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 Table of Contents  
CASE SERIES
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 2-6

Jatropha curcas poisoning in a family from rural Haryana


Department of Pediatrics, Kalpana Chawla Government Medical College and District Civil Hospital, Karnal, Haryana, India

Date of Submission30-Oct-2021
Date of Decision20-Jan-2022
Date of Acceptance28-Jan-2022
Date of Web Publication25-Feb-2022

Correspondence Address:
Dr. Sangeeta Choudhary
Kalyan Farm House, G. T. Road, Madhuban, Karnal - 132 037, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_333_21

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  Abstract 

Background: Jatropha curcas is a flowering plant found all over the world. It has traditionally been used for medicinal purposes and as an ornamental plant. Lately, it is being promoted for biodiesel production. Since it is a commonly grown plant with seeds that are often mistaken as edible nuts, accidental ingestion is common among children. The presence of various plant toxins results in gastrointestinal, hepatic renal cardiotoxic, and hemolytic manifestations. The general public and most pediatricians are unaware of this. Clinical Description: We report a case series of thirteen children who presented to the emergency department with lethargy, abdominal pain, vomiting, and diarrhea after acute ingestion of seeds of an unknown plant. The presentation varied in severity of symptoms as well as degree of dehydration, which seemed to correspond to the number of seeds consumed. The parents were asked to bring parts of the plant and the seeds were identified to belong to the Jatropha curcas plant after expert botanical consultation. Management and Outcome: All the children were admitted. None of them had manifestations of any specific toxidrome, however, there seemed to be isolated gastrointestinal involvement, clinically. Gastric lavage was done immediately. Intravenous fluid correction was administered based on the severity of dehydration. Supportive treatment with antiemetics and antacids was provided. Baseline investigations were planned to rule out organ dysfunction. The most common derangement was neutrophilic leukocytosis. All children recovered well without any complications or sequelae. Conclusion: Jatropha Curcas is a noxious plant that should not be grown in areas where children play. Unknown plant poisoning should be treated with the same gravity as any other poisonous substance. All efforts should be taken to look for indicators of a specific toxidrome in case an antidote is warranted, as well as identify the concerned plant.

Keywords: Dehydration, Jatropha, ricin, shock, unknown poisoning


How to cite this article:
Choudhary S, Gupta S, Sharma N. Jatropha curcas poisoning in a family from rural Haryana. Indian Pediatr Case Rep 2022;2:2-6

How to cite this URL:
Choudhary S, Gupta S, Sharma N. Jatropha curcas poisoning in a family from rural Haryana. Indian Pediatr Case Rep [serial online] 2022 [cited 2022 May 27];2:2-6. Available from: http://www.ipcares.org/text.asp?2022/2/1/2/338490

Acute poisoning with unknown substances is an important cause of preventable morbidity and mortality in children, if the nature of the poison can be determined and the patient managed in time. Common etiological agents include household poisons, drugs, pesticides, detergents, and even plants.[1] Plant poisoning accounts for 1.7% of all poisonous exposure in India, but most cases are accidental and consequences mild in nature.[2] There are nearly 10 known species of plants responsible for most of the accidental poisoning in India. These include Cleistanthus collinus, Ricinus communis, Abrus precatorius, Strychnos nux-vomica, Gloriosa superba, Calotropis, Datura, Chrysanthemum, Yellow oleander, and Papaya carica.[2] Young children are susceptible to accidental plant poisoning due to their tendency to put things in their mouths, newly acquired skills of mobility and exploration, and challenges in maintaining constant parental supervision. In contrast, older children may ingest parts of plants due to mistaken identity with edible plants, curiosity, impulsivity, and buckling to peer pressure.

Jatropha curcas, also known as biodiesel plant [Figure 1], is a noxious weed, commonly found throughout India, especially the southern parts.[3] Different parts of this plant are poisonous, like the fruit, seeds, leaf, bark, and latex. Seeds have the maximum toxicity.[4] Apart from growing wild and being cultivated for commercial purposes, it is also used for ornamental purposes in many households. Hence, it is easily accessible to children. Although cases of Jatropha poisoning are not rare, they are uncommonly reported.[5] Thus, there is limited information regarding the toxic effects of Jatropha in toxicology and medicine books,[6],[7] as well as less awareness among the general public.
Figure 1: Picture of Jatropha plant with flower and seeds

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We report thirteen children with unknown plant poisoning that was later identified to be due to the seeds of the “Jatropha” plant. The aim is to sensitize clinicians to look for indicators of a specific toxidrome, probe into the nature of poisoning using all possible means, make pediatricians and parents aware of the risks of Jatropha poisoning, highlight the heterogeneity of clinical features, as well as discuss the modalities of management that were used.


