Anticholinergic Syndrome and Supraventricular Tachycardia Caused by Lavender Tea Toxicity

Abstract

Lavender plants have been used for their cosmetic and biologic benefits for many centries. Extracts from Lavandula plants have been found to cause antimuscarinic effects by blocking sodium and calcium ion channels in in vitro and in vivo studies. We present a case of poisoning by ingestion of tea made from Lavender stoechas (grass). The patient was admitted to our emergency department with supraventricu-lar tachycardia due to anticholinergic syndrome triggered by drinking lavender tea. On electrocardi-ography, a narrow QRS complex tachycardia was evident. After carotid sinus massage, the patient im-mediately returned to sinus rhythm. There are no reported data about the toxicity of Lavender stoechas plants with respect to supraventricular tachycardia, anticholinergic syndrome or sympathetic nerve activity. (Keio J Med 61 (2) : 66–68, June 2012)

Full text

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CASE REPORT
Anticholinergic Syndrome and Supraventricular Tachycardia
Caused by Lavender Tea Toxicity
Ayca Acikalin,1 Muge Gulen,1 Banu Kara,2 Ferhat Icme,3, 4 Caglar Emre Cagliyan1 and Salim Satar1
1Adana Numune Education and Research Hospital, Department of Emergency Medicine, Adana, Turkey
2Adana Numune Education and Research Hospital, Department of Gastroenterology, Adana, Turkey
3Ankara Ataturk Education and Research Hospital, Department of Emergency Medicine, Ankara, Turkey
4Caglar Emre Cagliyan, Adana Numune Education and Research Hospital, Department of Cardiology,
Adana, Turkey
(Received for publication on July 11, 2011)
(Revised for publication on November 4, 2011)
(Accepted for publication on December 15, 2011)
Lavender plants have been used for their cosmetic and biologic benets for many centries. Extracts from
Lavandula plants have been found to cause antimuscarinic effects by blocking sodium and calcium ion
channels in in vitro and in vivo studies. We present a case of poisoning by ingestion of tea made from
Lavender stoechas ( grass). The patient was admitted to our emergency department with supraventricu-
lar tachycardia due to anticholinergic syndrome triggered by drinking lavender tea. On electrocardi-
ography, a narrow QRS complex tachycardia was evident. After carotid sinus massage, the patient im-
mediately returned to sinus rhythm. There are no reported data about the toxicity of Lavender stoechas
plants with respect to supraventricular tachycardia, anticholinergic syndrome or sympathetic nerve
activity. (Keio J Med 61 (2) : 66–68, June 2012)
Keywords: emergency, lavender, supraventricular tachycardia, poisoning
Introduction
Lavender plants have been in widespread use in our dai-
ly lives since the 18th century because of their cosmetic
and biologic effects. Teas and distilled oils prepared from
plants of Lavandula spp. have been used as antibacterial,
antifungal, sedative, expectorant and analgesic agents;
smooth muscle relaxants; antiseptic for urinary tract in-
fections; and for soothing burns and insect bites. Despite
the wide-ranging use of these teas and oils, their biologi-
cal effects and side effects are not known in detail.1
Because alternative medical treatments and use of me-
dicinal plants are increasing worldwide, allergic reactions
that can lead to serious poisoning are observed frequent-
ly. In this article, we present a poisoning case resulting
from the ingestion of tea made from Lavender stoechas
(Buckwheat grass), which was drunk by a woman for its
antitussive and expectorant effects in an attempt to treat
her cough. She was admitted to our emergency depart-
ment with supraventricular tachycardia triggered by an-
ticholinergic syndrome or sympathetic nerve activity,
which are frequent side effects of products made from
these plants.
Case
A 46-year-old woman was admitted to our emergency
department with palpitations and shortness of breath
that had been present for 6 h. She reported that she had
drunk buckwheat herb (Lavender stoechas) tea (Fig. 1) 7
h before admission for the treatment of her cough, which
had persisted for 1 week. Her symptoms were palpita-
tions, shortness of breath, headache, dizziness, nausea,
and epigastric pain and fever; these had started approxi-
mately 1 h after herbal tea ingestion. On admission to the
emergency room, the patient’s arterial blood pressure was
Reprint requests to: Sali m Satar, MD, Adana Numune Education and Research Hospital, Department of Emergency Medicine, Adana 01170,
Turkey, E-mail: salim.satar@yahoo.com
Copyright © 2012 by The Keio Journal of Medicine

