AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Alkaloids are alkalilike compounds that form salts with acids and contain nitrogen, generally in heterocyclic and/or ring structure. Found in a wide variety of plants, alkaloids have medicinal and toxic properties.

Quinoline and isoquinoline alkaloids are a heterogeneous group of alkaloids with known toxicity to humans and domestic animals. They are found in plants from a wide group of genera.

Plants containing quinoline alkaloids include the following:

• Baptisia species (false indigo)
• Cytisus species (scotch broom)
• Laburnum species (goldenchain, laburnum)
• Lupinus species (lupine, bluebonnet)
• Sophora species (mescal bean, frijolito)

Plants containing isoquinoline alkaloids include the following:

• Argemone species (prickly poppy)
• Chelidonium species (celandine poppy)
• Corydalis species (fitweed)
• Dicentra species (dutchman's breeches)
• Papaver species (poppy)
• Sanguinera species (bloodroot)

The most significant human toxins in this group are in the laburnum tree and the mescal bean. The laburnum bears golden pealike pods. Mescal bean is the seed of a small tree and often is used in ornamental jewelry. Cytisine, the alkaloid common to these plants, has nicotinelike effects on the gastrointestinal (GI) tract and the central nervous system (CNS).

The isoquinoline alkaloids papaverine, sanguinarine, protoverine, and chelidonine are GI tract irritants and CNS stimulants. Isoquinoline alkaloids are found in varying quantities in the prickly poppy, bloodroot, and celandine poppy. Many have varying degrees of neurologic effects, ranging from relaxation and euphoria to seizures. They also cause vasodilation.

Many of these plants have been used in herbal preparations. Scotch broom is smoked for relaxation and has mild sedative-hypnotic effects. Prickly poppy is smoked as a euphoriant. Mescal bean is a hallucinogenic, which is used in Native American rituals and medicinally. Sanguinaria species (bloodroot) extract is used commercially as a dental plaque inhibitor. Papaverine, found in prickly poppy and bloodroot, has been used medically as a smooth muscle relaxant. Prickly poppy extracts act as capillary dilators and have been implicated in epidemic glaucoma in India. Celandine extracts are used as treatment of gastric and biliary disorders.

As a group, the isoquinolines have proven to be more poisonous to domestic livestock than to humans. In humans, pediatric poisonings are most common.

Pathophysiology

Cytisine is similar in action to nicotine. In any isoquinoline or quinoline ingestion, GI irritation is common, and toxic ingestions almost invariably result in emesis. Onset of symptoms is rapid. GI upset and vomiting start 45 minutes to 4 hours after ingestion. CNS effects include drowsiness, weakness, loss of coordination, muscle fasciculations, seizures, coma, and mydriasis. Some anticholinergic effects, such as urinary retention, may manifest. Respiratory failure, as in nicotine poisoning, is observed in patients with severe cases.

The toxic alkaloids are concentrated in the pealike or brightly colored seeds in laburnum, mescal bean, and lupine. Danger to humans predominantly stems from these seeds' attractive appearance to children.

Most of the isoquinolines are noxious in smell and taste and discourage ingestion, thus human toxicity is rare. Interestingly, some domestic species tolerate ingestion of isoquinoline and other alkaloids, and humans can ingest toxic alkaloids from the milk of a poisoned animal and manifest symptoms.

Celandine and bloodroot may cause dermatitis, and celandine extract has been implicated in cases of acute hepatitis.

Corydalis species (fitweed) ingestion has demonstrated delayed hepatotoxicity.

Ingestion of poppies may result in narcotic effects from opiate alkaloids and papaverine, as well as hypotension and cardiovascular collapse.

Frequency

United States

Incidence of alkaloid poisoning is low and probably underreported.

International

Laburnum poisoning is reported widely in Great Britain; 50 cases were documented in 1979.

Mortality/Morbidity

Mortality is rare. A single adult case of death by laburnum poisoning is reported in a man with schizophrenia. Mescal bean and other quinoline and isoquinoline alkaloids have been documented with sporadic case reports of fatality.

Race

Isoquinoline and/or quinoline poisonings are not noted have increased frequency in any particular race.

Sex

Effects are related to dose and not sex.

Age

Most serious morbidity is reported in children.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Obtain as complete a history as possible, including the following:
• • Medications
  • Allergies
  • Suspected ingestion
  • Time of ingestion
  • Possible co-ingestions
• Identify the plant ingested if possible. An onsite plant reference text and established relationship with an emergency plant taxonomy consultant are useful resources.
• • Laburnum is a small tree, up to 30 feet tall, that bears golden sweet pea-shaped flowers and seeds in pealike pods. It is found in southeastern United States and Europe.
  • Mescal bean is a shrub or small tree with purple flowers and bright red seeds. It is found in the southwestern United States and Mexico.

Physical

• Tachycardia
• Tachypnea or respiratory depression
• Agitation or CNS depression
• Confusion
• Fasciculations
• Seizures
• Vomiting
• Bladder distension

Causes

Risk factors for quinoline and/or isoquinoline plant toxicity include use of medicinal herbs and/or preparations, recreational drug experimentation (most notably mescal bean and opium poppy), drinking of milk from animals that ingest toxic plants (rare), and, most commonly, childhood ingestion of ornamental plants (most notably laburnum).

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Assays for isoquinoline or quinoline alkaloids are not routinely available.
• A toxicology screen may be helpful in excluding amphetamine ingestion, but false-positive results may occur.
• Blood chemistries may be useful in assessing for other potential intoxicating ingestions.
• Perform a fingerstick glucose test for altered mental status.
• Perform a complete blood count (CBC), urinalysis, and blood and urine cultures in febrile patients with altered mental status.
• Always consider acetaminophen and salicylate levels in any potential toxic ingestion.
• Always obtain serum or urine human chorionic gonadotropin (HCG) levels in women of childbearing age.
• Draw a baseline liver function panel if ingestions of C majus (greater celandine) are suspected.

