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Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology
Toxicity, Plants - Castor Bean and Jequirity Bean
Article Last Updated: Jun 19, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 10  
Author: William Gluckman, DO, MBA, Assistant Professor, Department of Surgery, Section of Emergency Medicine, University of Medicine and Dentistry of New Jersey, University Hospital
William Gluckman is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Coauthor(s):
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;
Gregory S Sugalski, MD, Staff Physician, Department of Emergency Medicine, University of Medicine and Dentistry of New Jersey 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; Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System; 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:
castor bean, jequirity bean, Abrus precatorius, prayer bean, ricinus communis, rosary pea
Background
Although castor and jequirity beans are an uncommon cause of poisoning, they remain significant because their toxins are among the most lethal naturally occurring toxins known today. The beans most commonly are used for ornamental purposes, such as prayer or rosary beads, or in musical shakers (maracas).
The castor bean plant (Ricinus communis) is found primarily in Asia and Africa, but the plant has taken root in all temperate and subtropical regions around the world. In fact, the castor bean plant grows in the southwest United States mainly along streams and riverbeds. Castor beans are oblong and brown in color with speckled dark brown spots.
Jequirity bean plant (Abrus precatorius) is found primarily in southeast Asia, but has spread to subtropical regions. The jequirity bean has a shiny appearance and is mainly red in color with a black spot.
For centuries, ricin and abrin, the toxin contained in the seeds of the castor and jequirity beans, respectively, have been used for homicidal purposes. The ease of production of ricin makes it very attractive as an agent that could be used by a terrorist or other criminal. The Centers for Disease Control and Prevention (CDC) categorizes ricin as a category B agent because it is moderately easy to disseminate while causing moderate-to-high morbidity in humans.
During the 1980s, the Iraqi government made weapon-grade ricin, and it was tested on animals and in artillery shells. In 2003, ricin was found in US Senator Bill Frist's office, and, in January of that same year, Arabs connected to Al-Qaeda were arrested in a London apartment while trying to manufacture ricin. Due to the ongoing threat of weapons of mass destruction (WMD) in the United States, that physicians become familiar with the diagnosis and treatment of poisonings due to substances such as ricin is essential.
Pathophysiology
These beans contain potent toxalbumins that inhibit protein synthesis and cause severe cytotoxic effects on multiple organ systems. Castor beans contain the toxalbumin ricin, and jequirity beans contain abrin. The toxins are present in all parts of the plant but are most concentrated in the beans or seeds. Symptoms include delayed gastroenteritis, which may be severe and hemorrhagic, followed by delirium, seizures, coma, and death. The beans are covered by a hard, relatively impervious outer shell that must be chewed or broken in some way in order for the toxalbumin to be released and, thus, present a toxic hazard. Castor beans are particularly antigenic and may cause severe cutaneous hypersensitivity and systemic reactions.
Frequency
United States
Jequirity and castor bean ingestions are extremely uncommon. The American Association of Poison Control Centers (AAPCC) recorded 502,951 plant exposures from 1999-2004. Of these, only 1273 have been due to toxalbumin exposure, and only 2 cases of toxalbumin-related deaths have been reported during this time period.
Mortality/Morbidity
- Fatalities occasionally have been reported following ingestion of chewed castor beans.
- Chewing and swallowing as little as 1 bean may produce death in a child; however, swallowing an intact bean without chewing is unlikely to cause serious sequelae.
- Jequirity bean mortality is 5% for ingestion, and death may occur up to 14 days after poisoning.
History
- Assess the usual significant features that are associated with toxic environmental exposures. This includes the following:
- Identification of substance
- Time and duration of exposure
- Symptoms
- Treatment thus far
- Associated injuries
- Preexisting conditions
- Identification
- Ask the parents to bring in a sample of the bean, if it is possible. Having the exact bean greatly aids in the identification process.
- Knowing that beans often are known by a variety of names, both common and scientific, is important.
- Time and duration of exposure: Determine whether the child chewed or swallowed any beans.
