RSS-Feed abonnieren
DOI: 10.1055/s-0031-1298253
© Georg Thieme Verlag KG Stuttgart · New York
Plant Exposures Reported to the Poisons Information Centre Erfurt from 2001–2010
PD Dr. Med. Michael Deters
Poisons Information Centre
c/o HELIOS Klinikum GmbH
Nordhäuser Str. 74
99085 Erfurt
Germany
Telefon: +49 3 61 73 07 30
Fax: +49 36 17 30 73 17
eMail: michael_deters2002@yahoo.de
Publikationsverlauf
received Sept. 15, 2011
revised Nov. 16, 2011
accepted January 15, 2012
Publikationsdatum:
09. Februar 2012 (online)
- Abstract
- Abbreviations
- Introduction
- Participants and Methods
- Results
- Discussion
- Limitations
- Conclusions
- References
Abstract
At the moment, no recent study about plant exposures in Germany and in the federal states the Poisons Information Centre (PIC) Erfurt is serving is available. To get new information about important characteristics of plant exposures like the development of frequency, plants, age groups involved, circumstances of exposure, and symptom severity, we conducted a retrospective study including all human plant exposures reported to the PIC Erfurt over a 10-year period from the beginning of 2001 to the end of 2010. In total, 13 001 plant exposures were registered. While the absolute number of plant exposures discontinuously increased from 1110 in 2001 to 1467 in 2009, and decreased to 1157 in 2010, their relative frequency to all human exposures fell from 9.2 % in 2001 to 5.9 % in 2010. Age groups: children 87.5 % (toddler 60.0 %); adults 11.3 % (middle-aged adults 5.2 %). Gender: female 39.0 % and male 41.2 %. Circumstances: accidental 91.6 %, unknown 4.6 %, abuse 2.9 %, suicide 0.9 %. Severity of symptoms: none to slight 85.5 %, moderate 1.7 %, unknown 12.7 %, severe 0.1 % (in total 9, one 4-year-old girl, involved plant genera: Aconitum, Arum, Chelidonium, Datura, Brugmansia, Dieffenbachia, Ricinus, 2 Taxus), fatal 0.03 % (in total 4, involved plant genera: 2 Aconitum, 2 Taxus). In comparison to all human exposures, the relative frequency of severe symptoms in accidental and intentional plant exposures by abuse was significantly lower but as high by suicide. The significant higher involvement of children resulted mainly in none or mild symptoms. Severe symptoms could mostly be observed in adults in intentional plant exposures or when poisonous plants were mistaken for eatable. Because some plant exposures resulted in severe symptoms and even death, their dangerousness should not be trivialised.
Key words
plant exposures - poisoning - Poisons Information Centre - Aconitum - Brugmansia - Datura - Ranunculaceae - Solanaceae - Taxaceae - Taxus
Abbreviations
A: adult of unknown age > 17 years
AE: elderly > 65 years
AM: middle-aged adult 18–65 years
C: child of unknown age < 14 years
CA: adolescent 14–17 years
CB: baby < 1 year
CT: toddler 1–5 years
CS: schoolchild 6–13 years
CI95: 95 % confidence interval for differences of the relative frequencies
EP: endangering potential
Llower: lower limit of CI95
Lupper: upper limit of CI95
MME: moderate and major effects
n: number of total cases
p: x/n = relative frequency
PIC Erfurt: Poisons Information Centre Erfurt
PSS: Poisoning Severity Score
SQRT: square root
TPE: total plant exposures
u: age unknown
x: number of cases
#Introduction
Plant exposures are described to be one of the most frequent reasons for calls to poison information centres in Germany [1], [2] and Switzerland [3], [4], [5]. In a recent study in the United States [6], a steady decline of the absolute number of plant exposures and the percentage of all exposures registered by U. S. poison centres from 82 559 (4.9 %) in 2000 to 54 956 (2.4 %) in 2009 was observed. At the moment, no recent study is available about plant exposures in Germany and in the federal states the Poisons Information Centre (PIC) Erfurt is serving. To get new information about important characteristics of plant exposures like the development of frequency, plants, age groups involved, circumstances of exposure, and symptom severity, we conducted a retrospective study including all human plant exposures reported to the PIC Erfurt over a 10-year period from the beginning of 2001 to the end of 2010.
#Participants and Methods
The PIC Erfurt serves a population of 10.4 million inhabitants in four federal states (Mecklenburg-Western Pomerania, Saxony, Saxony-Anhalt, and Thuringia) in Germany. All calls regarding acute human plant exposure registered by the PIC Erfurt from 2001 to 2010 were analysed retrospectively. Data were evaluated regarding circumstances of exposure, patient age groups, plants involved, and symptom severity. Age groups were: baby (CB: < 1 year), toddler (CT: 1 to 5 years), schoolchild (CS: 6 to 13 years), child of unknown age (C: younger than 14 years), adolescent (CA: 14 to 17 years), middle-aged adult (AM: 18 to 65 years), elderly (AE: older than 65 years), adult of unknown age (A: older than 17 years), age unknown (u). The severity of symptoms was classified as none to mild (0 + 1), moderate (2), severe (3), and fatal, according to the Poisoning Severity Score (PSS) [7]. For all plant genera that caused at least twice moderate or severe symptoms the PSS classification as previously described [2] was used to assess the endangering potential (EP) of the single plant genus from symptoms described in the literature [8], [9], [10].
The relative frequencies of symptom severity, age groups, and circumstances of exposure were compared and analysed according to the chi-square test for significant differences (p < 0.05) between a plant and all exposures. The 95 % confidence interval (CI95) for the difference of relative frequencies was calculated by approximation to Gaussian distribution for big control samples according to the equation described by Sachs and Hedderich [11]:
Lupper: upper limit of CI95; Llower: lower limit of CI95; SQRT: square root; x = number of cases; n = number of total cases; p = x/n = relative frequency; z = 1.96 for CI95; for n × p > 5 and n × (1 − p) > 5:
Lupper ≈ (p + 1/2 n + z × SQRT (p × (1 − p)/n); Llower ≈ (p − 1/2 n − z × SQRT (p × (1 − p)/n).