67Keio J Med 2012; 61 (2): 66– 68
150/100 mmHg, pulse rate 164/min, temperature 38.7°C
and respiratory rate 22/min. Her Glasgow Coma Scale
(GCS) score was 15 and other systemic ndings were
normal. The patient’s complete blood count, biochemis-
try and blood gas levels were found to be in the normal
ranges. A narrow QRS complex tachycardia was found
on electrocardiography (Fig. 2). The patient was moni-
tored, 4 L/min oxygen was started via nasal cannula and
intravenous access was established. Because her fever
did not respond to cold compress application, intravenous
paracetamol was given, and this led to normalization of
body temperature at 36.7°C. Since her tachycardia per-
sisted despite normalization of body temperature, carotid
sinus massage was performed; this resulted in abrupt ter-
mination of the supraventricular tachycardia and mainte-
nance of sinus rhythm. The control electrocardiography
taken after the termination of supraventricular tachycar-
dia revealed normal sinus rhythm, and no other patho-
logical signs were observed (Fig. 3). Control vital signs
were as follows: arterial blood pressure, 130/70 mmHg;
pulse rate, 84/min; temperature, 36.7°C; respiratory rate,
16/min. The patient was hospitalized in the observation
unit, and after 24 h of observation, no additional prob-
lems occurred and the patient was discharged with advice
to use these kinds of herbal products cautiously.
Discussion
Lavender tea and oil obtained from lavender plants
have been in general use for many centuries. Lavandula
spp. are widely used because of their biological and cos-
metic properties. The most commonly used Lavandula
spp. are L. angustifolia, L. latifolia, L. stoechas and L. x
intermedia.1 The tea and oil of these plants are often used
as smooth muscle relaxants, antibacterial and antifungal
agents, and expectorants; they are also used to treat insect
bites owing to their relaxant effects.
Although Lavandula spp. are widely used, scientic
studies on the effects of these plants and their ingredients
have only been carried out in recent decades. The chemi-
cal constituents of Lavandula plants have been identied
by analysis of oils obtained from owers. Essential oils
of Lavandula spp. have complex compositions made up
of many different aromatic compounds. These substances
have been examined and determined by analytic tech-
niques such as gas chromatography, mass spectrometry
and infrared spectroscopy. The main components of these
oils are linalool, linalyl acetate, 1.8 cineole, β-ocimene,
terpinene-4-ol and camphor.2
The systemic effects of the chemical constituents of La-
vandula spp. may begin after contact of the skin with oils,
inhalation due to their volatile properties or the drink-
ing of tea. Plasma levels of linalool and linalyl acetate
increase about 19 min after the oils from these plants
contact the skin.3 Linalool and linalyl acetate have nar-
cotic and sedating effects on the central nervous system.
It is believed that these substances affect especially the
amygdala and hippocampus regions of the limbic system
by increasing the effects of gamma hydroxyl butyric acid
and resulting in benzodiazepine-like sedative effects.4
Antispasmodic effects of Lavandula spp. have occurred
because of the resulting increase in intracellular cAMP.5
Lavandula spp. are also believed to have antibacterial
and antifungal effects. In in vitro studies, L. Angustifolia
oil was shown to be reactive against methicillin-resistant
Staphylococcus aureus (MRSA) and vancomycin-resis-
tant Enterococcus faecalis (VRE) at concentrations of
less than 1%.6
Lavandula spp. contain many camphor-related sub-
stances. Those species with high camphor content are
preferred as insect repellents, whereas those with low
camphor content are preferred by the perfume industry.
L. stoechas has a high camphor content.1,7
L. stoechas, also known as buckwheat herb, is widely
used in the community as an analgesic, expectorant, sed-
ative and urinary antiseptic. The oils obtained from this
plant are preferred for topical application as antiseptic
solutions and insect repellents. The compounds found in
L. stoechas include saponins, glycosides, camphor, cin-
eol and borbor.8 Camphor levels are higher in L. stoechas
than in other Lavandula spp. Most of the dermal or sys-
temic effects are thought to result from the high levels
of camphor. Camphor is a cyclic ketone of the hydroaro-
matic terpene group with a strong and aromatic scent.
Camphor is used as an antibacterial, local analgesic, ino-
tropic agent, brain and nerve stimulant against syncope,
expectorant, antitussive, cold drug and moth repellent.8
It is used today in the pharmaceutical industry as a
topical antitussive and analgesic and is a preferred an-
esthetic and antipruritic agent. If it is used in improper
doses, however, it can cause poisoning. Poisoning related
to Lavandula spp. may occur with gastrointestinal intake,
skin contact or inhalation,8 and camphor toxicity begins
Fig. 1 Buckwheat herb (Lavender stoechas).
Our patient drank tea made from these plants.

