Key Concepts
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Most botanical exposures result in minimal toxicity and management is largely supportive.
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Most serious toxicities result from exposure to plants with anticholinergic, antimitotic, cardiovascular or convulsive properties.
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Most cases of mushroom ingestion in which gastrointestinal (GI) symptoms begin within the first 2 h will prove to involve a non–life-threatening substance.
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Delayed GI symptoms with an onset of more than 6–8 h after exposure suggest a potentially life-threatening ingestion, such as the cyclopeptide and gyromitrin mushroom groups.
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Regional poison control centers, mycologists, and botanists can assist in identifying potentially toxic plants and mushrooms. We recommend smart phone digital photography with expert consultation.
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Herbal medications are largely unregulated and may have inherent toxicity, herb-drug interactions, or contaminants. Clinicians should advise against the routine use of herbal medications.
Plants
Foundations
The nutritional, therapeutic, psychoactive and toxic properties of botanicals have made their usage pervasive since antiquity. The earliest documented use of plants for medicinal purposes can be found in Sumerian clay tablets that describe the use of over 200 different plants in the treatment of various maladies. Ancient Greeks recognized the lethal effects of botanicals, sentencing Socrates to death by ingestion of a poison hemlock-based liquid. The recreational abuse and medicinal use of opium poppies highlight the wide-ranging role plants have played throughout history.
Exposures to plants comprise over 42,000 calls nationally to US poison centers, with over half of cases involving pediatric patients less than 6 years of age. Over 85% of plant exposures are accidental ingestions. The overwhelming majority of plant exposures result in minimal toxicity and death is exceedingly rare. Plant exposures reported to US poison centers have been decreasing over the past three decades, ranking 3rd and comprising 9% of all exposures in 1983, but ranking 22nd and making up only 2% of all exposures in 2018. The most common plant exposures resulting in severe and occasionally fatal poisonings involve those with anticholinergic, antimitotic, cardiotoxic or convulsive properties.
Clinical Features
The vast majority of plants are considered non-toxic ( Table 153.1 ). However, serious toxicity can result from certain plant exposure ( Table 153.2 ). Toxicity does not correlate well with taxonomy, and plants within the same genera may have varying toxic profiles. Further complicating matters, the severity of exposure may depend on the method of exposure (chewed, swallowed, smoked or injected) and which part of the plant was ingested (berries, leaves, or stems). For example, although all parts of the water hemlock plant are considered toxic, cicutoxin is most concentrated in the root of the plant. The majority of serious or fatal outcomes occur when adults intentionally consume botanicals for suicidal or recreational intent. A focused history and physical exam should be aimed at identifying the etiology of the present illness and to identify any toxidrome common to botanical exposures.
TABLE 153.1
Non-toxic Plants
| Common Name | Botanical Name |
|---|---|
| Abelia | Abelia spp. |
| African daisy | Gerbera jamesonii |
| African violet | Saintpaulia ionantha |
| Aglaonema | Aglaonema spp. |
| Aluminum plant | Pilea cadierei |
| Alyssum | Slyssum spp. |
| Aralia | Dizygotheca elegantissima |
| Areca palm | Chrysalidocarpus lutescens |
| Artillery plant | Pilea spp. |
| Asparagus fern | Asparagus setaceus |
| Aspidistra | Aspidistra spp. |
| Aster | Callistephus chinensis, Townsendia sericea |
| Astilbe | Astilbe japonica |
| Baby’s breath | Gysophila paniculate |
