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Strychnine poisoning from a cambodian traditional remedy
Strychnine Poisoning From a Cambodian Traditional Remedy JAMES KATZ, MD, MPH,* KENNETH PRESCOTT, MD,1ALAN D. WOOLF, MD, MPH::I: Immigrant populations frequently continue to rely on nonallopathic medical treatments for various ailments after they arrive in the United States. Herbalists, acupuncturists, and other indigenous healers often prescribe remedies unfamiliar to the physician. In many cases such remedies are innocuous or helpful to the patient's convalescence from an illness, but occasionally they may be harmful or associated with important toxicities. We report the case of a woman who experienced severe poisoning from a traditional Cambodian remedy for a gastrointestinal disorder. Strychnine, a rare cause of poisoning in the United States today, was the toxic agent implicated in her clinical presentation.
CASE REPORT A 58-year-old Cambodian woman presented to the emergency department (ED) of a large community hospital with dizziness, an episode of falling at home, and crampy abdominal and leg pain following a "conscious seizure." Members of the family reported that the patient had painful tonic-clonic movements in all extremities while wide awake. These symptoms began shortly after the patient reportedly ingested a "Slang Nut" (Figure 1). Her family attempted to treat the woman's symptoms by coin rubbing to no avail; shortly thereafter, with no relief of her distress, they transported her to the ED. On examination, the patient was found to have orthostatic hypotension: lying blood pressure, 130/100 mm Hg, with a pulse of 110 beats/rain; sitting blood pressure, 100/60 mm Hg, with a pulse of 120 beats/min (the patient could not stand). She was conscious but confused and hyperreflexic. Thigh muscles were tense and tender to touch; knee jerks had seven beats of clonus. There was 2+ bilateral horizontal nystagmus. The rest of the examination results were within normal limits. She was admitted to the intensive care unit. Arterial blood gases revealed a pH of 7.43, PCO2of 34, PO2 of 90, and oxygen saturation of 97%. Other laboratory analyses showed the following levels: Na, 142 mEq/L; K, 2.9 mEq/L; C1, 104 mEq/L; HCO2, 23 mEq/L. The anion gap value was 15 mEq/L. The plasma lactate concentration was elevated at 3.8 mEq/L (normal 0.5 to 1.6 mEq/L), as was the serum myoglobin concentration. The patient recovered uneventfully without anticonvulsant therapy and was discharged 5 days after admission, Samples of the "Slang Nuts" were later sent for analysis by thin layer chromatography, which, qualitatively, confirmed the presence of strychnine. The "Slang Nut" was identified by a Cambodian interpreter as
From the Departments of *Medicine and -j-Emergency Medicine, Saint Joseph's Hospital, Lowell, MA, and the :[:Department of Pediatrics, Harvard Medical School, and the Massachusetts Poison Control System. Manuscript received July 10, 1995, accepted July 21, 1995. Address reprint requests to Dr Woolf, Massachusetts Poison Control Center, 300 Longwood Ave, Boston, MA 02115. Key Words: Poisoning, strychnine, Cambodian traditional remedy. Copyright © 1996 by W.B. Saunders Company 0735-6757/96/1405-001255.00/0
the fruit of a tree indigenous to Southeast Asia and commonly known by the Cambodian population as a "poisonous nut," which nevertheless has been used in the cure of some gastrointestinal illnesses. It was identified by the poison center as the fruit of the plant Strychnos nux vomica, the natural origin of the chemical strychnine.