#Results
In total, the PIC Erfurt registered 13 001 plant exposures corresponding to 8.2 % of all exposures from the beginning of 2001 to the end of 2010. While the absolute number of plant exposures discontinuously increased from 1110 in 2001 to 1467 in 2009, and decreased afterwards to 1157 exposures in 2010, the relative frequency to all human exposures fell from 9.2 % in 2001 to 5.9 % in 2010 ([Fig. 1]), because the number of all exposures rose from 12 012 in 2001 to 19 649 in 2010. Plant exposures showed typical seasonal changes with the highest total rates in July (1422), August (2143), September (2179), and October (1639). The lowest total rates of plant exposures were seen in December (570), January (463), February (424), and March (602). The plant genera involved most frequently in plant exposures are summarised in [Table 1]. While some plant genera like Taxus, Ligustrum, and Ficus were continuously among the most often involved plant genera during the whole study period, exposures to other plant genera like Brugmansia (decrease from 81 in 2001 to 7 in 2010) showed time-dependent changes.
![](https://www.thieme-connect.de/media/plantamedica/201205/thumbnails/v0888pm01.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Fig. 1 Frequency of plant exposures (in 100) and relative frequency of plant exposures to all exposures (in %) reported to the PIC Erfurt from the beginning of 2001 to the end of 2010.
2001 |
2002 |
2003 |
2004 |
2005 |
2006 |
2007 |
2008 |
2009 |
2010 |
2001–2010 |
|
1 |
Brugmansia 81 |
Taxus 72 |
Taxus 67 |
Taxus 78 |
Ligustrum 72 |
Taxus 89 |
Ligustrum 96 |
Ligustrum 82 |
Taxus 129 |
Taxus 65 |
Taxus 742 |
2 |
Ligustrum 70 |
Ligustrum 65 |
Lonicera 62 |
Ligustrum 63 |
Ficus 64 |
Sorbus 55 |
Physalis 87 |
Ficus 59 |
Physalis 78 |
Ficus 60 |
Ligustrum 633 |
3 |
Ficus 52 |
Brugmansia 49 |
Physalis 50 |
Ficus 61 |
Taxus 63 |
Ligustrum 55 |
Taxus 80 |
Taxus 58 |
Prunus 67 |
Physalis 40 |
Ficus 569 |
4 |
Lonicera 43 |
Lonicera 41 |
Ficus 50 |
Physalis 57 |
Physalis 59 |
Ficus 54 |
Ficus 74 |
Physalis 47 |
Ficus 54 |
Ligustrum 37 |
Physalis 519 |
5 |
Sorbus 41 |
Ficus 41 |
Ligustrum 47 |
Brugmansia 48 |
Euphorbia 50 |
Prunus 47 |
Prunus 63 |
Prunus 45 |
Lonicera 50 |
Spathiphyllum 35 |
Prunus 416 |
6 |
Taxus 41 |
Physalis 39 |
Brugmansia 46 |
Prunus 44 |
Lonicera 48 |
Physalis 38 |
Euphorbia 50 |
Crassula 43 |
Ligustrum 46 |
Euphorbia 35 |
Lonicera 405 |
7 |
Lathyrus 29 |
Sorbus 37 |
Sorbus 43 |
Lonicera 41 |
Prunus 46 |
Euphorbia 34 |
Mahonia 42 |
Lonicera 38 |
Sorbus 44 |
Crassula 27 |
Euphorbia 385 |
8 |
Datura 28 |
Euphorbia 33 |
Euphorbia 42 |
Euphorbia 36 |
Sorbus 42 |
Lonicera 30 |
Brugmansia 36 |
Euphorbia 37 |
Euphorbia 42 |
Convallaria 26 |
Brugmansia 377 |
9 |
Euphorbia 26 |
Cotoneaster 29 |
Prunus 41 |
Cotoneaster 28 |
Brugmansia 39 |
Brugmansia 30 |
Symphoricarpos 35 |
Sambucus 35 |
Lathyrus 41 |
Mahonia 26 |
Sorbus 365 |
10 |
Mahonia 25 |
Solanum 29 |
Sambucus 40 |
Lathyrus 27 |
Sambucus 31 |
Convallaria 29 |
Lonicera 32 |
Sorbus 34 |
Crassula 34 |
Zamioculcas 24 |
Mahonia 279 |
The distribution of age groups is summarised in [Table 2]. In comparison to all exposures, plant exposures were significantly more often seen in children of unknown age (p < 0.05) [plant exposures 164 (1.26 %), all exposures 757 (0.48 %)]; babies [plant exposures 2007 (15.44 %), all exposures 6324 (3.99 %)]; toddlers [plant exposures 7803 (60.02 %), all exposures 41 964 (26.46 %)]; and schoolchildren [plant exposures 1137 (8.75 %), all exposures 5952 (3.75 %)] and significantly less frequently observed in adolescents (p < 0.05) [plant exposures 270 (2.08 %), all exposures 8439 (5.32 %)]; adults of unknown age [plant exposures 662 (5.09 %), all exposures 29 953 (18.89 %)]; middle-aged adults [plant