Poinsettia Exposures Have Good Outcomes... Just As We Thought

Poinsettia Exposures Have Good Outcomes...
Just As We Thought
EDWARD P. KRENZELOK, PHARMD,* T.D. JACOBSEN, PHD,t
JOHN M. ARONIS, PHD:~
The poinsettia (Euphorbiapulcherrima)is a much-maligned plant which
is thought by the public and some health professionals to be extremely
toxic. Despite pronouncements by public health officials to the contrary,
the poinsettia continues to be recognized as a poisonous plant. To
determine if there was any validity to the toxicity claims, 849,575 plant
exposures reported to the American Association of Poison Control
Centers were electronically analyzed. Poinsettia exposures accounted
for 22,793 cases and formed the subset that was analyzed to critically
evaluate the morbidity and mortality associated with poinsettia exposures. There were no fatalities among all poinsettia exposures and 98.9%
were accidental in nature, with 93.3% involving children. The majority of
exposed patients (96.1%) were not treated in a health care facility and
92.4% did not develop any toxicity related to their exposure to the
poinsettia. Most patients do not require any type of therapy and can be
treated without referral to a health care facility. (Am J Emerg Med
1996;14:671-674. Copyright © 1996 by W.B. Saunders Company)
In the 1800s Joel R. Poinsett, the American Ambassador
to Mexico, introduced the poinsettia to the United States.
The plant gained immense popularity and became known as
the Christmas flower, Christmas Star, and of course, the
poinsettia, to acknowledge Ambassador Poinsett. However,
since 1920 the poinsettia (Euphorbia pulcherrima; Figure 1)
has been one mankind's most maligned and feared plants. In
that year, Rock 1 reported the unconfirmed fatality of a
2-year-old Hawaiian child who ingested a portion of a
poinsettia plant the previous year. However, that publication
was not the infamous one that catapulted the poinsettia into
the limelight as a sinister plant. That dubious distinction can
be traced to Arnold in his 1944 book entitled Poisonous
Plants of Hawaii. 2
The forward to the Arnold book provides an excellent
example of how misconceptions about the toxic nature of
plants are propagated and perpetuated. Arnold stated, "Even
a superficial study of the poisons found in various parts of
plants is sufficient to convince one that they are the most
dangerous known." Furthermore, Dr. Arnold indicated that
From the *Pittsburgh Poison Center, the Children's Hospital of
Pittsburgh, and the Schools of Pharmacy and Medicine, University of
Pittsburgh; the tHunt Institute for Botanical Documentation, Carnegie Mellon University; and the :~Keck Center for Computational
Biology, University of Pittsburgh.
Manuscript received November 26, 1995, returned December 29,
1995; revision received February 7, 1996, accepted February 26,
1996.
The data presented in this manuscript were provided to the authors
as a data grant from the American Association of Poison Control
Centers.
Reprints are not available.
Key Words: Poinsettia, Euphorbiapulcherrima, poisoning, toxicity,
plant poisoning.
Copyright © 1996 by W.B. Saunders Company
0735-6757/96/1407-001455.00/0
" . . . there are no poisons which even approach in strength
and in violence those found in plants . . . . "These statements
became a self-fulfilling prophecy that led to the authoritative
discussion of indigenous Hawaiian plants and their respective toxicities and formed the basis for the paranoia that has
surrounded the poinsettia.
In the section of the book that specifically discusses the
poinsettia, Arnold stated, "The two-year-old child of an
Army officer at Fort Schafter died from eating a poinsettia
leaf in 1919." He further stated, "It causes intense emesis
and catharsis, and delirium before death." In another section
of the book he said, " . . . Poinsettia, are highly poisonous
when ingested . . . . "Although Dr. Arnold later admitted that
the information regarding the poinsettia-related fatality had
never been confirmed and was merely hearsay, 3 his original
account became legendary and led to the dissemination of
information about the extremely toxic nature of the poinsettia plant.
