Severe uvular edema and resulting hypoxemia due to single use of Ecballium elaterium extract

Background

Ecballium elaterium (squirting cucumber) is a weedy oval-shaped plant whose surface is covered with thorn-like hard cilia, widely known in the Mediterranean region. In traditional Mediterranean medicine, the extract of its roots and fruit has been used as a remedy for hundreds of years. It is reported to have cathartic, anti-inflammatory and analgesic effects and has been used with questionable results.

The extract is called Elaterium, comes from the fruit, leaves and roots of the plant, and it is obtained with an ethanol-based procedure. Its medicinal effects apply due to a substance called elaterin that precipitates over time. The range of clinical conditions treated with Elaterium is vast and includes constipation, jaundice, pulmonary edema, ascites and alopecia [1]. Mainly, though, it has been used in a diluted form to treat sinusitis [2].

When used without dilution the E. elaterium extract is considered highly toxic and cases of laryngeal edema, sensorineural hearing loss, acute glaucoma crisis, and heart and renal failure have been reported [3]. In this article, we present a case of severe uvular edema followed by hypoxemia due to a single use of Ecballium elaterium extract for treatment of sinusitis and we discuss safety issues in the use of this remedy, analyzing findings in the literature.

Case Report

A 52-year-old male Caucasian presented to the emergency department with complaints of uvular edema, troubled breathing and retrosternal discomfort, which started a few hours before coming to the ER. The patient’s medical history revealed the use of Ecballium elaterium extract in an undiluted form the same day. The patient used the extract once in the form of nasal drops in an unknown quantity, since it was presented to him from his social environment as a remedy for sinusitis. Further questions revealed that the patients suffered from chronic paranasal sinusitis. He has been treated during the previous year with antibiotics (macrolide) without a significant relief of his symptoms. The patient was asked if he had used that specific or any other similar non-prescribed substances in the past and he responded negatively. He also did not mention any previous allergic reactions to drugs whatsoever.

During the clinical examination a severe uvular edema was noted. The breathing sounds were normal in both lungs. There were not any other pathological findings in the systemic evaluation. Vital signs presented as follows: blood pressure 150/85 mm Hg, heart rate 90 bpm, temperature 37.2°C, respiration rate 16/min, and SatO2 87%. Due to low SatO2 levels, a blood gas examination was performed. The results showed low pO2 at 58 mm Hg, pCO2 35 mm Hg, pH 7.35 and HCO2– 25 mmol/lt. As concluded from the lab results shown above, the patient had not established respiratory alkalosis, but had already shown the first signs of hypoxemia due to the uvular edema. Serological and chemical tests were also conducted and did not indicate any pathological values. The clinical status of the patient called for immediate treatment in order to reverse the effects of this particular substance and protect his respiratory function.

The patient was administered 35% O2 through a Venturi mask to improve SatO2 and pO2 levels. Simultaneously, we administered 250 mg of Hydrocortisone (Solu-Cortef), 4 mg of Dimethindene Maleate (Fenistil) and 50 mg of Ranitidine (Zantac) intravenously. Through the Venturi mask, 1 dose of Salbutamol and Ipratropium (Berovent) and 1 dose of Budesonide (Pulmicort) were also administered to the patient in order to relieve the bronchial spasm. Almost half an hour later, the patient’s clinical status had improved. He did not complaint about troubled breathing and SatO2 reached 92%. However, the uvular edema had not resolved fully. Due to the persistence of the edema, the patient was administered 25 mg Prednisolone (Prezolon) and 2 mg of Adrenaline through the Venturi mask in the form of an inhaled solution.

One hour after attendance to the ER, the uvular edema had significantly resolved and the patient’s SatO2 levels were back to normal (96%). Blood gas tests confirmed the improvement, with pO2 levels at 82 mm Hg. The patient was admitted to the hospital for 24-hour surveillance. During his hospitalization, the patient was stable without any deterioration of his respiratory function or recurrence of the uvular edema.

Discussion

Extract of Ecballium elaterium has been known as an anti-inflammatory agent in the Mediterranean region for many centuries and it has been used as a remedy against a vast spectrum of diseases, mainly against chronic and acute sinusitis. The effects of this particular extract are known empirically through time. The first attempt to prove Ecballium elaterium’s healing effect was made by Sezik et al. [4] who used it in a diluted form in a group of 49 volunteers with paranasal sinus infections. An appreciable percentage showed improvement of the symptoms (56–71%). In a later report Yesilada et al. [5] stated that the root of Ecballium elaterium had an inhibiting effect on the in vitro biosynthesis of IL-1 and TNF, which are known to be pro-inflammatory mediators.

The positive effects of Ecballium elaterium are seen only when it is used in diluted form, which reduces its efficacy by almost 10-fold. Use of undiluted extract can cause severe and possibly life-threatening adverse effects. The main mechanism depends on elaterin [6], which in high concentrations dramatically increases capillary permeability and causes watery evacuation of the mucosa. This effect can lead to severe edema of the nasal and pharyngeal mucosa and obstruct the respiratory tract. Kloutsos et al. [7] reported 42 exposures to Ecballium elaterium and more than 93% of the cases had a previous history of allergic reactions. Even higher concentrations of elaterin can cause neurotoxicity (in the form of convulsion or bradypnea), renal or heart failure, and death (doses over 1 g).

In the case presented, the patient did not mention any previous allergic reaction, or any previous use of Ecballium elaterium extract. He had used it, undiluted, in the form of nasal drops only once, on that specific day. This single use, though, resulted to a severe allergic reaction. The improvement of the symptoms with anti-allergic treatment indicates that the extract caused persistent irritation and inflammation of the mucosal membranes. Only after the use of inhaled adrenaline was the patient fully relieved of his symptoms. Apparently, the concentration was not high enough to cause toxic effects, which could not be confronted with the treatment used. It should also be noted that the patient did not know of possible adverse effects from the use of Ecballium elaterium.

Conclusions

The use of Ecballium elaterium extract as a remedy can cause severe adverse effects that should not be ignored. Uvular edema is one of the most common of these and can lead, as shown above, to hypoxemia, which is a potentially life-threatening situation. Treatment is necessary and should include the use of high-concentration O2 and inhaled adrenaline in order to secure the patency of the respiratory tract.