Case Report / Olgu Sunumu Wild Tuber Poisoning in a Child : Eminium Intortum (Banks & Sol.) KUNTZE – A first case report Bir Çocukta Yabani Yumru Zehirlenmesi: Eminium intortum (Banks & Sol.) Kuntze – İlk Olgu Sunumu Abit DEMİR 1 1 2 , Hasan AKAN 2 , Mehmet Maruf BALOS 2 , Hüseyin GÜMÜŞ 1 Harran University Medical Faculty, Department of Child Health and Diseases, Sanliurfa, TURKEY Harran University, Art & Science Faculty, Biology Department, Sanliurfa, TURKEY Abstract A case of poisoning, accidentally eating the tuber of the Eminium intortum (Banks & Sol.) Kuntze plant by a 16year-old young girl, is presented. Our patient while working in the field, eating a pieces of the tuber of a green leafy plant, complaining of a burning mouth in the mouth, excessive watering and shortness of breath, later applied to our Pediatric Emergency Department. After the initial evaluations, the poison hotline was called. In line with the recommendations, the patient was given activated charcoal with a nasogastric tube, vascular access was opened for fluid treatment, and routine blood tests were planned. Our case, who was conscious and whose vital signs were stable, was admitted to the pediatric health and diseases service. The case was discharged with full recovery after 6 days of observation and treatment. While the patient's treatment was continuing, explorations were made in the field with the patient's relatives to observe and identify the wild plant tuber that caused the poisoning in its natural environment, and it was understood that the plant was E. intortum. In this case report, it is aimed to present the intoxication experience that developed in this case after the tubers of E. intortum were eaten. Corresponding Author/Sorumlu Yazar Dr. Hasan AKAN Harran University, Art & Science Faculty, Biology Department, Şanlıurfa, TURKEY E-mail: hakan@harran.edu.tr Geliş tarihi / Received: 02.04.2021 Kabul tarihi / Accepted: 05.05.2021 DOI: 10.35440/hutfd.908597 Key Words: Araceae, Child, Eminium intortum, Poisoning Öz. Bu olgu sunumunda 16 yaşında genç bir kız hastanın Eminium intortum (Banks & Sol.) Kuntze bitkisine ait yumruyu yanlışlıkla yemesi sonucu oluşan zehirlenme olgusu sunulmaktadır. Olgumuz tarlada çalışırken adını bilmediği yeşil yapraklı bir bitkinin yumrusundan bir miktar yedikten sonra ağızda yanma hissi, aşırı sulanma ve nefes darlığı şikayetleri ile Çocuk Acil Servisi’mize başvurmuştur. İlk değerlendirmelerin ardından, zehir danışma hattı arandı. Öneriler doğrultusunda hastaya nazogastrik sonda ile aktif kömür verildi, sıvı tedavisi için damar yolu açıldı, rutin kan tetkikleri planlandı. Bilinci açık ve vital bulguları stabil olan olgumuz çocuk sağlığı ve hastalıkları servisine yatırıldı. Olgu 6 günlük gözlemden ve tedaviden sonra şifa ile taburcu edildi. Hastanın tedavisi devam ederken, zehirlenmeye sebep olan yabani bitki yumrusunun doğal ortamında gözlenmesi ve tespiti için hasta yakınları ile arazide keşifler yapılmış, bitkinin E. intortum olduğu anlaşılmıştır. Bu olgu sunumunda E. intortum bitkisine ait yumruların yenildikten sonra bu olguda gelişen intoksikasyon deneyiminin sunulması amaçlanmıştır. Anahtar kelimeler: Araceae, Çocuk, Eminium intortum, Zehirlenme Harran Üniversitesi Tıp Fakültesi Dergisi (Journal of Harran University Medical Faculty) 2021;18(2):349-352. DOI: 10.35440/hutfd.908597 349 Demir et al. Introduction In Turkey, the majority of the population live in rural areas with risk factors for exposure to wild plants. Mixing an edible plant with a poisonous plant causes serious poisoning, which can even result in death. It should be kept in mind that vital complications may develop in the cases of poisoning with unknown cause, especially at the first application to emergency departments. Eminium intortum (Banks & Sol.) Kuntze is taxonomically a plant species belonging to the Araceae family. This family generally contains poisonous plants. Eminium genus has 7 plant species in the world, while Turkey is represented by 5 taxa (1). It is known among