Temporary heal can possibly kill!

Silvera Samson Raj*

MRCEM Resident – 1st year, Department of Emergency Medicine, Kauvery Hospital, Chennai, India

*Correspondence: [email protected]

Abstract

Eucalyptus oil is a traditional herbal medicine widely used for a number of common ailments. Extreme toxicity following ingestion is well-documented, but public awareness is generally lacking. The toxic symptoms are rapid in onset, which include a burning sensation in the mouth and throat, abdominal pain, and spontaneous vomiting. The initial central nervous system (CNS) effects are giddiness, ataxia, and disorientation followed by loss of consciousness and convulsions occurring within 30 mins.

Case Presentation

A 49 years female, known systemic hypertension, type 2 diabetes mellitus and hypothyroidism, presented to ER with alleged history of accidental ingestion of eucalyptus oil of approximately 10ml in her residence after which she had 3 episodes of watery vomiting followed by 2 episodes of involuntary jerky movements involving all 4 limbs with up rolling of eyeballs, tongue bite and urinary incontinence.

On initial evaluation at ER

Patient in ictal state.

Airway

Threatened – suctioning done, Oropharyngeal airway inserted.

Breathing

RR – 28/ min, Spo2 – 66% RA – connected to high flow oxygen using NRBM.

B/L air entry equal, B/L wheeze with harsh vesicular sounds heard .

Circulation

BP – 170/ 100 mmHg. HR – 128/ min,

CVS -Tachycardic, S1S2 normal, no murmur, JVP – Normal,

PA – Soft, non-tender, no organomegally, bowel sounds heard.

Disability

Patient in status-Active GTCS+ , B/L PUPIL dilated.

CBG: 260 mg/dl

Exposure

Temp: 98.6 o F

Tongue bite with bloody frothy secretions noted.

POC

pH – 6.780

PCO 2 – 72.9 mmHg

PO 2 – 28 mmHg

BE – -24 mmol/ L

HCO 3 – 10.8 mmol/ L

LAC – >20 mmol/ L

Na+ – 141 mmol/ L

K+ – 3.3 mmol/ L

Cl- – 104 mmol/ L

BUN – 7 mg/dL

CREAT – 1.1 mg/dL

Course in ER

  1. Patient positioned in left lateral position, intravenous access commenced and injection lorazepam 4mg stat given.
  2. She had recurrent GTCS hence loaded on dual anti-epileptics after neurology consult.
  3. In view of prolonged seizures( formerly called as status epilepticus), she was intubated and connected to mechanical ventilator.
  4. In view severe metabolic acidosis, she was also given injection sodium bicarbonate 200mg bolus followed by infusion.
  5. After stabilization, and with provisional diagnosis of Eucalyptus oil poisoning – prolonged seizures,  Pneumonitis (Chemical vs Aspiration), patient shifted to ICU.

Repeat ABG

pH – 7.34

PCO 2 – 39 mmHg

PO 2 – 110 mmHg

BE – -3 mmol/ L

HCO 3  – 21.5 mmol/ L

LAC – 9.48 mmol/ L

Course in ICU

  • Patient GCS improved and extubated the very next day.
  • In view of chemical pneumonitis, patient was started on nebulisations.
  1. MRI brain and EEG – Normal.
  2. Anti-epileptics weaned off slowly.
  3. Patient discharged without any anti-epileptics and was normal in repeat follow ups.

Discussion

  1. Eucalyptus oil is a popular household product, commonly presented as an essential oil, medicinal product, cleaning product, inhalational/vaporiser fluid or topical preparation. Eucalyptus oil is highly toxic. Small ingestions of pure oil (≥5 mL) can lead to severe symptoms.CNS depression and respiratory compromise are the main features of eucalyptus oil poisoning to monitor for. The common side effects in children include depression in the level of consciousness, ataxia, seizures, and vomiting. In a study by

    K. Jagadish Kumar

    et al. out of 109 children with Eucalyptus oil ingestion, 59% of them were symptomatic. Minor poisoning (ataxia, vomiting, and abdominal pain) was observed in 30%, moderate poisoning (Glasgow coma scale of 8-14) in 25% and major poisoning with coma (coma scale of 3-7) accounting for 4%.

  2.  Many species of the genus Eucalyptus from the

    Myrtaceae

    family (

    Eucalyptus citriodora

    (EC), Eucalyptus tereticornis (ET), and

    Eucalyptus globulus

    (EG)) are used in Brazilian and Indian native medicine for the treatment of various medical conditions such as cold, flue, fever, and

    bronchial infections

    . α-pinene, myrcene, cineole, fenchone, α-terpinolene, and β-terpinyl acetate are well described in true eucalyptus oil, with cineole being the main constituent. Eucalyptus oil taken from the eucalyptus tree (true eucalyptus oil) does not contain camphor. However, the cineole fraction of camphor laurel that is also used to manufacture eucalyptus oil (which is considered “fake eucalyptus oil”) may contain camphor. Like eucalyptus oil, camphor is also epileptogenic.