exposures 682 (5.25 %), all exposures 55 797 (35.18 %)]; and the elderly [plant exposures 128 (0.98 %), all exposures 8115 (5.12 %)]. The proportion of each age group in plant and all exposures remained almost unchanged from 2001 to 2010 except for the proportion of adolescents, which decreased from 100 (4.37 %) in 2001 to 20 (0.76 %) in 2010 in plant exposures and for the same period from 2005 (8.23 %) to 1516 (3.95 %) in all exposures. The gender of persons involved in plant exposures was equally distributed amongst females (5062, 39.0 %) and males (5350, 41.2 %) ([Table 3]). The circumstance of exposure ([Table 4]) was significantly more often accidental in plant (11 894, 91.56 %) than in all exposures (70 972, 44.93 %) (p < 0.05). Other circumstances of exposure, however, were significantly less frequent in plant than in all exposures (p < 0.05) [abuse: plant exposures 371 (2.86 %), all exposures 6040 (3.81 %); suicide: plant exposures 119 (0.94 %), all exposures 210 (36.08 %); unknown: plant exposures 617 (4.6 %), all exposures 24 378 (15.17 %)]. The symptom severity ([Table 4]) was significantly more often none to mild in plant exposures (11 114, 85.5 %) than in all exposures (103 334, 65.20 %) (p < 0.05). The other symptom severity grades occurred significantly less frequently in plant than in all exposures (p < 0.05) [moderate: plant exposures 220 (1.69 %), all exposures 11 635 (7.33 %); severe: plant exposures 9 (0.07 %), all exposures 5504 (3.47 %); unknown: plant exposures 1654 (12.70 %), all exposures 37 828 (23.90 %); death: plant exposures 4 (0.03 %), all exposures 299 (0.18 %)]. Information on symptom severity in relation to the circumstances of plant and all exposures is given in [Table 4]. Accidental plant exposures resulted significantly more often in none to mild symptoms (10 578, 88.94 %) than in all accidental exposures (58 672, 82.67 %) (p < 0.05). Moderate and severe symptoms as well as fatalities and unknown symptoms occurred significantly more frequently in all accidental exposures [moderate symptoms: 1730 (2.44 %); severe symptoms: 351 (0.49 %)] than in accidental plant exposures [moderate symptoms: 97 (0.82 %); severe symptoms: 4 (0.03 %)] (p < 0.05) ([Table 4]). Intentional plant exposures by abuse caused significantly less none to mild (84, 22.64 %) and severe symptoms (1, 0.27 %) than all intentional exposures by abuse (p < 0.05) [none to mild symptoms: 2141 (35.45 %); severe symptoms: 429 (7.10 %)] ([Table 4]). Plant exposures with suicidal intention, however, showed nearly the same frequency of the symptom severity as all exposures in suicidal intention ([Table 4]). Fatalities, however, were even significantly more frequent with suicidal plant exposures (4, 3.36 %) than in all exposures (88, 0.36 %) with suicidal intention (p < 0.05) ([Table 4]). No significant differences between female and male persons in plant and all exposures concerning the symptom severity could be observed ([Table 3]).
Plant exposures |
All exposures |
Plant exposures |
All exposures |
Plant exposures |
All exposures |
Plant exposures |
All exposures |
Plant exposures |
All exposures |
Plant exposures |
All exposures |
|
Age groups |
2001–2002 |
2001–2002 |
2003–2004 |
2003–2004 |
2005–2006 |
2005–2006 |
2007–2008 |
2007–2008 |
2009–2010 |
2009–2010 |
2001–2010 |
2001–2010 |
C |
33 (1.44 %* CI95: 0.93–1.95 %) |
132 (0.54 % CI95: 0.45- 0.64 %) |
37 (1.44 %* CI95: 0.96–1.91 %) |
132 (0.48 % CI95: 0.42–0.53 %) |
29 (1.05 %* CI95: 0.65–1.46 %) |
153 (0.46 % CI95: 0.39–0.54 %) |
28 (1.01 %* CI95: 0.62–1.41 %) |
135 (0.39 % CI95: 0.32–0.45 %) |
37 (1.41 %* CI95: 094–1.88 %) |
205 (0.53 % CI95: 0.46–0.61 %) |
164 (1.26 %* CI95: 1.07–1.46 %) |
757 (0.48 % CI95: 0.44–0.51 %) |
CB |
331 (14.46 %* CI95: 13.00–15.92 %) |