the local people of Şanlıurfa, with names such as kari, kardi, gardi, asalan, fise pire, zilke araba, yılan yastığı and malmirat. The genus Eminium is common in Central Asia and the Middle East. It spreads in the Mediterranean, Eastern and Southeastern Anatolian provinces. Fresh leaves of the plant are collected from the region by traders and exported to Northern Iraq. It has a toxic effect when the plant is fresh. Many plants in the family of Araceae are poisonous raw and if eaten raw, this toxin gives you sensation as if hundreds of tiny needles are sticking into the mouth tongue etc. Howerer, it is easily destroyed by thoroughly cooking.The toxic principles in this plant are glycosides, calcium oxalate crystals packaged into bundles called raphides and proteolytic enzymes (2). The leaves of the plant are used for food purposes after it has undergone certain processes. The poison is taken by boiling and brine. There is no use of the tuber. The traditional use of E. intortum in Turkey has not been encountered. Even no literature on E.intortum poisoning has been found up to now. Wild tuber poisoning in a child eaten, gastrointstinal, neurological and especially respiratory system symptoms (such as shortness of breath after edema in the airway, bronchospasm) can be life-threatening. We present this case of tuber poisoning in order to draw attention to the importance of informing people living in rural areas. Case Report A 16-year-old girl residing in Şanlıurfa countryside applied to our pediatric emergency room 5 hours after consuming some 50 g of wild poisonous plant tubers. Among the complaints of arrival were swelling and pain in the patient's tongue, burning and bitter taste in the mouth, as well as mild dyspnea and secretions that spread out of the mouth. There was also minimal speech difficulties due to these complaints and pain. On arrival, the patient, who was conscious, cooperative and orientated, had overflowing mouth waters, tongue swelling, burning mouth, bitter taste and shortness of breath. Her physical condition was moderate, unconscious, cooperative, oxygen saturation in the room air was 96%, body temperature was 36.4 ◦C. Apart from mouth and throat complaints, the patient with mild respiratory distress had no pathological findings in the lung examination, the pulse rate was 92 / min in the cardiac examination, the blood pressure was 110/70 mmHg and there was no circulatory disorder. Abdominal examination, extremity and neurological examination, and genitourinary system examinations were natural. The patient's vascular access was opened, routine blood tests were taken. The laboratory tests, coagulation parameters, cardiac panel and blood gas values of the patient in the emergency room were within normal limits in Table 1. The patient was started on a dose of fluid appropriate for the vein, weight and age. Oral feeding was stopped. After the initial interventions and activated charcoal treatment, the patient was admitted to the pediatric health and diseases service. Control examinations sent to the laboratory on the 3rd day of service admission also came within normal limits in Table 1. Figure 1. A-B) General view of Eminium intortum in field, C-D) Its tubers E. intortum tuber is spherical, approximately 2.1-4.5 cm in diameter (Figure. 1). After the tuber of this plant is Figure 2. A-B: Mouth and tongue lesions on the 3rd day of hospitalization Harran Üniversitesi Tıp Fakültesi Dergisi (Journal of Harran University Medical Faculty) 2021;18(2):349-352. DOI: 10.35440/hutfd.908597 350 Demir et al. Wild tuber poisoning in a child Table 1. Laboratory findings of the patient in the emergency service (6th hour of poisoning) and on the 3rd day of hospitalization Parameter 6th hour Biochemical Tests Blood sugar (mg/dl) 102 Blood urea (mg/dL) 23 Serum creatinine (mg/dL) 0,4 ALT (U/L) 16 GGT (U/L) 11 ALP (U/L) 119 Albumin (g/dL) 5 Sodium (mEq/L) 138 Potassium (mEq/L) 3,7 Calcium (mg/dl) 9,3 Phosphorus (mg/dL) 2,8 Magnesium (mg/dl) 1,2 CK (U/L) 165 LDH (U/L) 