Epidemiologic Notes and Reports Jimson Weed Poisoning -- Texas, New York, and California, 1994

Ingestion of Jimson weed (Datura stramonium), which contains the anticholinergics atropine and scopolamine, can cause serious illness or death. Sporadic incidents of intentional misuse have been reported throughout the United States, and clusters of poisonings have occurred among adolescents unaware of its potential adverse effects. This report describes incidents of Jimson weed poisoning that occurred in Texas, New York, and California during June-November 1994. Texas

On June 19, 1994, the El Paso City-County Health and Environmental District was notified of two male adolescents (aged 16 and 17 years) who had died from D. stramonium intoxication. On June 18, the decedents and two other male adolescents had consumed tea brewed from a mixture of roots from a Jimson weed plant and alcoholic beverages, then fell asleep on the ground in the desert. Family and police found the decedents the following afternoon. The other two adolescents reported drinking only small amounts of the tea: one experienced hallucinations; the other had no signs or symptoms. Neither was treated, nor were biologic specimens collected. Screening of a toxicologic postmortem blood sample from one decedent detected atropine (55 ng/mL) and a blood alcohol concentration (BAC) of 0.03 g/dL (in Texas, intoxication is defined as a BAC greater than or equal to 0.1 g/dL). Analysis of the tea identified atropine, ethanol, and scopolamine. New York

On the morning of October 9, 1994, an 18-year-old man from Long Island was brought to an emergency department (ED) by his mother after she found him in his bedroom unclothed and hallucinating. Reports from friends indicated he had ingested 50 Jimson weed seeds and had used controlled substances (i.e., cocaine, "ecstacy," and marijuana) at a party the previous night. On evaluation, the patient was hallucinating and had fully dilated pupils, dry mouth, and decreased bowel sounds. He became progressively agitated and was sedated with intravenous diazepam and alprazolam. Hallucinations continued for 36 hours. On October 11, he was discharged for psychiatric counseling. He had a history of chronic substance abuse.

During October 8-November 15, a regional poison-control center was contacted about this case and for information about 13 other identified cases of Jimson weed intoxication. The mean age of the 14 patients was 16.8 years (range: 14-21 years), and eight were male. In the five incidents for which quantity of Jimson weed exposure was reported, ingestion ranged from 30 to 50 seeds per person. Manifestations included visual hallucinations (12 persons), mydriasis (10), tachycardia (six), dry mouth (five), agitation (four), nausea and vomiting (four), incoherence (three), disorientation (three), auditory hallucinations (two), combativeness (two), decreased bowel sounds (two), slurred speech (two), urinary retention (one), and hypertension (one). Four patients were treated and released from EDs, six were hospitalized, three were admitted to an intensive-care unit (ICU), and one refused medical care. Five of these patients were treated with activated charcoal, one was administered gastric lavage, and none received physostigmine. California

On October 22, 1994, two male and four female adolescents (aged 15-17 years) with a history of drinking Jimson weed tea were transported to an ED. Two persons were discharged from the ED; four were admitted to the ICU because of symptoms that included headache, fatigue, disorientation, fixed or sluggish dilated pupils, tachycardia (heart rates greater than 120 beats per minute), and hallucinations. These four patients were monitored with electrocardiograms, treated with physostigmine and activated charcoal, and discharged on October 23. The Los Angeles County Forestry Division reported that fires in the Los Angeles area may have promoted regrowth of Jimson weed in defoliated areas. Reported by: DM Perrotta, PhD, Bur of Epidemiology, Environmental Epidemiologist, Texas Dept of Health; LN Nickey, MD, El Paso City-County Health and Environmental District, El Paso. M Raid, T Caraccio, PharmD, HC Mofenson, MD, Winthrop Univ Hospital, Long Island Regional Poison Control Center, New York; C Waters, Injury Control Program, D Morse, MD, State Epidemiologist, New York State Dept of Health. AM Osorio, MD, S Hoshiko, MPH, Div of Environmental and Occupational Disease Control, GW Rutherford, III, MD, State Epidemiologist, California State Dept of Health Svcs. Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.