| Baby’s tears | Hypoestes phyllostachya, Soleirolia soleirolii |
| Baby’s toes | Centaurea cyanus |
| Bachelor’s buttons | Centaurea cyanus |
| Balsam | Impatients spp. |
| Bamboo | Phyllostachys aurea |
| Basket vine | Aeschynanthus spp. |
| Beauty bush | Kolkwitzia amabilis |
| Begonia | Begonia goegoensis, Cissus spp. |
| Bird’s nest fern | Asplenium nidus |
| Bleeding heart vine | Clerodendrum spp. |
| Blood leaf plant | Iresine spp. |
| Boston fern | Nephrolepis spp. |
| Bromeliad | Vriesea hieroglyphica |
| Brunch berry | Cornus canadensis |
| Butterfly bush | Buddleia davidii |
| Button fern | Pellaea rotundifolia |
| Calathea | Calathea spp. |
| Camellia | Camellia japonica, Thea japonica |
| Candle plant | Plectranthus oetendahlii |
| Cape primrose | Streptocarpus spp. |
| Cast iron plant | Aspidistra elatior |
| Cattail | Typha latifolia |
| China doll | Leea spp. |
| Chinese evergreen | Aglaonema modestum |
| Christmas cactus | Cactaceae |
| Coleus | Coleus spp. |
| Columbine | Aquilegia spp. |
| Coral bells | Kalanchoe uniflora |
| Cordyline | Cordyline spp. |
| Corn plant or cornstalk plant | Dracaena fragrans |
| Creeping Charlie (houseplant) | Pilea nummulariifolia, Plectranthus australis |
| Creeping Jennie | Lysimachia nummularia |
| Crocus (Spring ONLY) | Crocus spp. |
| Dahlia | Dahlia spp. |
| Dandelion | Taraxacum officinale |
| Day lily | Hermocallis spp. |
| Donkey’s tail | Sedum morganianum |
| Dracaena | Dracaena spp., Cordyline spp. |
| Dragon tree | Dracaena draco |
| Easter lily | Lilium longiflorum |
| Echeveria | Echeveria spp. |
| Emerald feather | Asparagus densiflorus sprengeri |
| Eugenia | Eugenia cyanocarpa, Syzgium cuminii |
| False aralia | Dizygotheca elegantissima |
| Fatsia | Fatsia japonica |
| Ferns | Davallia canariensis, Davallia fejeensis, Rumohra adiantiformis, Asplenium spp. |
| Ficus | Ficus benjamina |
| Fig | Ficus carica |
| Fingernail plant | Aregelia spp. |
| Firecracker flower | Crossandra spp. |
| Firecracker vine | Menettia bicolor |
| Fittonia | Fittonia spp. |
| Florida beauty | Dracaena spp. |
| Flowering quince | Chaenomeles spp. |
| Forsythia | Forsythia spp. |
| Friendship plant | Billbergia spp., Pilea involucrate |
| Fuchsia | Fuchsia spp. |
| Gardenia | Gardenia jasminoides |
| Gazania | Gazania spp. |
| Geranium | Pelargonium spp. |
| Glory tree | Clerodendrum thomsoniae |
| Gloxinia | Gloxinia perennis, Sinningia speciosa |
| Golddust plant | Alyssum spp., Aucuba japonica |
| Goldfish plant | Hypocyrta spp. |
| Hawthorn | Crataegus spp. |
| Hemlock tree | Tsuga spp. (not to be confused with Conium or Cicuta spp.) |
| Hens and chicks | Echeveria spp., Sempervivum tectorum |
| Hibiscus | Hibiscus spp. |
| Honey locust | Gleditsia triacanthos |
| Honeysuckle | Lonicera fragrantissima |
| Hosta | Hosta spp. |
| Hoya | Hoya spp. |
| Ice plant | Aptenia cordifolia, Lampranthus spp., Mesembryanthemum cordifolium |
| Impatients | Impatients spp. |
| Iron plant | Aspidistra spp. |
| Jade plant | Portulacaria afra |
| Janet Craig plant | Dracaena deremensis |
| Japanese aralia | Fatsia japonica |
| Japanese lantern | Hibiscus schizopetalus |
| Japanese snowbell | Styrax japonica |
| Kalanchoe | Kalanchoe spp. |
| King and queen fern | Asplenium spp. |
| Lavendar | Lavandula officinalis |
| Lilac | Syringa spp. |
| Linden tree | Tilia americana |
| Lipstick plant | Aeschynanthus spp. |
| Magnolia | Magnolia spp. |
| Maidenhair fern | Adiantum decorum |
| Maple tree | Acer spp. |
| Maranta | Calathea spp., Maranta spp. |
| Marigolds (except Marsh Marigolds) | Calendula spp. |
| Maternity plant | Kalanchoe spp. |
| Mexican snowball | Echeveria spp. |
| Mimosa | Albizia julibrissin |
| Mock orange | Philadelphus spp., Pittosporum tobira |
| Monkey plant | Ruellia makoyana |
| Mosaic plant | Fittonia argyroneura |
| Mother fern | Asplenium spp. |
| Mother of thousands | Kalanchoe pinnata |
| Mountain grape | Mahonia spp. |
| Mulberry tree or bush | Morus spp. |
| Nasturtium | Tropaeolum spp. |
| Neanthebella | Chamaedorea elegans |
