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Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology
Toxicity, Plants - Caladium, Dieffenbachia, and Philodendron
Article Last Updated: Jun 21, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Christopher P Holstege, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Virginia; Director, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Ctr, Associate Medical Toxicology Fellowship Director, VA Dept of Health
Christopher P Holstege is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Association for the Advancement of Science, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, Medical Society of Virginia, Society for Academic Emergency Medicine, Society of Toxicology, and Wilderness Medical Society
Coauthor(s):
Tracey H Reilly, MD, Fellow, Division of Medical Toxicology, Department of Emergency Medicine, Blue Ridge Poison Center, University of Virginia Health System;
Mark A Hostetler, MD, MPH, Assistant Professor of Pediatrics, University of Chicago; Chief, Section of Emergency Medicine, Department of Pediatrics, Medical Director of Pediatric Emergency Department, University of Chicago Children's Hospital
Editors: Michael E Mullins, MD, Assistant Professor, Department of Emergency Medicine, Washington University School of Medicine; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center; Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine; Maureen Strafford, MD, Arnold P Gold Foundation Associate Professor, Departments of Anesthesiology and Pediatrics, Tufts University and Tufts-New England Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
Caladium, Dieffenbachia, Philodendron, dumb cane, dumbcane, elephant's ears, plant poisoning, toxic plants
Background
According to the 2004 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System, 2,438,644 human exposures were reported, of which 74,811 (3.1%) were exposures to plants. Children younger than 6 years were responsible for 55,078 of those plant exposures. The plant species most frequently reported in human exposures were Spathiphyllum, Ilex, and Philodendron. Caladium and Dieffenbachia species were also listed among the most commonly reported plant exposures. Philodendron and Dieffenbachia species are commonly found in homes, offices, and waiting rooms.
Pathophysiology
Philodendron, dieffenbachia and caladium contain calcium oxalate crystals packaged into bundles called raphides. However, the presence of calcium oxalate crystals alone is not enough to cause the toxicity seen with exposure to these plants. Although the exact mechanism of toxicity remains unclear, the presence of proteolytic enzymes, in addition to specialized cells that forcibly expel the raphides, seems to be necessary to inflict injury.
Frequency
United States
In 2004, data collected by the American Association of Poison Control Centers indicated that plants were the eleventh most commonly reported substance involved in human toxic exposures. Children younger than 6 years were responsible for most of these exposures.
Mortality/Morbidity
Patients with history of oral exposure (chewing and/or swallowing) have been reported to have severe swelling, drooling, dysphagia, and respiratory compromise, but this is not common. In a large retrospective study of 188 patients with plant oxalate exposure, all cases were determined to be minor and all resolved with minor or no treatment. Patients can also experience dermal and ocular exposure, resulting in contact dermatitis or keratoconjunctivitis. Symptoms resulting from these routes of exposure also appear to resolve with supportive care.
Age
In patients with exposure to toxic plants, 80% are children younger than 6 years.
History
Assess the usual important features associated with toxic environmental exposure, namely, identification of the substance, time and duration of exposure, symptomatology, treatment thus far, associated injuries, and preexisting conditions.
- Identification: If possible, ask the parents to bring in a sample of the plant. Plants often are known by a variety of names, both common and scientific. Identification of the plant is greatly aided by the presence of the plant or a portion of it.
- Time and duration of exposure: Inquire about the level of exposure, including the amount and time of exposure.
- Symptomatology: Patients usually develop immediate burning and irritation of the oral mucosa, which generally deters any further exposure.
- Prior treatment: Patients may have been instructed to try demulcifying agents (eg, cold milk, ice cream) or may have taken analgesics prior to presentation.
- Associated injuries
- Inquire about any other potential exposures or injury. Often, more than one plant is present in the immediate vicinity.
- Children also may have fallen or bitten their lips in association with the pain or swelling.
- Preexisting conditions: Inquire about past medical history, medications, and allergies.
Physical
- Assess airway patency; however, swelling severe enough to cause airway compromise is extremely uncommon. Breathing and circulation usually are unaffected.
- Children who chew the leaves develop immediate burning and irritation of the oral mucosa, which may be red and edematous. Many children exhibit mild transient drooling. Severe swelling, drooling, dysphagia, and respiratory compromise have been reported but are not common.
- Cutaneous exposure can cause redness and irritation but is not nearly as common as oral exposure caused by chewing.
- Ocular exposure may result in eye pain, redness, and lid swelling.
Hypersensitivity Pneumonitis
Lab Studies
- No laboratory studies are indicated or necessary.
Imaging Studies
- No imaging studies are indicated or necessary.
Procedures
- Direct visualization of the upper respiratory tract using endoscopy is indicated in patients with severe swelling, stridor, or respiratory compromise, although it rarely is necessary.
- A complete ophthalmologic examination should be performed on patients who present with eye pain and redness. Fluorescein staining should be done to assess for corneal abrasions. Crystals may be visualized within the corneal stroma using a slit lamp.