Editorial Note

Editorial Note: D. stramonium grows throughout the United States and, historically, was used by American Indians for medicinal and religious purposes. All parts of the Jimson weed plant are poisonous, containing the alkaloids atropine, hyoscyamine, and scopolamine. Jimson weed -- also known as thorn apple, angel's trumpet, and Jamestown weed (because the first record of physical symptoms following ingestion occurred in Jamestown, Virginia, in 1676 {1}) -- is a member of the nightshade family. The toxicity of Jimson weed varies by year, between plants, and among different leaves on the same plant. Although all parts of the plant are toxic, the highest concentrations of anticholinergic occur in the seeds (equivalent to 0.1 mg of atropine per seed). The estimated lethal doses of atropine and scopolamine in adults are greater than or equal to 10 mg and greater than 2-4 mg, respectively (1,2).

Symptoms of Jimson weed toxicity usually occur within 30-60 minutes after ingestion and may continue for 24-48 hours because the alkaloids delay gastrointestinal motility. Ingestion of Jimson weed manifests as classic atropine poisoning. Initial manifestations include dry mucous membranes, thirst, difficulty swallowing and speaking, blurred vision, and photophobia, and may be followed by hyperthermia, confusion, agitation, combative behavior, hallucinations typically involving insects, urinary retention, seizures, and coma (3). Treatment consists of supportive care, gastrointestinal decontamination (i.e., emesis and/or activated charcoal), and physostigmine in severe cases (4).

In 1993, a total of 94,725 poisonings associated with toxic plants was reported in the United States Table_1. Although most cases of Jimson weed poisoning in the United States occur sporadically, increased incidence or clustering of cases may follow press and broadcast reports that heighten interest in -- but do not emphasize the adverse effects of -- Jimson weed ingestion. In 1993, the American Association of Poison Control Centers Toxic Exposure Surveillance System received 318 reports of Jimson weed exposure. Although the total number of reported exposures to Jimson weed did not rank among the 20 most frequently reported exposures to poisonous plants Table_1 (5), telephone calls to poison-control centers about Jimson weed poisoning are more likely than those about other hallucinogens to prompt a need for medical care (6). Poisoning associated with Jimson weed can be prevented through education of health-care providers and by press and broadcast reports to the public that emphasize the health hazards of Jimson weed ingestion, but that reduce access to the plant by omitting detailed descriptions and drawings and photographs.

References

1. Shervette RE, Schydlower M, Lampe RM, Fearnow RG. Jimson "loco" weed abuse in adolescents. Pediatrics 1979;63:520-3.

2. Hooper RG, Conner CS, Rumack BH. Acute poisoning from over-the-counter sleep preparations. Journal of the American College of Emergency Physicians 1979;8:98-100.

3. Rumack BH. Anticholinergic poisonings: treatment with physostigmine. Pediatrics 1973;52: 449-51.

4. Vanderhoff ST, Mosser KH. Jimson weed toxicity: management of anticholinergic plant ingestion. Am Fam Physician 1992;46:526-30.

5. Litovitz TL, Clark LR, Soloway RA. The 1993 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1994;12:546-84.

6. Klein-Schwartz W, Oderda GM. Jimson weed intoxication in adolescents and young adults. Am J Dis Child 1984;138:737-9.

TABLE 1. Twenty most frequently reported plants associated with human
poisonings, by plant and number of reported exposures -- United States, 1993
=============================================================================
                                              No. reported
Plant (Botanical name)                          exposures
-----------------------------------------------------------------------------
Philodendron (Philodendron sp.)                   4726
Pepper (Capsicum annuum)                          3912
Dumb cane (Dieffenbachia sp.)                     2837
Poinsettia (Euphorbia putcherrima)                2798
Holly (Liex sp.)                                  2651
Pokeweed/Inkberry (Phytolacoa Americana)          2231
Peace lilly (Spathiphyllum sp.)                   2086
Jade plant (Crassula sp.)                         1658
Pothos/Devil's ivy (Epipremnum aureum)            1401
Poison ivy (Toxicodendron/Rhus radicans)          1308
Umbrella tree (Brassaia actinophylia)             1141
African violet (Saintpaulia ionantha)             1137
Rhododendron/Azalea (Rhododendron sp.)            1029
Yew (Taxus sp.)                                    969
Eucalyptus (Eucalyptus globulua)                   945
Pyracantha (Pyracantha sp.)                        894
Spider plant (Chlorophytum comosum)                787
Christmas cactus (Schlumbergera bridgesii)         781
English ivy (Hedera helix)                         765
Climbing nightshade (Solanum dulcamara)            754
-----------------------------------------------------------------------------
Source: American Association of Poison Control Centers Toxic Exposure
Surveillance System.
=============================================================================

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