  Clinical Description Top


Thirteen children between the ages of 2 and 13 years were brought to the pediatric emergency department with sudden onset of abdominal pain, vomiting, and diarrhea. The children belonged to an extended joint family residing in rural Haryana. All of them had been playing in a nearby field, and each had allegedly consumed an unknown number of black-colored seeds originating from similar looking, but unidentified plants. The children became symptomatic within 30 min to an h of ingestion. Most of them initially developed abdominal pain, which was diffuse, intermittent, and cramping in nature, with intensity varying from mild to severe. After some time, they exhibited nausea, followed by vomiting which was nonprojectile, consisting of food particles and the seeds, and without blood. Subsequently, the children developed profuse watery diarrhea, with a high purge rate. There was no blood or mucus in the stools. None of the children displayed symptoms of headache, seizures, blurred vision, excessive salivation, sweating, difficulty in breathing or tightness in chest, sudden pallor, increased urination, or difficulty in passing urine.

At admission, none of the children had clinical evidence of compromised airways, breathing or circulation, though variability in the extent of dehydration was noted. Three children had tachycardia. None displayed pallor, cyanosis, or flushed skin. Lethargy was observed in the children presenting with severe dehydration. The central nervous system examination was normal with no signs of altered sensorium, miosis/mydriasis, hypotonia/flaccidity, muscle weakness or fasciculations. There was no guarding, rigidity, tenderness, or distension on abdominal examination. The respiratory and cardiovascular systems were unremarkable. The clinical details of individual cases are described in [Table 1].
Table 1: Clinical phenotype and laboratory reports of affected children according to dehydration

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  Management and Outcome Top


The children were triaged according to their symptoms and hemodynamic status on arrival. No particular phenotype of a specific toxidrome could be identified, based on vitals and clinical signs. However, three clinical patterns were discernible, predominantly related to the severity of gastrointestinal manifestations and extent of dehydration [Table 1]. The first group included four children with severe symptoms, signs of severe dehydration, and associated lethargy. The second group included three children with moderate symptoms. They were conscious, alert but had signs of some dehydration. The third group consisted of six children with mild symptoms and no dehydration. On further probing, it became apparent that the severity of symptoms was directly related to the number of seeds consumed. The plant could not be identified by the description given by the older children, so the caretakers were immediately sent home to bring the seeds and leaves for identification.

All the children received management as per the protocol of unknown poisoning: removal or neutralization of toxins and symptomatic and supportive treatment. Each child underwent gastric lavage. Activated charcoal could not be given due to poor tolerance. Fluid resuscitation was according to standard protocol, based on degree of dehydration and age of the affected child. A 13-year-old male child in the first group presented with early signs of hypovolemic shock. He responded well to appropriate fluid resuscitation and did not require inotropic support. Antiemetics and anta-acids were also used. Oral rehydration solution was started once the oral acceptance improved. Stabilization of vitals and improvement in hydration was noted within a few hours. All children were shifted to the ward after initial stabilization.

An important aspect of the management of unknown poisoning is looking for evidence of organ or system damage/dysfunction. Hence, hemogram and biochemical workup (random blood sugar, serum electrolytes, liver and kidney function tests, and coagulation profile) were sent. The former revealed leukocytosis with neutrophilic predominance in eight children [Table 1]. Children with severe dehydration showed mildly raised urea (which normalized with fluid resuscitation) but normal creatinine levels. Urine routine microscopy and electrocardiogram were normal in all the children.

The parents brought the seeds and leaves of the plant the next morning. The expertise of a botanical laboratory was sought, and the plant was identified as Jatropha curcas. The symptoms of all the children resolved within 8–10 h of admission. They were kept under observation and discharged the next day in a stable condition.


  Discussion Top


Jatropha curcas also known as “physic nut,” “purging nut,” and “poison nut” belong to the family Euphorbiaceae and is widely distributed in South East Asia and India.[8] Its colloquial names include “Ratanjyot,” “Jungle Erandi,” and “Bagranda.” This plant has been used in the Indian system of traditional medicine for treating ailments such as constipation, abdominal cramps/colic, skin diseases, deworming, purgative, and abortifacient. In recent years botanical research has demonstrated its potential in the production of biodiesel, a renewable biodegradable liquid fuel that is generated from vegetable oils, animal fats or recycled restaurant grease.[9],[10] The Central Salt and Marine Chemical Research Institute in Bhavnager, Gujrat, is cultivating the Jatropha plant since the seeds have high amounts of oil that can be easily converted to biodiesel.[3]

Although all the parts of this plant are poisonous, the seeds are most commonly ingested form as they are often mistaken for edible nuts, as was seen in this case series. The adverse effects are primarily due to the presence of toxins such as curcin, ricin, and cyanic acid.[3] Curcin is a toxalbumin that inhibits the 60s ribosomal subunit. It is proteolytic in nature and induces hepatotoxicity and gastroenteritis.[4] Ricin is a toxic glycoprotein that causes acute cell death by inactivating ribosomal ribonucleic acid and leads to hemorrhagic necrosis of several organs.[11] The purgative effect is mostly due to diterpenoids and curcanoleic acid that is found in the in the seed oil.[5]

