To the Editor:
In the January 2004, issue of Clinical Toxicology, Hui et al. reported a case of black locust tree poisoning. The patient developed nausea and vomiting without diarrhea as well as an elevated alkaline phosphatase and WBC count. The patient was treated with activated charcoal and supportive care before being discharged in stable condition.Citation1 Three other cases have been reported from Spain in 1990 and 2009. Although some patients were stated to be severe, presenting with both gastrointestinal (GI), and central nervous system (CNS) symptoms, they were all treated with GI decontamination and discharged within 2 days.Citation2–4
On 6 January 2012, a previously healthy 12-year-old Caucasian male presented to our emergency department after transfer from a referring hospital with nausea, vomiting, nonbloody diarrhea, loss of consciousness, and severe generalized weakness to the point where he was unable to rise from a prone position. The symptoms began shortly after lunch with his father who did not become ill. The boy's brother revealed that the patient ate approximately two handfuls of bark from a black locust tree that morning, noting a sweet taste.
The patient's parents reported no family history of GI disease, allergies, medications, and no recent illness or sick contacts. The patient was up to date on his immunizations and denied use of tobacco, alcohol, or recreational drugs. The patient was alert and oriented for his age with the physical examination being largely unremarkable other than a mild sinus tachycardia and abdominal pain. Routine labs were drawn and showed a pH of 7.31, a white blood cell (WBC) count of 25.6 × 103cells/L, and an alkaline phosphatase of 216 U/L. All other results were within normal limits. The use of gastric decontamination was deemed unnecessary due to the prolonged time since ingestion and vomiting. Antibiotics were also avoided as the elevated WBC count was thought to be inflammatory in nature.
One liter of normal saline and ondansetron had been administered prior to his arrival. The patient was then admitted for observation and telemetry was initiated but revealed no changes. The patient did not experience any additional episodes of diarrhea or emesis during his stay, and so, no further GI assessment was done and no medications were given other than intravenous fluids. By the following day, all vital signs were stable and he was discharged home.
It is important to recognize the potential for harm, especially in pediatric patients since the toxins contained in the tree are similar to ricin. The case presented above was similar in severity to the reports from Spain due to the development of CNS symptoms and a highly elevated WBC count. Some transient liver damage is likely in most cases as evident by the patient's increased alkaline phosphatase; however, since oral absorption of the toxins is poor, supportive care is the standard treatment and patients are expected to fully recover.Citation5
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
- Hui A, Marrafa J, Stork C. A rare ingestion of the black locust tree. J Toxicol Clin Toxicol 2004; 42:93–95.
- Artero Sivera A, Arnedo Pena A, Pastor Cubo A. Clinico-Epidemiologic study of accidental poisoning with Robina pseudoacacia L. in school children. An Esp Pediatr 1989; 3:191–194.
- Costa Bou X, Soler i Ros JM, Seculi Palacious JL. Poisoning by Robinia pseudoacacia. An Esp Pediatr 1990; 32:68–69.
- Calzado Agrasot M, Ortola Puig J, Cubelis Garcia E, Nuno Ballesteros M, Pereda Perez A. Robina pseudoacacia poisoning. An Esp Pediatr 2009; 70:399–400.
- Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldrank LR, Flomenbaum NE. Goldfrank's Toxicologic Emergencies. 9th ed. New York: McGraw-Hill; 2010:1549–1551.