| Nerve plant | Fittonia spp. |
| Norfolk Island pine | Araucaria heterophylla |
| October plant | Sedum sieboldii |
| Old man of the mountains | Hymenoxys grandiflora |
| Orchid | Cattleya spp., Cymbidium spp., Epidendrum spp., Oncidium spp. |
| Painted lady | Echeveria spp. |
| Panda plant | Kalanchoe tomentosa |
| Parlor palm | Chamaedorea elegans |
| Passion vine, purple | Gynura aurantiaca |
| Patient Lucy | Impatients spp. |
| Peacock plant | Calathea makoyana, Kaempferia spp. |
| Peperomia | Peperomia spp. |
| Petunia | Petunia spp. |
| Phlox | Phlox spp. |
| Piggyback plant | Tolmiea menziesii |
| Pilea | Pilea spp. |
| Pine trees | Pinus spp. |
| Pitcher plant | Darlingtonia californica |
| Pittosporum | Pittosporum spp. |
| Plantago | Plantago major |
| Plush plant | Echeveria spp., Kalanchoe spp. |
| Pocketbook plant | Calceolaria spp. |
| Poinsettia | Euphorbia pulcherrima |
| Polka Dot plant | Hypoestes phyllostachya |
| Pony Tail plant | Beaucarnea recurvata |
| Potentilla | Potentilla spp. |
| Prayer plant | Maranta leuconeura |
| Pregnant plant | Kalanchoe pinnata |
| Propeller plant | Crassula cultrate |
| Purple passion | Gynura aurantiaca |
| Pyracantha | Pyranchantha spp. |
| Queen’s tears | Billbergia spp. |
| Rabbit’s foot | Maranta leuconeura |
| Rainbow plant | Billbergia spp. |
| Red bud | Cercis canadensis |
| Red hot poker | Kniphofia spp. |
| Resurrection plant | Selaginella lepidophylla |
| Rex-begonia vine | Cissus discolor |
| Ribbon plant | Dracaena sanderiana |
| Rosary vine | Ceropegia woodii, Crassula rupestris |
| Rose, rosehips | Rosa spp. (except Rosa rugose) |
| Rose of Sharon | Hibiscus syriacus |
| Rubber plant | Ficus elastica |
| Salvia | Salvia spp. |
| Sedum | Sedum spp. |
| Sensitive plant | Mimosa pudica |
| Sentry palm | Howea forsterana |
| Silk tree | Albizia julibrissin |
| Silver bell | Halesia spp. |
| Silver berry | Elaeagnus spp. |
| Silver dollar plant | Astrophytum asterias, Crassula arborscens |
| Silver evergreen | Aglaonema spp. |
| Silver king | Aglaonema spp. |
| Silver vine | Actinidia polygama |
| Snapdragon | Antirrhinum majus |
| Snowball bush | Viburnum spp. |
| Spider aralia | Dizygotheca elegantissima |
| Spider flower | Cleome spp., Hermocallis spp., Tibouchina spp. |
| Spiraea | Astilbe japonica |
| Spirea | Spirea spp. |
| Spruce tree | Picea spp. |
| Staghorn fern | Platycerium spp. |
| Starfish flower | Stapelia spp. |
| Stone face | Lithops spp. |
| String of buttons | Crassula rupestris |
| Striped inch plant | Callisia spp. |
| Swedish ivy | Plectranthus australis |
| Sword fern | Polystichum munitum |
| Teddy bear plant or vine | Cyanotis kewensis |
| Tiger lily | Lilium spp. |
| Tulip tree | Liriodendron tulipifera, Spathodea campanulata |
| Umbrella plant | Eriogonum umbellatum |
| Umbrella tree | Magnolia tripetala |
| Velvet plant | Gynura aurantiaca |
| Viburnum | Viburnum spp. |
| Wandering Jew | Zebrina pendula |
| Wax flower | Stephanotis floribunda |
| Wax plant | Hoya spp. |
| Wild strawberry | Fragaria spp. |
| Willow | Salix spp. |
| Yellow wood | Cladrastis lutea, Rhodosphaera rhodanthema |
| Yucca plant | Yucca spp. |
| Zebra plant | Aphelandra squarrosa, Calanthea zebrina, Cryptanthus zonatus |
| Zinnia | Zinnia spp. |
Table 153.2
Toxic Plants
| Common Name | Botanical Name | Toxic Effects |
|---|---|---|
| Ackee tree | Blighia sapida | Hypoglycemia, gastrointestinal, neurologic |
| Almond, apricot, cherry, plum, peach | Prunus spp. | Cyanogenic |
| American mistletoe | Phoradendron spp. | Gastrointestinal |
| Angel trumpet | Brugmansia suaveolens | Anticholinergic |
| Autumn crocus, meadow or wild saffron | Colchicum autumnale | Gastrointestinal, multi-organ |
| Azalea | Azalea spp. | Cardiovascular |
| Betel nut | Areca catechu | Cholinergic |
| Bird-lime, blue thistle | Atractylis gummifera | Hepatic |
| Bitter orange | Citrus aurantium | Cardiovascular, neurologic |
| Black locust | Robinia pseudoacacia | Gastrointestinal |
| Buckeye | Aesculus glabra | Gastrointestinal, neurologic |
