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Clinical uses and toxicity of Atropa belladonna; an evidence based comprehensive retrospective review (2003-2017)

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Atropa belladonna (AB), commonly known as deadly nightshade is a poisonous plant which contains several alkaloids such as atropine and scopolamine etc. Any deliberate as well as unintentional ingestion of AB fruits, roots or leaves may result toxicity. Aim of the study: This study aims to present the clinical uses of atropine alongwith the adverse effects and toxicity associated with the use of atropine in the form of conventional or as herbal medication. A retrospective (2003-2017) literature was searched in various databases such as web of science, PubMed, google scholar, Scopus, E-Resource Portal of Imam Abdulrahman bin Faisal University etc. using the keywords i.e. AB, clinical uses of AB, adverse effects and cases reported with AB. Ten (10) cases met the eligibility criteria where the toxicity was mostly associated with the use of AB fruit, tablets and AB contaminated drinks. Major symptoms observed in these cases were related to Anticholinergic syndrome (ACS); tachycardia, dilated pupils, confusion, flushed dry skin, hallucinations and seizures in some cases along with a toxic megacolon. Furthermore, the treatment protocol used widely for ACS consisted of; gastric lavage and the use of Physostigmine as an antidote (antagonizes the central as well as peripheral toxicity of atropine). AB fruit revealed a vital role as anticholinergic drug, mydriatic agent and as an antidote for OP poisoning, however, its use deprived of medical supervision or in a large quantity, it may cause severe toxicity.
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Medical
Communication
Biosci. Biotech. Res. Comm. 11(1): 41-48 (2018)
Clinical uses and toxicity of
Atropa belladonna
; an
evidence based comprehensive retrospective review
(2003-2017)
Hanine Almubayedh1, Reem Albannay1, Kawthar Alelq1, Rizwan Ahmad2*, Niyaz Ahmad3
and Atta Abbas Naqvi4
1College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
2Natural Products and Alternative Medicines, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal
University, Dammam, Saudi Arabia
3Department of Pharmaceutics, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University,
Saudi Arabia
4Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University,
Saudi Arabia
ABSTRACT
Atropa belladonna (AB), commonly known as deadly nightshade is a poisonous plant which contains several alkaloids such as
atropine and scopolamine etc. Any deliberate as well as unintentional ingestion of AB fruits, roots or leaves may result toxicity.
Aim of the study: This study aims to present the clinical uses of atropine alongwith the adverse effects and toxicity associated
with the use of atropine in the form of conventional or as herbal medication. A retrospective (2003-2017) literature was searched
in various databases such as web of science, PubMed, google scholar, Scopus, E-Resource Portal of Imam Abdulrahman bin Faisal
University etc. using the keywords i.e. AB, clinical uses of AB, adverse effects and cases reported with AB. Ten (10) cases met the
eligibility criteria where the toxicity was mostly associated with the use of AB fruit, tablets and AB contaminated drinks. Major
symptoms observed in these cases were related to Anticholinergic syndrome (ACS); tachycardia, dilated pupils, confusion, ushed
dry skin, hallucinations and seizures in some cases alongwith a toxic megacolon. Furthermore, the treatment protocol used widely
for ACS consisted of; gastric lavage and the use of Physostigmine as an antidote (antagonizes the central as well as peripheral
toxicity of atropine). AB fruit revealed a vital role as anticholinergic drug, mydriatic agent and as an antidote for OP poisoning,
however, its use deprived of medical supervision or in a large quantity, it may cause severe toxicity.
KEY WORDS:
ATROPA BELLADONNA
, CLINICAL USES, TOXICITY, ANTICHOLINERGIC, CASES REPORTED
41
ARTICLE INFORMATION:
*Corresponding Author: rizvistar_36@yahoo.com
Received 12th Feb, 2018
Accepted after revision 25th March, 2018
BBRC Print ISSN: 0974-6455
Online ISSN: 2321-4007 CODEN: USA BBRCBA
Thomson Reuters ISI ESC / Clarivate Analytics USA and
Crossref Indexed Journal
NAAS Journal Score 2017: 4.38 SJIF 2017: 4.196
© A Society of Science and Nature Publication, Bhopal India
2018. All rights reserved.
Online Contents Available at: http//www.bbrc.in/
DOI: 10.21786/bbrc/11.1/6
42 A COMPREHENSIVE REVIEW ON
ATROPA
BELLADONNA
BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS
Hanine Almubayedh et al.
