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Toxicity, Terpene

Author: John Said Kashani, DO, Assistant Medical Director of the New Jersey Poison ad Information Education System; Assistant Professor, Department of Preventive Medicine and Community Health, Assistant Professor, Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey
Coauthor(s): Steven Marcus, MD, Professor, Department of Preventive Medicine and Community Health, Associate Professor, Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey; Executive and Medical Director, New Jersey Poison Information and Education System; Consulting Staff, Departments of Pediatrics and Internal Medicine, University Hospital, University of Medicine and Dentistry of New Jersey; Consulting Staff, Department of Pediatrics, Newark Beth Israel Medical Center
Contributor Information and Disclosures

Updated: Dec 11, 2007

Introduction

Background

Terpenes are natural products derived from plants that have medicinal properties and biological activity. Terpenes may be found in cleaning products, rubefacients, aromatherapy, and various topical preparations. Terpenes may exist as hydrocarbons or have oxygen-containing compounds such as ketone or aldehyde groups (terpenoids).

The basic structure of terpenes is repeating isoprene units (C5H8)n, and they are grouped according to the number of repeating isoprene units. Monoterpenes contain 2 isoprene units; examples include cantharidin, menthol, pinene, and camphor. Diterpenes contain 4 isoprene units; examples include phytol, vitamin A11 , and paclitaxel (Taxol).

The best-known compounds in this group are camphor oil and turpentine. The antineoplastic agent paclitaxel is a terpene derived from yew plant bark. An oil derived from the Saliva officinalis tree, thujone, has recently become popular because of its hallucinogenic qualities, and it is quickly becoming a drug of abuse.2

Absinthe, a green liquor containing thujone, has been thought to be responsible for enhancing the creativity of many famous artists including Edouard Manet, Vincent Van Gogh, and Henri de Toulouse-Lautrec.

Pathophysiology

Terpenes are local irritants and, thus, are capable of causing GI signs and symptoms. CNS manifestations may range from an altered mental status to seizures to coma. Aspiration is a particular concern and can result in fatalities and long-term complications.

Absorption begins in the oral cavity and is rapid as evidenced by the early onset of toxicity in significant ingestions. Terpenes are metabolized through cytochrome P450 and are excreted as conjugated metabolites by the kidney.

Frequency

United States

According to the 2005 Annual Report of the American Association of Poison Control Toxic Exposure Surveillance System, 4851 exposures to disinfectants containing pine oil, 10,502 exposures to camphor, and 633 exposures to turpentine were reported.3  Seven deaths were reported with exposures to pine oil or pine oil – containing products.3 No deaths were reported with exposure to camphor or turpentine.3

Mortality/Morbidity

Morbidity and mortality4 associated with exposure to terpenes is largely related to the degree of CNS depression and if aspiration occurs. Despite the toxicity of these agents, morbidity is extremely low.

Sex

Males overrepresent cases associated with terpenes.

Age

Most exposures are the result of unintentional exposures in childhood.

Clinical

History

  • Elicit the exact substance5 that the patient was exposed to, and the concentration of terpene should be noted.
  • Toxicity may first present with GI symptoms of nausea and vomiting.
  • In severe ingestions, seizures have been reported; they are often single and self-limited.

Physical

  • Respiratory symptoms from aspiration may occur early.
  • A careful examination of the chest and lungs is essential. CNS depression may occur early in the ingestion of a concentrated product or large ingestion.
  • Seizures may occur early in exposure and tend to be single and self-limited.
  • Cardiac arrhythmias have been reported; however, vital signs are usually normal.

Causes

  • Most exposures are the result of an unintentional ingestion.
  • Some subcultures of society continue to use turpentine as an antihelminthic, purgative, and general elixir of good health. This practice may produce the potentially disastrous situation where the product is available and considered to be innocuous.
  • Camphorated oil often is supplied in small bottles that closely resemble castor oil. The bottles may be kept on pharmacy or grocery store shelves next to each other so that an individual with vision impairment may easily choose the incorrect preparation.
  • A case report described camphor toxicity in a 35-year-old Cambodian male with diarrhea, vomiting, and altered mental status. He was described as having parallel and symmetric ecchymotic streaks on his back as a result "coining". In this case, toxicity occurred by the application of camphor to the skin prior to coining. Toxicity occurred presumably by transcutaneous absorption.

More on Toxicity, Terpene

Overview: Toxicity, Terpene
Differential Diagnoses & Workup: Toxicity, Terpene
Treatment & Medication: Toxicity, Terpene
Follow-up: Toxicity, Terpene
References
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References

  1. Lam HS, Chow CM, Poon WT, Lai CK, Chan KC, Yeung WL. Risk of vitamin A toxicity from candy-like chewable vitamin supplements for children. Pediatrics. Aug 2006;118(2):820-4. [Medline].

  2. Bücheler R, Gleiter CH, Schwoerer P, Gaertner I. Use of nonprohibited hallucinogenic plants: increasing relevance for public health? A case report and literature review on the consumption of Salvia divinorum (Diviner's Sage). Pharmacopsychiatry. Jan 2005;38(1):1-5. [Medline].

