Fatal plant poisoning cases in Tunisia: a five-case retrospective series

¹Laboratory of Pharmacognosy, Faculty of Pharmacy, University of Monastir, Rue Avicenne, 5000 Monastir, Tunisia, ²Department of Pharmacy, Fattouma Bourguiba University Hospital of Monastir, Rue du 1^er Juin 1995, 5000 Monastir, Tunisia, ³Laboratory of Toxicology, Fattouma Bourguiba University Hospital of Monastir, Rue du 1^er Juin 1995, 5000 Monastir, Tunisia

^&Corresponding author
Amira Horchani, Laboratory of Pharmacognosy, Faculty of Pharmacy, University of Monastir, Rue Avicenne, 5000 Monastir, Tunisia

Introduction    

Medicinal plants and herbal remedies have been widely used in the prevention and treatment of diseases due to their high content of bioactive compounds with therapeutic properties [1]. However, some plants contain toxic components that may cause adverse effects, ranging from mild skin irritation to severe illness or death [2]. In Tunisia, information regarding fatal plant poisoning incidents remains scarce [3]. This study aimed to describe fatal cases of plant poisoning reported to the toxicology laboratory of a Tunisian university hospital over ten years (2014-2023).

Methods     

This retrospective study was conducted at the Toxicology Laboratory of Fattouma Bourguiba University Hospital in Monastir, Tunisia, over nine years from 2014 to 2023. Data were collected from toxicological analysis reports and laboratory records. Only cases of suspected plant poisoning referred for medico-legal toxicological analysis and resulting in death were included. Non-fatal plant poisoning cases were managed in clinical departments, and follow-up information was not available. Collected data included patient demographics, suspected plant species, circumstances of exposure (including mode of preparation, route of administration, and context of poisoning), and clinical signs observed before death.

Results     

During the study period, five deaths due to plant poisoning were recorded. All intoxications occurred in the context of medicinal use, except one case in which the circumstances were uncertain but were reported to have followed advice from a spiritual healer. Three plant species were implicated. Table 1 summarizes the details of each fatal intoxication, including plant species, year, patient characteristics, plant part used, intended use, and clinical outcomes. Depending on the plant species, poisoning caused either neurological and gastrointestinal symptoms or multiorgan failure.

Discussion     

The plant species implicated in the fatal poisonings reported in this study are part of the Tunisian flora and are traditionally used for their therapeutic properties. However, traditional medicinal use does not guarantee safety, as many of these plants contain complex bioactive compounds, some of which may be toxic, particularly alkaloids [4]. The seeds of Peganum harmala L. contain β-carboline alkaloids such as harmalol, harmaline, and harmine. These compounds have been associated with toxic effects on the neurological, gastrointestinal, and cardiovascular systems, whether following therapeutic use or overdose [5,6]. Similarly, Ephedra species contain sympathomimetic alkaloids, principally ephedrine and pseudoephedrine, which are linked to adverse events such as hypertension, arrhythmias, seizures, and even fatal outcomes when used improperly. These risks have led to regulatory restrictions on Ephedra-containing products in several countries [7,8]. The juice of Ecballium elaterium L. contains cucurbitacins, which are potent, highly oxygenated tetracyclic triterpenoids. These compounds are highly toxic and may cause mucosal irritation, respiratory complications, multiorgan failure, and in severe cases, death when improperly handled or administered [9,10].

Limitations: this study uses data and relies on records from medico-legal toxicology that may have insufficient clinical information. Non-fatal cases of plant intoxication were not included, reducing the possibility of comparison between fatal and non-fatal cases. The small number of cases limits the generalizability of the results.

Conclusion     

These findings emphasize that the term "natural" is not necessarily associated with safety and highlight the need to increase awareness and education among clinicians, traditional practitioners, and the general public about the potential toxicity and dose-related risks of medicinal plants to prevent severe and sometimes fatal poisonings.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Wahiba Douki conceived the study and designed the methodology. Rim Hamdi and Latifa Thabti collected and analysed the data. Amira Horchani and Jihen Ladib contributed to data interpretation and critical revision of the manuscript. Amira Horchani drafted the manuscript. All authors have read and approved the final version of this manuscript.

Acknowledgments     

The authors would like to thank the staff of the Toxicology Laboratory for their contribution to data collection and technical support.

Table     

Table 1: fatal cases of medicinal plant poisoning

References