DISCUSSION A relatively tasteless and odorless white powder, strychnine has a long history of use as an instrument for suicide or homicide. It has also been used as an adulterant for drugs of abuse, primarily cocaine or heroin, by unscrupulous suppliers. Although it has been touted in the past as a purgative, digestive aide, a remedy for snakebite, an aphrodisiac, and a cure for sleep disorders, it in fact has no known medicinal value and is no longer available in the United States in any medicinal products. However, even in the 1990s, strychninecontaining "Spanish fly" has been reportedly imported from Mexico, resulting in cases of poisoning. Strychnine's previous commercial use has been as a pesticide and rodenticide, although it is no longer available, having been replaced in the United States by less dangerous formulations. Nevertheless, there have still been cases of poisoning in which a rodenticide has been implicated. >4 Most strychnine poisonings now, however, are associated with illicit drug use. 5 The 1992 report from the American Association of Poison Control Centers listed 21 human exposures to strychnine in the United States, with 2 reports of death. 6 The use of traditional healing is common among Southeast Asian people; 58% of a sample of 80 Southeast Asian refugees in a primary care clinic reported using one or more traditional health practices. 7 Such traditional practices may include coin-rubbing and massaging the skin, so-called "moxibustion" or burning of the skin, acupuncture, the pinching or "cupping" of the skin, dietary restrictions, hair-pulling, healing ceremonies, and the use of herbs, aromatic oils, and/or teas. 8,9 Different Southeast Asian cultures may utilize different practices for the same indications. Although some of these practices may be superficially dysfiguring, few are thought to be very harmful. Indeed, 78% of patients who use traditional healing techniques reported the alleviation of their symptoms, m Some herbal remedies, however, can cause serious, even life-threatening, adverse health effects, n There is little previously written in the medical literature about the use of the "Slang Nut" as a Cambodian traditional cure. In Thailand, the same nut, known as the "Slang Chai Nut," is also used by rural populations in traditional medical practices (personal communication, Dr. Surajit Suntorntham, May 1993). The high concentration of the extremely toxic substance, strychnine, 475
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
FIGURE 1. The "Slang Nut." in "Slang Nuts" makes this traditional therapy dangerous. "Slang Nuts" are the fruit of the small tree, Strychnos nox vomica (family Loganiaceae), which has ovate leaves and yellowish white tubular flowers. 12 The tree is indigenous to India but also grows in parts of Indochina, Northern Australia, and Hawaii. The fruit is 1.5 inches across, hard shelled, and yellow to orange in color, containing 0.5-inchdiameter greyish seeds. The whole plant, including the seeds, contains strychnine and is considered poisonous. The seeds contain 1.1% to 1.4% strychnine; in adults the lethal dose of strychnine is 50 to 100 mg. 13 Strychnine is readily absorbed from the small intestine and quickly distributed to target neuronal tissues, so onset of symptoms may occur as soon as 15 to 60 minutes after ingestion.~4 It is a potent toxin that blocks the receptor at the postsynaptic junction of the inhibitory neurons in the spinal cord, brain stem, and higher centers that use glycine as a neurotransmitter. Consequently the disinhibited motor neuron discharges continuously, resulting in profound excitational effects on muscles manifested as clonic and generalized "spinal seizures" during which the patient may be fully alert. Opithotonus, facial trismus, nystagmus, and rigid flexion or extension of large muscle groups are also seen. The neuronal hyperexcitability is exaggerated such that relatively minor stimuli may trigger seizurelike reactions. The seizures may have rapid onset, may be relentlessly repetitive, and may compromise respiratory function. Although initially awake, patients may become hypoxic from diaphragmatic or respiratory muscle paralysis. Death from respiratory arrest or secondary to hypoxic asphyxia may supervene. Strychnine is metabolized by the hepatic microsomal system and is probably eliminated within 12 hours of an acute overdose; patients who survive beyond that time will likely fully recover.15 Therapy should include oral decontamination and the use of benzodiazepines for seizures