Three types of side effects have been observed following the ingestion of seeds are gastrointestinal, cardiotoxic, and hemolytic.[11] Abdominal pain, diarrhea, vomiting, and nausea are the most common gastrointestinal manifestations.[12] [Table 2] presents available scientific literature related to children presenting with gastrointestinal manifestations. The combination of diarrhea and vomiting in the presence of pupillary constriction resembles organophosphate poisoning which is an important differential diagnosis of Jatropha poisoning. None of the children in this series presented with cholinergic signs or symptoms such as meiosis, excessive salivation, lacrimation, or sweating. The ricin toxin mainly causes cardiotoxic effects such as tachycardia, hypotension, peripheral circulatory collapse, and electrocardiographic changes.[11] Hepatic and renal dysfunction, as well hemolytic changes including agglutination of red blood cells, has been observed. None of these were noted in any of the affected children.
Table 2: Summary of previous scientific literature on Jatropha poisoning

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The treatment of Jatropha poisoning is essentially symptomatic and supportive, as there is no specific antidote. The initial steps of any acute unknown poisoning involve the assessment and stabilization of airway, breathing, and circulation. The secondary goal is to try to identify the unknown substance. Decontamination should be performed by either gastric lavage or administration of oral activated charcoal (once corrosive poisoning has been excluded) to prevent further absorption of ingested toxins. Active elimination techniques like forced diuresis, urinary alkalinization, whole bowel irrigation, and dialysis may be considered in unknown poisoning if indicated.[13] In this case series, we followed gastric decontamination with gastric lavage, fluid resuscitation and symptomatic treatment with antiemetics and antacids. A review of existing literature found mention of fluid resuscitation (including management of hypovolemic shock) and antiemetics.[11],[15] We were unable to find any report requiring alkalization of urine or dialysis.


  Conclusion Top


To conclude, poisoning with unknown substances and/or plants is common in children. There is a strong felt need to create public awareness about the detrimental effects of growing such poisonous plants in the vicinity of areas where children play. Clinicians should familiarize themselves with the protocol for unknown poisoning and recognition of various toxidromes. All attempts should be made to try to identify the plant or substance in question.



Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Dayasiri MB, Jayamanne SF, Jayasinghe CY. Plant poisoning among children in rural Sri Lanka. Int J Pediatr 2017;2017:6187487.  Back to cited text no. 1
    
2.
Babu SP, Chandrika DG, Kulkarni MR. Plant poisoning – An observational study in a tristate region emergency department. Int J Med Sci Public Health 2016;5:2158-62.  Back to cited text no. 2
    
3.
Singh RK, Singh D, Mahendrakar AG. Jatropha poisoning in children. Med J Armed Forces India 2010;66:80-1.  Back to cited text no. 3
    
4.
Levin Y, Sherer Y, Bibi H, et al. Rare Jatropha multifida intoxication in two children. J Emerg Med 2000;19:173-5.  Back to cited text no. 4
    
5.
Moshobane MC, Wium C, Mokgola LV. Acute poisoning in children from Jatropha curcas seeds. S Afr J Child Health 2017;11:149-50.  Back to cited text no. 5
    
6.
Reddy KS. The Essentials of Forensic Medicine and Toxicology. 34th ed. New Delhi: Jaypee, 2017.  Back to cited text no. 6
    
7.
Modi RB. A Textbook of Medical Jurisprudence and Toxicology. 24th ed. Gurgaon: Butterworths, 2012.  Back to cited text no. 7
    
8.
Fairless D. Biofuel: The little shrub that could – Maybe. Nature 2007;449:652-5.  Back to cited text no. 8
    
9.
Pramanik K. Properties and use of Jatropha curcas oil and diesel fuel blends in compression ignition engine. Renew Energy 2003;28:239-48.  Back to cited text no. 9
    
10.
Achten WM, Verchot L, Franken YJ, et al. Jatropha bio-diesel production and use. Biomass and Bioenergy 2008;32:1063-84.  Back to cited text no. 10
    
11.
Kosam A, Nahrel R. Clinical profile of Jatropha curcas poisoning in children. Int J Med Res Rev 2014;2:221-7.  Back to cited text no. 11
    
12.
Singhal KK, Chavali K, Nangalu R, et al. Absence of diarrhea in purge nut ingestion: A case series of eight children. J Ayurveda Integr Med 2013;4:176-80.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Riordan M, Rylance G, Berry K. Poisoning in children 1: General management. Arch Dis Child 2002;87:392-6.  Back to cited text no. 13
    
14.
Koltin D, Uziel Y, Schneidermann D, et al. A case of Jatropha multifida poisoning resembling organophosphate intoxication. Clin Toxicol (Phila) 2006;44:337-8.  Back to cited text no. 14
    
15.
Gupta A, Kumar A, Agarwal A, et al. Acute accidental mass poisoning by Jatropha curcas in Agra, North India. Egypt J of Forensic Sci 2016;6:496-500.  Back to cited text no. 15
    


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