INTRODUCTION
Solanaceae, an alkaloidal containing plants family, is
well known for its applications in cosmetics, traditional
medicines and as a poison since ancient times. Atropa
belladonna, synonym; deadly nightshade, belongs to
the family solanaceae and is known for its effects on
“increase pupil size” which imparted it the name of
“beautiful lady” (Atropa; Greek word means “goddess”
& Belladonna; Italian words means “beautiful lady”). It
is a tall plant that can reach up to ve feet and it’s
abundantly found in waste ground and quarries. AB
has oval shaped leaves, greenish to purple color owers
and black, globular shape, sweet berries. Though leaves
and roots are poisonous and ingestion of a single leaf
can cause severe ACS which may be fatal, however the
berries have been reported with more poisonous cases
in children due to its attractive look and sweet taste.
The major components in the leaves, fruits and roots
are mostly alkaloids such as Hyoscyamine, scopolamine
and more abundantly; atropine, which is responsible for
the plant’s Anti-cholinergic toxic effects, (Berdai et al.,
2017; Ahmad et al., 2017a).
Atropa belladonna plant is surrounded by fear, awe,
and myth. The Romans and Greeks believed the fact of
AB containing a deadly poison due to more wide use
by professional poisoners, sorcerors, and witches. Later
on, Linnaeus codi ed its remarkable properties such
as dilating the pupils and it was 1830s, when I-atro-
pine, the pure alkaloid, was extracted from AB plant.
It was pure I-atropine that helped as a substantial tool
in understanding the physiology of autonomic nervous
system and lead to identi cation of the important neu-
rotransmitters in mammalian biological system which is
acetylcholine, (Lee, 2007; Ahmad et al,. 2017b).
Deadly nightshade exerts clinical as well as toxic
effects through an anticholinergic mechanism in human
body, which can affect the central and the peripheral
nervous system. It is responsible for many symptoms
such as tachycardia, dry skin, hallucination, mydriasis
and choreoathetoid movements. On the other side it
may be clinically useful when used to do anamneses in
clinical examination as well as detailed imaging in cases
which are confused with acute cerebrovascular events.
Atropa belladonna poisoning should be considered when
diagnosing geriatric patients experiencing hallucination,
meaningless hand gestures and consciousness. (Saritas
et al., 2014; Ahmad et al., 2017c)
Atropa belladonna poisoning has been reported in
different age groups however the most dangerous part
of AB to children is its berries especially younger than
six years’ children, as they have a sweet taste and look
attractive to them. (Milanlioglu, 2011).Toxicity may
develop as a result of the ingestion of two to three bays
of AB in a child and ten bays in an adult. The most com-
mon cause of AB intoxication in children is confusion
with some other berries such as blueberries and black-
currant.(Berdai et al., 2012).
Atropa belladonna toxicity can be classi ed as
mild, moderate and severe intoxication. Various treat-
ment plan, depending the severity and condition of the
patients, are used for treatment of Atropa belladonna
intoxication including gastric lavage and Neostigmine
and Physostigmine, as an antidote. (Caksen et al., 2003;
Ahmad et al., 2017c)
Numerous literature is available regarding the clini-
cal uses, adverse effects and toxicity cases of AB; how-
ever none of the studies have reported a complete and
updated review about the comparative effects of AB in
treating various conditions and the adverse effects of
toxicity thus reported. Current study highlight evidence-
based clinical uses alongwith toxicity observed with AB
use and the most common reason of toxicity i.e. due to
intentional or unintentional use of atropine tablets, bar-
riers, leaves or plant as a whole.