or muscle spasms. If anticonvulsants are not effective in stopping the paroxysmal seizures, intubation, pharmacologic paralysis, and mechanical ventilation may be necessary. Ipecac is contraindicated because of the risk for aspiration during subsequent seizure activity, although lavage should be considered for decontaminating a patient early after the airway is secured and seizures are controlled. Activated charcoal is a very effective adsorbent of strychnine for use in decontaminating patients. The reflex hyperexcitability associated with strychnine poisoning dictates that any therapeutic intervention, such as lavage or the instillation of charcoal, be accompanied by careful securing of the airway. Extrane-
ous stimuli, including loud noises or excessive manipulation of the patient, should be avoided. Because strychnine is rapidly redistributed from the blood in an overdose, extracorporeal methods of elimination, such as hemodialysis, are unlikely to be effective.~6 In Cambodian patients, poisoning from "Slang Nuts" should be differentiated from other toxins that cause seizures, especially isoniazid, which has been previously shown to be an agent commonly used in suicide attempts by Cambodians with psychiatric disorders. 17 Other diagnoses sometimes confused with the seizures, nystagmus, and opisthotonos typical of strychnine poisoning include tetanus, rabies, hypocalcemic tetany, drug withdrawal syndromes, drug-induced dystonic reactions, or meningitis. TM The elevated anion gap, elevated plasma lactate concentration, and myoglobinemia with myoglobinuria, all seen in the present case, are common laboratory features of strychnine poisoning attributable to either the forceful muscle contractions or the resultant rhabdomyolysis. Extreme metabolic acidosis, although not seen in our case, is also commonly encountered during strychnine intoxication because of seizures and lactate production, even in the absence of significant hypoxia or cardiac arrest. In her country of origin, our patient had used "Slang Nuts" wrapped in tobacco and leaves and held against the buccal mucosa as a mild stimulant and for abdominal discomfort. Lacking the accessories here, she had placed the unclad seed in her mouth and chewed it. While it is unknown how prevalent the use of "Slang Nuts" is by Cambodian refugees in America and how such a remedy is acquired, it appears to be a common practice, especially among older Cambodians. We alert clinicians who treat Indochinese immigrants to the dangers of the use of "Slang Nuts" as a purgative in traditional Cambodian medicine. "Slang Nut" poisoning should be suspected in a Cambodian patient who presents with a clinical syndrome of abdominal distress followed by multiple clonic seizures, acidosis, and elevated lactate levels.
REFERENCES 1. Boston Globe: Warning is issued on Spanish fly. August 26, 1991 2. Perper JA: Fatal strychnine poisoning--A case report and review of the literature. J Forensic Sci 1985;30:1248-1255 3. Lambert JR, Byrick RJ, Hammeke MD: Management of acute strychnine poisoning. CMA Journal 1981 ;124:1268-1270 4. Winek CL, Wahba WW, Esposito FM, Collom WD: Fatal strychnine ingestion. J Analytical Toxico11986;10:120-121 5. Boyd RE, Brennan PT, Deng JF, et al: Strychnine poisoning-Recovery from profound lactic acidosis, hyperthermia, and rhabdomyolysis. Am J Med 1983;74:507-512 6. Litovitz TL, Holm KC, Bailey KM, Schmitz BF: 1992 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1993; 11:494-555 7. Buchwald D, Panwala S, Hooton TM: Use of traditional health practices by Southeast Asian refugees in a primary care clinic. West J Med 1992;156:507-511 8. Yeatman GW, Van Dang V: Cao Gio (coin rubbing)--Vietnamese attitudes toward health care. JAMA 1980;244:2748-2749 9. Reinhart MA, Ruhs H: Moxibustion. Clin Pediatr 1985;24:58-59 10. Buchwald D, Panwala S, Hooton TM: Use of traditional health practices by Southeast Asian refugees in a primary care clinic. West J Med 1992;156:507-511
KATZ ET AL • STRYCHNINE POISONING FROM CAMBODIAN REMEDY
11. Jin Bu Huan toxicity in children--Colorado, 1993. MMWR Mortal Morbid Wkly Rep 1993;42:633-636 12. Lampe KF, McCann MA: Strychnos nux vomica. In AMA Handbook of Poisonous and Injurious Plants. Chicago, IL, American Medical Association, 1985 13. Perper JA: Fatal strychnine poisoning--A case report and review of the literature. J Forensic Sci 1985;30:1248-1255 14. Gordon AM, Richards DW: Strychnine intoxication. J Am Cell Emerg Med 1979;8:520-522 15. Boyd RE, Brennan PT, Deng JF, et al: Strychnine poisoning.
