Letter to the Editor
Cycas revoluta intoxication
Intoxicación por Cycas revoluta
Fernando Alonso Ecenarro, Francesc Puchades Gimeno
, Benjamín Climent Díaz
Corresponding author
Servicio de Medicina Interna, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
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"documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2024;163:102-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Post-infantile giant cell hepatitis" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "102" "paginaFinal" => "104" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hepatitis de células gigantes post-infantil" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1570 "Ancho" => 3175 "Tamanyo" => 981182 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Liver biopsy histopathological examination: (a) Liver parenchyma with regenerative nodules with multinucleated giant hepatocytes (arrows), mainly in periseptal zones (H&E, 10×); (b) Masson's trichrome staining highlighting septal fibrosis (arrowheads), demarcating regenerative nodules, consistent with definitive cirrhosis (Ishak score 6); (c) Presence of septal and intralobular lymphocyte-predominant inflammatory infiltrate (arrows) and focal hepatocellular necrosis (dashed circle) (H&E, 100×); (d) Multinucleated giant hepatocytes (arrows) and mild interface hepatitis (asterisk) (H&E, 200×); (e) Multinucleated giant hepatocytes (arrows), having more than 4–5 nuclei, and the aforementioned features of hepatitis, allowing the diagnosis of PIGCH. Eosinophils are also noted (arrowhead) (H&E, 400×).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Inês Costa Santos, Cláudio Martins, Ana Luísa Alves" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Inês" "apellidos" => "Costa Santos" ] 1 => array:2 [ "nombre" => "Cláudio" "apellidos" => "Martins" ] 2 => array:2 [ "nombre" => "Ana Luísa" "apellidos" => "Alves" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020624002894?idApp=UINPBA00004N" "url" => "/23870206/0000016300000002/v1_202407220832/S2387020624002894/v1_202407220832/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "<span class="elsevierStyleItalic">Cycas revoluta</span> intoxication" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "104" "paginaFinal" => "105" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Fernando Alonso Ecenarro, Francesc Puchades Gimeno, Benjamín Climent Díaz" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Fernando" "apellidos" => "Alonso Ecenarro" ] 1 => array:4 [ "nombre" => "Francesc" "apellidos" => "Puchades Gimeno" "email" => array:1 [ 0 => "francesc.puchades@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "Benjamín" "apellidos" => "Climent Díaz" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Consorcio Hospital General Universitario de Valencia, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Intoxicación por <span class="elsevierStyleItalic">Cycas revoluta</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1975 "Ancho" => 2675 "Tamanyo" => 723066 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">a: patient's place of work. b: remains brought from the patient to the emergency department. c: female <span class="elsevierStyleItalic">Cycas revoluta</span> detail (macrosporangia). d: red-brown seed or fruit with whitish inner pinnae.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cycas revoluta</span> or sago palm, is an ornamental plant native to Madagascar, Australia and Polynesia, and is now widely distributed in public and private gardens in the Mediterranean basin.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We report four clinical cases of ingestion of <span class="elsevierStyleItalic">C. revoluta</span> in the city of Valencia and update the knowledge on the pathophysiology of the intoxication.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The first intoxication occurred in three members of the same family (a 73-year-old man, a 69-year-old woman and a 10-year-old girl) who presented to the emergency department with abdominal pain, nausea and uncontrollable vomiting 30 min after ingesting food. They ate palm leaves from their garden, fried in oil (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b), according to a recipe found on the Internet. Physical examination showed diffuse abdominal pain without pseudoperitonitis. Rehydration therapy was started and in the absence of neurological manifestations and normal complementary examinations, the three patients were discharged 24 h after admission. The second intoxication episode occurred in a 63-year-old woman who presented to the Emergency Department reporting nausea, abdominal pain and vomiting for 20 min after eating two uncooked palm seeds. She remarked that they tasted sweet and pleasant. As a background of interest, she worked as a gardener in a palm tree nursery (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a, c, d). Sweating but haemodynamically stable with no signs of respiratory distress on examination. The abdomen was diffusely painful without pseudoperitonitis and the neurological examination was normal, as were the complementary examinations. The emergency department performed a gastric lavage, which yielded abundant seed remains. After 24 h of hospitalisation, she was discharged from hospital.