900 (3.69 % CI95: 3.45–3.93 %) |
336 (13.04 %* CI95: 11.72–14.36 %) |
1012 (3.66 % CI95: 3.43–3.88 %) |
388 (14.11 %* CI95: 12.79–15.43 %) |
1153 (3.48 % CI95: 3.28–3.67 %) |
488 (17.67 %* CI95: 16.23–19.11 %) |
1544 (4.41 %* CI95: 4.19–4.63 %) |
464 (17.68 %* CI95: 16.20–19.16 %) |
1715 (4.47 %* CI95: 4.26–4.68 %) |
2007 (15.44 %* CI95: 14.81–16.06 %) |
6324 (3.99 % CI95: 3.89–4.08 %) |
CT |
1397 (61.03 %* CI95: 59.01–63.05 %) |
6367 (26.13 % CI95: 25.58–26.69 %) |
1598 (62.01 %* CI95: 60.12–63.90 %) |
7561 (27.32 % CI95: 26.79–27.85 %) |
1689 (61.44 %* CI95: 59.60–63.28 %) |
8995 (27.11 % CI95: 26.63–27.59 %) |
1631 (59.05 %* CI95: 57.20–60.90 %) |
9268 (26.48 %* CI95: 26.01–26.94 %) |
1488 (56.71 %* CI95: 54.79–58.62 %) |
9773 (25.47 % CI95: 25.03–25.90 %) |
7803 (60.02 %* CI95: 59.17–60.86 %) |
41 964 (26.46 % CI95: 26.24–26.68 %) |
CS |
171 (7.47 %* CI95: 6.37–8.57 %) |
966 (3.96 % CI95: 3.71–4.21 %) |
221 (8.58 %* CI95: 7.48–9.68 %) |
998 (3.61 % CI95: 3.38–3.83 %) |
240 (8.73.% * CI95: 7.66–9.80 %) |
1098 (3.31 % CI95: 3.12–3.50 %) |
263 (9.52 %* CI95: 8.41–10.63 %) |
1439 (4.11 % CI95: 3.90–4.32 %) |
242 (9.22 %* CI95: 8.10–10.35 %) |
1451 (3.78 % CI95: 3.59–3.97 %) |
1137 (8.75 %* CI95: 8.26–9.23 %) |
5952 (3.75 % CI95: 3.66–3.85 %) |
CA |
100 (4.37 %* CI95: 3.51–5.23 %) |
2005 (8.23 % CI95: 7.88–8.58 %) |
66 (2.56 %* CI95: 1.93–3.19 %) |
1801 (6.51 % CI95: 6.22–6.80 %) |
45 (1.64 %* CI95: 1.14–2.13 %) |
1639 (4.94 % CI95: 4.71–5.17 %) |
39 (1.41 %* CI95: 0.95–1.87 %) |
1478 (4.22 % CI95: 4.01–4.43 %) |
20 (0.76 %* CI95: 0.41–1.11 %) |
1516 (3.95 % CI95: 3.75–4.15 %) |
270 (2.08 %* CI95: 1.83–2.32 %) |
8439 (5.32 % CI95: 5.21–5.43 %) |
A |
103 (4.50 %* CI95: 3.63–5.37 %) |
3271 (13.42 % CI95: 12.99–13.86 %) |
121 (4.70 %* CI95: 3.86–5.53 %) |
4789 (17.30 % CI95: 16.85–17.75 %) |
138 (5.02 %* CI95: 4.19–5.85 %) |
6411 (19.32 % CI95: 18.90–19.75 %) |
146 (5.29 %* CI95: 4.43–6.14 %) |
6635 (18.95 % CI95: 18.54–19.37 %) |
154 (5.87 %* CI95: 4.95–6.79 %) |
8847 (23.05 % CI95: 22.63–23.48 %) |
662 (5.09 %* CI95: 4.71–5.47 %) |
29 953 (18.89 % CI95: 18.69–19.08 %) |
AM |
114 (4.98 %* CI95: 9.67–10.76 %) |
9306 (38.19 % CI95: 37.58–38.81 %) |
120 (4.66 %* CI95: 3.82–5.49 %) |
9826 (35.50 % CI95: 14.10–14.62 %) |
163 (5.93 %* CI95: 5.03–6.83 %) |
11 785 (35.52 % CI95: 35.00–36.04 %) |
122 (4.42 %* CI95: 3.63–5.20 %) |
12 466 (35.61 % CI95: 35.11–36.12 %) |
163 (6.21 %* CI95: 5.27–7.15 %) |
12 414 (32.35 % CI95: 31.88–32.82 %) |
682 (5.25 %* CI95: 4.86–5.63 %) |
55 797 (35.18 % CI95: 34.95–35.42 %) |
AE |
17 (0.74 %* CI95: 4.07–5.89 %) |
1173 (4.81 % CI95: 4.54–5.09 %) |
27 (1.05 %* CI95: 0.64–1.46 %) |
1222 (4.41 % CI95: 4.17–4.66 %) |
18 (0.65 %* CI95: 0.34–0.97 %) |
1625 (4.90 % CI95: 4.66–5.13 %) |
26 (0.94 %* CI95: 0.56–1.32 %) |
1846 (5.27 % CI95: 5.04–5.51 %) |
40 (1.52 %* CI95: 1.04–2.01 %) |
2249 (5.86 % CI95: 5.62–6.10 %) |
128 (0.98 %* CI95: 0.81–1.16 %) |
8115 (5.12 % CI95: 5.01–5.23 %) |
Unknown |
23 (1.00 % CI95: 0.57–1.44 %) |
245 (1.01 % CI95: 0.88–1.13 %) |
51 (1.98 %* CI95: 1.42–2.54 %) |
335 (9.06 % CI95: 8.70–9.42 %) |
39 (1.42 %* CI95: 0.96–1.88 %) |
319 (0.96 % CI95: 0.85–1.07 %) |
19 (0.69 % CI95: 0.36–1.01 %) |
193 (0.55 % CI95: 0.47–0.63 %) |
16 (0.61 % CI95: 0.29–0.93 %) |
207 (0.54 % CI95: 0.46–0.61 %) |
148 (1.14 %* CI95: 0.95–1.32 %) |
1299 (0.82 % CI95: 0.77–0.86 %) |
Number of cases |
2289 |
24 365 |
2577 |
27 676 |
2749 |
33 178 |
2762 |
35 004 |
2624 |
38 377 |
13 001 |
158 600 |
Plant exposures – Gender |
All exposures – Gender |
|||||
Symptom severity |
Male |
Female |
Unknown |
Male |
Female |
Unknown |
0 + 1 |
4519 (84.47 % CI95: 83.49–85.45 %) |
4386 (86.63 % CI95: 85.68–87.58 %) |
2209 (85.32 % CI95: 83.70–86.44 %) |
42 882 (64.46 % CI95: 64.10–64.82 %) |