MATERIAL AND METHODS
DATABASES SEARCHED
The relevant literature was searched using different data-
bases such as Central library Imam Abdulrahman bin
Faisal University, PubMed, Google Scalar, Science Direct
and Google scholar, Web of science. In addition, Jour-
nals (The American journal of therapeutics, Bali medical
journal, Human and experimental toxicology, and jour-
nal of the Royal college of physicians of Edinburgh) and
books (Lippincott’s pharmacology and Katzung’s basic,
clinical pharmacology and Neuropathy of Drug Addic-
tions and Substance Misuse) were also utilized as tools
for gathering related information.
Keywords Searched
Atropa belladonna, cases reported of Atropa belladonna
toxicity, Atropine intoxication, Atropa belladonna
intoxication, Deadly nightshade intoxication, Anticho-
linergic toxic syndrome cases and cases of Atropa bel-
ladonna poisoning.
Review Period
This article used a retrospective fourteen (14) years
review from year 2003 to 2017.
Inclusion Criteria
Clinical cases included in the review are only related to/
reported in human subjects only. Any adverse effect or
toxicity resulted due to use of atropine in conventional
BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS A COMPREHENSIVE REVIEW ON
ATROPA
BELLADONNA
43
Hanine Almubayedh et al.
system or herbal system as well as any use related to
intentional or unintentional ingestion was included in
the study. Furthermore, the toxicity or overdose associ-
ated with the use of any part of AB i.e. leaves, fruit and
berries as well as contamination/adulteration of herbs
with atropine, were also included.
Exclusion Criteria
Any clinical cases reported in animal subjects and in
vitro studies were excluded from the study. Similarly,
any case reporting traditional or general uses of AB
rather than evidence-based i.e. any clinical case reported
to hospital emergencies or clinics were also excluded
from the study.
Search Results
The literature search was re ned and a total of eleven
(11) articles matched the inclusion criteria and they are
reported in the literature review section as below.
LITERATURE REVIEW
All the relevant cases were collected, studied, analyzed
and reported after a broad literature review. The cases
are presented below with respect to the year of publica-
tion.
CLINICAL CASES REPORTED IN 2017
AB causing ACS due to adulteration with marshmallow
roots
Oerlemans et al., reported a case for a patient visiting ER
with ACS. The history revealed ingestion of hot choco-
late drink with marshmallow root (Althaea of cinalis)
for treating cold symptoms. However the lab reports
showed ingestion of 20-200 mg of atropine as the herb
was contaminated with Ab. The patient after transferring
to ICU was discharged in a healthy state. (Oerlemans et
al., 2017)
ACS due to use of AB berries
Ibrahim karagoz et al, in a study reported a patient case
from ER with anticholinergic toxic syndrome (ATS)
symptoms (tachycardia, dilated pupils and hot red-
dish extremities and trunk). Upon investigation it was
revealed that the patient used 5 to 6 blackberry like ber-
ries i.e. AB fruit. Symptoms resolved after application of
urine catheter and inhibition of oral intake except for
tachycardia. Redness also diminished leaving rashes on
his arms. Sinus tachycardia disappeared during follow-
up after oral intake resumed. Patient was discharged
healthy from the hospital after the follow-up period.
(Karagoz et al., 2017)
Toxic Megacolon devolved secondary to OP poisoning
treatment
An old man was admitted to ER with loss of con-
sciousness. The patient consumed pesticides containing
organophosphate. The treatment plan consisted of atro-
pine and pralidoxime intravenously however the patient
developed a megacolon following 4 days of atropine
administration. Atropine and pralidoxime tapering was
done and patient was put on a maintenance therapy. The
serum cholinesterase reached 3209 microkat/1, after 33
days. (Mostafazadeh et al., 2017).
CLINICAL CASE REPORTED IN 2016
AB in homeopathic remedies and ACS
A 20-days old infant was presented in ER with signs
of seizures and fever, after swallowing a homeopathic
agent containing AB for an infantile colic treatment.
Detailed clinical examination revealed and was treated
with Benzodiazepines. In addition i/v antibiotics were
administered due to septicemia. Several hours fol-
lowing the monitoring, no signs of fever were found
and the infant recovered from neurological abnor-
malities was thus discharged healthy. (Glatstein et al.,
2016).