249 Serum amylase (U/L) 131 CRP (mg/dl) 0,02 Cardiac Enzymes CK-MB (ng/ml) 1,9 Troponin-I (ng/ml) 0,00 3rd day reference value 131 32 0,4 30 11 94 4 141 4,1 8,7 4,2 1,4 146 202 71 1,1 74-106 19-50 0,2-1,2 7-40 <73 46-116) 3,2-5 136-145 3,5-5,1 8,7-10,4 2,4-5,1 1,6-2,6 26-190 120-246 30-118 0-0,5 2,54 0,00 0-5 0,02-0,07 Parameter Complete Blood Cell Count WBCs (× 109/L) Lymphocytes (× 109/L) Neutrophils (× 109/L) Monocytes (× 109/L) Eosinophils (× 109/L) Basophils (× 109/L) Hemoglobin (g/dL) Hematocrit(%) Platelets (× 109/L) Arterial Blood Gas pH PaCO2(mmHg) HCO3 (mEq/L) Base deficit (mEq/L) Lactate (mg/dL) Coagulation Parameters APTT (sec) PT (sec) INR 6th hour 3rd day reference value 6,6 1,4 4,7 0,4 0,07 0,02 13,4 40,9 279 4,9 1,5 2,8 0,4 0,15 0,01 13,2 39,7 227 3,7-10,1 1,09-2,99 1,63-6,96 0,24-0,79 0,03-0,44 0-0,08 12-18,1 35-53,7 142-424 7,37 45 24 1,4 1 7,41 35,5 23,2 -1,6 1 7,35-7,45 32-48 22-26 (-3)-(+3) 0,5-1,6 23,5 12,6 1,07 25 12,8 1,09 22-26 10,5-15,5 0,8-1,2 ALT: Alanine aminotransferase, GGT: Gamma-glutamyl transferase, ALP: Alkaline phosphatase, CK: Creatine kinase, LDH: Lactate dehydrogenase, CRP: C-reactive protein, WBCs: White blood cells, PaCO2: Partial pressure of arterial carbon dioxide, APTT: Activated partial thromboplastin time, PT: Prothrombin time, INR: International When the patient first applied to the pediatric emergency service, there was hypersalivation in the mouth, a burning sensation, swelling and numbness in the tongue, and on the 3rd day of his hospitalization, she had a aphthous wounds on the left side of the tongue and a necrotic wound under the tongue (Figure 2). After 3 days of treatment of mouth, swelling and pain in the tongue decreased, aphthous wounds in the mouth healed rapidly and began to be fed orally. While the patient's service stay continued, the plant tuber brought by the relatives of the patient was sent to the Botanical Department of Harran University. Since the tubers have a similar structure, it was not possible to identify them only from the tubers. For this reason, by going to Doğanlı village of Şanlıurfa where the incident occurred, observations were made in the field where the tubers of the plant causing poisoning and it was understood that the plant tuber causing poisoning belonged to E. intortum (Figure 2). The patient, whose general condition improved, started to be fed easily and had normal laboratory tests, was discharged with healing after 6 days of close observation.Informent constent was received from the family. Discussion In Turkey, the majority of the population use wild plants as food. The confusion of an edible plant with a poisonous one give rise to serious poisoning which may even result in death. The incidence of plant poisoning in Turkey is about 6% and especially high among children between ages of 2 and 11 living in rural areas (3). Aroids are medicinal plants, can also be used as food. There are also those that have a toxic effect (4). There is much literature on genus Arum (Araceae family) poisoning (5-6). We currently don't have any information about Eminium poisoning from literature, however it also belongs to the Araceae family, like the Arum genus. We suppose it also contains oxalate crystals and have similar GI (gastrointestinal system) irritation symptoms, and in some cases could lead to more serious outcomes like anaphylaxis (7). In the beginning, it was not known what the toxic substance was. Due to minimal respiratory distress in the airway, oxygen was given with a mask and treated symptomatically and the patient was followed up closely. There was no increase in respiratory distress. It was understood that the plant tuber was E. intortum as a result of Harran University Botanical Research. No literature and no antidote information were found on the clinical signs and management of E. intortum poisoning. This case report has a unique value in this respect. Wild tuber poisoning can be a life-threatening emergency that may require urgent resuscitation and aggressive airway