The lay press sensationalized the poinsettia as a botanical
villain of astronomical proportions. Activist citizen groups
demanded that poinsettias carry a caution label to alert
consumers about their inherent toxicity. In 1980 a county
health officer in North Carolina prohibited poinsettias in
nursing homes because of their toxicity. Even such an
authority as Kingsbury, who authored Deadly Harvest, 4 has
given credence to the poinsettia's lethality: " . . . poinsettia
has been responsible for deaths among children" and
" . . . poinsettias . . . . do not bear warning labels, yet most
persons are unaware of their potentially lethal nature."
According to the Society of American Florists, even the
Food and Drug Administration supported the issue by stating
in a 1970 press release, "One poinsettia leaf can kill a
child." However, the morbidity and mortality issues have
been neither scientifically validated in humans nor adequately addressed.
To paraphrase Paracelsus: "Everything is poisonous. The
amount dictates the expression of that toxicity." The same
can be said of the poinsettia. Literature reports and laboratory research make it apparent that there is little toxicity
associated with casual exposure to the speciesY -7 However,
this has never been conclusively and irrefutably confirmed
in a large human cohort. The objective of this research
project was to confirm that the poinsettia is not associated
with either significant morbidity or any mortality.
METHODS
Through a data grant from the American Association of Poison
Control Centers (AAPCC), an electronic search was undertaken of
poison exposure cases reported to the AAPCC Toxic Exposure
Surveillance System (TESS) by participating poison information
centers for the years 1985 to 1992 to extract all cases that involved
671
672
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 7 • November 1996
Thousands of Exposures
10
8
6
'
,,"t
4
2
0
Jul Aug Sop Oct Nov Dec Jan Feb Mar Apt May Jun
Month
FIGURE 2.
22, 793).
FIGURE 1. The poinsettia (Euphorbia pulcherrima). (Watercolor of Poinsettia, Euphorbia pulcherrima by Anne Ophelia
Dowden fi'om Poisons in our path: Plants that harm and heal
(1994). On indefiniteloan to Hunt Institute for Botanical Documentation, Carnegie Mellon University, Pittsburgh, PA.)
exposures to a plant. Those data were provided to the investigators
on electromagnetic computer tape, stored in a relational database
system, and then electronically analyzed using a DEC 5000
workstation to extract and form a subset of all cases involving
exposure to Euphorbia pulcherrima for computer analysis. The
data were analyzed using the parameters inherent to the AAPCC
TESS database. Specifically, the data were searched for frequency
of exposure by age group, sex, reason for exposure, route of
exposure, outcome, the pattern of referral to health care facilities,
and treatment. Specific symptomatology was not reported to
AAPCC TESS during the study period and is not included in the
analysis. The morphologic portion of the plant and the amount
ingested or involved in the exposure were not part of AAPCC TESS
and, therefore, are not included in the analysis. The data were
analyzed by using descriptive statistics.
The outcomes were defined by AAPCC TESS as no effect, minor
effect, moderate effect, major effect, fatality, not followed nontoxic
exposure, not followed potentially toxic exposure, unrelated effect,
and unknown. Those abbreviated and paraphrased outcome definitions are as follows: no effect, the patient developed no symptoms
as a result of the exposure; minor effect, the patient exhibited some
symptoms as a result of the exposure, but the symptoms were
minimally bothersome to the patient; moderate effect, the patient
exhibited symptoms as a result of the exposure that were more
pronounced, more prolonged, or more of a systemic nature than
minor symptoms and were not life-threatening; major effect, the
patient exhibited some symptoms as a result of the exposure and
the symptoms were life-threatening or resulted in a significant
residual disability or disfigurement; fatality, death resulted as a
consequence of the exposure; not followed nontoxic exposure, the
patient was not followed because the exposure was assessed as
nontoxic; not followed potentially toxic, the patient was not
followed, but the exposure was assessed as potentially toxic;
unrelated effect, the patient became symptomatic, but the effect
was probably unrelated to the exposure; unknown, the outcome of
the patient was unknown.
