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A 52-year-old man with a history of alcoholism was found unresponsive by his family during a family picnic at the park. The patient was found to be obtunded and required nasal intubation by paramedics on the scene. The patient’s family provided the pods pictured below and stated that the family was snacking on the seeds and the patient had eaten two pods worth and drank a bottle of vodka (a normal daily amount for him).

What plant also used by Haitian Voodoo doctors to make zombies caused this patient’s presentation?

What medicine was used to “awaken this zombie from the living dead?”

On arrival the patient was noted to have a temperature of 37 degrees centigrade, a heart rate of 110, a blood pressure of 116/80, and was intubated with a respiratory rate of 16 and oxygen saturation of 100 percent on a ventilator.

His heart was tachycardic without murmurs. His abdomen was soft and non-distended with hypoactive bowel sounds. The patient localized painful stimuli in all four extremities but was otherwise intubated and nonverbal and would not open his eyes to voice or painful stimuli.

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The patient had a negative chest radiograph and computed tomography of the head. A complete blood count and basic metabolic panel were within normal limits. A screening urine toxicology screen was negative. The patient’s blood alcohol level was 327, however per record review the patient had been seen in the emergency department awake and alert with similar alcohol levels in the past.

After consultation with toxicology, 2 milligrams of physostigmine were administered intravenously. Two minutes after administration, the patient awakened, was able to breathe spontaneously, and was able to follow commands. He was extubated and answered questions appropriately. Given the short duration of action of physostigmine the patient was admitted to the intensive care unit for close airway monitoring. He had an uneventful hospital course not requiring further intervention and was discharged from the hospital one day after admission.

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Datura stramonium is a naturally occurring herb found throughout the world in both urban and rural settings. The entire plant, especially the foliage and seeds, is toxic and hallucinogenic due to containing tropane alkaloids including atropine, L-hyoscyamine, and L-scopalamine.1 These tropane alkaloids inhibit central and peripheral muscarinic receptors, including at the level of exocrine glands, smooth muscle, and cardiac receptors. The inhibition of muscarinic receptors results in an anticholinergic syndrome characterized by flushed dry skin, mydriasis, tachycardia, urinary retention, ileus (peripheral effects), and delirium (central effect). In severe cases, hyperthermia, respiratory arrest, or seizures may be seen.

Datura stramonium is commonly known as jimsonweed or Jamestown weed, after the American colony of Jamestown, Virginia, where British soldiers sent to quell Bacon’s Rebellion in 1676 were poisoned with the plant and became delirious for eleven days. Other names for the plant include moonflower, devil’s trumpet, devil’s cucumber, devil’s weed, locoweed, thorn apple, Hell’s bells, malpitte, and mad seeds.

D. stramonium has been used for centuries by different cultures to induce hallucinations and supposedly communicate with spirits. Haitian voodoo doctors used the plant in combination with tetrodotoxin to lower metabolism enough to convince a person’s family the person was dead, bury the person, and then resurrect the person as a passive “zombie” who could be sold into slavery and have no recollection of the past several days.2,3 The plant was commonly used to treat asthma in the nineteenth century.4

Why would anyone want to ingest this dangerous plant? Accounts vary from a feeling of being high but thinking clearly to falling asleep with vivid dreams. Our patient had the additive effect of a very high blood alcohol level plus jimsonweed accounting for his stupor.

Treatment of anticholinergic toxicity, including D. stramonium toxicity, is largely supportive. Benzodiazepines may be used for seizures and cooling measures may be used for hyperthermia. Physostigmine Salicylate can be used as a temporary reversal agent.5 Physostigmine inhibits acetylcholinesterase, thereby increasing concentrations of acetylcholine. Physostigimine is a carbamate, which means it spontaneously hydrolyzes from acetylcholinesterase and reversibly inhibits the enzyme. Physostigmine is indicated as an aid in the diagnosis of anticholinergic intoxication when the diagnosis is uncertain and no contraindications to the use of physostigmine exist. It is administered in a dose of 0.5 to 2 milligrams (mg) intravenously at a rate of 0.5 mg per minute. The onset of action is three to five minutes and duration of action is one to two hours. Due to this short duration of action, the medication is primarily used for diagnostic rather than therapeutic purposes. Continuous infusions of physostigmine can be used in cases of supportive care failure. Relative contraindications to physostigmine use include bradycardia, preexisting heart block, salicylate toxicity, asthma, epilepsy, lactation, depolarizing neuromuscular blocking agents (e.g.-succinylcholine), and mechanical intestinal obstruction. Given the theoretical risk of bradycardia, atropine should be kept at the bedside during physostigmine administration.


References
1. Miraldi E, Masti A, Ferri S, Barni Comparini I. Distribution of hyoscyamine and scopolamine in Datura stramonium. Fitoterapia 2001;72:644-8.
2. Albuquerque UP, Melo JG, Medeiros MF, et al. Natural products from ethnodirected studies: revisiting the ethnobiology of the zombie poison. Evid Based Complement Alternat Med 2012;2012:202508.
3. Littlewood R, Douyon C. Clinical findings in three cases of zombification. Lancet 1997;350:1094-6.
4. von Mutius E, Drazen JM. A patient with asthma seeks medical advice in 1828, 1928, and 2012. N Engl J Med 2012;366:827-34.
5. Salen P, Shih R, Sierzenski P, Reed J. Effect of physostigmine and gastric lavage in a Datura stramonium-induced anticholinergic poisoning epidemic. Am J Emerg Med 2003;21:316-7.

Omeed Saghafi, MD is a 3rd year EM resident at the Denver Health EM Residency. Dr. Jennie Buchanan and Dr. Peter Pryor are faculty members at Denver Health, and Assistant Professors of Emergency Medicine at the University of Colorado School of Medicine.

 

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