  3. Eucalyptus oil is used as an over-the-counter medication in most countries, in addition to its myriad use in pharmaceutical, flavoring, pesticide, perfumery, and industrial uses. Its permissible limit is often unregulated, however. The use of camphor is similar. Most people, even physicians, are not aware of the toxic potential of these seemingly innocuous substances. Regulation regarding the permissible limits of these ingredients in substances that contain them should be strictly imposed. Also, the label of products that contain eucalyptus oil or camphor should have mandatory warnings of the potential toxic effects, including seizures.
  4. In 1898, the first case report of Eucalyptus oil induced seizure was reported from kerala. Most healthcare professionals are unaware of the epileptogenic potential of  eucalyptus oil. If a proper history is not obtained there is every possibility to label the seizures as Idiopathic seizures and patient may have to take long term antiepileptic drugs. These seizures don’t recur and AED can be safely withheld after two weeks.

Pathophysiology of Eucalyptus Oil-Induced Seizures:

Exposure to Eucalyptus Oil:

Eucalyptus oil is commonly used in aromatherapy, topical ointments, and as a remedy for various respiratory conditions.

Absorption and Distribution:

When eucalyptus oil is used, it can be absorbed through the skin, inhaled as vapor, or ingested in some cases.

Main Active Ingredient:

The main active ingredient in eucalyptus oil responsible for potential seizures is often cineole (also known as eucalyptol).

Neurological Impact:

Cineole can cross the blood-brain barrier and affect the central nervous system.

Neurotransmitter Disruption:

Cineole may disrupt the balance of neurotransmitters in the brain, particularly by affecting gamma-aminobutyric acid (GABA) and glutamate.

GABA Inhibition:

Cineole may reduce the inhibitory effects of GABA, an essential neurotransmitter that dampens neural activity and prevents excessive neuronal firing.

Increased Glutamate Activity:

With reduced GABA inhibition, there can be an increase in glutamate activity, which is an excitatory neurotransmitter.

Excitotoxicity:

The imbalance between GABA and glutamate can lead to a state of excitotoxicity, where excessive neuronal firing and hyperactivity occur.

Seizure Threshold Lowering:

Excitotoxicity and neuronal hyperactivity can lower the seizure threshold in susceptible individuals.

Seizure Onset:

In individuals with a lowered seizure threshold, the imbalance in neurotransmitters and hyperexcitability of neurons can trigger seizures.

Seizure Manifestation:

Seizures may manifest in various forms, including tonic-clonic seizures, absence seizures, or focal seizures, depending on the specific brain regions affected.

Individual Variability:

The susceptibility to eucalyptus oil-induced seizures can vary among individuals. Factors such as dosage, individual sensitivities, and pre-existing neurological conditions play a role.

tempo1

Conclusion

All physicians should be aware of the toxic effects of eucalyptus oil, which is used often in daily life in India. As there is no specific antidote, supportive care in ER, including rapid correction of metabolic acidosis and adequate maintenance of hemodynamic parameters, will lead to a rapid recovery.  Unlike ingestion , inhalation results in faster onset of CNS symptoms because inhaled volatile oils are known to reach the brain directly and stimulate the neurons. Hence warning labels should be made mandatory on all products that contain eucalyptus oil. The health hazard of eucalyptus oil must be made aware to public in order to prevent unnecessary complications.

Acknowledgement

For guiding me with the article, I would like to thank, Dr. Aslesha (Consultant & Clinical lead – Department of Emergency Medicine)

Reference

  1. Webb NJ, et al. Eucalyptus oil poisoning in childhood: 41 cases south-east Queensland. J Paediatr Child Health. 1993;29:368-71.
  2. Patel S, Wiggins J. Eucalyptus oil poisoning. Arch Dis Child. 1980;55:405-6.
  3. Flaman Z, et al. Unintentional exposure of young children to camphor and eucalyptus oils. Paediatr Child Health. 2001;6:80-3.
  4. Kumar KJ, et al. Eucalyptus oil poisoning. Toxicol Int. 2015;22(1):170-1.
  5. Dhakad AK, et al. Biological, medicinal and toxicological significance of eucalyptus leaf essential oil: a review. J Sci Food Agric. 2018;98(3):833-48.
  6. Darben T, et al. Topical eucalyptus oil poisoning. Australas J Dermatol. 1998;39(4):265-7.
  7. Manoguerra AS, et al. Camphor poisoning: an evidence-based practice guideline for out-of-hospital management. Clin Toxicol. 2006;44:357-70.
tempo2

DR.SILVERA SAMSON RAJ, EMERGENCY RESIDENT

Journals

Kauvery Hospital
Find Doctor
Book Appointment