Incidence of poinsettia exposures by month (n =
RESULTS
The analysis of AAPCC TESS for the 8-year period
yielded 849,575 plant exposures. Poinsettia exposures accounted for 22,793 cases. Males were involved in 49.1% of
cases, compared to 49.3% in females, with 1.6% being
unknown. Children accounted for 93.3% of the exposures,
with 77.3% occurring in children younger than 2 years of
age, 13.3% in children 2 to 5 years of age, 2.1% in children 6
to 12 years old, 0.6% in adolescents 13 to 17 years old, 5.5%
of exposures were experienced by adults, and the age was
u n k n o w n in 1.2% of the reports. Exposures reported during
the months of December, January, and February were
responsible for 74.9% of all cases (Figure 2).
The majority (98.9%) of the exposures were accidental
and only 0.9% had an intentional etiology. The reason for the
exposure was unknown in 0.2% of cases. Ingestion (94.5%)
was the primary route of exposure, followed by 4.8% of the
cases being dermal exposures (Table 1).
There were no poinsettia-related fatalities in the 22,793
cases. The outcome in 92.4% of the exposures was no effect
TABLE1. Route of Exposure Versus Patient Outcome
Patient
Outcome
Ingestion
(n = 22,314)
Dermal
Exposure
(n = 1,129)
All
Exposures
(n = 22,793)
No Effect
8,445 (37.8%) 423 (37.5%) 8,543 (37.2%)
Minor Effect
661 (3.0%)
109 (9.7%)
773 (3.4%)
Moderate Effect
12 (0.05%)
6 (0.5%)
19 (0.08%)
Major Effect
1 (0.004%)
0
1 (0.004%)
Fatal
0
0
0
Not Followed
Nontoxic
12,280 (55,0%) 507 (44.9%) 12,467 (54.3%)
Not Followed
36 (3.2%)
415 (1.8%)
Potentially Toxic
391 (1.8%)
44 (3.9%)
501 (2.2%)
Unrelated
458 (2.1%)
Unknown
66 (0.3%)
4 (0.4%)
74 (0.3%)
NOTE:Totals exceed 22,793 exposures because of multiple exposure
routes.
KRENZELOK ET AL • POINSETTIA EXPOSURES
673
or unknown nontoxic effect; minor effects were observed in
3.4% of the exposures (Table 1).
Most patients (96.1%) were not treated in a health care
facility. A small number (1.6%) of poinsettia-exposed individuals did not contact a poison center and self-referred or
were referred by another health care professional to a health
care facility for treatment. Poison centers were responsible
for 0.7% of the treatment referrals. The site of treatment was
unknown in 1.6% of patients. The ultimate disposition of
patients who had not been referred by a poison center and
were managed in a health care facility was that 74.1% were
treated and released, 9.3% were admitted for medical care,
3.8% were admitted for psychiatric care, and 12.8% were
lost to follow-up. Comparatively, among patients who were
referred for treatment by a poison center, 36.8% were treated
and released, 2.7% were admitted for medical care, 13.6%
refused referral, and 46.9% were lost to follow-up.
No therapy was used in the management of poinsettia
exposure patients in 34.6% of cases, and 62.7% received
some type of decontamination (miscellaneous therapies
were implemented in 2.7% of patients). Within the decontamination subset of patients, dilution was the most prevalent
form of intervention (89.6%), followed by irrigation of
external surfaces (6.3%) and emesis induced by syrup of
ipecac (2.2%). Other therapies accounted for the remaining
1.9% of decontamination procedures. For example, activated charcoal was used in the decontamination of only 29
patients. Gastric lavage was used 7 times in the 22,743
poinsettia exposures.
The effect of therapy versus no type of therapy in patients
who were initially asymptomatic was also tabulated; these
data are reflected in Table 2.
