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OJHAS Vol. 8, Issue 4: (2009
Oct-Dec) |
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| An
interesting case of suicidal poisoning |
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Mohit
Sharma Junior Resident,
Satish Kumar, Senior Resident,
Aditi Prashar, Intern,
Ashok
Sharma, Professor
Dept. of Medicine, Indira Gandhi Medical
College,
Shimla - 17001 (Himachal Pradesh) |
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Address For Correspondence |
H. No - 2082/3,
Sector - 45-C, Chandigarh - 160047.
E-mail:
docmohitsharma@gmail.com |
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Sharma M, Satish Kumar, Prashar A, Sharma A. An interesting case
of suicidal poisoning. Online J Health Allied Scs.
2009;8(4):14 |
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Submitted: Mar 22, 2009;
Suggested revision: Apr 14, 2009; Resubmitted: July 8, 2009; Accepted:
Jul 10, 2009; Published: Apr 30, 2010 |
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| Abstract: |
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Aconite is one of the most
poisonous known herbs. It has been known to be used as a homicidal
poison
from long time in history. However this is rarely known to be used as suicidal poison. Poisoning
with aconite is usually fatal and death commonly occurs due to arrhythmias and cardiotoxicity.
We report a case of attempted suicidal poisoning by aconite where
patient
survived in spite of documented cardiotoxic effects of the poison.
Key Words:
Suicidal poisoning, aconite, mohra |
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Aconite tubers are most toxic
wild plants distributed from Asia to western Europe.1-4 It Was notorious in the 19th
century
as an agent for homicides and suicides. Aconite was believed by the
Greeks to be the first poison created by the goddess Hecate from foam
of the river Cerebrus.5 Before the birth of Christ it was
known as ‘queen mother of all poisons. Aconite was also known to Hindu
medicine as recorded in Vedas around 900 BC.6 The Lepchas
of sikkim have a saying that Aconite is ‘useful to hunters for
destroying
elephants and tigers, useful to the rich for putting troublesome
relatives
out of the way and useful for jealous husbands for destroying
faithless wives’. The Lepchas are believed to have poisoned the water
supply of British troops with powdered aconite in the expedition of
1887.5 Indian
Aconite root or Nepal
Aconite consists of the root of A.
laciniatum. It is
also called Bikh or Bish, and is collected in Nepal. It is a conical
root, 2 to 4 inches long and an inch or more at the top, of a light
brown color. Other varieties of Aconite are A. chasmanthum, known in India as Mohri and Mohra,
which contains Indaconitine. Aconite is common in the Himalayas. In the
state of Himachal Pradesh it occurs sporadically in many areas. In
traditional
medicine aconite is used externally in mustard oil for massage in
neuralgia,
paralysis and rheumatism. Root is used in diseases such as Leprosy and
Cholera, and as a tonic in diarrhea and cough.7 Aconite
has been used as Chinese herbal medicine, which are freely purchased
from herb shops and used as decoction by herbal practitioner for pain
control.8 In Japan, some cases of aconite
poisoning appeared as result of committing suicide or accidental
ingestion,
mistaken for edible grass. However aconite alkaloids have potential
of serious and even fatal cardiotoxity, which is difficult to manage.
It has still remained difficult to save these patients with therapeutic
resistant fatal arrhythmias.9,10 We are reporting a case of
suicidal poisoning with a herb locally known as mohri or mohra, the
local name for aconite.11
A 30 years old female patient
was referred from a primary health centre with diagnosis of unknown herbal poisoning.
The name of the alleged poison was mentioned as ‘mohra’ in the medicolegal case report
attached with the referral slip. Patient’s attendants told that when patient’s husband
retuned home from work in the evening she was anxious and had two
episodes
of vomiting. Her seven year old son told that the patient had consumed
a herb known as ‘mohra’. Patient’s attendants knew this herb to
be a very poisonous herb which grew in the forest near the village and
caused fatal poisoning. Attendants had this knowledge from local hearsay
and also reported that this herb was available with local quacks
and religious healers and was used in preparing medicines.
On further questioning they
described the herb found with the patients as dry woody roots. Patient was
asymptomatic
apart from having restlessness and feeling of suffocation and nausea. Physical
examination
was unremarkable apart from occasional irregular beats in pulse and the patient
was hemodynamically stable. Electrocardiogram showed presence
of ventricular ectopics.(Fig-1)
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Figure 1
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The treating doctors did
not know about the herb but based on the description of the herb and
presence of ectopics in the ECG possibility of aconite poisoning was
kept and patient was shifted to cardiac care unit for continuous ECG and hemodyanamic
monitoring.
Patient’s attendants were shown pictures of aconite plant and roots and
recognized
these as those consumed by the patient. Patient was managed
conservatively
and improved. ECG changes reverted to normal after one day (Fig-2).
Patient subsequently remained asymptomatic and was discharged after
five days.
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Figure 2 |
Aconite was
used throughout Europe as a wolf poison, and in India as a tiger
poison,
lacing meat left
for the man-eaters to scavenge. Several of its common names allude to
this value: Wolfsbane, Leopard Bane, Tiger Bane, Dog's Bane, &
occasionally,
a mite absurdly, Wolf's Hat. It was even called Mousebane, because
of the belief that its odour could kill a mouse at a great distance. Aconite root contains from 0.3 to
1 per cent alkaloidal matter, consisting of Aconitine - crystalline,
acrid and highly toxic - with the alkaloids Benzaconine (Picraconitine)
and Aconine.12 Aconitine is the only crystallizable alkaloid
in it and amounts to less than 0.2 percent. The Aconitines are a group
of highly toxic alkaloids derived from various species of Aconite. They
are chemically distinguishable according to the source from which they
are obtained. The Aconitines are divided into two groups: (1) the
Aconitines
proper, including Aconitine, Japaconitine and Indaconitine, and (2)
the Pseudaconitines - Pseudaconitine and Bikhaconitine.
