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Foxglove tea poisoning
Foxglove Tea Poisoning
S. DICKSTEIN, M.D. FREDERICK W. KUNKEL, M.D.
EMIL
Youngstown. Ohio
Herbal teas occasionally produce toxic reactions. Unwitting use of the foxglove plant for brewing tea resulted in cardiac glycoside toxicity in an otherwise healthy man. Potentially toxic plants are omnipresent whereas herbal tea imbibing has had an enhanced popularity. Physicians will have increasing contact with patients who have inadvertently poisoned themselves with such concoctions. Herbal teas have been used for centuries for the promotion of good health and as therapy for a wide variety of ailments. In the last few years there has been a resurgence in the use of herbal teas [l-4]. Benefits are reportedly widespread although untoward effects are rarely mentioned. We describe a patient who experienced an unpleasant reaction to one type of herbal tea. CASE REPORT
From the Department of Medicine, Youngstown Hospital Association, Youngstown, Ohio. Requests for reprints should be addressed to Dr. Emil S. Dickstein. Department of Medicine, Youngstown Hospital Association, 5437 Mahonine Avenue, Youngstown. Ohio 44515. Manuscript
accepted
August
21,.1979.
An 85 year old retired steel worker who had been healthy all his life, generally avoided medical care and relied on home remedies. His wife had regularly concocted herbal teas from leaves found in their backyard without problems for many years; however on the day of admission his wife felt ill and the patient picked some leaves from an unfamiliar plant, and made some tea which had an unusually bitter taste. He drank one cup and his wife had only one sip. Within a few hours he felt weak, nauseated, and began to notice yellow halos around objects. The nausea increased and he was brought to the emergency room where he was admitted. He denied the use of alcohol, tobacco or medications except for occasional vitamin E capsules. The patient was a slim, elderly man, rather anxious but in no acute distress. His blood pressure was 150/80 mm/Hg, pulse rate 80/min, respiratory rate 18, and his temperature was within normal limits. His skin was cool without diaphoresis. There was a mild pectus carinatum. The heart sounds were distant but considered to be regular without gallops. A grade 2/6 systolic ejection murmur was heard at the base of the heart radiating into the neck. There was mild epigastric tenderness. The remainder of his physical examination was unremarkable. An electrocardiogram was taken which revealed a sinus rhythm with prolonged P-R intervals and marked S-T segment depressions. The patient was monitored in the coronary care unit. He was found to have ventricular tachvcardia which resnonded to the administration of phenvtoin. On the second day he had a junctIona rhythm and on the third day atr”ia1 fibrillation, with a ventricular rate as low as 40 beats/minute with multiple premature ventricular contractions. The administration of phenytoin was discontinued on the fourth day, and the patient reverted to a normal sinus rhythm on the sixth day. Nausea and xanthopsia stopped on the fourth day. Routine laboratory and roentgenographic data were unremarkable. The maximum plasma potassium value was 5.4 meq/liter and the highest calcium
July 1980
The American Journal of Medicine
Volume 69
167
FOXGLOVE TEA POISONING-DICKSTEIN,
TABLE
I
Serum Digitoxin Hospital Course
tlospilal W
KUNKEL
and Digoxin Values
Diglloxin Wml)
1
During
Digoxin Wml) 1.8
n
G
4 5 6 7 8 9 10 11 12 13 14
59.0 56.0 44.5 41.2 38.5 38.0 35.5 28.5 28.5 25.5 24.0
for centuries. Several digitalis leaf preparations are still available for use. They are produced by grinding and milling leaves of Digitalis purpurea in the United States, whereas European leaf preparations are usually made from D. lanata; D. lanata contains digoxin, but D. purpurea does not. After ingestion, glycosides of D. purpurea are hydrolyzed to various active compounds including digitoxin, gitoxin and gitalin; minute amounts of digitoxin are then metabolized by the liver to digoxin.
1.01
NOTE: The patient ingested 0. purpurea which does not contain digoxin and these latter values are artifactual, as explained under “Comments”.
value was 7.7 meq/liter. Table I lists the serum digitoxin and digoxin values obtained by radioimmunoassay. The remainder of the hospital course was uneventful. Leaves were obtained from the plant used by the patient for his tea and examined by the Botany Department of Youngs-
town State University, where they were identified as belonging to the foxglove plant Digitalis purpurea (Figure 11. It is unknown if the patient or his wife continue to brew herbal tea.
