Patient Report

Datura stramonium intoxication in two children

Falihery Rakotomavo, Caroline Andriamasy, Ndrantoniaina Rasamoelina and Nasolotsiry Raveloson

Department of Anesthesia and Intensive Care, Fianarantsoa Teaching Hospital, Fianarantsoa, Madagascar

Abstract Datura stramonium is a toxic plant member of the Solanaceae family. Its consumption may result in severeanticholinergic toxicity. We report the intoxication of 5- and 4-year-old brothers with Datura stramonium, whichpresented in two different manners. The first child presented agitation, hallucination and mydriasis that improved rapidlywith benzodiazepine medication. The second presented comatose, mydriasis and Babinski signs. Gastric lavage andactivated charcoal administration were performed. The child was intubated and mechanically ventilated until conscious-ness improvement. Datura stramonium poisoning may be considered by physicians in case of acute onset of decreasedconsciousness or behaviour trouble associated with anticholinergic signs and symptoms.

Key words agitation, anticholinergic toxicity, comatose, Datura stramonium, intoxication.

Datura stramonium is a hallucinogenic plant, a member of theSolanaceae family, which is widely distributed and easily acces-sible.1 It contains three alkaloids, atropine, hyoscyamine andscopolamine, which may induce anticholinergic syndrome afteringestion.1,2 We report the poisoning of two children with thisplant. Our aim is to describe the clinical features, managementand outcome of Datura poisoning and we will discuss the pub-lished data.

Case report

Two brothers were brought to the pediatric emergency depart-ment after ingestion of herb tea prepared with leaves and flowersof Datura stramonium, which was recognized by their parents. Afew hours before, the children had been healthy. They did nothave any history of neurologic or psychiatric diseases and theywere not under medication. The time of plant intake could not beaccurately given by parents.

The first child, a 5-year-old boy, 20 kg, 1.25 m, was veryagitated. He presented disorientation and hallucinogenic deliriumwith zoopsic themes. He had a Glasgow Coma Scale of 12/15(E = 4, M = 5, V = 3). On the initial physical examination, bloodpressure was 112/78 mmHg, heart rate was 114 b.p.m., respira-tory rate was 30 breaths/minute, oxygen saturation was 98% onroom air and temperature was 37.9°C. His mouth was dry. Aneurological examination showed a bilateral mydriasis, not reac-tive to light. Deep tendon reflexes, sensitive and motor investi-gations were normal. The rest of the examination, complete bloodcount and biochemical parameters were found to be withinnormal limits. Intravenous crystalloids and 4 L/min oxygen weregiven. Also, 8 mg of diazepam was injected to relieve his agita-

tion. The child was transferred to a quiet room. Hemodynamicparameters remained stable. The next day, an improvement of hisstate of consciousness was noted with decrease of the restlessnessand the delirium. The bilateral mydriasis lasted until his dis-charge at 48 h.

The second child, a 4-year-old boy, 16 kg, 1.18 m, was lethar-gic upon arrival. His Glasgow Coma Scale was initially 8/15(E = 2, M = 5, V = 1). Blood pressure was 108/82 mmHg andheart rate was 132 b.p.m., respiratory rate was 32 breaths/min,oxygen saturation was 98% on room air and temperaturewas 37.6°C. The neurological examination revealed a bilateralmydriasis with weak reaction to light. Muscles tone and deeptendon reflexes were normal but bilateral Babinski signs wereobserved. There were not focal neurological signs or signs ofmeningeal irritation. After perfusion with normal saline, the childwas transferred to the pediatric intensive care unit. Because of thepresence of comatose, gastric lavage, once, was decided afterorotracheal intubation to protect airways. Activated charcoal(15 g) was administered through a nasogastric tube. The childwas sedated with intravenous midazolam (bolus of 100 μg/kgfollowed by 75 μg/kg/h) and mechanical ventilation was per-formed. Urinary retention was observed and a Foley catheter wasplaced. The white cell count was 11.5 × 109/L with neutrophilspredominant. Liver enzymes, renal function tests and bloodionogram were within normal range. The electrocardiogramshowed a regular sinus tachycardia. Twelve hours after admis-sion, the sedation was stopped and the child was extubated a fewhours later. An improvement in his consciousness was observed.Mydriasis persisted until the child’s discharge after 72 h.

Discussion

Datura stramonium, also called “angel’s trumpet” or “Jimsonweed,” is a highly toxic plant due to its richness of alkaloids(atropine, scopolamine, hyoscyamine), which may cause anatropine-like effect (Fig. 1). Those alkaloids are mainly stocked

Correspondence: Falihery Rakotomavo, MD, Department of Anesthe-sia and Intensive Care, Fianarantsoa Teaching Hospital, Fianarantsoa301, Madagascar. Email: falyrakotomavo8@gmail.com

Received 8 May 2013; revised 18 December 2013; accepted 28January 2014.

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Pediatrics International (2014) 56, e14–e16 doi: 10.1111/ped.12363

© 2014 Japan Pediatric Society

in the seeds but may also be present in other parts of the plant.3 Itis a plant widely distributed in Madagascar, explaining its easyrecognition by the parents of our patients. Datura stramoniumintoxication in children is mainly accidental.