DISCUSSION
It is apparent from these data that poinsettia exposures
have good outcomes, just as we thought. This conclusion
was based on the analysis of 22,793 exposures to Euphorbia
pulcherrima, otherwise known as the poinsettia plant. These
data represent the largest compilation of human exposures to
TABLE 2. Influence of Decontamination on Patient Outcome in
Asymptomatic Patients
Patient
Outcome
No Therapy
(n = 7,124)
No Effect (A)
2,318 (32.5%)
Minor Effect
47 (0.7%)
Moderate Effect
1 (0.01%)
Major Effect
1 (0.01%)
Fatal
0
Not Followed
Nontoxic (B) 4,615 (64.8%)
Not Followed
Potentially
Toxic
112 (1.6%)
Unrelated
20 (0.3%)
Unknown
10 (0.1%)
A + B
97.3%
General
Ipecac-Induced
Decontamination
Emesis
(n - 13,601)
(n = 303)
5,883 (43.3%)
176 (1.3%)
7 (0.05%)
0
0
209 (69.0%)
8 (2.6%)
0
0
0
7,261 (53.4%)
77 (25.4%)
223 (1.6%)
20 (0.1%)
30 (0.2%)
96.7%
7 (2.3%)
1 (0.3%)
1 (0.3%)
94.4%
NOTE: Analysis of patients who were initially asymptomatic n =
21,203.
the poinsettia, as reported to poison information centers. It is
hoped that the large sample size, the low incidence of mild
toxicity, and the lack of any documented fatalities will
resolve the controversy about the morbidity and mortality
associated with the poinsettia.
In contrast to the normal age distribution of poisoning
exposure reports, in which approximately 56% of the
exposures occur in children younger than 5 years of age,
90.6% of the poinsettia exposures involved that age group. 8
Most likely, this is due to the attractiveness of the poinsettia's foliage to a curious child and to the location of the
plants, which are frequently within the reach of a child. Not
surprisingly, nearly 75% of the exposures occurred during
the 3-month period (December through February) that
coincides with the Christmas holidays, when the poinsettia
is used to decorate homes and businesses.
Since the majority of the poisoning exposure reports
involved children, it is not surprising that 98.9% of poinsettia exposures were accidental. The poinsettia has no chemical abuse potential and, despite its notoriety as a poisonous
plant, it is not used as a homicidal or suicidal agent with any
frequency. However, the poinsettia was used by 16 individuals for abuse purposes and by 27 people as a suicidal agent.
Excessive hand-to-mouth activity by young children is
probably responsible for the majority of pediatric exposures.
Accordingly, ingestions (94.5%) accounted for the majority
of poinsettia exposures, followed by a small percentage
(4.8%) of dermal exposures. Those who experienced a
dermal exposure had a greater incidence of minor and
moderate toxicity. In the dermal exposure category 82.4% of
the patients had an outcome of "no effect" or "not followed,
nontoxic," compared with 92.8% in the ingestion group.
This does validate as a standard outcome the occasional
reports that describe oral or dermal toxicity9,1°; however, it
represents a rather insignificant issue because only 6 of the
1,129 dermal exposure patients experienced a moderate
outcome. Following dermal exposure to the latex from a
poinsettia, skin irrigation and cleansing should prevent or
diminish the risk of minor irritation.
AAPCC TESS reports a known patient outcome only
when a follow-up call has been placed to determine the
patient's final disposition. If it is the opinion of the Specialist
in Poison Information that the exposure is insignificant from
either a quantity or toxin perspective, the case may be
documented as "not followed, nontoxic." When the data
from this category are combined with the documented "no
effect" data, 92.4% of the patients suffered no adverse effect
from the poinsettia exposures. There were no fatalities and
only one case was classified as resulting in a major effect.
Based on a review of the computerized record of the patient
with the only reported major effect, it is apparent that the
case was incorrectly coded. A 13-month-old girl ingested
some portion of the poinsettia plant, was initially symptomatic, received no therapy, and was not known to be admitted
to the hospital. This is totally inconsistent with the reported
outcome since, by definition, cases resulting in a major
effect must have a life-threatening problem, a severe disfigurement, or a disability that results in hospitalization.