- Symptomatology:
- Following ingestion of jequirity beans, a latent period of about 3 days occurs, and symptoms may persist more than 10 days later. Patient may present with nausea, vomiting, diarrhea, abdominal cramps, hematemesis, and melena. In some cases, acute renal failure and hepatotoxicity may occur.
- Drowsiness and seizures have been reported after jequirity bean ingestion. If eye contact is made, the patient may report eye irritation and blindness. Skin contact may result in a rash.
- Following ingestion of castor beans, the patient may become symptomatic from 8-24 hours after exposure. The clinical picture may appear very similar to jequirity bean ingestion, with gastrointestinal symptoms that can progress to hypotension, liver and renal failure, and death.
- Inhalation of castor bean toxin can cause illness within 8 hours. Symptoms include cough, dyspnea, arthralgias, fever, respiratory distress, and death. Injection of ricin causes symptoms within 6 hours, which may include weakness and myalgias with progression of the illness to fever, hypotension, multiorgan failure, and death.
- Prior treatment: Determine if any treatment has been administered to the child prior to presentation.
- Associated injuries: Inquire about any other potential exposures or injury.
- Preexisting conditions: Inquire about past medical history, medications, and allergies.
Physical
- Assess airway patency. It is extremely uncommon to have any oral or upper airway swelling of sufficient magnitude to cause airway compromise. Breathing usually is unaffected. Circulation may become affected as shock develops, secondary to severe gastroenteritis.
- Patients may develop severe cutaneous hypersensitivity or systemic allergic reactions. An urticarial, immunoglobulin E–mediated allergic reaction may occur with the development of tongue or facial swelling, bronchospasm, and acute upper airway obstruction.
Causes
- Sources
- Both castor and jequirity beans commonly are encountered as ornamental beans or seeds.
- Castor and jequirity beans commonly are used as prayer beads, bracelets, or necklaces.
- Castor and jequirity beans also are used as the seeds that rattle in maracas.
Influenza
Plague
Salmonella Infection
Sepsis
Shigella Infection
Staphylococcus Aureus Infection
Tularemia
Other Problems to be Considered
Staphylococcal enterotoxin B
Trichothecene mycotoxin
Pyrolysis byproducts of Teflon, Kevlar
Phosgene
Paraquat
Acute arsenic toxicity
Acute inorganic mercury, thallium, or iron ingestion
Acute radiation sickness
Chemotherapeutic drugs
Capillary leak syndromes (eg, autoimmune vasculitis, Stevens-Johnson syndrome [SJS])
Lab Studies
- Laboratory evaluation should initially include CBC count with differential, basic metabolic profile (electrolyte levels), and liver function tests. Coagulation studies may be necessary if the gastroenteritis becomes hemorrhagic.
- Critically ill and hypotensive patients and those that meet systemic inflammatory response/sepsis criteria should have an arterial blood gas and lactate and cortisol levels measured.
- An enzyme-linked immunoassay (ELISA) can detect ricin in human urine and serum at concentrations of 100pg/mL or greater. Testing for ricin can be done by polymerase chain reaction (PCR) at a regional public health center laboratory by collecting 25 mL of urine.
- Additional analytic methods may be available for ricin detection through the US Army Medical Research Institute for Infectious Diseases and the CDC.
Imaging Studies
- Imaging studies are not necessary because the beans generally are not detectable by plain radiography.
Procedures
- Whole bowel irrigation
- Whole bowel irrigation (WBI) has been suggested as a possible treatment to ensure rapid and complete decontamination of the gastrointestinal tract; however, the potential benefit (if any) remains unproven.
- Consult with a medical toxicologist at the nearest regional poison control center before undertaking WBI.
- WBI is accomplished by a continuous instillation of a polyethylene glycol electrolyte lavage solution through the gastrointestinal tract until the effluent from the rectum is clear.
- Inserting a nasogastric tube and setting a continuous flow rate will accomplish WBI best.
