CASE A 15-year-old girl is brought to the emergency department with a 12-hour history of confusion, hallucinations, and agitation. Her boyfriend arrives and reports that, while at a party the previous night, the patient had ingested approximately 100 seeds from a plant that they call "pods" (see the photograph).
The patient's medical history is significant for depression, attention deficit hyperactivity disorder, and suicide attempts; she takes bupropion and sertraline and has no known drug allergies or surgical history.
Family history is noteworthy for bipolar disorder and social history for tobacco use and frequent alcohol and marijuana use. The patient's mother states that her daughter seemed more depressed than usual over the past week and that she wrote a letter to her grandfather stating that she hated life and wished she were dead. The mother denies that the patient has been febrile or had sweats, chills, cough, rhinorrhea, dyspnea, chest discomfort, nausea, vomiting, diarrhea, constipation, abdominal pain, or urinary symptoms.
The physical examination reveals temperature, 100.2F (rectal); BP, 140/90 mm Hg; pulse, 105 beats per minute and regular; respiration rate, 21 breaths per minute; and oxygen saturation, 99% on room air. Mydriasis is present, the face appears flushed, axillae are dry, and bowel sounds are decreased. The patient is well-nourished and well-developed but extremely agitated and combative. She attempts to bite the staff while they place her in restraints. A Foley catheter is placed.
Laboratory and chemistry results show hemoglobin, 12.7 g/dL; bicarbonate, 20 mEq/L; creatine kinase, 1.12 U/L; normal anion gap; negative urine drug screen; negative urine human chorionic gonadotropin; negative alcohol level; and negative acetaminophen and salicylate levels. An ECG shows sinus tachycardia.
* What is the likely diagnosis?
* What steps would you take to treat the problem?
COMMENT Those symptoms led the physician to consider an overdose of an anticholinergic agent, in this case, Jimsonweed seeds. Jimsonweed (Datura stramonium), also known as angel trumpet, trumpet lily, devil's apple, thorn apple, locoweed, ditch-weed, Jamestown weed, and stinkweed, is a member of the nightshade family and grows in this country. Modes of ingestion include eating, smoking, and drinking a tea brewed from different parts of the plants.
The entire plant is poisonous, containing the alkaloids atropine, hyoscyamine, and scopolamine. The highest concentration of alkaloids is in the seeds. Anticholinergic signs and symptoms can develop within 30 to 60 minutes of consumption and may last for up to 48 hours. They include mydriasis, hyperthermia, skin flushing, dry mucous membranes, hypertension, tachycardia, urinary retention, decreased GI motility, agitation, hallucinations, confusion, combative behavior, seizures, and coma.
Treatment consists of supportive care beginning with an assessment of the patient's airway, breathing, and circulation. Once stabilized, the patient's agitation should be brought under control with restraints and sedation for her own protection and that of hospital personnel. GI decontamination via activated charcoal with or without gastric lavage should be implemented. Physostigmine may be considered in severe cases in the presence of seizures, severe hypertension, life-threatening arrhythmias, or coma.
In this case, the patient was given lorazepam, 6 mg IV total, and activated charcoal, 40 g, via nasogastric tube. She was transferred to the pediatric ICU, where she was placed on a midazolam infusion. A psychiatric consult was ordered. She was discharged 2 days later.