The number of self-referrals, meaning that a poison
information center was not consulted prior to this decision,
was low (1.6%) compared with the normal pattern of
674
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 14, Number 7 • November 1996
self-referral (12.2%). 8 While this represents superior utilization of the poison center, it is expected because the majority
of poinsettia exposures involve children where poison center
utilization is high. Referral by poison centers was very low
compared with normal referral patterns (0.7% v 12.2%). 8
Poison information centers are knowledgeable about the
lack of toxicity from a poinsettia exposure and refer only
symptomatic patients when medical evaluation is necessary.
As expected, there was no correlation between patient
outcome and therapeutic intervention in asymptomatic patients. While the data in Table 2 gives the appearance that the
induction of emesis provides an improved outcome, this is
misleading. Combining the "no effect" and "not followed,
nontoxic" categories as an indicator of a nontoxic outcome
demonstrates that the "no therapy" group had a nontoxic
incidence of 97.3%. This is compared to 96.7% in the
category which combined all types of decontamination and
94.4% in the ipecac-induced emesis group. The induction of
emesis, the use of dilution, and even skin decontamination
appear to be of little or no value.
The limitations of the study are somewhat overshadowed
by the large sample size. However, these data are from
poison information centers and there is only verbal, not
visual or professional, identification of the plants. The
poinsettia has very characteristic features and is well known
by the general public. Therefore, the number of inaccurate
identifications was probably minimal. A further limitation
was that the data allow neither quantification of the amount
of plant material nor identification of which morphologic
portion of the plant was responsible for the exposure.
Nevertheless, the influence of this limitation is probably
minimal because animal research, which supports our human low toxicity data, utilized poinsettia leaves, bracts, and
flowers, as well as homogenates of the plant in oral doses of
up to 50 g/kg. 3,5,6
CONCLUSIONS
The analysis of 22,793 poinsettia exposure cases has
confirmed that the poinsettia is associated with neither
significant morbidity nor any mortality despite the fact that
there is a high exposure incidence among children. The
majority of patients can be treated without referral to a
health care facility. Gastrointestinal decontamination using
dilution or emesis induced by syrup of ipepac has no impact
on patient outcome and is not recommended. Dermal
exposures to the poinsettia produce a slightly higher incidence of minor irritation than is observed among those who
ingest the poinsettia. Although skin irritation is uncommon
and minor when it does occur, dermal decontamination is
easy to accomplish and may prevent the irritation.
REFERENCES
1. Rock JF: The poisonous plants of Hawaii. Hawaiian Forest
Agric 1920;17:61
2. Arnold HL: Poisonous Plants of Hawaii. Honolulu, HI, Tong
Publishing Company, 1944
3. Stone RP, Collins W J: Euphorbiapulcherrima: Toxicity to rats.
Toxicon 1971;9:301-302
4. Kingsbury JM: Deadly Harvest: A Guide to Common Poisonous
Plants. New York, NY, Holt, Rinehart and Winston, 1969
5. Winek CL, Butala J, Shanor SP, et al: Toxicology of poinsettia.
Clin Toxicol 1978; 13:27-45
6. Runyon R: Toxicity of fresh poinsettia (Euphorbiapulcherrima)
to Sprague-Dawley rats. Clin Toxicol 1980;16:167-173
7. Klug S, Saleem G, Honcharuk L, et al: Toxicity potential of
poinsettia. Is the plant really toxic? Vet Hum Toxicol 1990;32:368
8. Litovitz TL, Clark LR, Soloway RA: 1993 Annual report of the
American Association of Poison Control Centers Toxic Surveillance
System. Am J Emerg Med 1994;12:546-584
9. Edwards N: Local toxicity from a poinsettia plant: A case report.
J Pediatr 1983; 102:404-405
10. D'Arcy W: Severe contact dermatitis from poinsettia. Arch
Dermatol 1974; 109:909-910