The
symptons of poisoning are tingling and numbness of tongue and mouth
and a sensation of ants crawling over the body, nausea and vomiting
with epigastric pain, difficult breathing, irregular and weak pulse,
cold and clammy skin, giddiness with preserved sensorium.12 Aconite
alkaloids have potential of serious and even fatal cardiotoxity, which
is difficult to manage. It has still remained difficult to save these
patients with therapeutic resistant fatal arrhythmias.9,10
Mechanistically, aconitine increases sodium influx through the sodium
channel, increasing inotropy while delaying the final repolarization
phase of the action potential and promoting premature excitation Sinus
bradycardia and ventricular dysrhythmias can occur. Symptoms can occur
from 5 minutes to 4 hours after ingestion.5
This patient had typical
symptoms of aconite poisoning including nausea, vomiting, epigastric
discomfort and weak, irregular pulse. Patient was in hypotension and
had ventricular ectopics in her ECG. The patient improved with
conservative
management and didn’t develop other arrhythmias. This relatively benign
course may be because poison consumed had probably been processed for
medicinal use. Though aconite is considered to be an ideal homicidal
poison for many reasons, it has also been used for suicide at many
occasions.
But not all deaths
have been intentional homicides or suicides, for Monkshood is sometimes
mistaken for fennel or horseradish or other edible plant, as even the
species name napellus or "Little Turnip"
alludes to its resemblance to something edible.12 Aconite chasanthamum
is the most commonly used species among the poisonous species of aconite.
It is used in a number of medicines after mitigation/detoxification.
Detoxification usually involves soaking aconite roots in cows urine
for several weeks or prolonged boiling for as long as 48 hours.11 According to an article
by the Indian
scientists Thorat and Dahanukar, "Crude aconite is an extremely
lethal substance. However, the science of Ayurveda looks upon aconite
as a therapeutic entity. Crude aconite is always processed i.e. it
undergoes
'samskaras' before being utilized in the Ayurvedic formulations. This
study was undertaken in mice, to ascertain whether 'processed' aconite
is less toxic as compared to the crude or unprocessed one. It was seen
that crude aconite was significantly toxic to mice (100%) mortality
at a dose of 2.6 mg/mouse) whereas the fully processed aconite was
absolutely
non-toxic (no mortality at a dose even 8 times as high as that of crude
aconite). Further, it says “all the steps in the processing were
essential
for complete detoxification”.13 This
patient had consumed aconite in the form of a dry root which is some
times kept by faith healers and quacks for medicinal purposes. She took
it with the intention of committing suicide but survived, may be because
the dried roots of aconite kept for medicinal use are usually processed
by various methods mentioned above. This case was unique because despite
of being touted as an ideal homicidal poison aconite is very uncommonly
implicated or even suspected in poisonings. Survival after aconite
ingestion
is even less common. Even more intriguing is the fact that given the
relatively easy availability, ease of administration, simulation of
natural illness by symptoms and difficulties in isolating poison from
viscera.5 It still remains
a rare cause of poisoning deaths. Or is it that it is not just suspected
to be!
- Geoffrey French. Aconitine-Induced
Cardiac Arrhythmia. Br. Heart J 1958;20: 140-142
- Tai YT, But PP, Young K, Lau CP. Cardiotoxity After Accidental Herb-Induced Aconite
Poisoning. Lancet 1992;340:1254-1256
- Chan TY. Aconitine
Poisoning:
A Global Perspective. Vet Hum Toxicolo 1994;36:326-328
- 4. Chan TY, Tomlinson B, Tse LK, Chan
JC, Chan WW, Critchley JA. Aconitine Poisoning
Due To Chinese Herbal Medicines: A Review. Vet Hum Toxicolo 1994;36:452-455
- Vij K. Textbook of
Forensic Medicine and Toxicology: Principles and Practice. 3rd
edition. Reed Elsevier India Private Ltd. India. 2005:647-750.
- Das RK. Epidemiology of
insecticide poisoning at AIIMS emergency services and role of its
detection by gas liquid chromatography in diagnosis. Med Leg Update
2007;7:49-60.
- Chauhan NS. Medicinal
and Aromatic Plants of India. Indus Publishing. 1999. pp 65-69.
- Fatovich DM. Aconite:
A Lethal Chinese Herb. Ann Emerg Med 1992;21:309-311
- Kolev ST, Leman P, Kite GC, Stevenson
PC, Shaw D, Murray VS. Toxicity Following
Accidental Ingestion of Acotinum Containing Chinese Remedy. Hum Exp Toxicol
1996;15:839-842
- Honerjager P, Meissner A. The Positive Inotropic Effect
of Aconitine. Naunyn Schmiedebergs
Arch Pharmacol 1983;322:49-58
- Shah NC. Conservation
aspects of Aconitum species in the Himalayas
with special
reference to Uttaranchal (India). Newsletter of the Medicinal Plant
Specialist Group of
the IUCN Species Survival Commission 2005; vol 11: 9-15.
- Grieve M. Aconite. A
modern
herbal. Available at
http://www.botanical.com
- Thorat S, Dahanukar S. Can We Dispense With
Ayurvedic
Samskaras? J Postgrad
Med. Jul 1991;37(3):157-9.
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