Epidemic dropsy following transcutaneous absorption of Argemone mexicana oil

510 Tw.~s~cnms

OF THE ROYAL SOCETY OF TROPICALMEDICINE AND HYGIENE (1985) 79, 510-512

Epidemic

dropsy

following Argemone

transcutaneous mexicana oil

absorption

of

N. N. SOODI*, MAHIPAL S. SACHDEV’, MADAN MOHAN’, S. K. GUFTA’ AND H. P. S. SACHDEV’ ‘Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India; ‘Safdarjung Hospital, New Delhi, India Abstract

Four casesmanifesting features characteristic of epidemic dropsy following body massagewith contaminated mustard oil are reported. A transcutaneous route of absorption for the toxin (sanguinarine) resulting in epidemic dropsy has not been documented previously in man. Oil used for body massagewas found to be adulterated with Argemone mexicana oil, while hydrogenated vegetable fat used for cooking did not reveal any contamination. Diagnosis of the diseasewas confirmed by establishing the presence of sanguinarine in the urine and serum of all four cases. Introduction

Epidemic dropsy, an acute toxic disease, is caused by the unintentional ingestion of Argemone mexicana oil as an adulterant of cooking oils, especially mustard oil (MANSON-BAHR & APTED, 1982). The alkaloids sanguinarine and dihydrosanguinarine have been shown to be the toxic aetiological agents found in Argemone mexicana oil (SARKAR, 1948).

The most striking feature is the explosive onset of oedema of the legs in a previously unaffected community using contaminated mustard oil for cooking. Other manifestations include cutaneous features consisting of tenderness, erythema and rash over the oedematous parts, gastro-intestinal symptoms, lowgrade fever, hepatomegaly, tachycardia, wide pulse pressure, congestive cardiac failure which may eventually be fatal, glaucoma, retinal vascular changes in the form of dilated, tortuous vessels and superficial retinal haemorrhages (MANSON-BAHR & -APTED, 1982; TANDON er al., 1975; MOHAN et al., 1984; RATHORE, 1982).

Widespread epidemics have been reported from India. Mauritius. Fiii Islands. North-West Cane Districts of South Africa and possibly also Madagascar (MANSON-BAHR & APTED, 1982). Although suggested by CHAKRAVARTY

&

CHAUDHRY (1951). corroborative clinical evidence establishing toxin’absorption from the skin is still lacking. Four individuals developed the disease following body massagewith contaminated mustard oil. The source of the oil and the clinical features in these subjects were similar to those of 233 other patients (ingesting contaminated mustard oil) investigated by us (MOHAN et al., 1984) recently during an outbreak of epidemic dropsy in Delhi. This communication reports and documents the development of typical manifestations of epidemic dropsy following body massagewith mustard oil adulterated with Argemone mexicana oil. Subiects

and Methods

A field survey was carried out in three colonies and one village of South Delhi to investigate an outbreak of epidemic dropsy. Four patients presenting with symptoms characteristic of epidemic dropsy but with a definite negative history of oral intake of contaminated mustard oil were studied in detail.

After obtaining a detailed and reliable history, a thorough systemic and ocular examination was carried out. Investigations included urine examination, haemogram, blood sugar, urea, serum proteins and transaminases. Electrocardiogram and M-mode echocardiography was carried out in three cases. Diagnosis of epidemic dropsy was established by biochemical tests for the detection of sanguinarine in the oil, serum and urine of all these casestested separately. Samples of oil used for bodv massaaeand veaetable fat (ahee) used for cooking were subjected ‘fo the fe;ric chloridi and cupric acetate tests (MOHAN et al., 1984; SEN, 1946). The sanguinarine alkaloid in urine and serum was estimated by the soectro-fluoroohotometric method (TANDON et al., 1975) using Silica gel-e. Results