477
Recovery from profound lactic acidosis, hyperthermia, and rhabdomyolysis. Am J Med 1983;74:507-512 16. Dittrich K, Bayer MJ, Wanke LA: A case of fatal strychnine poisoning. J Emerg Med 1984;1:327-330 17. Blanchard PD, Yao JDC, McAIpine DE, Hurt RD: Isoniazid overdose in the Cambodian population of OImstead County, Minnesota. JAMA 1986;256:3131-3133 18. Mackler S, Moskowitz M: Tetanus or drug reaction? Hosp Pract (Office Edition) 1989;24:75-89
CASE REPORT A 58-year-old Cambodian woman presented to the emergency department (ED) of a large community hospital with dizziness, an episode of falling at home, and crampy abdominal and leg pain following a "conscious seizure." Members of the family reported that the patient had painful tonic-clonic movements in all extremities while wide awake. These symptoms began shortly after the patient reportedly ingested a "Slang Nut" (Figure 1). Her family attempted to treat the woman's symptoms by coin rubbing to no avail; shortly thereafter, with no relief of her distress, they transported her to the ED. On examination, the patient was found to have orthostatic hypotension: lying blood pressure, 130/100 mm Hg, with a pulse of 110 beats/rain; sitting blood pressure, 100/60 mm Hg, with a pulse of 120 beats/min (the patient could not stand). She was conscious but confused and hyperreflexic. Thigh muscles were tense and tender to touch; knee jerks had seven beats of clonus. There was 2+ bilateral horizontal nystagmus. The rest of the examination results were within normal limits. She was admitted to the intensive care unit. Arterial blood gases revealed a pH of 7.43, PCO2of 34, PO2 of 90, and oxygen saturation of 97%. Other laboratory analyses showed the following levels: Na, 142 mEq/L; K, 2.9 mEq/L; C1, 104 mEq/L; HCO2, 23 mEq/L. The anion gap value was 15 mEq/L. The plasma lactate concentration was elevated at 3.8 mEq/L (normal 0.5 to 1.6 mEq/L), as was the serum myoglobin concentration. The patient recovered uneventfully without anticonvulsant therapy and was discharged 5 days after admission, Samples of the "Slang Nuts" were later sent for analysis by thin layer chromatography, which, qualitatively, confirmed the presence of strychnine. The "Slang Nut" was identified by a Cambodian interpreter as
From the Departments of *Medicine and -j-Emergency Medicine, Saint Joseph's Hospital, Lowell, MA, and the :[:Department of Pediatrics, Harvard Medical School, and the Massachusetts Poison Control System. Manuscript received July 10, 1995, accepted July 21, 1995. Address reprint requests to Dr Woolf, Massachusetts Poison Control Center, 300 Longwood Ave, Boston, MA 02115. Key Words: Poisoning, strychnine, Cambodian traditional remedy. Copyright © 1996 by W.B. Saunders Company 0735-6757/96/1405-001255.00/0
the fruit of a tree indigenous to Southeast Asia and commonly known by the Cambodian population as a "poisonous nut," which nevertheless has been used in the cure of some gastrointestinal illnesses. It was identified by the poison center as the fruit of the plant Strychnos nux vomica, the natural origin of the chemical strychnine.