Imaging Studies

• Consider a CT scan of the head in any patient whose altered mental status is not clearly due to toxicity of the ingested substance.

Other Tests

• Obtain an ECG in all patients with possible toxic ingestions to evaluate for tricyclic antidepressant toxicity.

Procedures

• Perform lumbar puncture on any febrile patient with altered mental status if meningitis is considered as a potential diagnosis.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• Transport the patient to the nearest emergency facility with advanced life support (ALS) capabilities.
• Focus assessment and treatment on ABCs.
• • Check serum glucose and treat if hypoglycemic.
  • Consider naloxone.
  • Obtain IV access and provide oxygen and cardiac monitoring.
  • Use benzodiazepines to treat seizures.

Emergency Department Care

Emergency care is primarily supportive, focusing in emergency medicine airway, breathing, circulation, disability, and exposure (ABCDEs).

• Provide supplemental oxygen. If CNS or respiratory depression is present, intubate and provide ventilatory support.
• Check serum glucose and treat if hypoglycemic.
• Consider intravenous naloxone for any patient with altered mental status and an opiate toxidrome.
• The cornerstone of treatment is GI contamination with activated charcoal (1 g/kg). A single dose usually is adequate.
• • Induction of emesis with ipecac syrup provides little benefit and is associated with increased risk of aspiration if the patient's mental status declines.
  • Gastric lavage is controversial but may provide maximum benefit when performed within 1 hour of ingestion.
• Supportive care generally is all that is required postdecontamination. Continuous cardiac monitoring and frequent vital sign determinations are warranted.

Consultations

Consulting a medical toxicologist or poison control center may prove helpful in developing differential diagnoses and identifying toxic ingestion.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to reduce toxicity, reduce morbidity, and prevent complications.

Drug Category: GI decontaminant

Activated charcoal is the treatment of choice for all quinoline and/or isoquinoline plant ingestions. It is the most effective substance known for adsorbing most poisons. Ipecac syrup administered as a precursor to charcoal is no longer recommended, and gastric lavage has limited use.

Drug Category: Benzodiazepines

Agents of choice for cytisine-induced or other alkaloid-induced seizures.

Drug Category: Antidotes for opiate agonists

Used in patients with altered mental status and opiate toxidrome.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Patients with no signs of neurologic or cardiovascular involvement may be discharged from the hospital after 6 hours of observation.
• Admit any patient with altered mental status, seizure activity, or cardiovascular instability to an intensive care unit (ICU) setting for observation and further treatment as needed.
• Draw a baseline liver function panel if ingestions of C majus (greater celandine) are suspected and refer the patient for follow-up repeat liver function tests.

Further Outpatient Care

• Ensure close follow-up care with a pediatrician or internist and instruct a responsible individual to return the patient to the emergency department immediately if altered mental status, seizure, vomiting, or any other concerns arise.

Complications

• Most patients with quinoline and/or isoquinoline plant ingestions do well and are discharged from the emergency department after a period of observation.
• Rarely, seizure, cardiovascular collapse, and aspiration secondary to emesis may complicate care.
• Celandine has been reported to have significant hepatotoxicity.

Prognosis

• Most patients recover fully and are discharged from the emergency department.

Patient Education

• Educate families regarding common household plant toxicity. Tailor education to individual ingestions.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• As with any ingestion, consider co-ingestions, especially those that are potentially serious and treatable (eg, tricyclics, acetaminophen).
• Consider all possible causes for altered mental status.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Bara V. Laburnum. In: Paediatric Toxicology Handbook for Poisoning in Children. 1997:198-199.
• Benninger J, Schneider HT, Schuppan D, et al. Acute hepatitis induced by greater celandine (Chelidonium majus). Gastroenterology. Nov 1999;117(5):1234-7. [Medline].
• DeManuelle MS, Orava RS. Systemic poisonous plant intoxication. In: Emergency Toxicology. 2nd ed. 1997:1067-1079.
• DiPalma JR. Poisonous plants. Am Fam Physician. Apr 1984;29(4):252-4. [Medline].
• Forrester RM. "Have you eaten laburnum?". Lancet. May 19 1979;1(8125):1073. [Medline].
• Galloway JH, Farmer K, Weeks GR, et al. Potentially hazardous compound in a herbal slimming remedy. Lancet. Jul 18 1992;340(8812):179. [Medline].
• Hardin JW, Arena JM. Common poisonous plants. In: Human Poisoning From Native and Cultivated Plants. 1969:27-124.
• Hill RJ, Folland D. Poisonous Plants of Pennsylvania. 1986:1-162.
• Kingsbury JM. Angiosperms. In: Poisonous Plants of the United States and Canada. 1964:124-503.
• Kunkel DB. Poisonous plants. In: Clinical Management of Poisoning and Overdose. 1998.
• Kunkel DB, Spoerke DG. Evaluating exposures to plants. Emerg Med Clin North Am. Feb 1984;2(1):133-44. [Medline].
• Lampe KF, Fagerstrom R. Plants having a nicotine-like action. In: Plant Toxicity and Dermatitis: A Manual for Physicians. 1968:107-114.
• Lampe KF, McCann MA. Systemic plant poisoning. In: AMA Handbook of Poisonous and Injurious Plants. 1985:17-185.
• Turner NJ, Szczawinski AF. Poisonous garden and crop plants. In: Common Poisonous Plants of North America. 1991:102-208.

Article Last Updated: Mar 22, 2006