All four patients (belonging to different households) were males aged one, 20, 25 and 32 years and presented with bilaterally symmetrical swelling of the feet for periods ranging between three and sevendays. Nausea, anorexia, diarrhoea and local symptoms of burning, tingling sensation, pain and rednessover the oedematousfeet appeared subsequently in two cases. History of fever, cardiovascular, respiratory and renal symptoms were absent. As a daily routine, mustard oil was being used for body anointment before bathing in all these subjects. The approximate quantities of oil used for one massagewas about 20 to 40 cc. The duration of contact before bathing ranged between 30 min and one hour. Onlv tinned hvdroeenated vegetablefat was used for cooking purposes.The oil used by all these four patients, as also by the other 233 patients who developed the diseasesecondary to ingestion of contaminated mustard oil, was procured loose from a common vendor who visited the localities regularly. Salient positive examination findings included bilateral pitting oedema with erythema, rash and tenderness;pallor; low grade fever; and tachycardia in all cases. Wide pulse pressure in three cases; nontender hepatomegaly

and dilated,

tortuous

retinal

veins were found additionally in two cases. A peripapillary superficial retinal haemorrhage was observed in one case.There was no evidence of raised intraocular pressure in any of these cases. *For correspondence and reprints.

N.

N.

SOOD

et

511

d.

Table I-Details of history, manifestations characteristic of epidemic dropsy and biochemical investigations in four cases following the use of mustard oil contaminated with Argemone mexicana oil for body massage

Case 1

Case 2

Case 3

Case 4

1

20

25

32

4

5

6

5

376 90155 -

3;2 120165 -c

115160 -

3Lo 130170 +

-

+ -

-

+ +

i.6 4

3.5 0.7 3.5

2.6 0.8 4

142 5

Age in years Duration of use of contaminated oil (weeks) Gastro-intestinal symptoms Temperature (Centigrade) Blood pressure (mm of Hg) Hepatomegaly Dilated and tortuous retinal veins Retinal haemorrhage Sanguinarine levels in: a. Serum (pg/lOO ml) b. urine (pg/lOO ml) c. mustard oil (%)

Investigations revealed a normocytic, hypochromic anaemia as a constant feature. Blood sugar, urea, serum transaminases, serum proteins and urine examination were essentially normal. Electrocardiogram and echocardiography (three cases)were within normal limits. The diagnosis of epidemic dropsy was confirmed by the presence of sanguinarine in blood ranging from 2 to 4 pg/lOO ml and urine (0.6 to 1.2 pg/lOO ml) Mustard oil used for body massage showed sanguinarine contamination in all samples. Tinned hydrogenated vegetablefat was being used for cooking in all the four households. Samples from these were found to be negative for sanguinarine. On discontinuation of body massage and symptomatic treatment consisting of diuretics, antipyretics, anti-inflammatory drugs and multivitamins, the diseasemanifestations subsided in one to three weeks in all these cases.Retinal vascular changestook two to three weeks to resolve, haemorrhagebeing the first to disappear. Salient features as regards history, clinical manifestations and investigations of all four casesare given in Table I. Discussion

In monkeys, it has been shown by CHAKRAVARTY & CHAUDHRY(1951) that application of pure Argemaneoil on the skin produces cutaneous lesions asalso histopathological changescharacteristic of the disease in various tissues. They concluded that Argenume oil is absorbed from the intact, healthy skin of monkeys and incriminated such a mode of absorption in human epidemic dropsy. Also, CHAKRAVARTY& CHAUDHRY (1951) reported development of local erythema (without any other signs or symptoms of epidemic dropsy) in one of the animal handlers after accidental brushing with pure Argemone oil. Interestingly enough, conclusive evidence in a clinical setting, resulting in a picture of the disease, similar to that which is caused by ingestion of oil contaminated with Argemone oil is still lacking. Oedema of the feet, rash, erythema, local tenderness, tachycardia, wide pulse pressure, anaemia, low grade fever and retinal vascular changes present in

