ToxCard: Plants in the Home – Pretty, Possibly Problematic, and Potentially Poisonous

Authors: Vanessa Goff, MD (Pediatric Emergency Medicine Fellow, Atrium Health’s Carolinas Medical Center); Christine Murphy, MD (Emergency Medicine Attending, Medical Toxicologist, Atrium Health’s Carolinas Medical Center) // Reviewed by: Cynthia Santos, MD (@CynthiaSantosMD); Alex Koyfman, MD (@EMHighAK); and Brit Long, MD (@long_brit)

Overview:

Cultivation of houseplants is a common practice. Houseplants are prized for their beauty and for suspected health benefits such as decreasing the levels of carbon dioxide, volatile organic compounds and particulate matter in the air. There are even studies suggesting indoor greenery can support mental health. (1) Exposure to or ingestion of houseplants, particularly in the pediatric population, is the source of many calls to American Poison Control Centers and occasionally leads to ED visits. Unfortunately, emergency healthcare workers are not always familiar with common houseplants or their potentials for toxicity. In one study, 56 healthcare professionals were able to identify only 17% of plants by common name and correctly identify 13% as being toxic or not. (2)
This post does not encompass all potential houseplants or all toxicities but seeks to bring familiarity to several groups of common houseplants: soluble and insoluble oxalate plants, phorbol esters, saponins, solanines and toxalbumins.

 

Philodendrons and Other Insoluble Oxalate Containing Plants (3,4)

  • Examples: Anthurium, Arrowhead Vine, Arum, Burning Bush, Begonia, Black Lily, Caladium, Calla Lily, Devil’s Ivy, Daffodil Bulb, Dieffenbachia (Dumb Cane), Dragon Root, Elephant Ear, Jack in the Pulpit, Jaggery Palm, Marble Queen, Mexican Breadfruit, Narcissus, Nephthytis, Peace Lily, Philodendron, Pothos, Skunk Cabbage, Spathiphyllum, Swiss Cheese Plant, Taro, Wild Calla
  • Mechanism of action: Insoluble calcium oxalate crystals are grouped into raphides and hundreds of raphides are packaged with proteolytic enzymes into idioblasts
    • Mechanical force from chewing or rubbing causes raphides to fire out of the cell and cause local injury
  • Presentation:
    • Ocular Exposure: chemical conjunctivitis, chemosis, pain and corneal abrasions
    • Oral Exposure: oropharyngeal pain and swelling, profuse salivation, dysphagia, loss of speech
      • Symptoms begin immediately when leaves are chewed
      • It can take 4-8 days for pain and swelling begin to improve
  • Evaluation:
    • Consider endoscopic evaluation for oral burns or significant dysphagia
    • Perform slit lamp exam to evaluate for ocular injuries
  • Management:
    • Monitor ABCs
    • Pain control
    • Treat oral pain with soothing liquids and ice
    • Can consider topical or oral corticosteroids depending on area affected
    • Antihistamines may not provide relief
  • While most of these cases do well with minimal intervention, serious complications have been reported:
    • 12-year-old female with aortoesophageal fistula after dieffenbachia ingestion (5)
    • 11-month-old male with esophageal erosion and stricture and ultimately cardiac arrest after philodendron ingestion (6)
    • Case reports exist of adults requiring surgical airways from upper airway obstruction from swelling (7)

Shamrock and Other Soluble Oxalate Plants (3,4)

  • Examples: American Ivy, Boston Ivy, Rhubarb Leaves, Soursop, Virginia Creeper, Woodbind, Sorrel, Shamrock
  • Mechanism of action: soluble oxalates precipitate with calcium to form calcium oxalate crystals.
  • Consumption of large amounts of soluble oxalate containing plants over an extended period can lead to nephrolithiasis – this is why we tell patients with renal stones to avoid spinach and other foods with high soluble oxalate content.
  • Presentation:
    • Mucosal membrane irritation is rare making it possible to ingest large quantities
    • Nephrolithiasis
    • Theoretical risk exists for hypocalcemia to occur in large ingestions, but this has not been well documented in humans
  • Management:
    • Supportive care
    • Pain management and standard treatment for nephrolithiasis
    • Electrolyte panel and potentially calcium replacement for large, chronic ingestions of soluble oxalate containing plants

Poinsettia and Other Phorbol Ester Containing Plants (3)

  • Examples: Candelabra Cactus, Crown of Thorns, Pencil Tree, Poinsettia
  • Mechanism of action:
    • Phorbol esters found in the milky sap of these plants and can cause irritant dermatitis
    • No clear toxin causing the GI effects
  • Presentation:
    • Most exposures result in little to no symptoms
    • Minor GI symptoms like nausea and vomiting
    • Skin irritation from the sap
    • Ex: the manchineel tree sap can cause more significant skin effects than other plants in this group (3)
    • Patients with histories of atopy or latex allergy can have significant allergic reactions to poinsettias with 40% of latex allergic patients developing a cross reactivity to poinsettia causing irritant contact dermatitis, a type 1 or type 4 hypersensitivity reaction (8)
  • Management:
    • Supportive care
    • Skin decontamination if sap residue is present