management. Because delay in airway protection may increase the rate of illness and death in critical patients (8). E. intortum ingestion has been observed to cause burning, swelling, tongue swelling, difficulty swallowing and nausea in the oral mucosa. If this plant or its components are eaten raw or consumed in large quantities, it is possible to develop gastrointestinal discomfort, severe upper pathway obstruction, cardiovascular collapse, central nervous system depression or mortality. Therefore, when such symptoms develop, E. intortum or similar family intoxications should be considered and a detailed history should be taken. Physicians should be aware of complications that may develop if E. intortum and similar toxic Harran Üniversitesi Tıp Fakültesi Dergisi (Journal of Harran University Medical Faculty) 2021;18(2):349-352. DOI: 10.35440/hutfd.908597 351 Demir et al. plants are consumed. It is also important to raise awareness of people living in rural areas, especially in cases of such poisoning. It is a place where plant-borne food poisoning is common in the southeastern Anatolia region. For example; Euphorbia helioscopia is a plant commonly found in rural areas. Contact dermatitis (irritant contact dermatitis or allergic contact dermatitis) is known in relation to this herb (9). Another example is the mallow plant (Malva sylvestris). It is a plant that is frequently consumed by the people for various reasons and accepted as safe. However, upper gastrointestinal system bleeding due to mallow was reported in a case report (10). Ethical Approval: Written informed consent was obtained from the patient for the study. Author Contributions: Concept: H.A, A.D. Literature Review: M.M.B., A.D., H.A. Design : H.A., A.D., M.M.B., H.G. Data acquisition: H.A., A.D., M.M.B., H.G. Analysis and interpretation: H.A., A.D., M.M.B., H.G. Writing manuscript: H.A., A.D., M.M.B. Critical revision of manuscript: H.A., A.D., M.M.B., H.G. Conflict of Interest: The author(s) declare(s) that there is no conflict of interest regarding the publication of this article. Financial Disclosure: Authors declared no financial support. Wild tuber poisoning in a child References Çeçen C, Akan H, Balos MM. Şanlıurfa Yöresinde Doğal Yayılış Gösteren Eminium (Blume) Schott (Araceae Juss.) Cinsine Ait Taksonların Anatomik ve Morfolojik Yönden İncelenmesi. Kahramanmaraş Sütçü İmam Üniversitesi Tarım ve Doğa Dergisi. 2019; 22(2): 296-309. 2. Al-Farwachi MI, Al-Badranii BA. Anticoagulant Effects of Eminium spiculatum Aqueous Leaf Extract in Rabbits. Basrah journal of veterinary research.2013; 12(2): 332337. 3. Oztekin-Mat A. Plant poisoning cases in Turkey. In: Annales Pharmaceutiques Francaises. 1994, 52. 5: 260-5. 4. Bown D. Aroids: Plants of the Arum Family. Second Ed. USA: Timber Press, 2000:392 pp. 5. Raju KP, Goel K, Anandhi D, Pandit VR, Surendar R, Sasikumar M. Wild tuber poisoning: Arum maculatum–A rare case report.. International journal of critical illness and injury science 2018; 8(2): 111. 6. Maree A, Hashavya S, Gross I, Asaf, Y, Bentur Y. Arum palaestinum poisoning: revenge of the witch. European Journal of Pediatrics. 2020; 179:1553–1557. 7. Yurt NŞ, Türe E, Çubukçu M. Nivik Otu Zehirlenmesi: Arum maculatum-Bir Olgu Sunumu. Ankara Medical Journal. 2019; 19(4): 796-799. 8. Anandhi D, Raju KP, Saya RP, Pandit VR. Difficult airway management in a case of hair dye poisoning. International Journal of Academic Medicine. 2017; 3(1): 120-123. 9. Bucak IH, Almış H, Tepe B, Turgut M. A Rare Cause of Emergency Department Visit: Euphorbia helioscopia Contact Dermatitis. Turkish Journal of Emergency Medicine. 2016; 16 (3): 121-122. 10. Bucak IH, Almış H, Çelik V, Apaydın HÖ, Turgut M. Ebegümeci: Çocukluk Yaş Grubunda İlk Kez Belirlenen Üst Gastrointestinal Sistem Kanaması Nedeni Olabilir mi?. Harran Üniversitesi Tıp Fakültesi Dergisi. 2015; 12(2): 296-299. 1. Harran Üniversitesi Tıp Fakültesi Dergisi (Journal of Harran University Medical Faculty) 2021;18(2):349-352. DOI: 10.35440/hutfd.908597 352