- Rates of WBI vary according to age.
- Children aged 0-6 years: Flow rate is 500 mL/h.
- Children aged 6-12 years: Flow rate is 1000 mL/h.
- Children older than 12 years: Flow rate is 1500-2000 mL/h.
Medical Care
- The first priority in treating a patient with castor or jequirity bean poisoning is to establish that the patient's airway is patent and that breathing and circulation are adequate.
- Supportive care that is based upon clinical symptoms is the primary therapy. Replace GI fluid losses with intravenous fluids.
- WBI has been suggested to ensure rapid and complete decontamination of the gastrointestinal tract; however, the clinical utility of WBI has not been demonstrated. In theory, rapid elimination of the bean before erosion of the outer shell may decrease or prevent the release of potent toxins. Consult the nearest regional poison control center before undertaking WBI.
- Count beans to assure complete recovery.
- Patients should remain under observation for at least 4-6 hours. Asymptomatic patients may be discharged safely after this period.
- Once the patient is symptomatic, supportive care involves attention to fluid, glucose, and electrolyte replacement.
Consultations
- Poison control center
- Report all exposures to the regional poison control center.
- The AAPCC is the only national organization currently tracking all potentially poisonous ingestions and may be helpful in bean identification.
- Expert consultation with a trained toxicologist also is recommended and can be obtained at the regional poison control center.
Further Inpatient Care
- WBI is continued until the rectal effluent is clear and/or all of the beans have been recovered.
- Continue intravenous (IV) fluids at a rate that maintains adequate hydration and replacement of electrolytes.
- All symptomatic patients should be admitted to the hospital. Clinical course after ingestion and inhalation typically progresses over 4-36 hours, and monitoring in an ICU may be warranted.
Further Outpatient Care
- Maintain adequate hydration
- Antispasmodics, such as loperamide, are contraindicated.
Transfer
- Transfer children with severe systemic toxicity to a center that is capable of handling critically ill children.
- Transfer should occur after the child has been stabilized and whole bowel decontamination has been initiated.
Deterrence/Prevention
- Keep all potentially poisonous and injurious plants and plant-related products away from children.
- Homes should be purged of all potentially toxic plant items, just as they are for medications and cleaning supplies.
- Specifically instruct children to never eat plants, beans, or wild berries.
- Vaccine development has been attempted in animal studies, with evidence that either active immunization or passive prophylaxis is effective against IV or intraperitoneal intoxication only if given within a few hours of exposure. Vaccination is ineffective against aerosolized forms of the toxin.
- Ricin toxin vaccine (RiVax; DOR BioPharma, Miami, FL) has been shown in one small pilot study to be safe; it elicited ricin neutralizing antibodies, but larger studies are needed.
Complications
- Complications of toxalbumin toxicity include severe multisystem organ damage and death.
- Shock may occur.
- Disseminated intravascular coagulation (DIC) may occur.
- Seizures may occur.
Prognosis
- Prognosis for patients who develop symptoms generally is good with appropriate fluid management (and possibly with continuous WBI).
- Studies are limited, and accurate statistics are not known.
Patient Education
- Instruct parents or guardians to childproof homes from all potentially toxic plants and plant-related items.
Medical/Legal Pitfalls
- Failure to identify the correct exposure
- Failure to provide adequate decontamination in a timely manner
- Failure to maintain adequate circulation and normal electrolyte levels
Special Concerns
- Electrolyte disturbance
- Shock
- Hemorrhagic gastroenteritis
- Multisystem organ failure
- Other concerns:
- In the face of credible threats, clinicians should consider ricin poisoning in patients who present with GI or respiratory illness. Be sure to notify poison control centers, public health, and local law enforcement agencies.
- Clinicians must have a low threshold of suspicion for patients who present with nonspecific systemic illness especially when a large number of patients with similar symptoms are present.
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Toxicity, Plants - Castor Bean and Jequirity Bean excerpt Article Last Updated: Jun 19, 2006
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