eMedicine Specialties > Emergency Medicine > Toxicology

Plant Poisoning, Oxalates

Author: Jason F Kearney, MD, Consulting Staff, Department of Emergency Medicine, Emergency Medicine Associates, PC, Southwest Washington Medical Center
Coauthor(s): William K Chiang, MD, Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center
Contributor Information and Disclosures

Updated: May 27, 2009

Introduction

Background

Plant exposures are some of the most frequent poisonings reported to poison control centers. Exposures to plants containing oxalate crystals, such as Philodendron and Dieffenbachia, are among the most common toxic plant exposures reported in the US.

For the past 200 years, the irritant properties of the Dieffenbachia plant have had various uses, including punishing slaves and treating gout, impotence, and frigidity. Today, plants containing oxalate are admired for their ornamental beauty and found in public places and homes.

The following plants contain oxalates:

  • Anthurium (Anthurium species)
  • Arum, Araceae (Arisaema species)
  • Caladium (Caladium bicolor)
  • Calla lily (Zantedeschia species)
  • Chinese evergreen (Aglaonema species)
  • Dieffenbachia (Dieffenbachia species) (see Media file 1)


Dieffenbachia

Dieffenbachia

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Dieffenbachia

Dieffenbachia


Jack-in-the-Pulpit

Jack-in-the-Pulpit

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Jack-in-the-Pulpit

Jack-in-the-Pulpit

  • Monstera, Ceriman (Monstera deliciosa)
  • Nephthytis (Syngonium podophyllum)
  • Philodendron (Philodendron species)
  • Pothos or Hunter's robe (Epipremnum aureum)
  • Skunk cabbage (Symplocarpus foetidus) (see Media files 3-4)


Skunk Cabbage

Skunk Cabbage

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Skunk Cabbage

Skunk Cabbage



Skunk Cabbage

Skunk Cabbage

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Skunk Cabbage

Skunk Cabbage

Pathophysiology

Nonsoluble calcium oxalate crystals are found in plant stems, roots, and leaves. The stalk of the Dieffenbachia plant produces the most severe reactions. These needlelike crystals produce pain and edema when they contact lips, tongue, oral mucosa, conjunctiva, or skin.1 Edema primarily is due to direct trauma from the needlelike crystals and, to a lesser extent, by other plant toxins (eg, bradykinins, enzymes).2,3

Frequency

United States

Philodendron and Dieffenbachia exposures are among the most common plant exposures reported to poison control centers.

According to the 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS), 7368 single exposures were documented for oxalate plant poisonings.4

Mortality/Morbidity

In most cases, nonsoluble oxalate plants produce self-limited symptoms and clinical manifestations. Significant morbidity or mortality is extremely rare. One case report of an infant fatality attributed to airway obstruction after exposure to Dieffenbachia exists.

The 2007 Annual Report of the American Association of Poison Control Centers' NPDS reported 1145 minor outcomes, 81 moderate outcomes, 3 major outcomes, and no deaths from oxalate plant exposures.4

Age

The majority of oxalate plant exposures occur in children younger than 5 years while sampling houseplants in the home.

The 2007 Annual Report of the American Association of Poison Control Centers' NPDS reported 6020 oxalate plant exposures in those younger than 6 years, 762 exposures in those aged 6-19 years, and 455 exposures in those older than 19 years.4

Clinical

History

Symptoms, if they develop, occur rapidly and may include the following:

  • Keratoconjunctivitis and corneal abrasions after contact with plant material
  • Edema, erythema, bullae, and inflammation of mouth and oral mucosa after contact; esophagitis
  • Slurred or unintelligible speech
  • Laryngeal edema (with sufficient contact)
  • Superficial necrosis developing days after initial contact
  • Local skin erythema and/or edema (typical of a contact dermatitis) due to contact with plant sap or juices

Physical

No physical findings exist in the majority of oxalate exposures.

More on Plant Poisoning, Oxalates

Overview: Plant Poisoning, Oxalates
Differential Diagnoses & Workup: Plant Poisoning, Oxalates
Treatment & Medication: Plant Poisoning, Oxalates
Follow-up: Plant Poisoning, Oxalates
Multimedia: Plant Poisoning, Oxalates
References
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References

  1. Gardner DG. Injury to the oral mucous membranes caused by the common houseplant, dieffenbachia. A review. Oral Surg Oral Med Oral Pathol. Nov 1994;78(5):631-3. [Medline].

  2. Lin TJ, Hung DZ, Hu WH, Yang DY, Wu TC, Deng JF. Calcium oxalate is the main toxic component in clinical presentations of alocasis macrorrhiza (L) Schott and Endl poisonings. Vet Hum Toxicol. Apr 1998;40(2):93-5. [Medline].

