Death due to poisoning with Gloriosa superba (‘Niyagala’) seeds

A 35year old female patient presented with self ingestion of about 50 seeds of Gloriosa superba (‘Niyagala’) 20 hours back. She had watery diarrhea, hypokalaemia and acute liver failure and died due to respiratory failure. Usually tubers of 'Niyagala' are ingested for the deliberate self-harm. But here we report a case of death due to poisoning of Gloriosa superba seeds which was not previously documented.


Introduction
Plant poisoning may be accidental or intentional.Accidental poisoning is normally a problem of young children 1 .Ingestion of yellow oleander seeds (Thevetia peruviana) has recently become a popular method of self-harm in northern Sri Lanka 2 .Here we report a case of death due to poisoning with 'Niyagala' ('glory lily', Gloriosa superba) seeds.

Case report
A 35 year old female patient was transferred to Provincial General Hospital, Ratnapura, from Base Hospital, Kahawatte with a history of loose stools following self ingestion of about 50 'Niyagala' seeds (figure 1) more than 10 hours previously.

Figure 1: Gloriosa superba ('Niyagala') seeds and fruits
The patient who had no previous illnesses was a mother of one child.On admission she had moderate watery diarrhoea but no vomiting or abdominal pain.On examination she was afebrile, blood pressure (BP) 87/56mmHg, pulse rate 96/min, respiratory rate 30/min, SpO 2 96% on room air, normal bilateral lung fields on auscultation and mild lower abdominal tenderness.As this was a late presentation, gastrointestinal decontamination with gastric lavage and activated charcoal was not performed.Initial investigations revealed white blood cell count 27.The following day, she developed shortness of breath associated with a few bilateral crepitations and acute liver dysfunction (AST 292.1U/L and ALT 50.7U/L).Arterial blood gas (ABG) analysis on room air was suggestive of metabolic acidosis (pH 7.283, pCO 2 28mmHg, pO 2 68.6mmHg, serum HCO 3 13.4mmol/L,base excess -13.5mmol/L) for which intravenous 8.4% NaHCO 3 50 ml was administered with fluid bolus of 500 ml Hartmann's solution.She was on O 2 inhalation via face mask (10L/min).There was no renal impairment (normal urine output, serum creatinine 98.7µmol/L) and she maintained normal O 2 saturation and blood pressure.Repeat serum K + was 3.9mmol/L.Her vital functions were monitored.However, she died on day two following hospital admission (42hrs after ingestion) due to sudden onset severe respiratory failure in spite of resuscitation with Ambu ventilation and attempts at intubation.
Post mortem examination showed mild enlargement of the liver with yellow discoloration, reduced cortico-medullary demarcation in both kidneys, petechial haemorrhages on the outer surface of kidneys and mild gastric erosions.

Discussion
Deliberate self-harm using 'Niyagala' usually occurs due to ingestion of tubers (roots)3,4,5.However in this case the victim had ingested seeds, which is not the common practice.
'Glory Lily' is a plant that grows wild in all regions of Sri Lanka.All parts of this plant are poisonous of which tubers may be the most poisonous.They have been found to contain several alkaloids such as colchicine, gloriocine, superbine etc., among which colchicine is the most important alkaloid 6 which results in multi-organ toxicity.The commonest clinical presentation of poisoning is severe gastroenteritis associated with nausea and vomiting.
Other features include muscle weakness, respiratory failure, bone marrow depression, convulsions, polyneuropathy and coagulation defects 7 . Generalized alopecia 4 and dermatitis 5 are late manifestations that develop about 1-2 weeks after poisoning.Cardiac toxicity (ST elevation in ECG) following 'Niyagala' poisoning has also been documented 3 .
This patient had watery diarrhoea, hypokalaemia, moderately elevated liver enzymes and clotting defects (elevated international normalised ratio (INR) 2.76) and died due to sudden onset of severe respiratory failure.On day 2 of admission (around 35 hours after ingestion) the patient developed shortness of breath and mild dyspnoea (respiratory rate of 40/min), few bilateral crepitations in lungs and ABG analysis showed lowering of pO 2 (68.6mmHg).But at this stage we were unable to do a chest x-ray as the patient deteriorated.Autopsy examination revealed that both lungs were normal in appearance.Therefore, sudden onset of respiratory failure may be due the action of colchicine on intercostal muscles.Angunawela et al. suggested that respiratory failure is due to the paralysis of intercostal muscles rather than the direct depression of the respiratory centre by colchicines 5 .
The patient may have ingested a lethal dose of colchicine which varies from 6-20mg.She had ingested about 50 seeds (weight-10g).It is estimated that 10g of fresh tuber contains about 6mg of colchicines 7 and in severe poisoning there may be respiratory depression 8 .The LD50 of colchicine for rats was 5 mg/kg 6 .This case report points out the importance monitoring respiratory function and the need for early respiratory support for a patient with 'Niyagala' poisoning.