Pokeweed and Other Saponin Glycoside Containing Plants (3)

  • Examples: Agave, Beech (European and Japanese), California Privet, Coffee Tree, Guaiac, English Ivy, Inkberry, Pokeweed, Pigeonberry, Sky Flower, American Holly
    (Disclaimer: The following discussion does not refer to saponin containing plants with cardiac glycosides or glycyrrhizin, aka licorice root)
  • Mechanism of action: Saponins cause alterations in permeability of small intestinal mucosal cells leading to diarrhea
  • Presentation:
    • Vomiting and diarrhea with a foaming or soapy appearance (4)
    • Rare reports of mydriasis, hyperthermia, drowsiness and cardiac dysrhythmias including ventricular fibrillation (9)
  • Management:
    • Supportive care with antiemetics and fluids

Nightshades and Other Solanine Containing Plants (3,8)

  • Examples: Green parts of eggplant and green potatoes, Jessamine, Jerusalem Cherry, Nightshades, Ornamental Pepper, Silver cup
  • Mechanism of action:
    • Immature fruits are more toxic than ripened
    • Inhibits cholinesterase in vitro and in animal studies
  • Presentation:
    • Onset of symptoms 2-24hrs after ingestion and can last several days
    • Typical symptoms include abdominal cramping, vomiting, and diarrhea
    • Rare reports of presentation with salivation, bradycardia, hypotension, hallucinations, delirium and coma
  • Management:
    • Supportive care with fluids and antiemetics
    • Prolonged monitoring of children may be needed if high suspicion of ingestion given toxic effects are more potent in children than adults

Mistletoe Toxalbumins (3,4,8)

  • Examples: American Mistletoe, European Mistletoe
  • Mechanism of action: phoratoxin and viscotoxin inhibit cellular synthesis and affect cells with rapid turnover
  • Presentation:
    • Most ingestions of a few berries or leaves do not produce significant symptoms
    • Vomiting, diarrhea, and dehydration can occur with larger ingestions or ingestions of teas or exposure to medicinal preparations
    • Onset of symptoms can occur several hours after ingestion
    • Rare presentations of seizures, ataxia and hepatotoxicity reported
  • Management:
    • Supportive care with fluids and antiemetics

References:

1. Dzhambov AM, Lercher P, Browning MHEM, et al. Does greenery experienced indoors and outdoors provide an escape and support mental health during the COVID-19 quarantine? Environ Res. 2020. Epub ahead of print. PMID: 33157110.

2. Harchelroad F, Scalise JA, Dean BS, Krenzelok EP. Identification of common houseplants in the emergent care setting. Vet Hum Toxicol. 1988. 30(2):161-163. PMID: 3381488.

3. Nelson LS, Goldfrank LR. Plants. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. Eds (2019). Goldfranks Toxicologic Emergencies. 11the New York: McGraw-Hill. https://accessemergencymedicine-mhmedical-com.libproxy.lib.unc.edu/content.aspx?bookid=2569&sectionid=210276997. Accessed March 18, 2021.

4. Froberg B, Ibrahim D, Furbee RB. Plant poisoning. Emerg Med Clin North Am. 2007. 25(2):375-433; doi: 10.1016/j.emc.2007.02.013. PMID: 17482026.

5. Jiří Šnajdauf, Vladimír Mixa, Michal Rygl, Martin Vyhnánek, Jiří Morávek, Zdenĕk Kabelka. Aortoesophageal fistula—an unusual complication of esophagitis caused by Dieffenbachia ingestion. Journal of Pediatric Surgery. 2005. 40(6): e29-e31. PMID: 15991162

6. McIntire MS, Guest JR, Porterfield JF. Philodendron – an infant death. Journal of Toxicology: Clinical Toxicology. 1990. 28(2):177 – 183. PMID: 2398518.

7. Cumpston KL, Vogel SN, Leikin JB, Erickson TB. Acute airway compromise after brief exposure to a Dieffenbachia plant. J Emerg Med. 2003. 25(4):391-7. PMID: 14654179. Erratum in: J Emerg Med. 2004 May;26(4):491.

8. Evens ZN, Stellpflug SJ. Holiday plants with toxic misconceptions. West J Emerg Med. 2012. 13(6):538-42; doi: 10.5811/westjem.2012.8.12572. PMID: 23359840.

9. Litovitz TL, Klein-Schwartz W, White S, et al. 2000 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. 2001. 19(5):337-95. doi: 10.1053/ajem.2001.25272. PMID: 11555795

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