Hyoscyamus niger Intoxication: A Case Report.

Aims: To present the clinical findings and intensive care management of Hyoscyamus niger (HN) intoxication in a 7-year-old patient. Presentation of Case: A seven-year-old girl was admitted to the emergency department who had eaten a plant in large amounts. She had psychomotor agitation, inability to recognize her family, slurred speech, dry mouth, flushing, over-distended urinary bladder, visual and hearing hallucinations. After a nasogastric tube was inserted, gastric lavage was performed and activated charcoal was administered. Symptomatic treatment including oxygen, fluid-electrolyte balance, and gastric protective drugs was established. Physostigmine infusion (0.02 mg/kg) was given due to tachycardia at the second hour of hospitalization. The plant that was responsible for the clinical picture was confirmed as ‘deli bat bat grass’. The clinical symptoms resolved after 2-hours administration of physostigmine. She was transferred to pediatric ward after 24 hours of monitorization in intensive care unit. Discussion: HN is commonly known as black henbane or deli bat bat grass in the Eastern Anatolian Region in Turkey. Oral intake of this plant can cause central and peripheral anticholinergic effects. This clinical picture described as ‘central anticholinergic syndrome’ is characterized by thought impairment, hallucinations, hyperpyrexia, ataxia, excitement, drowsiness, Case Study


INTRODUCTION
Hyoscyamus niger, is a plant, commonly known as 'black henbane' or 'deli bat bat grass' in the Eastern Anatolian Region, especially in Erzurum city, in Turkey. It grows in most locations, as long as it has sunshine. It is not too fussy about the type of soil but it needs to be well drained, it doesn't tolerate waterlogged conditions. Oral intake of this plant can cause central and peripheral anti-cholinergic effects. Hyoscyamus niger poisoning is a rare kind of poisoning in the literature. Diagnosis is mainly based on history and clinical findings, especially anti-cholinergic syndrome and hallucination [1]. When it is suspected, respiration and circulation should be assured and antidote treatment should be started as soon as possible. In here, clinical findings and intensive care management of Hyoscyamus niger intoxication in a 7-year-old patient are presented.

PRESENTATION OF CASE
A seven-year-old girl was admitted to the emergency department with her relatives who told that she had eaten a plant in large amounts 6 hours ago. Her past and family history was unremarkable. She had psychomotor agitation, inability to recognize members of the family, and slurred speech. Her orientation to place, time and person was impaired. On physical examination; blood pressure 90/70 mmHg, pulse rate 152/minute, axillary temperature 36.5°C, and respiratory rate 28/minute. She had dry mouth, flushing, over-distended urinary bladder, hypoactive bowel sounds, and visual and hearing hallucinations. Her pupils were isochoric and mydriatic. Laboratory examination revealed that complete blood count and biochemical parameters were within normal limits. Approximately 200 ml of urine was drained with a urinary catheter. After a nasogastric tube was inserted, gastric lavage was performed and activated charcoal was administered. The patient was monitorized in the intensive care unit. Symptomatic treatment including oxygen, fluidelectrolyte balance, and gastric protective drugs was established. Conduction abnormalities (e.g. PR, QRS, or QTc interval prolongation) were checked and physostigmine infusion (0.02 mg/kg) was given due to tachycardia at the second hour of hospitalization. The plant that was possibly responsible for the clinical picture was brought to hospital by her relatives and was confirmed as 'deli bat bat grass'. The clinical symptoms resolved immediately after 2hours administration of physostigmine. She was transferred to pediatric ward once the symptoms completely resolved after 24 hours of monitorization in intensive care unit.

DISCUSSION
In the spring, roots and leaves of deli bat bat are consumed as food by many adults and children and thus, they are brought to hospitals with poisoning symptoms [1]. Fortunately, cases of intoxication due to plants, especially due to deli bat bat are rare [2]. All part of Hyoscyamus niger including leaves, seeds, and roots contain some alkaloids such as hyoscyamine, atropine, tropane, and scopolamine, competitively block the binding point of acetylcholine in the central nervous system and the muscarinic receptors of parasympathetic postganglions and eventually produce anti-cholinergic effects. The anti-cholinergic effects mostly depend on the antagonism of peripheral muscarinic receptors [3]. Central effects may result in confusion, anxiety, delirium, hallucination, myoclonus, dysarthria, choreoathetosis, hyperactive deep tendon reflexes, convulsions, and coma. Peripheral effects may be mydriasis, peripheral vasodilation, hyperpyrexia, tachycardia, urinary retention, decreased gastrointestinal motility, decreased secretions, and respiratory depression [4].
Diagnosis of Hyoscyamus niger intoxication is based on clinical symptoms and history. A through history is the mainstay in patients with anti-cholinergic symptoms, in which this type of plants consumption should be questioned. Our patient had typical atropine poisoning clinical picture and when the patient's relatives brought the plant, ingestion of Hyoscyamus niger was confirmed.
Hyoscyamus niger intoxication can seriously compromise those who ingest them. Gastrointestinal decontamination, gastric lavage and supportive therapy are routinely recommended for almost all plant intoxications [5,6]. Our patient was performed gastric lavage and administered activated charcoal. Charcoal and gastric evacuation is recommended because atropine-containing plants can impair gastrointestinal motility and lead to prolonged absorption of atropine and its alkaloids. In addition, the association of gastric lavage with charcoal in children is reported to be much more effective than emetics (e.g. ipecac syrup) in prevention of toxin absorption [7,8]. Physostigmine is a specific antidote which can cross the blood brain barrier, reversibly inhibits anticholinesterase. It should be given in cases of tachycardia, coma, and respiratory arrest with caution [9]. In this case, the use of physostigmine as an antidote resulted in a favorable outcome without any complications.

CONCLUSION
As a consequence, physicians in the emergency department should always keep in mind for plant poisoning in patients with anti-cholinergic symptoms. Even for this kind of rare known plants, the nature, medical uses, clinical features, differential diagnosis, and management of poisonings should be known. Hyoscyamus niger intoxication in children is self-terminating, and responds to supportive therapy.

CONSENT
All authors declare that 'written informed consent was obtained from the patient (or other approved parties) for publication of this case report and accompanying images.

ETHICAL APPROVAL
Ethical approval is not applicable.