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Tropane Alkaloid Poisoning

  • Author: Richard A Wagner, MD, PhD, FACEP, FAAEM; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Dec 06, 2015
 

Background

Alkaloids are plant metabolites that have a nitrogen-containing chemical ring structure, alkali-like chemical reactivity, and pharmacologic activity.[1] The alkaloids represent a very diverse group of medically significant compounds that include well-known drugs like the opiates.

A subgroup of the alkaloids is the alkaloid amines. The three major pharmacologic groups of alkaloid amines are the hallucinogenic alkaloid amines, the stimulant alkaloid amines, and the highly anticholinergic tropane alkaloids (also called the belladonna alkaloids or bicyclic alkaloids).

Plants that contain the tropane alkaloids atropine, scopolamine, and hyoscyamine include the following:

  • Datura species (jimson weed, angel's trumpet, thorn apple) [2, 3]
  • Hyoscyamus niger (henbane)
  • Atropa belladonna (deadly nightshade) [4, 5]
  • Mandragora officinarum (mandrake)

All of these plants have long histories of hallucinogenic use and have been connected with sorcery, witchcraft, native medicine, and magico-religious rites dating back to 1500 BC and Homer's Odyssey. (Homer's use of the plant moly as an antidote to Circe's poisonous anticholinergic drugs may have been the first recorded use of an anticholinesterase to reverse central anticholinergic intoxication.)

Chinese herbal medicines containing tropane alkaloids have been used to treat asthma, chronic bronchitis, pain, and flu symptoms. In Mexico, Datura (see the images below) is taken by Yaqui women to lessen pain of childbirth. In Africa, a common use is to smoke leaves from Datura to relieve asthma and pulmonary problems. Many cultures worldwide add plants with tropane alkaloids (particularly Datura species) to alcoholic beverages to increase intoxication.

Datura stramonium (jimson weed). Note 4-5 inch lon Datura stramonium (jimson weed). Note 4-5 inch long white flowers.© 2000 Richard Wagner
Datura stramonium flower. Note the trumpetlike sha Datura stramonium flower. Note the trumpetlike shape.© 2000 Richard Wagner
Datura stramonium (close-up of unripe seed pods). Datura stramonium (close-up of unripe seed pods). Note spiny appearance of pods.© 2000 Richard Wagner

Recently, Datura has been used as a recreational hallucinogen in the US, resulting in sporadic cases of anticholinergic poisoning and death. Numerous cases of anticholinergic poisoning also have resulted from belladonna alkaloid contaminants in foods, including commercially purchased Paraguay tea (an herbal tea derived from Ilex paraguariensis), hamburger, honey,[6] stiff porridge made from contaminated millet, and homemade "moon flower" wine. Other accidental ingestions include misuse as an edible wild vegetable[7] and inclusion in homemade toothpaste,[8] as well as a large epidemic in New York and the eastern US that resulted from heroin contaminated with scopolamine[9] .

Although most tropane alkaloids cause an anticholinergic syndrome, a recent report indicates that the tropane alkaloid–containing medicinal herb Erycibe henri Prain ("Ting Kung Teng") contains a tropane alkaloid that may cause a cholinergic syndrome, as well as renal, hepatic, and erythrocyte toxicity.[10] This is considered atypical for the tropane alkaloids, which are predominantly strongly anticholinergic.

See 11 Common Plants That Can Cause Dangerous Poisonings, a Critical Images slideshow, to help identify plant reactions and poisonings.

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Pathophysiology

Toxicity from plants containing tropane alkaloids manifests as classic anticholinergic poisoning. Symptoms usually occur 30-60 minutes after ingestion and may continue for 24-48 hours because tropane alkaloids delay gastric emptying and absorption.

Scopolamine, acting as an antagonist at both peripheral and central muscarinic receptors, is thought to be the primary compound responsible for the toxic effects of these plants. Tropane alkaloids are found in all parts of the plants, with highest concentrations in roots and seeds.

Atropine is an artifact of purification, produced by racemization of l-hyoscyamine. The proportion of each alkaloid present varies among species, time of year, location, and part of plant. As little as one-half teaspoon of Datura seed, equivalent to 0.1 mg of atropine per seed, has caused death from cardiopulmonary arrest. The usual route of ingestion is as a tea, although ingesting seeds or other plant parts and smoking dried leaves also are common.

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Epidemiology

Frequency

United States

Incidence is sporadic, with clusters of poisoning cases, mostly among adolescents using plants for their hallucinogenic effects.

According to the American Association of Poison Control Centers' National Poison Data System Annual Report 2014, 610 single exposures to anticholinergic plants were reported; 191 of those were treated in health care facilities. Major outcomes occurred in eight cases, but no deaths were documented.[11]

During 1998-2004, a total of 188 reported human exposures were identified by Texas Poison Control Centers.[12] Seventy-six percent of the exposures occurred in June-October, 82% of the cases occurred in males, and 72% of cases occurred in those aged 13-19 years.

Widespread access to information on hallucinogenic plants through the Internet may lead to a further increase in the incidence.

International

Worldwide incidence is unknown. However, cases have been reported in Germany, Italy, Greece, Saudi Arabia, Tanzania, Australia, Brazil, Hong Kong, Taiwan, Mexico, Chile, and Venezuela, attesting to broad geographic distribution of Datura species.

Mortality/Morbidity

Nonfatal cases are likely underreported.Note the following:

  • Of the 610 anticholinergic plant poisonings reported to the American Association of Poison Control Centers in 2014, none proved fatal. [11]
  • In 1993, 318 cases of Datura poisoning were reported to the American Association of Poison Control Centers; the Centers for Disease Control and Prevention (CDC) reported two deaths.
  • In 1994, the CDC reported seven cases of anticholinergic poisoning in three families who consumed contaminated commercial Paraguay tea. [13]
  • Reports of sporadic cases or clusters of cases involving intentional use as a hallucinogen are frequent; most patients recover uneventfully, although fatalities do occur.
  • Related deaths from drowning, exposure, and lack of supportive care have been reported.

Sex- and Age-related Demographics

Males are more frequently involved in cases of intentional exposure.

No age predilection exists, although Datura use as a recreational drug is more common among adolescents. Accidental ingestion and resultant toxicity in children has been reported.

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Contributor Information and Disclosures
Author

Richard A Wagner, MD, PhD, FACEP, FAAEM Staff Physician, William Beaumont Army Medical Center

Richard A Wagner, MD, PhD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Samuel M Keim, MD, MS Professor and Chair, Department of Emergency Medicine, University of Arizona College of Medicine

Samuel M Keim, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Michael Hodgman, MD Assistant Clinical Professor of Medicine, Department of Emergency Medicine, Bassett Healthcare

Michael Hodgman, MD is a member of the following medical societies: American College of Medical Toxicology, American College of Physicians, Medical Society of the State of New York, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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Datura stramonium (jimson weed). Note 4-5 inch long white flowers.© 2000 Richard Wagner
Datura stramonium flower. Note the trumpetlike shape.© 2000 Richard Wagner
Datura stramonium (close-up of unripe seed pods). Note spiny appearance of pods.© 2000 Richard Wagner
Datura stramonium is the plant shown. © 2000 Richard Wagner
The plant shown is foxglove (Digitalis purpura), which contains cardiac glycosides, not tropane alkaloids. © 2000 Richard Wagner
 
 
 
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