CLINICAL CASE REPORTED IN 2014
Jimsonweed as a source of suicide
Glatstein et al, (2016) reported a study of ten adoles-
cent cases with serious ACS and two with a history
of suicidal attempt. Detailed investigation revealed
the use of Jimson weed (atropine containing plant)
in half of the patients whereas remaining half of the
patients used different atropine tablets. Treatment plan
included Physostigmine, activated charcoal, benzodi-
azepines and haloperidol and all the patients were dis-
charged healthy. (Glatstein et al., 2014; Ahmad et al.,
2017a).
CLINICAL CASE REPORTED IN 2013
Wild fruit of AB vs consciousness
Abdullah Demirhan et al., reported an emergency case
for a patient presented with symptoms; loss of con-
sciousness and fatigue, red neck and face, dry mouth
and dilated pupils. The care taker for patient revealed
the use of large amount of a forest fruit AB and the
start of symptoms after four hours of ingestion. Gastric
lavage followed by administration of activated charcoal
(1mg/kg) diminished the symptoms within 24 hours and
the patient was discharged healthy. (Demirhan et al.,
2013).
Hanine Almubayedh et al.
44 A COMPREHENSIVE REVIEW ON
ATROPA
BELLADONNA
BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS
Table 1. Clinical cases reported about Atropa belladonna (nightshade)
Case
No.
Form of Atropine
Ingested Age Gender Clinical Manifestation Treatment Protocol Cause of
Ingestion
1 Althaea of cinalis 28 / 27 Female /
Male ACS -
Ingestion of
contaminated hot
drink
2 AB fruit 71 Male
-Tachycardia
-Dilated pupils
-Redness of extremities and trunk
-Confusion with
blackberry fruit
3 IV Atropine 52 Male Toxic megacolon Tapering of Atropine
and Pralidoxime
Treatment for OP
poisoning
4Homeopathic agent
containing AB 20 days - -Seizures
-Fever -Treatment of
infantile colic
5Jimsonweed /
Atropine Tablets Adolescents - ACS
-Physostigmine
-Activated charcoal
-Benzodiazepine
-Haloperidol
Two of patients
had them as
suicide attempts
6 AB fruit 49 Female
-Loss of consciousness
-Fatigue
-Redness of face and neck
-Dilated and isochoric pupils
-Dryness of mouth
-Gastric Lavage
-Activated Charcoal
-Supportive therapy
Confusion with
forest fruit
7 11 Female
-Confusion
-visual and hearing hallucinations
-uncontrollable vomiting
-incoherent speech
Diazepam Treatment of
jaundice
8 AB Leaves 40 Male
-Flushed warm skin
-Dry tongue
-Sudden psychomotor agitation
-Disorientation
-Dilated pupils
-Tachycardia
-Activated charcoal
-Diazepam
-Supportive therapy
Treatment of
chronic peptic
ulcer
9 AB Fruit 2 - Central and Peripheral ACS Confusion with
wild berries
10 - 48 Male
-Tachycardia
-severe disorientation
-Aggressiveness
-Activated charcoal
-Diazepam
-IV Physostigmine
-
11 - Children -
-Tachycardia
-Flushed skin
-Meaningless speech
-Mydriasis
Neostigmine -
CLINICAL CASE REPORTED IN 2012
ATS developed from jaundice treatment
An eleven-year-old girl was administered with AB for
the sake of treating jaundice developed due to use of
rifampicin and isoniazid for lymph node treatment. The
patient developed ATS with symptoms; confusion, vis-
ual and hearing hallucinations, uncontrollable vomiting,
and incoherent speech. The treatment plan consisted of
diazepam (5 mg) for sedation purpose whereas charcoal
wasn’t administered as AB was ingested a day before.
For treating jaundice the tuberculosis treatment was
stopped. (Berdai et al., 2012)
CLINICAL CASE REPORTED IN 2011
Chronic peptic ulcer treatment causing ACS
A patient was admitted to ER with symptoms; warm and
ushed skin, dry tongue, sudden psychomotor agitation,
disorientation, dilated pupils and tachycardia. Patient
history revealed the ingestion of AB leaves for relieving
peptic ulcer. Treatment was successful after administra-
Hanine Almubayedh et al.
BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS A COMPREHENSIVE REVIEW ON
ATROPA
BELLADONNA
45
tion of activated charcoal, diazepam (10mg) and gastric
decontamination. (Milanlioglu, 2011).
AB wild barriers causing central and peripheral
Atropine poisoning symptoms
A two year old child after eating wild berries was brought
to ER. The plant as presented by his mother was identi-
ed to be AB whereas the symptoms observed were both
peripheral and central atropine poisoning. Following a
proper treatment, the patient was discharged healthy.
(Laffargue et al., 2011).
CLINICAL CASE REPORTED IN 2009
AB Vs ATC
A forty eight year man ingested three handful of AB and
developed symptoms of tachycardia, severe disorienta-
tion and aggressiveness, in the rst six hours of inges-
tion. He was treated with diazepam, activated charcoal
and Physostigmine (continuous therapy) and was recov-
ered within two days. (Zimmermann et al., 2009)
CLINICAL CASE REPORTED IN 2003
Severe to mild AB toxicity symptoms in 49 children.
AB toxicity was reported in forty nine children’s in
a study. They were divided into two groups i.e. sever
intoxication symptoms group (6 child’s) and mild to
moderate symptoms group (43 child’s). The most com-
monly observed symptoms were; tachycardia, ushed
skin, meaningless speech, and mydriasis. Due to lack of
Physostigmine availability, Neostigmine was used as an
antidote for treatment. No death cases were reported,
(Caksen et al., 2003).
DISCUSSION
Atropa belladonna, known as deadly nightshade, can be
very toxic. It has an anticholinergic effect on human
body which can affect the central as well as the periph-
eral nervous systems. The symptoms and its severity may
vary among age groups and gender depending upon the
ingested dose and patients experience anticholinergic
toxic syndrome with different symptoms, (Glatstein et
al., 2014; Ahmad et al., 2017a; Ahmad et al., 2017b).
However, the most common symptoms reported in
the cases founded in current literature i.e. from 2003-
2017 includes; tachycardia, seizures, dryness of mouth,
dilated pupils, hallucinations and confusion. This review
underlines the clinical uses as well as any clinical mani-
festations associated with or any toxicity resulted due
to use of atropine in any of its form i.e. plant extract,
berries, tablets, powder etc. Generally, the plant AB is
considered as a toxic one and using the plant without
proper knowledge and guidance may be harmful.
Toxic dose of Atropa belladonna: Atropa belladonna
was commonly used by professional poisoners, sorcerors
and witches since ages. Mature fruits and green leaves
have the highest concentration of atropine whereas the
mature fruit is claimed to contain 2 mg of atropine,
(Passos et al., 2016) As per Martindale, the mortal dose
of atropine is 10mg (equal to 5 AB fruits) and 100mg
(equal to 50 AB fruits) or less for children and adults,
respectively. Duration of action: ACS symptoms start
usually within one hour after ingestion and Sub-mortal
clinical symptoms may continue for 2 days, (Spina et
al., 2007). The severity of ACS/ATS, however, depends
upon whether and when medical intervention was taken.
(Adamse et al., 2015).
Atropine induced psychosis: as mentioned in the lit-
erature review, Atropa belladonna intoxications cause
central ATS symptoms which include hallucinations,
confusion and psychosis. Psychosis is induced as a result
of decrease in acetylcholine transmission, accompanied
with an increase in dopamine transmission in the Cen-
tral nervous system, as their levels are in uenced by
each other. (Gaudreau et al., 2005). Atropine induced
psychosis is explained by the ability of Tropane alka-
loids to rapidly cross the blood brain barrier and affect
the CNS functions. Having cholinergic blocking effects,
atropine can block M1 receptors (Ardila et al., 1991) in
the brain causing psychosis by the mentioned mecha-
nism. Although central and peripheral ATS have been
reported in cases of overdose, rare cases are founded to
cause such symptoms at pharmacological doses in sen-
sitive subjects. Baker and Farley reported toxic psycho-
sis caused by atropine eye-drops. The patient was pre-
scribed with 1% atropine eye-drops in her right eye for
the treatment of retinal detachment. Following a treat-
ment of three and half weeks, she developed toxic psy-
chosis and peripheral symptoms of ATS, (Baker, 2010).