48 715 (64.17 % CI95: 63.83–64.51 %) |
11 737 (72.65 % CI95: 71.96–73.34 %) |
2 |
119 (2.22 % CI95: 1.82–2.62 %) |
86 (1.70 % CI95: 1.33–2.07 %) |
15 (0.58 % CI95: 0.27–0.89 %) |
5170 (7.77 % CI95: 7.57–7.97 %) |
5899 (7.77 % CI95: 7.58–7.96 %) |
566 (3.50 % CI95: 3.22–3.79 %) |
3 |
3 (0.06 % CI95: n. c.) |
6 (0.12 % CI95: 0.01–0.23 %) |
0 (0 % CI95: n. c.) |
2501 (3.76 % CI95: 3.61–3.91 %) |
2835 (3.73 % CI95: 3.59–3.87 %) |
168 (1.04 % CI95: 0.88–1.20 %) |
Fatal |
1 (0.02 % CI95: n. c.) |
3 (0.06 % CI95: n. c.) |
0 (0 % CI95: n. c.) |
152 (0.23 % CI95: 0.19–0.27 %) |
127 (0.17 % CI95: 0.14–0.20 %) |
20 (0.12 % CI95: 0.07–0.18 %) |
Unknown |
708 (13.23 % CI95: 12.32–14.16 %) |
581 (11.48 % CI95: 10.59–12.37 %) |
365 (14.10 % CI95: 12.74–15.46 %) |
15 822 (23.78 % CI95: 23.46–24.10 %) |
18 341 (24.16 % CI95: 23.85–24.47 %) |
3665 (25.93 % CI95: 25.25–26.60 %) |
Number of cases |
5350 |
5062 |
2589 |
66 527 |
75 917 |
16 156 |
n. c. = not calculated |
Accidental |
Abuse |
Suicide |
Unknown |
All circumstances |
||||||
Symptom severity |
Plant exposures |
All exposures |
Plant exposures |
All exposures |
Plant exposures |
All exposures |
Plant exposures |
All exposures |
Plant exposures |
All exposures |
0 + 1 |
10 578 (88.94 %* CI95: 88.37–89.50 %) |
58 672 (82.67 % CI95: 82.39–82.95 %) |
84 (22.64 %* CI95: 18.25–27.03 %) |
2141 (35.45 % CI95: 34.24–36.67 %) |
62 (52.10 % CI95: 42.70–61.50 %) |
30 098 (52.61 % CI95: 52.20–53.02 %) |
383 (62.07* CI95: 58.16–65.98 %) |
12 125 (49.74 % CI95: 49.11–50.37 %) |
11 114 (85.50 %* CI95: 84.89–86.11 %) |
103 334 (65.20 % CI95: 64.97–65.43 %) |
2 |
97 (0.82 %* CI95: 0.65–0.98 %) |
1730 (2.44 % CI95: 2.32–2.55 %) |
74 (19.95 % CI95: 15.75–24.15 %) |
1316 (21.79 % CI95: 20.74–22.845) |
16 (13.45 % CI95: 6.90–20.00 %) |
6354 (11.10 % CI95: 10.84–11.36 %) |
33 (5.35 %* CI95: 3.49–7.21 %) |
2209 (9.06 % CI95: 8.70–9.42 %) |
220 (1.69 %* CI95: 1.46–1.92 %) |
11 635 (7.33 % CI95: 7.20–7.46 %) |
3 |
4 (0.03 %* CI95: n. c.) |
351 (0.49 % CI95: 0.44–0.55 %) |
1 (0.27 %* CI95: n. c.) |
429 (7.10 % CI95: 6.44–7.76 %) |
3 (2.52 % CI95: n. c.) |
3649 (6.38 % CI95: 6.18–6.58 %) |
1 (0.16 %* CI95: n. c.) |
1069 (4.38 % CI95: 4.12–4.64 %) |
9 (0.07 %* CI95: 0.02–0.12 %) |
5504 (3.47 % CI95: 3.38–3.56 %) |
Fatal |
0 (0 %* CI95: n. c.) |
25 (0.04 % CI95: 0.02–0.05 %) |
0 (0 % CI95: n. c.) |
26 (0.43 % CI95: 0.26–0.60 %) |
4 (3.36 %* CI95: n. c.) |
160 (0.28 % CI95: 0.24–0.32 %) |
0 (0 % CI95: n. c.) |
88 (0.36 % CI95: 0.28–0.44) |
4 (0.03 %* CI95: n. c.) |
299 (0.18 % CI95: 0.16–0.20 %) |
Unknown |
1215 (10.22 %* CI95: 9.67–10.76 %) |
10 194 (14.36 % CI95: 14.10–14.62 %) |
212 (57.14 %* CI95: 51.97–62.31 %) |
2128 (35.23 % CI95: 34.02–36.44) |
34 (28.57 % CI95: 20.03–37.20 %) |
16 949 (29.63 % CI95: 29.25–30.01 %) |
200 (32,41 % CI95: 28.64–36.18 %) |
8887 (36.46 % CI95: 35.85–37.07 %) |
1654* (12.70 % CI95: 12.12–13.28 %) |
37 828 (23.90 % CI95: 23.69–24.37 %) |
Number of cases (relative frequency and CI95 in % of total plant and all exposures) |
11 894 (91.56 %* CI95: 91.12–92.08 %) |
70 972 (44.93 % CI95: 44.65–45.14 %) |
371 (2.86 %* CI95: 2.57–3.15 %) |
6040 (3.81 % CI95: 3.72–3.90 %) |
119 (0.94 %* CI95: 0.77–1.11 %) |
57 210 (36.08 % CI95: 35.86–36.34 %) |
617 (4.64 %* CI95: 4.27–5.01 %) |
24 378 (15.17 % CI95: 15.02–15.38 %) |
13 001 |
158 600 |
n. c. = not calculated |
More detailed information on plant exposures with severe symptoms or even a fatal outcome is given in [Table 5]. In total, only 9 severe plant exposures (plant genera: Aconitum, Arum, Chelidonium, Datura, Brugmansia, Dieffenbachia, Ricinus, 2 Taxus) were observed. A child (4-year-old girl) was involved only once. In four cases (plant genera: 2 Aconitum, 2 Taxus), the outcome of the plant exposure was fatal.
