symptoms improved and she was discharged after 24 hours [46].

3.9 Mushroom poisoning

Mushrooms are abundant worldwide, but certain species can be highly toxic, leading to severe poisoning. The symptoms of poisoning vary depending on the specific type of mushroom consumed. Toxic ingredients responsible for these effects include cyclopeptide, gyromitrine, muscarine, coprine, ibotenic acid, muscimol, orelline, orellanine and psilocybin. In particular, mushrooms containing amatoxin are very toxic and have a lethal risk. Consequently, consuming wild mushrooms collected from nature is an important problem. Treatment approaches can include symptomatic management, poison removal and antidote depending on the type of toxic mushroom involved [47].

The liver and kidneys are mainly damaged in Amanita mushroom poisoning, which contains amatoxin. Treatments for affected patients may involve hemoperfusion, hemodialysis, high doses of penicillin, activated charcoal, liver transplantation and forced diuresis. Two siblings were admitted to the hospital due to gastrointestinal complaints approximately ten hours after eating Amanita phalloides. Hemoperfusion treatment was applied to both cases and improvement was observed [48]. Two male patients, aged 55 and 42, who collected and consumed mushrooms in the forest area, were admitted to the hospital with complaints of nausea, vomiting, diarrhea and fatigue. The patients were successfully treated using silibinin [49].

A 44-year-old female patient was admitted to the hospital with complaints of nausea and vomiting two days after eating mushrooms. In biochemical tests; blood urea nitrogen and creatinine levels were very high. Hemodialysis and plasmapheresis were applied several times. Diuretic and oxygen therapy were also administered, and the patient recovered after 15 days [50]. A 51-year-old female, a 55-year-old male, and a 59-year-old male who consumed Amanita proxima mushrooms were also hospitalized with complaints of nausea and vomiting. All three patients with acute kidney injury received hemodialysis treatment and their kidney damage completely healed [51].