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Wild lettuce (Lactuca virosa) toxicity

Authors:
Sima Besharat at Golestan University of Medical Sciences
Sima Besharat
Mahsa Besharat
Mahsa Besharat
Mahsa Besharat
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Ali Jabbari at Golestan University of Medical Sciences
Ali Jabbari
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Abstract

Wild lettuce (Lactuca virosa) can cause toxic effects when eaten. Wild lettuce grows in the north of Iran and some natives consume it unaware of its adverse side effects. We describe eight patients with manifestations of wild lettuce toxicity, admitted to a general hospital affiliated to the Golestan University of Medical Sciences. All the patients recovered (although one had to spend 48 h in the intensive care unit) and no chronic complications were reported. A clinical suspicion of toxicity caused by wild lettuce intake and an accurate history formed the basis of the diagnosis. Conservative treatment, vital sign monitoring, control of patient intake and output, and reducing patient agitation provided the basis for treatment.
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11/8/2019 Other full case: Wild lettuce (Lactuca virosa) toxicity
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031874/?report=printable 1/4
BMJ Case Rep. 2009; 2009: bcr06.2008.0134.
Published online 2009 Apr 28.
doi: 10.1136/bcr.06.2008.0134: 10.1136/bcr.06.2008.0134
PMCID: PMC3031874
PMID: 21686920
Other full case
Wild lettuce (Lactuca virosa) toxicity
Sima Besharat, Mahsa Besharat, and Ali Jabbari
Golestan University of Medical Sciences, Shalikoobi Ave, 21st Edalat, Gorgan, 49177-44563, Islamic Republic of
Iran
Golestan Research Center of Gastroenterology and Hepatology, 5 Azar St, Gorgan, 49177-44563, Islamic
Republic of Iran
Golestan University of Medical Sciences, Shalikoobi Ave, Gorgan, 4917744563, Islamic Republic of Iran
Golestan University of Medical Sciences, 5 Azar Hospital, Gorgan, 4917744563, Islamic Republic of Iran
Sima Besharat, s_besharat_gp@yahoo.com
Copyright 2009 BMJ Publishing Group Ltd
Abstract
Wild lettuce (Lactuca virosa) can cause toxic effects when eaten. Wild lettuce grows in the north of Iran
and some natives consume it unaware of its adverse side effects. We describe eight patients with
manifestations of wild lettuce toxicity, admitted to a general hospital affiliated to the Golestan University
of Medical Sciences. All the patients recovered (although one had to spend 48 h in the intensive care unit)
and no chronic complications were reported. A clinical suspicion of toxicity caused by wild lettuce intake
and an accurate history formed the basis of the diagnosis. Conservative treatment, vital sign monitoring,
control of patient intake and output, and reducing patient agitation provided the basis for treatment.
BACKGROUND
Iran grows a variety of herbs, some of which are processed for pharmaceutical purposes. Wild lettuce (
fig 1), which is known as “Laitue vireuse” in French, “Wilder lattich” in German and “Allubbyne” in
Arabic, is also known as “opium lettuce”. Its scientific name is Lactuca virosa; in Latin, lactuca means
“milky extract” and virosa means “toxic”. A biennial herb, wild lettuce grows on the banks of rivers and
on waste grounds to a maximum height of 6 feet, flowering in July and August. It has a smooth and light
green, sometimes purple spotted, erect stem which springs from a brown tap root. It is cultivated in
different regions of the world, such as Austria, France, Germany, Scotland and Iran.
The whole plant is rich in a milky juice that flows freely when it is scratched. The juice has a bitter taste
and a noxious odour. When dried, it hardens, turns brown, and is known as lactucarium. L virosa has been
found to contain lactucic acid, lactucopicrin which is amorphous, 50–60% lactucerin (lactucone) and
lactucin. Lactocerine is the main component of the lactucarium, which is a neutral insoluble material.
Lactucarium is a diuretic, laxative and sedative agent which relieves dyspnoea, and decreases
gastrointestinal inflammation and uterus contractions. It has anticonvulsant and hypnotic effects as well. In
addition, the lettuce contains traces of hyoscyamine, which is probably responsible for its sedative effects.
Before the Victorian period, wild lettuce was well known as a painkiller and sedative. In the 19th century,
wild lettuce, especially the desiccated lactescent juice lactucarium, was used as a sedative and analgesic.
It was used in kidney disorders, for ameliorating painful uterine contractures, and for generalised oedema
and icterus, due to its diuretic effect. In its catalogue of medicinal plants published in 1917, the Servall
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11/8/2019 Other full case: Wild lettuce (Lactuca virosa) toxicity
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Company asserted that wild lettuce was “highly esteemed to quiet coughing and allay nervous irritation, a
good safe remedy to produce sleep, to be used when opium and other narcotics are objectionable”. This
was written at a time when opium and cocaine could still be obtained over the counter.
