Abstract
A 26-year-old man was foraging for “ramps” (Allium tricocca) while hiking on the eastern seaboard of the United States and picked a striated broad-leafed plant for addition to his spaghetti later in the evening (Figure 1). While consuming his dinner he noticed a tingling sensation along his tongue and developed a sensation that his “throat was closing up.” He stopped eating the meal “after 4 bites” and spontaneously vomited within a half hour of the meal.
Leaf from plant ingested by the patient.
What Is the Diagnosis? What Is the Clinical Course? What Is the Pathophysiology? What Is the Treatment?
Diagnosis
False hellebore (Veratrum viride) ingestion.
Clinical Course
The patient was transported via emergency medical services to the emergency department due to intractable vomiting and dizziness. He complained of tongue and extremity paresthesias. Initial vital signs on admission were: blood pressure 83/42 mm Hg; heart rate 42 beats per minute; respiratory rate 20 breaths per minute; temperature 36.2° C. His examination was significant for anxiety (stated he thought he was “going to die”), diaphoresis, and mild diffuse abdominal tenderness. His initial electrocardiogram was significant only for sinus bradycardia at a rate of 40 beats per minute, PR duration 188 ms, QRS duration 87 ms, and QTc duration 367 ms. A leaf saved from the plant ingested was brought to the hospital for identification (Figure 1). A local clinician recognized the plant as false hellebore (Veratrum viride) and a picture was digitally sent to a university botanist who concurred. The patient received 3 L of normal saline and was admitted to a monitored bed. His initial laboratory tests (chemistry, complete blood cell count, hepatic panel) were normal. Because his mentation was normal and his urine output was excellent, the patient was simply treated with intravenous maintenance fluids. The patient's pulse and systolic blood pressure increased above 60 beats per minute and 90 mm Hg, respectively, approximately 8 hours following the ingestion with no sequelae.
Discussion
The patient in this case consumed false hellebore (Veratrum viride), a member of the family Liliaceae, that grows in wet swamps, meadows and woodlands along the Eastern Coast of the United States. Broad, fan-like leaves 6 to 12 inches long and 3 to 6 inches wide initially emerge from the ground in early spring on a leafy stalk that can grow up to 6 feet tall (Figure 2). Numerous greenish-yellow flowers are produced in open clusters from May to July. 1 Veratrum viride ingestion has been previously reported in individuals who mistook it for edible ramps (also called wild leek), a member of the onion family. 2 A tingling sensation of the tongue, nausea, vomiting, and hypotension are all commonly reported within a couple of hours of ingestion. 3 Bradycardia, shortening of QT intervals, blockade of intraventricular conduction, peaked T waves, and depressed ST segments may all be seen on the electrocardiogram.2,4 There have been no reported deaths from ingestion of Veratrum viride.
Veratrum viride growing in the wild of the Blue Ridge Mountains.
Pathophysiology
The acute characteristics of false hellebore consumption are mediated by toxic veratrum alkaloids. These compounds were used in the past for the acute control of hypertension, but a low therapeutic window limited their clinical viability. 5 In experimental models on nerve and muscle, these alkaloids have been shown to cause persistent depolarization of excitable membranes through the activation of voltage dependent Na+ channels. This ion shift delays repolarization, thus decreasing the threshold for membrane excitation, allowing a repetitive response to a single stimulus. 2 This increased excitation ability is primarily seen on the afferent nerve fibers of the carotid sinus and left ventricle baroreceptors. The increase in afferent firing from these receptors results in a decrease in peripheral alpha adrenergic tone, a vagally mediated bradycardia, and sensory paresthesias. 4 The bradycardia may not be reversed with atropine due to the direct toxic effects of the alkaloids on the myocardium. 6 The combination of vasodilation and bradycardia caused by veratrum alkaloids is called the Bezold-Jarisch reflex. 7
Treatment
The initial treatment of acute hellebore toxicity involves aggressive fluid resuscitation to maintain hemodynamic stability. In addition to fluids, atropine in 0.5- to 1.0-mg doses may be used in an attempt to reverse the vagal-induced bradycardia. Dopamine has been reported to initiate a peripheral vasoconstriction if fluids are unable to resolve the hypotensive crisis. Nausea can be controlled with antiemetics. 4 In the majority of case reports of Veratrum viride toxicity, complete resolution of symptoms occurs in less than 48 hours; however, cases of prolonged hypotension and bradycardia have been reported up to 3 days in duration. 2