  3. Zhong LY, Wu H. [Current researching situation of mucosal irritant compontents in Araceae family plants]. Zhongguo Zhong Yao Za Zhi. Sep 2006;31(18):1561-3. [Medline].

  4. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline]. [Full Text].

  5. Cheeke PR. Endogenous toxins and mycotoxins in forage grasses and their effects on livestock. J Anim Sci. Mar 1995;73(3):909-18. [Medline]. [Full Text].

  6. Fochtman FW, Manno JE, Winek CL, Cooper JA. Toxicity of the genus Dieffenbachia. Toxicol Appl Pharmacol. Jul 1969;15:38-45. [Medline].

  7. Jaspersen-Schib R, Theus L, Guirguis-Oeschger M, Gossweiler B, Meier-Abt PJ. [Serious plant poisonings in Switzerland 1966-1994. Case analysis from the Swiss Toxicology Information Center]. Schweiz Med Wochenschr. Jun 22 1996;126(25):1085-98. [Medline].

  8. Krenzelok EP, Jacobsen TD, Aronis JM. Plant exposures: a state profile of the most common species. Vet Hum Toxicol. Aug 1996;38(4):289-98. [Medline].

  9. Lampe KF. AMA Handbook of Poisonous and Injurious Plants. AMA; 1985:1-6, 72.

  10. Loretti AP, da Silva Ilha MR, Ribeiro RE. Accidental fatal poisoning of a dog by Dieffenbachia picta (dumb cane). Vet Hum Toxicol. Oct 2003;45(5):233-9. [Medline].

  11. Manríquez O, Varas J, Ríos JC, Concha F, Paris E. Analysis of 156 cases of plant intoxication received in the Toxicologic Information Center at Catholic University of Chile. Vet Hum Toxicol. Feb 2002;44(1):31-2. [Medline].

  12. McIntire MS, Guest JR, Porterfield JF. Philodendron--an infant death. J Toxicol Clin Toxicol. 1990;28(2):177-83. [Medline].

  13. Mitchell JC, Rook A. Botanical Dermatology: Plants and Plant Products. 1979:114-5.

  14. Mrvos R, Dean BS, Krenzelok EP. Philodendron/dieffenbachia ingestions: are they a problem?. J Toxicol Clin Toxicol. 1991;29(4):485-91. [Medline].

  15. Ogzewalla CD, Bonfiglio JF, Sigell LT. Common plants and their toxicity. Pediatr Clin North Am. Dec 1987;34(6):1557-98. [Medline].

  16. Pamies RJ, Powell R, Herold AH, Martinez J III. The dieffenbachia plant. Case history. J Fla Med Assoc. Nov 1992;79(11):760-1. [Medline].

  17. Rauber A. Observations on the idioblasts of Dieffenbachia. J Toxicol Clin Toxicol. 1985;23(2-3):79-90. [Medline].

  18. Tagwireyi D, Ball DE. The management of Elephant's Ear poisoning. Hum Exp Toxicol. Apr 2001;20(4):189-92. [Medline].

  19. Watson JT, Jones RC, Siston AM, Diaz PS, Gerber SI, Crowe JB. Outbreak of food-borne illness associated with plant material containing raphides. Clin Toxicol (Phila). 2005;43(1):17-21. [Medline].

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Further Reading

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Keywords

plant poisoning, poisonous plant, toxic plants, oxalate crystals, oxalate exposures, Philodendron, Dieffenbachia, Anthurium, Anthurium species, Arum, Araceae, Arisaema species, Caladium, Caladium bicolor, Calla lily, Zantedeschia species, Chinese evergreen, Aglaonema species, Dieffenbachia, Dieffenbachia species, Jack-in-the pulpit, Arisaema triphyllum, Monstera, Ceriman, Monstera deliciosa, Nephthytis, Syngonium podophyllum, Philodendron, Philodendron species, Pothos or Hunter's robe, Epipremnum aureum, skunk cabbage, Symplocarpus foetidus

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Contributor Information and Disclosures

Author

Jason F Kearney, MD, Consulting Staff, Department of Emergency Medicine, Emergency Medicine Associates, PC, Southwest Washington Medical Center
Jason F Kearney, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

William K Chiang, MD, Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center
William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Miguel C Fernández, MD, FAAEM, FACEP, FACMT, Associate Clinical Professor; Medical and Managing Director, South Texas Poison Center, Department of Surgery/Emergency Medicine and Toxicology, University of Texas Health Science Center at San Antonio
Miguel C Fernández, MD, FAAEM, FACEP, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, American College of Occupational and Environmental Medicine, Society for Academic Emergency Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & 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.

Managing Editor

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.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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