Lactucarium is not easily made into powder, and is only slightly soluble in boiling water, though it softens
and becomes plastic. Powdered components of the herb have been used for external use and it is still used
for making a lotion for the skin to relieve sunburn and roughness. Its boiled form is used as an enema for
intestinal irritations.
CASE PRESENTATIONS
Here we present eight patients aged between 12–38 years referred with various manifestations of wild
lettuce toxicity. All of them were managed successfully and discharged after a full recovery.
Patient 1 exhibited a decreased level of consciousness, agitation, dry mucosa, mydriatic pupils,
urinary retention and hypoactive bowel sounds. Patient 2 had ataxia, blurred vision, red conjunctiva
and severe anxiety. Both patients were members of a climbing group and after taking a complete
history, it became obvious that they had ingested a great deal of the herb “wild lettuce”. It was said
that in the region they used to go to occasionally, the herb is eaten raw as a vegetable. The second
patient developed dizziness, nausea and vomiting gradually and lost consciousness. After that
episode, all members of the group were called to the emergency department.
Patients 3 and 4 experienced hallucinations, sympathetic hyperactivity, nausea and vomiting, and
were referred to the hospital 2 h later.
Patients 5 and 6 were admitted with normal vital signs, dry mucosa, mydriasis and anxiety,
headache, dizziness, vomiting and blurred vision.
Patients 7 and 8 presented with agitation, severe sweating, flushing, euphoria, abdominal cramps,
urinary retention and normal vital signs.
TREATMENT
Patients were kept fasted and treated with intravenous fluids to maintain adequate hydration.
Blood and urine samples were taken for laboratory examination and arterial blood gas analysis was
undertaken. Vital signs were monitored. Following interviews with the oriented patients, nasogastric
intubation and gastro-oesophageal lavage was performed. The liquid of the lavage was sent for laboratory
analysis and the presence of fine particles of wild lettuce was confirmed by the laboratory. No other
suspect material was seen in the blood, urine and gastric lavage fluid of the patients.
Treatment continued with charcoal and sorbitol, about 30 ml/h for 6–12 h after the nasogastric intubation
and lavage.
OUTCOME AND FOLLOW-UP
All eight patients recovered and were discharged 48 h later. Only patient 1 was sent to the intensive care
unit (for 48 h) due to the prolonged loss of consciousness. No long lasting complications were seen.
DISCUSSION
It has been proposed that wild lettuce has hypoglycaemic effects, causes insomnia, provides relief from
painful menstruation, and causes psychogenic coughs. Some considered it has no therapeutic effects,
others believe it has sedative and hypnotic effects, and some classify it as a poison. In the USA, there
have been reports of the herb being used as a substitute for opium. Mullins and Horowitz reported
intravenous injection of wild lettuce extract and valerian root in three young intravenous drug users. All of
them developed fever, chills, abdominal pain, low back pain, neck stiffness, headache, leucocytosis and
moderate liver function disorders. All recovered in 3 days.
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The milk-like extract and the leaves are the useful components of the herb, and act as a spasmolytic and a
sedative. Medicines which contain lactucarium are used in the treatment of pertussis, bronchial asthma
and urinary tract diseases. The seed’s oil is effective in atherosclerosis. Some of its side effects and toxicity
resulting from overdose include mydriasis and photophobia, dizziness, diaphoresis, auditory hallucination,
and cardiovascular and respiratory difficulties caused by dysrhythmia. We observed most of these signs
and symptoms in our patients. The severity of the toxicity was dose dependent, according to the history
taken from the patients.
Common presentations of toxicity in our patient were mydriasis, dizziness and anxiety, urinary retention,
decreased bowel sounds and sympathetic overactivity, suggesting an anticholinergic mechanism. Moderate
doses given to animals can act as a narcotic, even causing death if injected.
Our patients suffered from the harmful effects of wild lettuce. The toxicity may have occurred because the
herb was ingested when it was fresh and before the usual time for harvesting herbs (our patients ate the
wild lettuce in May).
LEARNING POINTS
A clinical suspicion of toxicity cause by wild lettuce intake and an accurate history provided the
basis for the diagnosis.
Conservative treatment, vital sign monitoring, control of patient intake and output, and reducing
their agitation formed the basis of treatment.
Eating of unknown substances, even herbs, should always be avoided. If herb intake is
suspected, immediate contact with medical centres is required.
Footnotes
Competing interests: none.