DISCUSSION A relatively tasteless and odorless white powder, strychnine has a long history of use as an instrument for suicide or homicide. It has also been used as an adulterant for drugs of abuse, primarily cocaine or heroin, by unscrupulous suppliers. Although it has been touted in the past as a purgative, digestive aide, a remedy for snakebite, an aphrodisiac, and a cure for sleep disorders, it in fact has no known medicinal value and is no longer available in the United States in any medicinal products. However, even in the 1990s, strychninecontaining "Spanish fly" has been reportedly imported from Mexico, resulting in cases of poisoning. Strychnine's previous commercial use has been as a pesticide and rodenticide, although it is no longer available, having been replaced in the United States by less dangerous formulations. Nevertheless, there have still been cases of poisoning in which a rodenticide has been implicated. >4 Most strychnine poisonings now, however, are associated with illicit drug use. 5 The 1992 report from the American Association of Poison Control Centers listed 21 human exposures to strychnine in the United States, with 2 reports of death. 6 The use of traditional healing is common among Southeast Asian people; 58% of a sample of 80 Southeast Asian refugees in a primary care clinic reported using one or more traditional health practices. 7 Such traditional practices may include coin-rubbing and massaging the skin, so-called "moxibustion" or burning of the skin, acupuncture, the pinching or "cupping" of the skin, dietary restrictions, hair-pulling, healing ceremonies, and the use of herbs, aromatic oils, and/or teas. 8,9 Different Southeast Asian cultures may utilize different practices for the same indications. Although some of these practices may be superficially dysfiguring, few are thought to be very harmful. Indeed, 78% of patients who use traditional healing techniques reported the alleviation of their symptoms, m Some herbal remedies, however, can cause serious, even life-threatening, adverse health effects, n There is little previously written in the medical literature about the use of the "Slang Nut" as a Cambodian traditional cure. In Thailand, the same nut, known as the "Slang Chai Nut," is also used by rural populations in traditional medical practices (personal communication, Dr. Surajit Suntorntham, May 1993). The high concentration of the extremely toxic substance, strychnine, 475
476
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 5 • September 1996
FIGURE 1. The "Slang Nut." in "Slang Nuts" makes this traditional therapy dangerous. "Slang Nuts" are the fruit of the small tree, Strychnos nox vomica (family Loganiaceae), which has ovate leaves and yellowish white tubular flowers. 12 The tree is indigenous to India but also grows in parts of Indochina, Northern Australia, and Hawaii. The fruit is 1.5 inches across, hard shelled, and yellow to orange in color, containing 0.5-inchdiameter greyish seeds. The whole plant, including the seeds, contains strychnine and is considered poisonous. The seeds contain 1.1% to 1.4% strychnine; in adults the lethal dose of strychnine is 50 to 100 mg. 13 Strychnine is readily absorbed from the small intestine and quickly distributed to target neuronal tissues, so onset of symptoms may occur as soon as 15 to 60 minutes after ingestion.~4 It is a potent toxin that blocks the receptor at the postsynaptic junction of the inhibitory neurons in the spinal cord, brain stem, and higher centers that use glycine as a neurotransmitter. Consequently the disinhibited motor neuron discharges continuously, resulting in profound excitational effects on muscles manifested as clonic and generalized "spinal seizures" during which the patient may be fully alert. Opithotonus, facial trismus, nystagmus, and rigid flexion or extension of large muscle groups are also seen. The neuronal hyperexcitability is exaggerated such that relatively minor stimuli may trigger seizurelike reactions. The seizures may have rapid onset, may be relentlessly repetitive, and may compromise respiratory function. Although initially awake, patients may become hypoxic from diaphragmatic or respiratory muscle paralysis. Death from respiratory arrest or secondary to hypoxic asphyxia may supervene. Strychnine is metabolized by the hepatic microsomal system and is probably eliminated within 12 hours of an acute overdose; patients who survive beyond that time will likely fully recover.15 Therapy should include oral decontamination and the use of benzodiazepines for seizures or muscle spasms. If anticonvulsants are not effective in stopping the paroxysmal seizures, intubation, pharmacologic paralysis, and mechanical ventilation may be necessary. Ipecac is contraindicated because of the risk for aspiration during subsequent seizure activity, although lavage should be considered for decontaminating a patient early after the airway is secured and seizures are controlled. Activated charcoal is a very effective adsorbent of strychnine for use in decontaminating patients. The reflex hyperexcitability associated with strychnine poisoning dictates that any therapeutic intervention, such as lavage or the instillation of charcoal, be accompanied by careful securing of the airway. Extrane-