Toxic megacolon developed form atropine intoxi-
cation: though incidence of atropine-associated toxic
megacolon is very rare, however still few cases have
reported such complication. These case reports sug-
gested an involvement of atropine in the manifestation
of toxic megacolon, (Mostafazadeh et al., 2017; Scharer
et al., 1964; Mann et al., 1977). In the rst two cases,
toxic megacolon developed after the administration of
anticholinergic agent and was reversed after the dis-
continuation of the anticholinergic agent. Although
the pathophysiological bases of atropine involvement
in toxic megacolon remain unclear, some theories sug-
gest that anticholinergic agents, such as atropine, lead to
gastrointestinal peristalsis inactivity and delay intestinal
transit time which in turn may have caused toxic mega-
colon. (Mostafazadeh et al., 2017).
Hanine Almubayedh et al.
46 A COMPREHENSIVE REVIEW ON
ATROPA
BELLADONNA
BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS
Memory defects caused by Hyoscine: Hyoscine, also
known as scopolamine (an active drug in AB plant), has
been widely used in clinical practice for years. However,
many cases of hyoscine toxicities have been reported.
Hyoscine toxicity has been associated with ATS as
atropine and amnesia. An analysis done after days of
hyoscine intoxication, by Ardila and Moreno in 1991,
showed signi cant decrease in logical memory, visual
reproduction, digits, associative learning which suggest
defects in residual memory after hyoscine intoxications,
(Ardila et al., 1991). Although hyoscine induced amne-
sia has been reported as an intoxication complication,
hyoscine helped in inducing amnesia for testing of the
anti-amnesic effect in medications and plants such as
Ficus religiosa, (Kaur et al., 2010).
In our study we reported AB intoxication in retro-
spective years i.e. 2003-2017, in adults, children and
adolescents. Almost half of the subjects were adults
whereas the other half was children and adolescents.
Furthermore, intoxication was produced irrespective of
gender however the subjects mostly affected were male.
In addition, few of the cases highlighted the use of AB
fruit instead of forest fruit by mistake due to similar
appearance. One of the cases reported the use of atropine
tablets by adolescent subjects however majority of the
case reports suggests the fact; ACS syndrome was asso-
ciated with the use of AB fruit/plant for treating various
diseases such as Jaundice, peptic ulcer, organophosphate
poisoning and infantile colic. The literature review and
eleven cases observed during the last fteen years may
not be suf cient evidence to claim a plant as a toxic one
and disqualify it. As evident in the previously reported
cases, ACS was one of the major drawback observed
with the use of AB plant however lack of any causal-
ity or death still favor its use as a medicinal plant. The
reported cases showed the use of Ab/atropine for various
ailments, hence AB plays a major role in various condi-
tions till date, as discussed.
Atropine as antidote in Organophosphate poisoning:
Atropine has a huge therapeutic value and is widely
used as an antidote in cases of organophosphate poi-
soning. Organophosphates are one of the long acting
Ach esterase inhibitors used mainly as war gases. (Kat-
zung et al., 2012) Symptoms of OP poisoning manifest
as a result of accumulation of Ach at the nerve junc-
tion causing acute cholinergic crisis. Atropine is consid-
ered to be an important agent that reverses central and
peripheral symptoms of organophosphate poisoning for
its central and peripheral anticholinergic affects. (Dong
et al., 2017; Kumar et al., 2001; Mustafa et al., 2016).
Atropine in the management of myopia; Atropine is
a nonselective anticholinergic agent that can be admin-
istrated locally for controlling mild to moderate myopia,
which is one of refractive disorders. In the last decade,
atropine was used as an evidence-based treatment but
the mechanism of action is unknown yet. It is considered
to be well effective and tolerated at low doses in the
management of low and moderate cases. Atropine has
been also used to slow the progression of ocular axial
elongation and myopia. Audrey et al., studied the ef -
cacy and safety of atropine in Asian children with myo-
pia. Atropine in this study was very effective and well
tolerated in slowing down the advancement of myopia
and ocular axial elongation. (Chuang, 2017; Chia et al.,
2012; Chua et al., 2006).