Alkaloids of Datura stramonium act by competitive block-ade of acetylcholine at muscarinic receptors both centrally andperipherally, as well at the end organ site of the parasympa-thetic nerve system. It affects smooth muscle function in theeye, the gastrointestinal tract and urinary bladder. It alsoimpairs the ability to regulate sweat, salivary and mucosalgland activity. Inhibition of vagal effect on the sinoatrial noderesults in sinus tachycardia and inhibition of central musca-rinic receptors impairs cognition, motor coordination andperception.3,4

Therefore, intoxication by Datura stramonium results inclassic symptoms of anticholinergic poisoning: “hot as a hare,blind as a bat, dry as bone, red as a beet and mad as a hatter.”Signs and symptoms of anticholinergic activity appear 1–4 hafter ingestion.3–5 Children are particularly sensitive to thisintoxication. Symptomatology differs following the season, themode of consumption, the part of the plant ingested, the doseabsorbed and the patient’s age.1 Amount of intake of plant wasnot specified here, but the dissimilarity of age and weightcould explain the different symptomatology observed in thetwo children. The younger patient was more susceptible topoisoning.

Peripheral and central syndromes are observed. The mainperipheral syndromes are: dry and flushed skin, diminished sali-vary, sudoriferous and bronchial secretion, tachycardia, hyper-tension and hyperthermia. Urinary retention is common. Centralsyndrome includes visual and hearing hallucinations, confusion,disorientation, restlessness and anxiety. Mydriasis is frequentlynoted and may persist several days after ingestion.1,3 In the severeforms, respiratory failure, cardiovascular collapsus, convulsions,coma with pyramidal syndrome and signs of localization mayoccur.1,6,7 A pediatric case with rhabdomyolysis and fulminanthepatitis was also reported.8

Biological assessments are often normal and no biologicalfindings can state the specific diagnosis. Toxicological investiga-tions are required for eliminating the differential diagnosis.1

Most of the time, the treatment is essentially symptomatic. Itis carried out in a hospital due to the risk of auto or heteroaggression and the exceptional risk of organ failure.1,4,9

Rehydration and oxygenation are performed. Hyperpyrexia iscontrolled by acetaminophen, fluids and other cooling measures.Agitation is controlled by titration of benzodiazepines.Phenothiazines and butyrophenones should be used with precau-tion due to their anticholinergic properties. In comatose cases, thepatient should be intubated and mechanically ventilated.

Gastric lavage and activated charcoal administration may beuseful in the first 24 h after ingestion, as decreased gastric motil-ity associated with atropine poisoning may lead to prolongedabsorption and effect. Appropriate airway protection may beconsidered before the procedure for avoiding aspiration.1,4,6 Thedecision to provide gastric lavage, which is also traumatizing, isbased on the seriousness of intoxication. Therefore, we did notapply it to the first child.

The specific antidote is physostigmine. It is a reversibleacetylcholinesterase inhibitor that increases synaptic acetylcho-line concentration. It is able to cross the blood–brain barrier and,therefore, antagonizes both central and peripheral anticholinergiceffects. Physostigmine is given slowly, with an initial dose of1–2 mg for adults and 0.02 mg/kg for children. The dose may berepeated in 10–15 min if the reversal of anticholinergic effectshas not occurred. Due to its short half-life, physostigmine gen-erally needs repeated reinjections that expose the patient to therisk of cholinergic crisis. So, its indication is often limited tosevere signs of intoxication, like tachydysrhythmia causinghemodynamic impairment, coma, persistent seizures, severe agi-tation and respiratory depression.1,4,9

In one retrospective case–control series, Salen et al. observedthat the use of physostigmine and the successful nasogastriclavage, even if they are effective, did not result in decreasedintensive care use or shorter length of stay in the hospital forDatura stramonium poisoning.10 Physostigmine was not admin-istered in either of the two cases because it is not available in ourcountry.

The outcome is generally favorable after 24–48 h, but some-times, intoxication may lead to death by respiratory and centralnervous system depression or cardiovascular collapsus, espe-cially in children.5,6

Conclusion

Ingestion of Datura stramonium by children due to ignorance isless frequent than voluntary intoxication by older young people.In any case, intoxication with this plant may constitute a realmedical emergency and be fatal. If the plant is not identified, theacute onset of consciousness alteration, or restlessness or delir-ium associated with other symptoms or signs of anticholinergicintoxication may help in the diagnosis, in the context of plantingestion. The possibility of a vegetal intoxication may be con-sidered by physicians in children with behavioral trouble admit-ted to the emergency department.

Fig. 1 Datura stramonium.

Datura stramonium intoxication e15

© 2014 Japan Pediatric Society

References

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10 Salen P, Shih R, Sierzenski P, Reed J. Effect of physostigmine andgastric lavage in a Datura stramonium-induced anticholinergicpoisoning epidemic. Am. J. Emerg. Med. 2003; 21: 316–7.

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© 2014 Japan Pediatric Society