ous stimuli, including loud noises or excessive manipulation of the patient, should be avoided. Because strychnine is rapidly redistributed from the blood in an overdose, extracorporeal methods of elimination, such as hemodialysis, are unlikely to be effective.~6 In Cambodian patients, poisoning from "Slang Nuts" should be differentiated from other toxins that cause seizures, especially isoniazid, which has been previously shown to be an agent commonly used in suicide attempts by Cambodians with psychiatric disorders. 17 Other diagnoses sometimes confused with the seizures, nystagmus, and opisthotonos typical of strychnine poisoning include tetanus, rabies, hypocalcemic tetany, drug withdrawal syndromes, drug-induced dystonic reactions, or meningitis. TM The elevated anion gap, elevated plasma lactate concentration, and myoglobinemia with myoglobinuria, all seen in the present case, are common laboratory features of strychnine poisoning attributable to either the forceful muscle contractions or the resultant rhabdomyolysis. Extreme metabolic acidosis, although not seen in our case, is also commonly encountered during strychnine intoxication because of seizures and lactate production, even in the absence of significant hypoxia or cardiac arrest. In her country of origin, our patient had used "Slang Nuts" wrapped in tobacco and leaves and held against the buccal mucosa as a mild stimulant and for abdominal discomfort. Lacking the accessories here, she had placed the unclad seed in her mouth and chewed it. While it is unknown how prevalent the use of "Slang Nuts" is by Cambodian refugees in America and how such a remedy is acquired, it appears to be a common practice, especially among older Cambodians. We alert clinicians who treat Indochinese immigrants to the dangers of the use of "Slang Nuts" as a purgative in traditional Cambodian medicine. "Slang Nut" poisoning should be suspected in a Cambodian patient who presents with a clinical syndrome of abdominal distress followed by multiple clonic seizures, acidosis, and elevated lactate levels.
REFERENCES 1. Boston Globe: Warning is issued on Spanish fly. August 26, 1991 2. Perper JA: Fatal strychnine poisoning--A case report and review of the literature. J Forensic Sci 1985;30:1248-1255 3. Lambert JR, Byrick RJ, Hammeke MD: Management of acute strychnine poisoning. CMA Journal 1981 ;124:1268-1270 4. Winek CL, Wahba WW, Esposito FM, Collom WD: Fatal strychnine ingestion. J Analytical Toxico11986;10:120-121 5. Boyd RE, Brennan PT, Deng JF, et al: Strychnine poisoning-Recovery from profound lactic acidosis, hyperthermia, and rhabdomyolysis. Am J Med 1983;74:507-512 6. Litovitz TL, Holm KC, Bailey KM, Schmitz BF: 1992 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1993; 11:494-555 7. Buchwald D, Panwala S, Hooton TM: Use of traditional health practices by Southeast Asian refugees in a primary care clinic. West J Med 1992;156:507-511 8. Yeatman GW, Van Dang V: Cao Gio (coin rubbing)--Vietnamese attitudes toward health care. JAMA 1980;244:2748-2749 9. Reinhart MA, Ruhs H: Moxibustion. Clin Pediatr 1985;24:58-59 10. Buchwald D, Panwala S, Hooton TM: Use of traditional health practices by Southeast Asian refugees in a primary care clinic. West J Med 1992;156:507-511
KATZ ET AL • STRYCHNINE POISONING FROM CAMBODIAN REMEDY
11. Jin Bu Huan toxicity in children--Colorado, 1993. MMWR Mortal Morbid Wkly Rep 1993;42:633-636 12. Lampe KF, McCann MA: Strychnos nux vomica. In AMA Handbook of Poisonous and Injurious Plants. Chicago, IL, American Medical Association, 1985 13. Perper JA: Fatal strychnine poisoning--A case report and review of the literature. J Forensic Sci 1985;30:1248-1255 14. Gordon AM, Richards DW: Strychnine intoxication. J Am Cell Emerg Med 1979;8:520-522 15. Boyd RE, Brennan PT, Deng JF, et al: Strychnine poisoning.
477
Recovery from profound lactic acidosis, hyperthermia, and rhabdomyolysis. Am J Med 1983;74:507-512 16. Dittrich K, Bayer MJ, Wanke LA: A case of fatal strychnine poisoning. J Emerg Med 1984;1:327-330 17. Blanchard PD, Yao JDC, McAIpine DE, Hurt RD: Isoniazid overdose in the Cambodian population of OImstead County, Minnesota. JAMA 1986;256:3131-3133 18. Mackler S, Moskowitz M: Tetanus or drug reaction? Hosp Pract (Office Edition) 1989;24:75-89