COMMENTS We have not found documented instances of digitalis toxicity due to foxglove herbal tea preparation in recent medical publications. Herbal tea poisonings per se certainly occurred long before Socrates drank his famous cup of hemlock. In 50 A.D. Dioscorides warned against abuse of herbal preparations in his De Materia Medica, a compilation of Greek and Roman leaf lore
M. Herbal poisonings continue to occur. The side-effects after ingestion of herbal teas range from atropine-like actions, veno-occlusive disease and severe hematologic disorders, to bizarre behavioral reactions and tumor growths such as hepatomas and esophageal cancers [5-81.
Innumerabl’e plants have been used in toxic teas, including the jimson weed, marijuana, juniper, persimmon and passion flower plants, among many others. Certain plants have digitalis-like activities such as the dogbane Apocynum cannabinum, the wallflower Cheiranthus cheiri, the lily-of-the-valley Convallaria majalis, and the oleander Narium oleander [5-81. Regular nonherbal tea (Camellia sinensis) itself has not escaped an association with rat carcinogenic@ [8]. The foxglove plant has a worldwide distribution. Foxglove-derived digitalis compounds in the form of powdered leaf and tincture were standard medicinals
166
July 1960
The American Journal of Medicine
Figure 1.
The foxglove plant Digitalis purpurea. From Hardin
and Arena
[ 51.
Volume 69
FOXGLOVE TEA POISONING-DICKSTEIN,
The radioimmunoassay for digitoxin lacks complete specificity hence artifactual values for glycosides not present are obtained. Thus, our patient had significant levels of nonexistent digoxin as noted in Table I. The duration of toxic effects in our patient was four to six days, a typical length of time reflecting serum half-lives of digitoxin and gitalin of 4.6 to 5.6 days. The potential for abuse of glycosides was known long ago. William Withering discussed digitalis toxicity and protested against iatrogenic misuse of the plant in 1785 [I$]. In the last few years there have been frequent reports of suicidal and accidental ingestion of digoxin
KUNKEL
and digitoxin as well as clinical overdosage. Death is usually due to lethal arrhythmias and refractory hyperkalemia [lo-121. Toxic gastrointestinal symptoms are multiple and well-known; psychiatric manifestations are often present but poorly recognized [13]. Our patient’s experience suggests that physicians should be aware of the prevalence of herbal tea drinking and of the widespread availability of potentially toxic plants such as the foxglove. People who plan to use these commonly grown plants should familiarize themselves with their potential toxicity before using them for medicinal or other purposes [5].
REFERENCES 1.
2. 3. 4. 5. 6. 7. 8.
Garrison FH: An introduction to the history of medicine. 4th ed. Philadelphia: WB Saunders, 1963. Grieve M: A modern herbal. London: Peregrine Books, 1976. Rose J: Herbs and things. New York: Grosset & Dunlap, 1972. Lust J: The herb book. New York: Bantam Books, 1974. Hardin JW, Arena JM: Human poisoning from native and cultivated plants, 2nd ed. Durham, North Carolina: Duke University Press, 1974. Siegel RK: Herbal intoxication. JAMA 1976; 236: 473-476. Stein H. Isaacson C: Veno-occlusive disease of the liver. Br Med J 1962; 1: 372-374. Kapadia GJ, Paul BD. Chung EB, Ghosh B. Pradhan SN:
9. 10. 11. 12. 13.
July 1980
Carcinogenicity of Camellia sinensis [teal and some Tannin-containing folk medicinal herbs administered subcutaneously in rats. JNCI 1976; 57: 207-209. Withering W: An account of the foxglove. In: Willins FA, Keys TE. eds. Classics of cardiology, vol. 1. New York: Dover Publications, 1961: 232-252. Smith TW, Willerson JT: Suicidal and accidental digoxin ingestion. Circulation 1971: 44: 29-36. Reza MJ, et al.: Massive intravenous digoxin overdosage. N Engl J Med 1974; 291: 777-778. Iacuone JJ: Accidental digitoxin poisoning. Am J Dis Child 1976; 130: 425-427. Shear M, Sacks MH: Digitalis delirium: report of two cases. Am J Psychiatry 1978: 135: 109-110.
