ACMT Toxicology Visual Pearls – A Poke in the Belly

Jan 20, 21
ACMT Toxicology Visual Pearls – A Poke in the Belly

Which component of the pictured plant is the cause of gastrointestinal symptoms when ingested?

  1. Histamine
  2. Lectins
  3. Oxalates
  4. Ribosomal inhibiting proteins
  5. Saponin glycosides

Answer: 5. Saponin glycosides

Discussion [1-7] 

Phytolacca americana<, also known as pokeweed, is a tall perennial with purple-red stems and berries in grape-like clusters found in the Midwest and Eastern North America.  The plant contains toxic compounds such as saponin glycosides (including phytolaccatoxin), a lectin called pokeweed mitogen, and a ribosomal inhibiting protein called pokeweed antiviral protein (PAP). The mature, deep purple berries are less toxic than immature berries.  The roots are the most toxic.  The leaves, stems, and berries are ingested as part of a salad or imbibed as tea. Historically, pokeweed has been purported to treat ailments such as rheumatoid arthritis, various forms of dermatitis, or as an emetic.  Some consumers parboil the plant components to avoid unwanted symptoms.

The saponin glycosides are the cause of gastrointestinal irritation with the ingestion of pokeweed.  Pokeweed mitogen is responsible for the hematologic abnormalities that can be seen following ingestion.  PAP does not seem to cause significant clinical effects in humans due to difficulty entering the cell membranes of higher animal forms.  However, PAP has been extracted for use as an antiviral agent due to its ability to remove purine groups from the rRNA of viruses, and for its possible antitumor capabilities, highlighting its potential pharmacological uses.

Clinical manifestations [2,3,5,9] 

  • Symptoms typically begin within a half hour to six hours following ingestion and are often self-limited.
  • Symptoms are more likely after ingestion of raw berries or leaves.
  • Predominantly gastrointestinal symptoms are seen, ranging from self-limited gastroenteritis to severe hemorrhagic gastritis.
  • Rarely, other clinical symptoms manifest including bradycardia, ventricular dysrhythmias, hypotension, sweating, weakness, incontinence, syncope, confusion, tremors, seizures, and encephalopathy.

Diagnostics and Management [2,3,5,10]

  • Identification of the plant is useful for anticipatory guidance.
  • Red-purple skin discoloration, particularly over the hands or perioral area, may indicate ingestion of pokeweed berries.
  • Dark stool with negative fecal occult blood tests may be seen with ingestion.
  • An atypical lymphocytosis may occur which typically resolves within ten days.
  • Activated charcoal may limit toxin absorption in absence of contraindications.
  • Supportive care consists of rehydration and symptom control.
  • Central nervous system (CNS) hyperexcitation should be treated with benzodiazepines.
  • Symptoms last up to 24 hours and may require prolonged observation.

Bedside pearls

  • Saponin glycosides are the cause of gastrointestinal irritation with the ingestion of pokeweed.
  • Patients may present with hypotension, weakness, cardiotoxicity, and CNS findings.
  • Symptoms typically begin a half hour to six hours following ingestion of pokeweed and are often self-limited. Symptoms can last up to 24 hours.
  • Activated charcoal may be considered in absence of contraindications.
  • Supportive care is the mainstay of therapy.

This post has been peer-reviewed on behalf of ACMT by Blake Froberg, Bryan Judge, and Louise Kao

References

  1. Froberg B, Ibrahim D, & Furbee RB.  Plant poisoning. Emergency Medicine Clinics of North America, 2007. 25(2), 375–433; abstract ix. PMID 17482026
  2. Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR.  Goldfrank’s Toxicologic Emergencies, 11e. New York, NY: McGraw-Hill. 2019.
  3. Barker BE, Farnes P, LaMarche PH. Peripheral blood plasmacytosis following systemic exposure to Phytolacca americana (pokeweed). Pediatrics. 1966 Sep; 38(3):490-3. PMID 5920416
  4. Domashevskiy AV, & Goss DJ. Pokeweed antiviral protein, a ribosome inactivating protein: activity, inhibition and prospects. Toxins, 2015. 7(2), 274–298. PMID 25635465
  5. Burrows GE, Tyrl RJ.  Phytolaccaceae.  Toxic Plants of North America.  2013. Wiley-Blackwell. Pp 864 – 869.
  6. Di R, & Tumer NE. Pokeweed antiviral protein: its cytotoxicity mechanism and applications in plant disease resistance. Toxins, 2015. 7(3), 755–772.  PMID 25756953
  7. Hassan, Y, Ogg, S, & Ge, H. Expression of novel fusion antiviral proteins ricin a chain-pokeweed antiviral proteins (RTA-PAPs) in Escherichia coli and their inhibition of protein synthesis and of hepatitis B virus in vitro. BMC Biotechnology. 2018. 18(1), 47. PMID 30081895
  8. Zhabokritsky A, Mansouri S, & Hudak KA. Pokeweed antiviral protein alters splicing of HIV-1 RNAs, resulting in reduced virus production. RNA.  2014. 20(8), 1238–1247. PMID 24951553
  9. Jaeckle KA, & Freemon, FR. Pokeweed poisoning. Southern Medical Journal, 1981. 74(5), 639–640. PMID 7244729
  10. Soloway, RAG. “Pokeberries: A Grape Look Alike.”  National Capital Poison Center, 8 Oct. 2019, www.poison.org/articles/2012-aug/pokeberries-and-grapes-look-alike.

Author information

Caitlin Baldwin, DO

Caitlin Baldwin, DO

Emergency Medicine / Internal Medicine Resident
Jefferson Health - Northeast

The post ACMT Toxicology Visual Pearls – A Poke in the Belly appeared first on ALiEM.

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