Managing Smooth muscle spasms hyoscine is an
active constituent in the Buscopan formulation as Hyos-
cine-n-butyl bromide. Intestinal spasms result from the
cholinergic stimulation of smooth muscle in the GIT,
which increases its motility and secretions. (Whalen,
2015; Ardila et al., 1991; Zhu et al., 2017). Hyoscine can
comfort the pain of bowl and stomach cramps by block-
ing the M1 receptors therefore, blocking the cholinergic
effects on the intestinal muscles. In addition, hyoscine is
used as cervical antispasmodic agent in labor whereby
exert effects via decreasing the duration of rst stage in
labor, owing to its anticholinergic effects of the smooth
muscles of the uterus. (Sirohiwal et al., 2005).
Antiemetic effect of hyoscine: hyoscine also blocks
the motility of the smooth muscles as well as their secre-
tions by its anti-muscarinic action. Having these effects,
hyoscine can be used to control the vomiting and nau-
sea. A case reported by Brown et al., presented a breast
cancer patient having nausea and vomiting which were
resistant to the widely available anti-emetics, who was
treated successfully with hyoscine transdermal patch.
(Fay and Llio, 2016).
To conclude; AB ingestion may induce ACS however
not all of the characteristics of ACS may be found in
few of the AB poisoning cases. The fact is supported
by the presence of hybrid form within AB plant, (Cikla
et al., 2011). The major aim of current review was to
search and report any recently observed cases related
to AB use and explore the most widely observed and
common symptoms of AB toxicity. The aforementioned
cases suggest two types of clinical manifestation i.
central nervous system effects (CNS) and ii. Peripheral
nervous system effects (PNS). The symptoms presented
with CNS includes; short-term memory loss, ataxia, hal-
lucinations, agitated delirium, disorientation, seizures,
confusion, psychosis, coma leading towards respiratory
failure as well as cardiovascular collapse. PNS symp-
toms includes; dry mucous membranes, hyperre exia,
mydriasis with cyclopedia, diminished bowel sounds
or ileus, ushed skin, hypertension or hypotension,
tachycardia and urinary retention. Furthermore, the
symptoms in children consisted of; lethargy, meaning-
less speech, absence of tachycardia and coma. The ACS
Hanine Almubayedh et al.
BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS A COMPREHENSIVE REVIEW ON
ATROPA
BELLADONNA
47
reported in most of the cases was due to use of AB for
different treatment purposes including myopia, smooth
muscle spasm, jaundice, peptic ulcer and organophos-
phorus poisoning however all the cases were properly
managed with charcoal, gastric lavage and Physostig-
mine/neostigmine without any death.
CONCLUSION
Atropa belladonna, as a medicinal plant possesses a huge
respect in patient treatment. Every plant, its extract or
active drug as well as any conventional medication may
produce speci c side effects or adverse effects which is
commonly associated with the use of these agents. AB
produces ACS and the symptoms are properly treated
with the available treatments or antidote. However,
despite its wide therapeutic uses, AB if used inappro-
priately or without any proper medical supervision may
be toxic. In addition, lack of proper treatment protocol
as well as the antidote i.e. Physostigmine in most of the
cases, may exaggerate the toxicity symptoms and lead
towards fatal condition.
CONFLICT OF INTERESTS
No con ict of interest exists among the authors.
FINANCIAL SUPPORT
No support was provided by any government or private
funding agency.
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... Several herbal medicines have significant action on the central nervous system. Many of them have also become important sources of modern drugs, including atropine (Atropa belladonna L.), morphine (Papaver somniferum L.), caffeine (Coffea arabica L.), and ephedrine (Ephedra sinica Stapf) [31][32][33][34][35]. Data also show that some species are still used as an abuse drug or due their recreational potential (e.g., Erythroxylum coca Lam. and Cannabis sativa L. [36][37][38]. ...
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