Case number |
Plant |
Circumstances of exposure |
Patient |
Symptoms |
Measures |
1 |
Aconitum napellus unknown amount |
suicidal ingestion |
woman, age unknown |
initially no symptoms, afterwards death |
no treatment |
2 |
Aconitum napellus unknown amount of a soup from the plant |
suicidal ingestion |
63-year-old man |
20 min after ingestion first symptoms with malaise, vomiting, abdominal pain, coma, respiratory insufficiency, hyporeflexia, hypothermia, bradycardia (54 beats/min), initial hypertension then hypotension (systolic RR 40 mmHg), in X-ray atelectasis of the left lung |
intubation and ventilation, gastric lavage, activated charcoal plus sodium sulfate, cardiopulmonary monitoring, catecholamines, infusion, sedation with propofol, acetylcysteine and antibiotics to treat bronchopneumonia (38 °C) in the further course, recovered completely |
3 |
Aconitum napellus unknown amount of a liquid extraction from the plant |
suicidal ingestion |
74-year-old man |
coma, respiratory failure, hypotension |
died in the further course of treatment at an intensive care unit |
4 |
Arum cornutum unknown amount of the root tuber |
accidental ingestion, mix-up with celery |
man, age unknown |
swelling of the left side of the tongue and pharynx, respiratory insufficiency |
cardiopulmonary monitoring, antihistaminics, improvement of the symptoms in the further course |
5 |
Chelidonium majus unknown amount |
accidental ingestion as herbage |
man, age unknown |
jaundice, convulsion, shortly high elevation of transaminases |
viral hepatitis was excluded, symptomatic treatment, transaminases decreased in the further course |
6 |
Datura stramonium unknown amount of tea prepared from seeds |
ingestion for unknown reason |
42-year-old woman |
initially coma, in the further course apathia, pronounced agitation, tachycardia, mydriasis |
cardiopulmonary monitoring, infusion, clonidine, nitroglycerin, diazepam, haloperidol, single dose of physostigmine and furosemide, recovered completely |
7 |
Brugmansia unknown amount |
abusal ingestion |
17-year-old girl |
pronounced psychotic reaction, tachycardia (180 beats/min), mydriasis |
ipecac-induced emesis, activated charcoal, cardiopulmonary monitoring, unknown outcome |
8 |
Dieffenbachia unknown amount of plant juice |
accidental dermal contamination of an open wound of the thumb 1 month ago |
42-year-old woman |
dermal necrosis |
surgical debridement and plastic coverage of the wound, delayed wound healing, no underlying disease (diabetes) was known |
9 |
Ricinus communis unknown amount of leaves |
accidental ingestion, mix-up with leaves from Rheum rhabarbarum |
4-year-old girl |
permanent vomiting, bloody aqueous diarrhoea, hypotension, hypothermia |
intravenous administration of fluid and electrolytes, diagnostically no other cause was found, unknown outcome |
10 |
Taxus baccata unknown amount of leaves |
suicidal ingestion |
16-year-old girl |
initially malaise, unconsciousness, in autopsy pronounced mydriasis, brain and lung oedema, congestion in liver, spleen, and kidneys |
resuscitation, death, in autopsy big amounts of Taxus baccata leaves in larynx, oesophagus, stomach and duodenum |
11 |
Taxus baccata unknown amount of leaves |
suicidal ingestion |
woman, age unknown |
no information, the woman was found dead |
in postmortem analysis the serum concentration of 3,5-dimethoxyphenol was 60 µg/L |
12 |
Taxus baccata unknown amount of leaves |
suicidal ingestion |
48-year-old woman |
coma, respiratory and renal failure, hypotonia |
intubation and ventilation, gastric lavage, activated charcoal, cardiopulmonary monitoring, recovered completely |
13 |
Taxus baccata unknown amount of leaves |
suicidal ingestion |
52-year-old woman |
coma, asystole, after resuscitation and defibrillation bradycardia with escape rhythm, pronounced QRS complex widening |
intubation and ventilation, gastric lavage, multiple-dose activated charcoal, cardiopulmonary monitoring, pacemaker installation, lidocaine (50 mg as i. v. bolus and 1 g/24 h) reduced remarkably the QRS complex widening, recovered completely after 7 days of treatment at an intensive care unit |
[Table 6] shows all plant genera that caused at least twice moderate or severe symptoms after exposure. The most frequent moderate or severe symptoms were seen in exposures to Brugmansia (54), Datura (23), and Euphorbia (17).
Plant genera |
EP |
TPE |
MME |
MME/TPE in % |
Brugmansia |
+++ |
377 |
54 |
14.3 |
Datura |
+++ |
127 |
23 |
18.1 |
Euphorbia |
+ |
385 |
17 |
4.4 |
Taxus |
+++ |
742 |
9 |
1.2 |
Atropa |
+++ |
53 |
6 |
11.3 |
Heracleum |
++ |
59 |
6 |
10.2 |
Laburnum |
++ |
143 |
5 |
3.5 |
Sambucus |
+ |
268 |
5 |
1.9 |
Narcissus |
+ |
115 |
4 |
3.5 |
Aconitum |
+++ |
43 |
3 |
7.0 |
Dictamnus |
++ |
7 |
3 |
42.9 |
Dieffenbachia |
++ |
210 |
3 |
1.4 |
Digitalis |
++ |
67 |
3 |
4.5 |
Ricinus |
+++ |
40 |
3 |
7.5 |
Solanum |
++ |
246 |
3 |
1.2 |
Colchicum |
+++ |
59 |
2 |
3.4 |
Hedera |
++ |
119 |
2 |
1.7 |
Discussion
As described above, the U. S. poison centres registered a steady decline of 33 % of the relative percentage as well as of the absolute number of plant exposures during the decade of 2000–2009 [6]. This decline was even more dramatic (a decrease of 400 %) if a time period over 3 decades (1983–2009) was investigated. The authors explained this phenomenon with the increasing use of the Internet for identifying plants and getting information about them. In Germany, the use of the Internet in persons older than 14 years also rose from 38.8 % in 2001 to 69.4 % in 2010 [13]. In the present study, plant exposures reported to the PIC Erfurt discontinuously increased from 1110 in 2001 to 1467 in 2009 and decreased afterwards to 1157 in 2010 ([Fig. 1]). Therefore, from our point of view, the hypothesis that augmented Internet use resulted in a decreased number of calls concerning plant exposure seems to be questionable, at least for the federal states that the PIC Erfurt is serving.
Like in the U. S. [6], in our present study plant exposures were mostly seen during the more temperate months of the northern hemisphere. Differences, however, were observed in the rank order of the most common plant exposures. While in the U. S. study Spathiphyllum, Ilex, Philodendron, Euphorbia, Phytolacca, Fragaria, Hemerocallis, Schefflera, Calendula, and Ficus were among the 10 most frequent plant exposures, the rank order in our study was Taxus, Ligustrum, Ficus, Physalis, Prunus, Lonicera, Euphorbia, Brugmansia, Sorbus, and Mahonia, which is comparable, with small differences, to the rank order seen in other studies conducted in Germany [2] and Switzerland [3], [4], [5].
While the rate of accidental exposures to plant genera like Taxus, Ligustrum, and Ficus was continuously high during the whole study period, the exposure by abuse to plant genera like Brugmansia and Datura showed time-dependent changes with the highest rate being in 2001 and a decreasing frequency in the following years. Concurrently, with the decrease of Datura and Brugmansia exposure, the proportion of adolescents compared to the other age groups in plant exposures was also reduced, while the proportion of the other age groups involved in plant exposures remained quite stable ([Table 2]). Datura and Brugmansia genera were mainly abused by adolescents and young adults, and were mostly responsible for moderate or severe symptoms in plant exposures in our study and in other studies as well [1], [2], [3], [4], [5], [6], [12], [14] ([Table 6]). Unfortunately, in these studies no information was given if the exposure to these plant genera by abuse was also decreasing.
