Oxalate Poisoning

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Background

Plant exposures are some of the most frequent poisonings reported to poison control centers. Exposures to plants containing oxalate crystals, such as Philodendron and Dieffenbachia, are among the most common toxic plant exposures reported in the US.

For the past 200 years, the irritant properties of the Dieffenbachia plant have had various uses, including punishing slaves and treating gout, impotence, and frigidity. Today, plants containing oxalate are admired for their ornamental beauty and found in public places and homes.

The following plants contain oxalates:

Pathophysiology

Nonsoluble calcium oxalate crystals are found in plant stems, roots, and leaves. The stalk of the Dieffenbachia plant produces the most severe reactions. These needlelike crystals produce pain and edema when they contact lips, tongue, oral mucosa, conjunctiva, or skin.[1] Edema primarily is due to direct trauma from the needlelike crystals and, to a lesser extent, by other plant toxins (eg, bradykinins, enzymes).[2, 3]

Epidemiology

Frequency

United States

Philodendron and Dieffenbachia exposures are among the most common plant exposures reported to poison control centers.

According to the 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS), 6,803 single exposures were documented for oxalate plant poisonings.[4]

Mortality/Morbidity

In most cases, nonsoluble oxalate plants produce self-limited symptoms and clinical manifestations. Significant morbidity or mortality is extremely rare. One case report of an infant fatality attributed to airway obstruction after exposure to Dieffenbachia exists.

The 2007 Annual Report of the American Association of Poison Control Centers' NPDS reported 1145 minor outcomes, 81 moderate outcomes, 3 major outcomes, and no deaths from oxalate plant exposures.[4]

Age

The majority of oxalate plant exposures occur in children younger than 5 years while sampling houseplants in the home.

The 2007 Annual Report of the American Association of Poison Control Centers' NPDS reported 6020 oxalate plant exposures in those younger than 6 years, 762 exposures in those aged 6-19 years, and 455 exposures in those older than 19 years.[4]

History

Symptoms, if they develop, occur rapidly and may include the following:

Physical

No physical findings exist in the majority of oxalate exposures.

Prehospital Care

Emergency Department Care

Most exposures are self-limited and only require analgesics for patient comfort.

For oral exposures, physically remove any plant material in the oral cavity. Assess for any airway compromise. Individuals without airway compromise can drink cold liquids and eat crushed ice, ice cream, or frozen ice pops or desserts for relief. Oral swishing with diphenhydramine elixir provides local anesthetic and antihistaminic effects. Individuals with laryngeal edema may be treated with antihistamines and observed and/or admitted until edema improves. No clinical data support use of steroids in laryngeal edema induced by oxalate-containing plants.

Treat eye exposures with copious water irrigation. Employ slit lamp examination and fluorescein staining to rule out corneal involvement.

Skin exposures require irrigation with fluid and local wound care. Some individuals may develop a contact dermatitis.

Consultations

Nearly all cases of houseplant exposures involving oxalate-containing plant species are managed at home in consultation with a regional poison control center. Poison control centers may be helpful with plant identification, particularly if a fax copy or digital picture of the plant can be transmitted.

Medication Summary

Analgesics may be required for pain.

Acetaminophen (Tylenol)

Clinical Context:  DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.

Ibuprofen (Motrin, Advil)

Clinical Context:  DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort, which is beneficial for patients who have sustained trauma or sustained injuries.

Diphenhydramine (Benadryl)

Clinical Context:  For symptomatic relief of symptoms caused by release of histamine.

Class Summary

Treatment for significant oral and/or laryngeal edema.

Further Inpatient Care

Prognosis

Author

Jason F Kearney, MD, Consulting Staff, Department of Emergency Medicine, Emergency Medicine Associates, PC, Southwest Washington Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

William K Chiang, MD, Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center

Disclosure: Nothing to disclose.

Specialty Editors

Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT, Associate Clinical Professor, Department of Surgery/Emergency Medicine and Toxicology, University of Texas School of Medicine at San Antonio; Medical and Managing Director, South Texas Poison Center

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

Disclosure: Nothing to disclose.