Medical Care
- Begin treatment with simple decontamination. All pieces of plant should be removed and the mouth gently rinsed with water to eliminate all residual components. Induced emesis and gastric lavage are not indicated.
- Ingesting demulcifying agents, such as cold milk or ice cream, may help.
- Based on severity of pain, analgesics, including acetaminophen, ibuprofen, or codeine derivatives, may be necessary.
- Steroids may be beneficial for severe cases. Antihistamines may improve patient comfort in moderate or severe cases. No controlled trials have reported on the use of steroids or antihistamines in this clinical setting.
- Ophthalmology follow-up should be arranged for ocular injuries. Antibiotic eyedrops, steroids, or both may be prescribed, but consultation with an ophthalmologist about what agent to prescribe is recommended.
Consultations
- Poison control centers
- Report all exposures to the regional poison control center.
- Poison control centers are the only national organizations currently tracking all poisonous and injurious plant exposures.
- Staff members at poison control centers may be helpful with plant identification and can provide follow-up telephone calls to patients at home.
- Ophthalmologist: In children with eye involvement, an ophthalmologist should be contacted and appropriate follow-up for reevaluation should be arranged.
Drug Category: Analgesic agents
The mainstay of treatment is to control pain, and, usually, over-the-counter acetaminophen or ibuprofen can be used. Codeine derivatives occasionally may be necessary.
| Drug Name | Acetaminophen (Tylenol) |
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| Description | DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Effective in relieving mild to moderate acute pain; however, has no peripheral anti-inflammatory effects. |
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| Adult Dose | 325-650 mg PO/PR q4-6h or 1000 mg tid/qid; not to exceed 4 g/d |
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| Pediatric Dose | <12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 4 g/d |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; contained in many OTC products and combined use with these products may result in toxicity due to cumulative doses exceeding recommended maximum dose |
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| Drug Name | Ibuprofen (Advil, Motrin) |
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| Description | DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. |
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| Adult Dose | 200-600 mg PO q8h prn |
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| Pediatric Dose | 10 mg/kg PO q6-8h prn |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding |
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| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
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| Precautions | Pregnancy category D in third trimester; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy |
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| Drug Name | Codeine |
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| Description | For symptomatic relief pain not relieved by acetaminophen or ibuprofen. Binds to opiate receptors in CNS, causing inhibition of ascending pain pathways, altering perception and response to pain. |
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| Adult Dose | 10-20 mg/dose PO q4-6h prn; not to exceed 120 mg/d |
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| Pediatric Dose | <2 years: Not established
2-6 years: 1-1.5 mg/kg/d PO divided q4-6h prn; not to exceed 30 mg/d PO
6-12 years: 1-1.5 mg/kg/d PO divided q4-6h prn; not to exceed 60 mg/d PO
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Toxicity increases with concurrent administration of tricyclic antidepressants, MAO inhibitors, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics |
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| Pregnancy | C - Safety for use during pregnancy has not been established.
|
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| Precautions | May depress hypoxic ventilatory rate and respiratory drive during sleep |
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Further Inpatient Care
- Inpatient care is rarely necessary.
Further Outpatient Care
- Analgesia is the mainstay of treatment, and usually, over-the-counter acetaminophen or ibuprofen can be used. Codeine derivatives occasionally may be necessary.
- Maintain adequate hydration with clear cool fluids.
- Instruct patients to avoid salty or spicy foods, which may worsen the pain.
In/Out Patient Meds
- Acetaminophen
- Ibuprofen
- Codeine, hydrocodone, or oxycodone
Transfer
- Transfer is rarely necessary, except in patients with severe swelling with airway compromise.
Deterrence/Prevention
- Since 80% of exposures occur in children younger than 6 years, mostly within the home, prevention is paramount.
- All poisonous and injurious plants must be kept away from children.
- Parents of small children should keep potentially toxic household plants out of reach of children, just as they do with medications and cleaning supplies. The simplest and most effective way of safeguarding children is to avoid keeping toxic plants in and around the home.
- Children should be specifically instructed never to eat plants or wild berries.
Complications
- No long-term complications have been reported.
Prognosis
- Although painful, effects are self-limited.
- Prognosis is excellent.
Patient Education
- Instruct parents or guardians to accurately identify all ornamental plants and foliage around the home and to remove all potentially toxic plants.
- Instruct children to never eat plants or wild berries.
Medical/Legal Pitfalls
- Failure to identify the correct exposure(s)
- Failure to provide adequate decontamination
- Failure to provide adequate analgesia
- Failure to provide adequate instructions that detail the early warning signs of excessive drooling or stridor
- Failure to provide adequate follow-up for ocular exposures
Special Concerns
- Provide adequate analgesia so that the patient can take oral fluids and maintain hydration.
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Toxicity, Plants - Caladium, Dieffenbachia, and Philodendron excerpt Article Last Updated: Jun 21, 2006
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