In the above-mentioned U. S. study [6], nearly 55 % of the plant-related fatalities involved males and slightly more than 60 % of the exposures that had a moderate or major outcome occurred in males. In our present study, no such gender specific influence on the symptom severity was observed ([Table 3]).
In our study as well as in other studies [1], [2], [3], [4], [5], [6], [12], plant exposures more frequently resulted in none to mild symptoms and less often resulted in moderate and severe symptoms, and even death, than all exposures. These results can at least partially be explained by the fact that the proportion of babies and toddlers and accidental exposure was significantly higher, and the proportion of adults and intentional exposure by abuse and suicide was significantly lower in plant exposures than in all exposures ([Table 4]). To exclude the influence of the circumstances of exposure on symptom severity, we directly compared the frequencies of symptom severity in the single circumstance groups in plant and all exposures ([Table 4]). After this procedure, accidental plant exposures also resulted more often in none to mild symptoms and resulted less often in moderate and severe symptoms, and even death, than all accidental exposures; but these differences were less pronounced than in the analysis regardless of the circumstances of exposure. In plant exposures by abuse, significant differences to all exposures by abuse were only seen for the frequencies of none to mild and severe symptoms. When exposure occurred due to suicidal intention, no significant difference between plant and all exposures concerning symptoms with none to high severity was observed. Fatalities, however, were even more significantly (p < 0.05) frequent in suicidal plant exposures than in all exposures due to suicidal intention ([Table 4]).
As can be seen in [Table 5], we observed only 9 severe plant exposures (plant genera: Aconitum, Arum, Chelidonium, Datura, Brugmansia, Dieffenbachia, Ricinus, 2 Taxus) and four fatal cases (plant genera: 2 Aconitum, 2 Taxus) ([Table 4]). While in the U. S. study mainly Datura and Cicuta species were responsible for fatal outcomes and only one Taxus chinensis exposure resulted in death, no fatality after Aconitum napellus exposure was observed [6]. In Switzerland, 3 of 4 fatal plant exposures were caused by Colchicum autumnale and one by Taxus baccata.
While Aconitum contains the sodium channel activators aconitine and related alkaloids in all parts of the plant, especially in the leaves and roots, in Taxus baccata, most of the plant, including the seeds but not the red aril, contains the toxic taxine alkaloids that block sodium and calcium currents [8]. Most paediatric cases of Taxus baccata exposure involve ingestion of the seeds and aril with usually none to minimal symptoms. Therefore, the toxic potential of Taxus baccata could be underestimated [15]. Substantial ingestion of the leaves, however, that ocurrs mainly with the intention of suicide can result in severe cardiovascular effects including bradycardia, premature ventricular contractions, atrioventricular conduction defects, or ventricular tachydysrhythmias [16].
Betweeen 2001 and 2010, 20 % of all exposures in children registered by the PIC Erfurt concerned plant exposures. The main groups of callers due to plant exposure besides private persons (8212, 63.0 %) were physicians from hospitals (2217, 17.1 %) and general practitioners or practice-based paediatricians (1624, 12.5 %). These data show that the clinical significance of plant exposure is high because the knowledge about plants and their toxicity in the general public as well as in health care professionals seems to be low.
#Limitations
Our study had several limitations. The study was only retrospective. Case records of the PIC Erfurt were from self-reported calls, and reflect only information provided by a layperson or health care professional. Exact information about the ingested amount of the plant was often missing. Therefore, it was not possible to investigate the relationship of plant amount and its toxicity. The plant involved in exposure was often not identified by a plant expert and the plant exposure was mostly not confirmed by laboratory analysis.
#Conclusions
In contrast to the development seen by the U. S. PICs, the PIC Erfurt observed a decrease in the frequency of plant exposures in relation to all exposures but not in their absolute numbers in the decade 2001–2010.
While some plants genera like Taxus, Ligustrum, and Ficus were continuously among the most often involved plant genera during the whole study period, exposures to other plant genera like Brugmansia and Datura showed time-dependent changes.
In comparison to all human exposures, the relative frequency of severe symptoms in accidental and intentional plant exposures by abuse is significantly lower, but as high by suicide.
The significantly higher involvement of children resulted mainly in none or mild symptoms. Severe symptoms can mostly be observed in adults with intentional ingestion when poisonous plants are mistaken for eatable.
Because the ingestion of some plants resulted in severe symptoms (Aconitum, Arum, Chelidonium, Datura, Brugmansia, Dieffenbachia, Ricinus, 2 Taxus) and even death (2 Aconitum, 2 Taxus), their dangerousness should not be trivialized.
#Conflict of Interest
All contributing authors state that no conflict of interest is involved with this work.