The American Journal of Medicine
Volume 69
169
S. DICKSTEIN, M.D. FREDERICK W. KUNKEL, M.D.
EMIL
Youngstown. Ohio
Herbal teas occasionally produce toxic reactions. Unwitting use of the foxglove plant for brewing tea resulted in cardiac glycoside toxicity in an otherwise healthy man. Potentially toxic plants are omnipresent whereas herbal tea imbibing has had an enhanced popularity. Physicians will have increasing contact with patients who have inadvertently poisoned themselves with such concoctions. Herbal teas have been used for centuries for the promotion of good health and as therapy for a wide variety of ailments. In the last few years there has been a resurgence in the use of herbal teas [l-4]. Benefits are reportedly widespread although untoward effects are rarely mentioned. We describe a patient who experienced an unpleasant reaction to one type of herbal tea. CASE REPORT
From the Department of Medicine, Youngstown Hospital Association, Youngstown, Ohio. Requests for reprints should be addressed to Dr. Emil S. Dickstein. Department of Medicine, Youngstown Hospital Association, 5437 Mahonine Avenue, Youngstown. Ohio 44515. Manuscript
accepted
August
21,.1979.
An 85 year old retired steel worker who had been healthy all his life, generally avoided medical care and relied on home remedies. His wife had regularly concocted herbal teas from leaves found in their backyard without problems for many years; however on the day of admission his wife felt ill and the patient picked some leaves from an unfamiliar plant, and made some tea which had an unusually bitter taste. He drank one cup and his wife had only one sip. Within a few hours he felt weak, nauseated, and began to notice yellow halos around objects. The nausea increased and he was brought to the emergency room where he was admitted. He denied the use of alcohol, tobacco or medications except for occasional vitamin E capsules. The patient was a slim, elderly man, rather anxious but in no acute distress. His blood pressure was 150/80 mm/Hg, pulse rate 80/min, respiratory rate 18, and his temperature was within normal limits. His skin was cool without diaphoresis. There was a mild pectus carinatum. The heart sounds were distant but considered to be regular without gallops. A grade 2/6 systolic ejection murmur was heard at the base of the heart radiating into the neck. There was mild epigastric tenderness. The remainder of his physical examination was unremarkable. An electrocardiogram was taken which revealed a sinus rhythm with prolonged P-R intervals and marked S-T segment depressions. The patient was monitored in the coronary care unit. He was found to have ventricular tachvcardia which resnonded to the administration of phenvtoin. On the second day he had a junctIona rhythm and on the third day atr”ia1 fibrillation, with a ventricular rate as low as 40 beats/minute with multiple premature ventricular contractions. The administration of phenytoin was discontinued on the fourth day, and the patient reverted to a normal sinus rhythm on the sixth day. Nausea and xanthopsia stopped on the fourth day. Routine laboratory and roentgenographic data were unremarkable. The maximum plasma potassium value was 5.4 meq/liter and the highest calcium
July 1980
The American Journal of Medicine
Volume 69
167
FOXGLOVE TEA POISONING-DICKSTEIN,
TABLE
I
Serum Digitoxin Hospital Course
tlospilal W
KUNKEL
and Digoxin Values
Diglloxin Wml)
1
During
Digoxin Wml) 1.8
n
G
4 5 6 7 8 9 10 11 12 13 14
59.0 56.0 44.5 41.2 38.5 38.0 35.5 28.5 28.5 25.5 24.0
for centuries. Several digitalis leaf preparations are still available for use. They are produced by grinding and milling leaves of Digitalis purpurea in the United States, whereas European leaf preparations are usually made from D. lanata; D. lanata contains digoxin, but D. purpurea does not. After ingestion, glycosides of D. purpurea are hydrolyzed to various active compounds including digitoxin, gitoxin and gitalin; minute amounts of digitoxin are then metabolized by the liver to digoxin.
1.01
NOTE: The patient ingested 0. purpurea which does not contain digoxin and these latter values are artifactual, as explained under “Comments”.
value was 7.7 meq/liter. Table I lists the serum digitoxin and digoxin values obtained by radioimmunoassay. The remainder of the hospital course was uneventful. Leaves were obtained from the plant used by the patient for his tea and examined by the Botany Department of Youngs-
town State University, where they were identified as belonging to the foxglove plant Digitalis purpurea (Figure 11. It is unknown if the patient or his wife continue to brew herbal tea.