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The increasing use of ornamental plants, as well as the growing interest in food innovation, makes it necessary for the internist to be aware of their toxic potential. Intoxications can be intentional (oral intake or smoking of concentrated extract) or accidental and the most common clinical consequences are mild physiological effects: gastrointestinal, cardiac, pulmonary neurological, dermatological or haematological. Serious and/or life-threatening intoxications are rare and have been reported in exposures to hemlock, dandelion seed, castor bean, jequirity bean, aconite, autumn crocus and oleander.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a><span class="elsevierStyleItalic">C. revoluta</span> is a plant classified as a pseudopalm tree. Long-term consumption intoxication has been reported on the island of Guam and on the Kii Peninsula, leading to amyotrophic lateral sclerosis parkinsonism-dementia complex.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a> In our setting, intoxication is mainly described in animals.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Female plants have a central area where the seeds are located (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>c). These seeds contain cycasin (methylazoxymethanol β-<span class="elsevierStyleSmallCaps">d</span>-glucoside) and neocycasin, substances belonging to the cyanogenic glycosides. These compounds contain a cyanide group which, when processed after ingestion, gives rise to hydrocyanic acid (HCN). The mechanism of catabolism involves the enzyme β-glycosidase which produces <span class="elsevierStyleSmallCaps">d</span>-glucose and aglycone (MAM), the latter dissociating into hydrocyanic acid and aldehyde. The hydrocyanic compound forms a stable bond with the cytochrome, resulting in inhibition of this enzyme and thus inhibition of aerobic metabolism with known lethality. Although the cyanogenic potential of <span class="elsevierStyleItalic">C. revoluta</span> is known, no associated lethality has been described. This suggests that it may be a pseudo-cyanogen, which would have to be ingested in high concentrations and broken down under extreme conditions to cause cyanide intoxication. The treatment used is mainly supportive, and gastric lavage may be used to avoid absorption of the compounds in the seeds. Observation for 24 h together with liver function tests and venous blood gas analysis are recommended. We believe that we are currently witnessing an increase in the frequency of intoxication by ornamental plants. Although in our cases only gastrointestinal symptoms occurred, we should not forget the cyanogenic potential of the seeds of this plant and the possibility of using a specific antidote for cyanogenic poisoning (hydroxocobalamin and sodium thiosulphate).</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Ethical considerations</span><p id="par0025" class="elsevierStylePara elsevierViewall">Informed consent has been obtained from all four patients.</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0020" class="elsevierStylePara elsevierViewall">This work has not received any funding.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1975 "Ancho" => 2675 "Tamanyo" => 723066 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">a: patient's place of work. b: remains brought from the patient to the emergency department. c: female <span class="elsevierStyleItalic">Cycas revoluta</span> detail (macrosporangia). d: red-brown seed or fruit with whitish inner pinnae.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guam ALS/parkinsonism-dementia: a long-latency neurotoxic disorder caused by «slow toxin(s)» in food?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P.S. Spencer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Can J Neurol Sci" "fecha" => "1987" "volumen" => "14" "paginaInicial" => "347" "paginaFinal" => "357" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3676916" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1556086421023030" "estado" => "S300" "issn" => "15560864" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Plant poisoning" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Froberg" 1 => "D. Ibrahim" 2 => "R.B. 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Caloni" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.tvjl.2013.03.007" "Revista" => array:6 [ "tituloSerie" => "Vet J" "fecha" => "2013" "volumen" => "197" "paginaInicial" => "163" "paginaFinal" => "168" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23570777" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000016300000002/v1_202407220832/S238702062400278X/v1_202407220832/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000016300000002/v1_202407220832/S238702062400278X/v1_202407220832/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062400278X?idApp=UINPBA00004N" ]