377

-

these cases are all well documented features of epidemic dropsy. A negative history of oral intake of oil, the presence of sanguinarine in the serum and urine and in the oil used for body massage,as also the alleviation of toxic symptoms following dtscontinuation of body massage with contaminated mustard oil, irrefutably confirmed that the diseasecan also be causedby toxin absorption through the skin in man. To the best of our knowledge, this is the first clinical report documentmg such a mode of absorption in humans, resulting in typical cutaneous, systemic and ocular manifestations characteristic of epidemic dropsy. On heating, Argemone oil loses much of its toxicity (CHOPRAet al., 1939). Relatively poorer absorption through the skin as compared with that from the gastro-intestinal tract could well be compensated for by the fact that oil used for body massageis not heated before use. This finding is of importance in view of the fact that body massage with mustard oil is an extremely common practice in India. According to MANSONBAHR & APTED (1982) sucklings are seldom affected by the disease. Similarly, breast fed babies may still be vulnerable to this diseasebecauseof body massage with oil, as we observed in a child. References Chakravarty,N. K. & Chaudhry,R. N. (1951).Production of epidemicdropsyin monkeys.Indian Medical Gazette, 86, 391-395.

Chopra,R. N., Pasricha,C. L., Goyal, R. T., Lal, S. & Sen,

A. K. (1939). The experimental production of syndrome of epidemic dropsy in man. Indian Medical Gazette, 74, 193-195. Manson-Bahr, P. E. C. & Apted, F. I. C. (1982). Plant Poisons. In: Manson’s Tropical Diseases. (18th edit.). London: The English Language Book Society and Baillitre Tindall, pp. 571-572. Mohan, M., Sood, N. N., Dayal, Y., Sachdev, M. P. S., Chandrashekhar, G., Gupta, S. K. & Bhatnagar, S. (1984). Ocular and clinicoepidemiological study of epidemicdropsy.IndianJoumal ofMedical Research,80, 449-456. Rathore, M. K. (1982). Ophthalmological study of epidemic dropsy. British Juumal of Ophthalmology, 66, 573-575.

EPIDEMIC

512

DROPSY

FOLLOWING

Sarkar, S. N. (1948). Isolation from Argemone oil of ~~ydro~~~~e and Sanguinarine; toxicity of Sangoinarine.

Nutwe,

ABSORPTION

OF MUSTARD

OIL

Tandon, B. N. (1975). Epidemic dropsy in New Delhi. of Clinical Nutrition, 28, 883-887.

American Jawnal

162, 265-266.

Sen, A. K. (1946). Argemone oil. Indian medical Gazette, 81, 126-128. Tandon, R. K., Singh, D. S., Arora, R. R., Lal, P. &

Accepted jii

~~&licuti~ 24th Se~t~ber,

1984.

Book Review Tropical M~rob~o~o~.

D. G. Montefiore,

K.

0.

Alausa and 0. Tomori. ‘Medicine in the Tronics’ Series. Edinburgh: Churchill Livingstone, 358=pp. ISBN 0 443 02741 2. The title is wrong: “Microbiology in the tropics” might be more appropriate, as tropical microbiology implies the study of purely tropical conditions, which this volume does not do. There are two general sections of the book: one deals with the general properties of bacteria, collection of samples, normal body flora, sterilization and disinfection, immunology of infection, antigen-antibody reactions, h~rsensitivity, immunity and immoo-deficiencies, the general properties of viruses, laboratory diagnosis of virus infections, and immunity to viruses. The second section deals with systemic microbiology, of bacteria, chlamydia and rickettsiae, and viruses. Each chapter of systemic microbiology starts with a short statement called “Tropical implications”, which states, in very simple terms, whether the clinical conditions produced by the organism under discussion are common or rare in the tropics: there then

follow paragraphs dealing with (sometimes) microbiology, pathogenesis, diseasesstates, and treatment. The book gives a reasonable, clear, and readable account of the important microbial conditions of man. My main anxiety is that I cannot seewho is going to use the book: in their introduction, the authors claim that it is aimed at students, but will benefit general practitioners and post-graduate doctors in the tropics: however, microbiologists will find the technical sections quite inadequate: clinicians will find little of value in the sections dealing with disease states and treatment (for example, the treatment of plague states “tetraevcline is the drug of choice”-no doses. no routes,* no duration, no alternatives, no combked therapies, nothing on ~hemoprophyl~s). The Medicine in the Tropics series is a most useful and well-though out series: this present volume complements the series, but is, in itself, inadequate except for medical students looking for an easily-read and relaxed form of revision. G. H. RIFE