  3. Lai MW, Klein-Schwartz W, Rodgers GC, Abrams JY, Haber DA, Bronstein AC. 2005 Annual Report of the American Association of Poison Control Centers' national poisoning and exposure database. Clin Toxicol (Phila). 2006;44(6-7):803-932. [Medline].

  4. Soo Hoo GW, Hinds RL, Dinovo E, Renner SW. Fatal large-volume mouthwash ingestion in an adult: a review and the possible role of phenolic compound toxicity. J Intensive Care Med. May-Jun 2003;18(3):150-5. [Medline].

  5. Myhre AM, Carlsen MH, Bøhn SK, Wold HL, Laake P, Blomhoff R. Water-miscible, emulsified, and solid forms of retinol supplements are more toxic than oil-based preparations. Am J Clin Nutr. Dec 2003;78(6):1152-9. [Medline].

  6. Brook MP, McCarron MM, Mueller JA. Pine oil cleaner ingestion. Ann Emerg Med. Apr 1989;18(4):391-5. [Medline].

  7. Dalgarno P. Subjective effects of Salvia divinorum. J Psychoactive Drugs. Jun 2007;39(2):143-9. [Medline].

  8. Decker WJ, Corby DG, Hilburn RE, Lynch RE. Adsorption of solvents by activated charcoal, polymers, and mineral sorbents. Vet Hum Toxicol. 1981;23(Suppl 1):44-6. [Medline].

  9. Gambelunghe C, Melai P. Absinthe: enjoying a new popularity among young people?. Forensic Sci Int. Dec 4 2002;130(2-3):183-6. [Medline].

  10. Guillen MD, Manzanos MJ. Extractable components of the aerial parts of Salvia lavandulifolia and composition of the liquid smoke flavoring obtained from them. J Agric Food Chem. Aug 1999;47(8):3016-27. [Medline].

  11. Love JN, Sammon M, Smereck J. Are one or two dangerous? Camphor exposure in toddlers. J Emerg Med. Jul 2004;27(1):49-54. [Medline].

  12. Manoguerra AS, Erdman AR, Wax PM, Nelson LS, Caravati EM, Cobaugh DJ. Camphor Poisoning: an evidence-based practice guideline for out-of-hospital management. Clin Toxicol (Phila). 2006;44(4):357-70. [Medline].

  13. Olsen RW. Absinthe and gamma-aminobutyric acid receptors. Proc Natl Acad Sci U S A. Apr 25 2000;97(9):4417-8. [Medline].

  14. Ragucci KR, Trangmar PR, Bigby JG, Detar TD. Camphor ingestion in a 10-year-old male. South Med J. Feb 2007;100(2):204-7. [Medline].

  15. Rampini SK, Schneemann M, Rentsch K, Bachli EB. Camphor intoxication after cao gio (coin rubbing). JAMA. Jul 3 2002;288(1):45. [Medline].

  16. Riordan M, Rylance G, Berry K. Poisoning in children 4: household products, plants, and mushrooms. Arch Dis Child. Nov 2002;87(5):403-6. [Medline].

  17. Rodricks A, Satyanarayana M, D'Souza GA, Ramachandran P. Turpentine-induced chemical pneumonitis with broncho-pleural fistula. J Assoc Physicians India. Jul 2003;51:729-30. [Medline].

  18. Shannon M, McElroy EA, Liebelt EL. Toxic seizures in children: case scenarios and treatment strategies. Pediatr Emerg Care. Jun 2003;19(3):206-10. [Medline].

  19. Wilson CR, Sauer J, Hooser SB. Taxines: a review of the mechanism and toxicity of yew (Taxus spp.) alkaloids. Toxicon. Feb-Mar 2001;39(2-3):175-85. [Medline].

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Further Reading

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Keywords

terpene toxicity, terpenes, terpenoids, monoterpenes, isoprene unit, diterpenes, terpene exposure, terpene poisoning, cantharidin, menthol, pinene, camphor, phytol, vitamin A1, paclitaxel, Taxol

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Contributor Information and Disclosures

Author

John Said Kashani, DO, Assistant Medical Director of the New Jersey Poison ad Information Education System; Assistant Professor, Department of Preventive Medicine and Community Health, Assistant Professor, Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey
John Said Kashani, DO is a member of the following medical societies: American College of Emergency Physicians and American College of Medical Toxicology
Disclosure: Nothing to disclose.

Coauthor(s)

Steven Marcus, MD, Professor, Department of Preventive Medicine and Community Health, Associate Professor, Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey; Executive and Medical Director, New Jersey Poison Information and Education System; Consulting Staff, Departments of Pediatrics and Internal Medicine, University Hospital, University of Medicine and Dentistry of New Jersey; Consulting Staff, Department of Pediatrics, Newark Beth Israel Medical Center
Steven Marcus, MD is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Clinical Toxicology, American Academy of Pediatrics, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Medical Society of New Jersey
Disclosure: Nothing to disclose.

Medical Editor

Lance W Kreplick, MD, MMM, FAAEM, FACEP, Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC
Lance W Kreplick, MD, MMM, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, ABAT, Director of Pharmacy, Sacred Heart Hospital
John T VanDeVoort, PharmD, ABAT is a member of the following medical societies: American Academy of Clinical Toxicology and American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Michael J Burns, MD, Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center
Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
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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