#References
- 1 Wolfle J, Kowalewski S. Epidemiology of ingestions in a regional poison control center over twenty years. Vet Hum Toxicol. 1995; 37 367-368
- 2 Pietsch J, Koch I, Hermanns-Clausen M, Hüller G, Wagner R, Dressler J. Pediatric plant exposures in Germany, 1998–2004. Clin Toxicol. 2008; 46 686-691
- 3 Jaspersen-Schib R, Theus L, Guirguis-Oeschger M, Gossweiler B, Meier-Abt P J. Serious plant poisonings in Switzerland 1966–1994. Case analysis from the Swiss Toxicology Information Center. Schweiz Med Wochenschr. 1996; 126 1085-1098
- 4 Kupper J, Reichert C. Intoxications with plants. Ther Umsch. 2009; 66 343-348
- 5 Fuchs J, Rauber-Lüthy C, Kupferschmidt H, Kupper J, Kullak-Ublick G A, Ceschi A. Acute plant poisoning: analysis of clinical features and circumstances of exposure. Clin Toxicol. 2011; 49 671-680
- 6 Krenzelok E P, Mrvos R. Friends and foes in the plant world: a profile of plant ingestions and fatalities. Clin Toxicol. 2011; 49 142-149
- 7 Persson H E, Sjöberg G K, Haines J A, Pronczuk de Garbino J. Poisoning severity score. Grading of acute poisoning. Clin Toxicol. 1998; 36 205-213
- 8 Frohne D, Pfänder H J. Giftpflanzen, 5th edition. Stuttgart: Wissenschaftliche Verlagsgesellschaft GmbH; 2004
- 9 Ritter-Franke S, Bunjes R. Vergiftungsunfälle mit Pflanzen. In: Von Mühlendahl K E, Oberdisse U, Bunjes R, Brockstedt M, editors Vergiftungen im Kindesalter, 4th edition. Stuttgart, New York: Thieme Verlag; 2003
- 10 Teuscher E, Lindequist U. Biogene Gifte. 3rd edition. Stuttgart: Wissenschaftliche Verlagsgesellschaft GmbH; 2010
- 11 Sachs L, Hedderich J. Angewandte Statistik, 12th edition. Berlin, Heidelberg, New York: Springer Verlag; 2006: 256
- 12 Litovitz T, White N C, Watson W A. Epidemiology of pediatric poison exposures: An analysis of 2003 poison control center data. Clin Ped Emerg Med. 2005; 6 68-75
- 13 van Eimeren B, Frees B, Gerhard H, Oehmichen E, Schröter C. ARD/ZDF-Onlinestudie 1998–2011. Available at http://www.ard-zdf-onlinestudie.de/index.php?id=onlinenutzung00 Accessed November 9, 2011
- 14 Lin T, Nelson L S, Tsai J L, Hung D Z, Hu S C, Chan H M, Deng J F. Common toxidromes of plant poisonings in Taiwan. Clin Toxicol. 2009; 47 161-168
- 15 Krenzelok E P, Jacobsen T D, Aronis J. Is the yew really poisonous to you?. J Toxicol Clin Toxicol. 1998; 36 219-223
- 16 Kalentzi C, Wattenberg M, Ernstberger J, Deters M, Schaper A, Hentschel H. Yew can be really poisonous to you. Clin Toxicol. 2010; 48 309
PD Dr. Med. Michael Deters
Poisons Information Centre
c/o HELIOS Klinikum GmbH
Nordhäuser Str. 74
99085 Erfurt
Germany
Telefon: +49 3 61 73 07 30
Fax: +49 36 17 30 73 17
eMail: michael_deters2002@yahoo.de
References
- 1 Wolfle J, Kowalewski S. Epidemiology of ingestions in a regional poison control center over twenty years. Vet Hum Toxicol. 1995; 37 367-368
- 2 Pietsch J, Koch I, Hermanns-Clausen M, Hüller G, Wagner R, Dressler J. Pediatric plant exposures in Germany, 1998–2004. Clin Toxicol. 2008; 46 686-691
- 3 Jaspersen-Schib R, Theus L, Guirguis-Oeschger M, Gossweiler B, Meier-Abt P J. Serious plant poisonings in Switzerland 1966–1994. Case analysis from the Swiss Toxicology Information Center. Schweiz Med Wochenschr. 1996; 126 1085-1098
- 4 Kupper J, Reichert C. Intoxications with plants. Ther Umsch. 2009; 66 343-348
- 5 Fuchs J, Rauber-Lüthy C, Kupferschmidt H, Kupper J, Kullak-Ublick G A, Ceschi A. Acute plant poisoning: analysis of clinical features and circumstances of exposure. Clin Toxicol. 2011; 49 671-680
- 6 Krenzelok E P, Mrvos R. Friends and foes in the plant world: a profile of plant ingestions and fatalities. Clin Toxicol. 2011; 49 142-149
- 7 Persson H E, Sjöberg G K, Haines J A, Pronczuk de Garbino J. Poisoning severity score. Grading of acute poisoning. Clin Toxicol. 1998; 36 205-213
- 8 Frohne D, Pfänder H J. Giftpflanzen, 5th edition. Stuttgart: Wissenschaftliche Verlagsgesellschaft GmbH; 2004
- 9 Ritter-Franke S, Bunjes R. Vergiftungsunfälle mit Pflanzen. In: Von Mühlendahl K E, Oberdisse U, Bunjes R, Brockstedt M, editors Vergiftungen im Kindesalter, 4th edition. Stuttgart, New York: Thieme Verlag; 2003
- 10 Teuscher E, Lindequist U. Biogene Gifte. 3rd edition. Stuttgart: Wissenschaftliche Verlagsgesellschaft GmbH; 2010
- 11 Sachs L, Hedderich J. Angewandte Statistik, 12th edition. Berlin, Heidelberg, New York: Springer Verlag; 2006: 256
- 12 Litovitz T, White N C, Watson W A. Epidemiology of pediatric poison exposures: An analysis of 2003 poison control center data. Clin Ped Emerg Med. 2005; 6 68-75
- 13 van Eimeren B, Frees B, Gerhard H, Oehmichen E, Schröter C. ARD/ZDF-Onlinestudie 1998–2011. Available at http://www.ard-zdf-onlinestudie.de/index.php?id=onlinenutzung00 Accessed November 9, 2011
- 14 Lin T, Nelson L S, Tsai J L, Hung D Z, Hu S C, Chan H M, Deng J F. Common toxidromes of plant poisonings in Taiwan. Clin Toxicol. 2009; 47 161-168
- 15 Krenzelok E P, Jacobsen T D, Aronis J. Is the yew really poisonous to you?. J Toxicol Clin Toxicol. 1998; 36 219-223
- 16 Kalentzi C, Wattenberg M, Ernstberger J, Deters M, Schaper A, Hentschel H. Yew can be really poisonous to you. Clin Toxicol. 2010; 48 309
PD Dr. Med. Michael Deters
Poisons Information Centre
c/o HELIOS Klinikum GmbH
Nordhäuser Str. 74
99085 Erfurt
Germany
Telefon: +49 3 61 73 07 30
Fax: +49 36 17 30 73 17
eMail: michael_deters2002@yahoo.de
![](https://www.thieme-connect.de/media/plantamedica/201205/thumbnails/v0888pm01.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
Fig. 1 Frequency of plant exposures (in 100) and relative frequency of plant exposures to all exposures (in %) reported to the PIC Erfurt from the beginning of 2001 to the end of 2010.