Abstract
The Veratrum genus of plants contains multiple toxic alkaloid compounds, and ingestion of Veratrum species may result in clinically significant human illness. Although many cases of Veratrum ingestion have been reported in the Eastern United States and Europe, no case report of human toxicity from the most common California species, Veratrum californicum, exists in the literature. We report on the clinical course and treatment of a patient with a known Veratrum californicum ingestion. We discuss the identification of the Veratrum species and compare our case to other cases of Veratrum ingestions reported in the literature. We find that similar to ingestions of other Veratrum species, our patient became hypotensive and bradycardic, requiring fluid resuscitation. Similar to other reports, our patient responded to treatment with atropine and was able to safely discharge after a short hospital stay. Our case adds the first reported ingestion of Veratrum californicum to the literature of other Veratrum ingestions and suggests that this toxicity similarly responds to atropine and hemodynamic support.
Keywords
Introduction
Misidentification of foraged plants is a common cause of toxic plant ingestions. California false hellebore, also known as the California corn lily (Veratrum californicum), is a member of the lily family that grows in marshy areas of the Western Sierra. 1 Veratrum species are common throughout the world, and many case reports exist of misidentification of these plants resulting in toxic ingestions. Veratrum viride is a species that is found in the Pacific Northwest and eastern seaboard of the United States and has been foraged by individuals seeking wild ramps.2–5 In Eastern Europe, Veratrum album is sometimes mistaken for yellow gentian, an additive in alcoholic drinks.6–9 In central and eastern Europe, the species Veratrum lobelianum is processed into a tincture that is used as a home remedy for diverse conditions. High dosages are associated with toxicity. 10 Finally, a report of foragers mistaking Veratrum parviflorum, a species native to the Southeastern United States, for wild leeks was reported in 2018. 11 Although many ingestions of other toxic Veratrum species have been previously documented in the literature (Table 1), we discuss the first reported case of an ingestion of Veratrum californicum.
Summary of existing case reports of veratrum toxicity.
Case Report
A 50-year-old female with a history of hypertension and diabetes mellitus presented to the emergency department for nausea, vomiting, and dizziness after ingesting a plant she believed to be edible, which she had foraged while hiking in the Sierra Nevada foothills. The patient lived in Southeast Asia before moving to California and noted that the plant looked like a nontoxic species she had foraged while living in Asia. She reported that she cooked the leaves in a stir-fry, and an hour after ingestion, she felt lightheaded, nauseated, and had several episodes of vomiting. She had shared the meal with her husband and mother, both of whom only tasted the meal and reported no ill effects. Her systolic blood pressure, as measured at home, was in the 70s, prompting her to call emergency medical services (EMS). On EMS arrival, she had a blood pressure of 70/36 and a heart rate of 54 beats per minute. She was given 4 mg sublingual ondansetron without relief of nausea. A prehospital 12-lead electrocardiogram was negative for ST elevation myocardial infarction (STEMI). EMS was unable to obtain IV access.
In the ED, initial vital signs were: temperature 98.1 F, heart rate 60 bpm, blood pressure 80/p, and oxygen saturation 96% on room air. CBC demonstrated WBC 5.8 × 103/uL, Hgb 11.6 g/dL (baseline Hgb 12 g/dL), platelet 176 × 103/uL. CMP was within normal limits. Her lactic acid was elevated at 3.0 mmol/L. Electrocardiogram showed sinus bradycardia at a rate of 54 bpm, PR interval of 165 ms, QRSd of 89 ms, and QTc by Bazett's of 470 ms. She received an initial bolus of 1L normal saline with transient improvement of her blood pressure to 102/58. One hour later, she became hypotensive again and was given 1L of lactated ringer’s without improvement. She had brought in a few leaves from the foraged plant as well as several photographs (Figure 1). The ED physicians used a reverse image search to identify the plant as a Veratrum species.
An image from the patient's phone of a foraged plant (left). An image taken from a similar geographic area of Veratrum californicum during flowering season (right).
At this point, the inpatient medical toxicology service was consulted and recommended initial treatment with atropine titrated to blood pressure. The patient was given atropine 0.5 mg IV, which improved her blood pressure from 82/43 to 104/55 and her HR from 63 to 80 bpm. She was admitted to the intensive care unit (ICU) for closer monitoring. Repeat ECG showed sinus rhythm of 64, QRSd of 92, and QTc of 452. Repeat labs 8 h later demonstrated normalization of lactic acid. Transthoracic echocardiogram was obtained, which showed normal ventricular size with ejection fraction at 60–65% with no significant valvular abnormalities. The patient was monitored with no recurrence of bradycardia or hypotension and was discharged home after 24 h.