Michael Hodgman, MD, Assistant Clinical Professor of Medicine, Department of Emergency Medicine, Bassett Healthcare

Disclosure: Nothing to disclose.

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

References

  1. Gardner DG. Injury to the oral mucous membranes caused by the common houseplant, dieffenbachia. A review. Oral Surg Oral Med Oral Pathol. Nov 1994;78(5):631-3. [View Abstract]
  2. Lin TJ, Hung DZ, Hu WH, Yang DY, Wu TC, Deng JF. Calcium oxalate is the main toxic component in clinical presentations of alocasis macrorrhiza (L) Schott and Endl poisonings. Vet Hum Toxicol. Apr 1998;40(2):93-5. [View Abstract]
  3. Zhong LY, Wu H. [Current researching situation of mucosal irritant compontents in Araceae family plants]. Zhongguo Zhong Yao Za Zhi. Sep 2006;31(18):1561-3. [View Abstract]
  4. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol (Phila). Dec 2010;48(10):979-1178. [View Abstract]
  5. Cheeke PR. Endogenous toxins and mycotoxins in forage grasses and their effects on livestock. J Anim Sci. Mar 1995;73(3):909-18. [View Abstract]
  6. Fochtman FW, Manno JE, Winek CL, Cooper JA. Toxicity of the genus Dieffenbachia. Toxicol Appl Pharmacol. Jul 1969;15:38-45. [View Abstract]
  7. Jaspersen-Schib R, Theus L, Guirguis-Oeschger M, Gossweiler B, Meier-Abt PJ. [Serious plant poisonings in Switzerland 1966-1994. Case analysis from the Swiss Toxicology Information Center]. Schweiz Med Wochenschr. Jun 22 1996;126(25):1085-98. [View Abstract]
  8. Krenzelok EP, Jacobsen TD, Aronis JM. Plant exposures: a state profile of the most common species. Vet Hum Toxicol. Aug 1996;38(4):289-98. [View Abstract]
  9. Lampe KF. AMA Handbook of Poisonous and Injurious Plants. AMA; 1985:1-6, 72.
  10. Loretti AP, da Silva Ilha MR, Ribeiro RE. Accidental fatal poisoning of a dog by Dieffenbachia picta (dumb cane). Vet Hum Toxicol. Oct 2003;45(5):233-9. [View Abstract]
  11. Manríquez O, Varas J, Ríos JC, Concha F, Paris E. Analysis of 156 cases of plant intoxication received in the Toxicologic Information Center at Catholic University of Chile. Vet Hum Toxicol. Feb 2002;44(1):31-2. [View Abstract]
  12. McIntire MS, Guest JR, Porterfield JF. Philodendron--an infant death. J Toxicol Clin Toxicol. 1990;28(2):177-83. [View Abstract]
  13. Mitchell JC, Rook A. Botanical Dermatology: Plants and Plant Products. 1979:114-5.
  14. Mrvos R, Dean BS, Krenzelok EP. Philodendron/dieffenbachia ingestions: are they a problem?. J Toxicol Clin Toxicol. 1991;29(4):485-91. [View Abstract]
  15. Ogzewalla CD, Bonfiglio JF, Sigell LT. Common plants and their toxicity. Pediatr Clin North Am. Dec 1987;34(6):1557-98. [View Abstract]
  16. Pamies RJ, Powell R, Herold AH, Martinez J III. The dieffenbachia plant. Case history. J Fla Med Assoc. Nov 1992;79(11):760-1. [View Abstract]
  17. Rauber A. Observations on the idioblasts of Dieffenbachia. J Toxicol Clin Toxicol. 1985;23(2-3):79-90. [View Abstract]
  18. Tagwireyi D, Ball DE. The management of Elephant's Ear poisoning. Hum Exp Toxicol. Apr 2001;20(4):189-92. [View Abstract]
  19. Watson JT, Jones RC, Siston AM, Diaz PS, Gerber SI, Crowe JB. Outbreak of food-borne illness associated with plant material containing raphides. Clin Toxicol (Phila). 2005;43(1):17-21. [View Abstract]

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