Acikalin A, et al: Lavender and Supraventricular Tachycardia68
within the rst hours after intake. The rst signs are oral
and epigastric burning, nausea, vomiting and headache.
Other adverse effects are tachycardia, elevated liver en-
zymes, and central nervous system and cardiovascular
system toxicity.9,10 The toxic effect on the central nervous
system can result in mental confusion and convulsion.
Severe poisoning can cause status epilepticus, apnea,
asystole, circulatory collapse and death.10 Serious central
nervous system toxicity related to accidental camphor ex-
posure, especially in children, has been reported in the
literature. Camphor exhibits cardiovascular toxicity and
it is known to cause hypertension and tachycardia during
the early stage of toxicity and to cause peripheral vas-
cular collapse and shock in serious cases. QT and pro-
longed QTc in electrocardiograms and acute myocarditis
due to camphor toxicity have been reported in one case in
the literature.10 Since our center was not able to measure
camphor levels, we could not determine the plasma level
in our patient.
We think that the tachycardia, hypertension and signs
of high temperature seen in our patient may have resulted
from the camphor in L. stoechas plants or may have been
consequences of either sympathomimetic or anticholiner-
gic toxicity as well. Ghelerdani et al. showed that plants
of Lavandula spp. may cause antimuscarinic effects by
blocking sodium and calcium ion channels in in vitro
and in vivo studies.9 The fever, tachycardia and signs
of hypertension occurring in our patient may have been
related to antimuscarinic effects caused by inhibition of
central and peripheral muscarinic cholinergic nerve con-
duction. There are no data in the literature demonstrating
sustained arrhythmias (e.g., supraventricular tachycardia
and ventricular tachycardia) and anticholinergic symp-
toms triggered by L. stoechas. The patient did not drink
the herbal tea again after her recovery, so we could not
observe a direct relationship between herbal tea inges-
tion and arrhythmia generation. This fact diminishes the
proof of our hypothesis and is the main limitation of this
article.
In conclusion, we reported on a patient who experi-
enced hyperthermia, hypertension and supraventricular
tachycardia after drinking a very popular kind of herbal
tea that contains L. stoechas (Buckwheat herb). The ex-
tracts of L. stoechas may show adverse antimuscarinic
effects, and therefore appropriate advice should be given
to patients who have arrhythmic conditions.
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Fig. 2 A narrow QRS tachycardia was seen on electrocardiogra-
ph y.
Fig. 3 Normal sinus rhythm was seen after termination of supra-
ventricular tachycardia.