Initial identification of the species was done in the emergency department with a photo from the patient's phone using reverse image search, which classified the plant as Veratrum viride. After the patient's discharge and during the writing of this case report, we consulted with two botanists at our local university who identified the plant from the patient's original photos as Veratrum californicum. A subsequent trip during flowering season to the area where the patient reported foraging the plant confirmed thick growth of a white petalled Veratrum species most consistent with Veratrum californicum, as opposed to Veratrum viride, which has green petals (Figure 1).
Discussion
Veratrum californicum, commonly called California false hellebore, is one of the species in the Veratrum genus. This is the first reported case of toxicity caused by the California species, although case reports exist for ingestions of closely related family members. Importantly, the symptoms displayed by this patient closely resemble those in other cases of Veratrum ingestion despite the difference in species. As in other cases, our patient responded hemodynamically to atropine and was able to be discharged after a short ICU stay. Veratrum californicum contains many of the same toxic steroidal alkaloids as viride and album. 12
Veratrum species contain toxic veratrum steroidal alkaloids that readily cross cell membranes and act as persistent sodium channel openers in animal models, causing increased vagal tone and peripheral vasodilation.5,11,13 Early experiments with Veratrum extracts showed that ingestion of the compounds caused a triad of hypotension, bradycardia, and apnea, termed the Bezold–Jarisch reflex after the investigators. 14 These same researchers found that these effects could be mitigated by severing the vagal nerve, suggesting that these compounds act through vagal stimulation. 14 Drugs derived from veratrum compounds were briefly used as anti-hypertensive agents for hypertensive emergencies and eclampsia but were eventually withdrawn due to a narrow therapeutic window and undesirable side effects. 14
Our patient initially presented with nausea, vomiting, and hypotension as measured on a home BP cuff about an hour after the ingestion. Published case reports demonstrate that the most common symptoms of Veratrum toxicity, reported in nearly all cases, appear to be nausea and vomiting (Table 1). 15 Additionally, other commonly reported signs and symptoms include abdominal pain, diarrhea, hypotension, bradycardia, and syncope. Symptom onset is usually rapid, occurring from 30 min to 4 h post-ingestion. 15 Duration of symptoms has been reported as long as 10 days, but most cases resolved within 1–2 days with supportive treatment, as was the case for our patient. 15 Importantly, in our case and many other case reports, the plant was cooked prior to ingestion, suggesting that at least some Veratrum compounds may be heat stable.
Guidance for the treatment of the Veratrum-poisoned patient comes primarily from case studies. Various decontamination strategies have been used, including activated charcoal and gastric lavage (Table 1). In our case, by the time the plant was identified, it had been about 3 h post-ingestion, and we did not pursue decontamination. There is no antidote for Veratrum toxicity, and the mainstays of treatment are supportive. These include fluid resuscitation, vagal agents such as atropine, and ionotropes. 15 In a few cases, the overlap of symptoms between Veratrum poisoning and cardiac glycoside toxicity have resulted in patients being considered for digoxin toxicity. In one case report, a digoxin assay was positive, resulting in several patients being treated with digoxin immune Fab.2,11 However, cardiac glycosides are not a known component of Veratrum extract, and so it is unclear whether this case represented a true positive or cross-reactivity of the assay with another compound found in Veratrum.
Most commonly, Veratrum species are mistaken for similar-appearing edible counterparts. In this case, the patient mistook Veratrum leaves for plantain leaves common in Southeast Asia. Because they may not be familiar with local ecology, immigrants face higher risks of poisoning from foraged plants. In 2018, Minnesota faced several cases of ingestion of toxic mushrooms stemming from the resemblance of a toxic species to an edible Southeast Asian mushroom. 16 In this case, the patient described foraging for wild plantains and mistakenly identified the false hellebore as an edible plant. Interestingly, our patient had at least one plant identification application on her phone that identified the species as Veratrum viride, a close toxic relative of Veratrum californicum, although she had not used the application prior to foraging for the plant. As plant identification applications are inconsistent in reliably differentiating between toxic and edible plants, we recommend using them in conjunction with local experts for people who forage. 17
In conclusion, we discuss a patient who ingested Veratrum californicum and displayed symptoms similar to those observed in other ingestions of Veratrum plant species. This is an abundant plant in Sierra Nevada and commonly encountered by hikers and foragers who would likely benefit from education in identifying and differentiating this species from edible lookalikes.
Footnotes
Acknowledgments
We would like to thank Dr Katherine Waselkov and Wendy E Cooper of the Department of Biology at California State University Fresno for their assistance with plant identification.
Author Contribution(s)
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
