Toxicology
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Case #1
A 2-year-old child is brought into the ED by frantic parents who state the child chewed on several poinsettia leaves during a family holiday gathering at her grandparents’ home. On physical exam, the child has stable vital signs, is afebrile, and is in no acute distress.

Case #2
Two college students attempted to get “a legal holiday high” by smoking dried poinsettia leaves sprinkled with nutmeg. In the ED, they complain of nausea, vomiting, headache and palpitations.

Trivia question: Who was the Poinsettia named after? answer at the bottom of the page

Poinsettia (Euphorbia pulcherrima)
Indigenous to Mexico and Central America, the red green poinsettia (or Christmas Star), was first introduced to the US in the 1800s. The plant’s reputation for toxicity stemmed from a single unconfirmed case fatality of a 2-year-old child in the early 1900s. Despite no further confirmatory medical reports, many lay public sources continue to claim this plant is poisonous to humans. A review of 23,000 exposures reported to the Poison Control System confirms that ingestion of this plant is relatively nontoxic. A child weighing 50 lbs would have to ingest over 500 poinsettia leaves in order to reach a potentially toxic dose. Most exposures (95%) can be managed at home without a hospital referral. In the ED, simple supportive care is indicated and no decontamination methods have proven to be beneficial.

To verify that the poinsettia is nonpoisonous to humans, every holiday season members of our University medical toxicology service meet to ceremoniously ingest several leaves of poinsettia (chased with spiked eggnog). After 20 years of this practice, the author’s liver function tests and renal clearing capacity have remained unaltered.

The college students in the 2nd case most likely suffered nausea, vomiting and palpitations from the nutmeg (Myristica fragrans) added to the dried poinsettia leaves. In large enough doses, nutmeg can induce tachycardia, headache, GI side effects, and delirium.
 
Holly (Ilex aquifolium)
There are over 300 species of holly, but Christmas holly is the most frequently encountered. The plant produces green berries that mature to red giving a classic holiday appearance against a background of green pointed leaves. The bright red berries are particularly attractive to small children. Both the leaves and berries are GI irritants producing vomiting and diarrhea, but rarely severe enough to require emergent care.

Mistletoe (Phoradendron sp)
Reports of toxicity from mistletoe involve the European variety (Viscum album), which contains a cardiotoxic substance demonstrated in animal models. There are a few historical deaths reported in humans from this variety, but it is not well studied. The American version (Phoradendron) contains an alkaloid that can cause gastroenteritis. A large retrospective review from poison control center data confirms that any potential toxicity in humans is extremely low.

Enjoy the holidays knowing that most of these decorative plants are relatively nontoxic. Not surprisingly, the most common poison with the most profound toxic morbidity and mortality remains ethanol. So pace your self with the holiday punch and drive safely.

 

REFERENCES

Krenzelok, EP, Jacobsen, TD, Aronis, JM. Poinsettia exposures have good outcomes...just as we thought. Am J Emerg Med; 14:671, 1996.

Krenzolok EP, Jacobsen TD, Aronis J: American mistletoe exposures. Am J Emerg Med 15:516-20, 1997.

Carlson A, Krenzolek EP: Poisonous plants. In Erickson T, Ahrens W, Aks S, et al (eds) Pediatric Toxicology: Diagnosis and Management of the Poisoned Child. McGraw-Hill, New York, pp541-7, 2005.

Stein U, Greyer H, Hentschel H: Nutmeg (myristicin) poisoning- report on a fatal case and a series of cases recorded by poison information centre. Forensic Sci Int.15;118(1):87-9, 2001.

 


Trivia Answer: Joel Roberts Poinsett (1779-1851) was a physician, botanist and American statesman. He was the first United States Minister to Mexico and the US Secretary of War under Martin Van Buren. He was also the cofounder of the National Institute for the Promotion of Science (a predecessor of the Smithsonian Institution).



 

 

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