REFERENCES
1. Zargari A. Medicinal plants. Tehran University Publications 1978; 3: 223–8
2. Heber D. PDR for herbal medicine, 3rd ed Thomson Company, 2004: 495–6
3. Trojanowska A. Lettuce, lactuca sp., as a medicinal plant in polish publications of the 19th
century.Kwart Hist Nauki Tech 2005; 50: 123–34 [PubMed: 17153150]
4. Mullins ME, Horowitz BZ. The case of the salad shooters: intravenous injection of wild lettuce extract.
Vet Hum Toxicol 1998; 40: 290–1 [PubMed: 9778767]
Figures and Tables
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Figure 1
Wild lettuce.
Articles from BMJ Case Reports are provided here courtesy of BMJ Publishing Group
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Locikové opium je zaschlá mléčná šťáva, která vytéká při naříznutí Lociky jedovaté (Lactuca virosa L.). Šťáva má hořkou chuť a po vysušení ztvrdne a zhnědne. Ve středověku byla známá jako lactucarium a používána jako levná náhraž-ka opia známá pod názvem locikové opium. 1 Lactucarium bylo využíváno jako lék proti boles-ti, laxativum a sedativum. 2 Pro svůj močopudný účinek bylo také aplikováno při poruchách led-vin, ke zmírnění bolestivých děložních kontrak-tur a na generalizované otoky či ikterus. Mělo Abstrakt: V minulosti se sušená mléčná šťáva z Lociky jedovaté, známá také jako lactucarium či locikové opium, považovala za omamnou látku s vlastnostmi analgetik a sedativ. Ačkoliv její účinek byl slabší než u opia, nezpůsobovala žádné zazname-nané vedlejší účinky. Lékařská praxe potvrzovala, že lactucarium mělo v některých případech dokonce lepší terapeutické účinky než tradiční opium. Novější výzkumy, které se zaměřovaly na potvrzení léčivých účinků lactucaria a identifikaci odpověd-né látky za tyto účinky, však nepřinesly očekávané výsledky. Složka odpovědná za léčivé vlastnosti lactucaria zatím nebyla identifikována. Až pozdější studie odhalily v locikovém opiu několik bioaktivních látek, jako je lactucin a lactucopicrin, které vykazují analgetické účinky. Co se týče rekreačního užití locikového opia jako dro-gy, informace o psychofarmakologických vlastnostech drogy a jejích jednotlivých složkách jsou dostupné jen omezeně.
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The case of the salad shooters: Intravenous injection of wild lettuce extract
Article
Full-text available
  • Nov 1998
  • Vet Hum Toxicol
Three young adult drug users obtained wild lettuce and valerian root, prepared a crude aqueous extract of the wild lettuce, and injected the extract i.v. One also injected an alcohol extract of the valerian root. All 3 rapidly became ill with fevers, chills, abdominal pain, flank and back pain, neck stiffness, headache, leucocytosis and mild liver function abnormalities, but recovered over the next 3 d. Various literature and internet sources claim that wild lettuce has opiate properties not demonstrated in this case.
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[Lettuce, lactuca sp., as a medicinal plant in polish publications of the 19th century]
Article
  • Feb 2005
Mentions of lettuce Lactuca sp. that have appeared since antiquity contained similar information on its curative properties, but such properties were ascribed to different species or varieties. Apart from the wild and poisonous lettuce, also garden or common lettuce were identified as having curative action, and some publications lacked information enabling the precise identification of the lettuce in question. In the 19th century, attempts were made to put some order into the knowledge of lettuce as a medicinal plant. Information contained in Polish medical studies of the 19th century on lettuce points to the poisonous species, Lactuca virosa, and the common or garden lettuce, Lactuca sativa v. Lactuca hortensis, as being used as a medicinal plant. In that period, lettuce and especially the the desiccated lactescent juice obtained from it, lactucarium, were considered to be an intoxicant, and were used as a sedative and an analgesic. The action of the substance was weaker than that of opium but free of the side-effects, and medical practice showed that in some cases lactucarium produced better curative effects than opium. To corroborate those properties of lettuce and its lactescent juice, studies were undertaken to find the substance responsible for the curative effects of the juice. However, such studies failed to produce the expected results, and the component responsible for the curative properties of letuce was not identified. Medical practice thus had to restrict itself to the uses of the desiccated lactescent juice and extracts obtained from it. The possibility of obtaining lactucarium from plants cultivated in Poland caused Polish pharmacists and physicians to take an interest in the stuff and launch their own research of lettuce and the lactescent juice obtained from it. Results of research on lettuce were published in 19th-century journals by, among others, Jan Fryderyk Wolfgang, Florian Sawiczewski and Józef Orkisz.
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PDR for herbal medicine
  • D Heber