| Calabar bean | Physostigma venenosum | Cholinergic |
| Cassava | Manihot exculentus | Cyanogenic |
| Castor bean | Ricinus communus | Gastrointestinal, multi-organ |
| Cayenne pepper | Capsicum spp. | Dermatologic, mucosal irritant |
| Chysanthemum, dandelion | Chrysanthemum spp. | Dermatologic |
| Cinchona | Cinchona spp. | Cardiovascular, cinchonism |
| Common, white or pink oleander | Nerium oleander | Cardiovascular |
| Deadly nightshade | Atropa belladonna | Anticholinergic |
| Dumbcane, mother-in-law plant | Dieffenbachia spp. | Dermatologic, mucosal irritant |
| Elderberry | Sambucus nigra | Gastrointestinal, metabolic |
| Elephant ear, angel wings, heart of Jesus | Caladium spp. | Dermatologic, mucosal irritant |
| Ergot | Claviceps purpurea | Cardiovascular, neurologic, oxytocic |
| Eucalyptus | Eucalyptus spp. | Dermatologic, gastrointestinal |
| European or true mandrake | Mandragora officinarum | Anticholinergic |
| Fava bean | Vicia fava | Hematologic |
| Foxglove | Digitalis spp. | Cardiovascular |
| Glory lily | Gloriosa superba | Gastrointestinal, multi-organ |
| Golden chain or rain | Laburnum anagyroides | Gastrointestinal, neurologic |
| Grass pea | Lathyrus sativus | Neurologic, skeletal |
| Green tomato | Lycopersicon spp. | Gastrointestinal, neurologic, anticholinergic |
| Guarana | Paullinia cupana | Neurologic, cardiac |
| Henbane, hyoscyamus | Hyoscyamus niger | Anticholinergic |
| Holly | Ilex spp. | Gastrointestinal |
| Ipecac | Cephaelis ipecacuanha, Cephaelis acuminata | Gastrointestinal |
| Jequirity pea, rosary or prayer bead | Abrus precatorius | Gastrointestinal, neurologic |
| Jimsonweek, angel’s trumpet | Datura Stramonium | Anticholinergic |
| Khat | Catha edulis | Cardiovascular, neurologic |
| Larkspur | Delphinium spp. | Cardiovascular, neurologic |
| Lily of the valley | Convallaria majalis | Cardiovascular |
| Mad honey | Rhododendron spp. | Gastrointestinal, cardiac |
| Madagascar periwinkle, vinca | Catharanthus roseus | Gastrointestinal |
| Marijuana, hashish, pot | Cannabis | Neurologic |
| Mayapple | Podophyllum emodi, Podophyllum peltatum | Multi-organ |
| Milkweed | Asclepias spp. | Cardiovascular |
| Monkshood, Wolfsbane | Aconitum napellus | Cardiovascular, neurologic |
| Nightshade (various), potato | Solanum spp. | Anticholinergic |
| Opium poppy | Papaver somniferum | Neurologic, respiratory |
| Peace lily | Spathiphyllum spp. | Dermatologic, mucosal irritant |
| Peyote, mescal | Lophophora williamsii | Neurologic |
| Philodendron | Philodendron spp. | Dermatologic, mucosal irritant |
| Pilocarpus | Pilocarpus jaborandi, Pilocarpus pinnatifolius | Cholinergic |
| Pink-eyed cerbera, sea mango, suicide tree, pong pong tree | Cerbera spp. | Cardiovascular |
| Poison hemlock | Conium maculatum | Neurologic, pulmonary |
| Poison ivy, poison oak, poison sumac | Toxicodendron spp. | Dermatologic |
| Pokeweed | Phytolacca americana | Gastrointestinal |
| Poplar | Populus spp. | Salicylism |
| Pothos | Epipremnum aureum | Dermatologic, mucosal irritant |
| Queen sago, indu | Cycas circinalis | Neurologic |
| Rattlebox | Crotalaria spp. | Hepatotoxic |
| Red squill | Urginea maritima, Urginea indica | Cardiovascular |
| Spider plant | Chlorophytum comosum | Dermatologic, mucosal irritant |
| Tansy | Tanacetum vulgare | Neurologic |
| Tobacco | Nicotiana spp. | Gastrointestinal, neurologic |
| Tonka beans | Dipteryx odorata, Dipteryx oppositifolia | Hematologic |
| Tubocurare, curare | Chondrodendron spp., Curarea spp., Strychnos spp. | Neurologic |
| Tullidora, buckthorn | Karwinskia humboldtiana | Neurologic, respiratory |
| Umbrella tree | Schefflera spp., Brassaia spp. | Dermatologic, mucosal irritant |
| Water hemlock | Cicuta maculata | Neurologic |
| Water hemlock | Oenanthe crocata | Neurologic |
| White cedar | Thuja occidentalis | Neurologic |
| Wormwood, absinthe | Artemisia absinthium | Neurologic |
| Yellow oleander | Thevetia peruviana | Cardiovascular |
| Yew | Taxus spp. | Cardiovascular |
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