COMMENTS We have not found documented instances of digitalis toxicity due to foxglove herbal tea preparation in recent medical publications. Herbal tea poisonings per se certainly occurred long before Socrates drank his famous cup of hemlock. In 50 A.D. Dioscorides warned against abuse of herbal preparations in his De Materia Medica, a compilation of Greek and Roman leaf lore
M. Herbal poisonings continue to occur. The side-effects after ingestion of herbal teas range from atropine-like actions, veno-occlusive disease and severe hematologic disorders, to bizarre behavioral reactions and tumor growths such as hepatomas and esophageal cancers [5-81.
Innumerabl’e plants have been used in toxic teas, including the jimson weed, marijuana, juniper, persimmon and passion flower plants, among many others. Certain plants have digitalis-like activities such as the dogbane Apocynum cannabinum, the wallflower Cheiranthus cheiri, the lily-of-the-valley Convallaria majalis, and the oleander Narium oleander [5-81. Regular nonherbal tea (Camellia sinensis) itself has not escaped an association with rat carcinogenic@ [8]. The foxglove plant has a worldwide distribution. Foxglove-derived digitalis compounds in the form of powdered leaf and tincture were standard medicinals
166
July 1960
The American Journal of Medicine
Figure 1.
The foxglove plant Digitalis purpurea. From Hardin
and Arena
[ 51.
Volume 69
FOXGLOVE TEA POISONING-DICKSTEIN,
The radioimmunoassay for digitoxin lacks complete specificity hence artifactual values for glycosides not present are obtained. Thus, our patient had significant levels of nonexistent digoxin as noted in Table I. The duration of toxic effects in our patient was four to six days, a typical length of time reflecting serum half-lives of digitoxin and gitalin of 4.6 to 5.6 days. The potential for abuse of glycosides was known long ago. William Withering discussed digitalis toxicity and protested against iatrogenic misuse of the plant in 1785 [I$]. In the last few years there have been frequent reports of suicidal and accidental ingestion of digoxin
KUNKEL
and digitoxin as well as clinical overdosage. Death is usually due to lethal arrhythmias and refractory hyperkalemia [lo-121. Toxic gastrointestinal symptoms are multiple and well-known; psychiatric manifestations are often present but poorly recognized [13]. Our patient’s experience suggests that physicians should be aware of the prevalence of herbal tea drinking and of the widespread availability of potentially toxic plants such as the foxglove. People who plan to use these commonly grown plants should familiarize themselves with their potential toxicity before using them for medicinal or other purposes [5].
REFERENCES 1.
2. 3. 4. 5. 6. 7. 8.
Garrison FH: An introduction to the history of medicine. 4th ed. Philadelphia: WB Saunders, 1963. Grieve M: A modern herbal. London: Peregrine Books, 1976. Rose J: Herbs and things. New York: Grosset & Dunlap, 1972. Lust J: The herb book. New York: Bantam Books, 1974. Hardin JW, Arena JM: Human poisoning from native and cultivated plants, 2nd ed. Durham, North Carolina: Duke University Press, 1974. Siegel RK: Herbal intoxication. JAMA 1976; 236: 473-476. Stein H. Isaacson C: Veno-occlusive disease of the liver. Br Med J 1962; 1: 372-374. Kapadia GJ, Paul BD. Chung EB, Ghosh B. Pradhan SN:
9. 10. 11. 12. 13.
July 1980
Carcinogenicity of Camellia sinensis [teal and some Tannin-containing folk medicinal herbs administered subcutaneously in rats. JNCI 1976; 57: 207-209. Withering W: An account of the foxglove. In: Willins FA, Keys TE. eds. Classics of cardiology, vol. 1. New York: Dover Publications, 1961: 232-252. Smith TW, Willerson JT: Suicidal and accidental digoxin ingestion. Circulation 1971: 44: 29-36. Reza MJ, et al.: Massive intravenous digoxin overdosage. N Engl J Med 1974; 291: 777-778. Iacuone JJ: Accidental digitoxin poisoning. Am J Dis Child 1976; 130: 425-427. Shear M, Sacks MH: Digitalis delirium: report of two cases. Am J Psychiatry 1978: 135: 109-110.
The American Journal of Medicine
Volume 69
169