A case report on Liu Shen Wan ( 六神丸 )Poisoning. History A 26 year old man Accidentally taken...
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Transcript of A case report on Liu Shen Wan ( 六神丸 )Poisoning. History A 26 year old man Accidentally taken...
A case report on Liu Shen Wan (六神丸 )Poisoning
History
A 26 year old man Accidentally taken 100 tablets of
LiushenwanHe got mild upper respiratory tract
infectionTook the pills as remedy
Symptoms started 1 hour laterFelt dizzy and nauseatedPalpitation, chest discomfort and limb
weaknessNo vomitingNo epigastric pain
Physical Examination
Vitals were stableBP 145/79Pulse 77/minAfebrile Cold extremitiesGCS 15/15
Abdomen soft and nontenderBowel sound sluggishChest clear, equal AEHeart sound dual, no murmurNo focal neurological signs
H’stix: normalECG : sinus rhythm, no ischemic changesCXR : normalAdmit to medical ward subsequently
CBPR/LFTAmylaseParacetamol, Salicylate level: normalSymptoms subsided quicklyDischarge the next day after admission
Liu Sheng Wan 六神丸Well known Chinese composite herbal
medicationSix ingredients: Niu Huang 牛黃 ,
SheXiang 麝香 , CianSu 蟾酥 , BingPiang冰片 , Xiong Huang 雄黃 , Pearl 珍珠
Indications: URTI, apthous ulcer, otitis media, gingivitis, cellulitis
Different brands of Liu Shen Wan
Used for over 100 years in China4 major brands: Lui’s, Yeung’s, Ji’s and Leung’s
Packing: 6 bottles in 1 pack, 10 pills per bottle
Dosage :for adults 10 pills 3 times a day
Route of administration:OralAs lozenges
Composition (Lui’s) : Pearl 珍珠 28% SheXiang 麝香 20% NiuHuang 牛黃 22% Xiansu 蟾酥 24%
Others 6%
CianSu 蟾酥
Milky venomous secretion from Toad’s parotid glands
Methical beliefs: analgesic, anesthetic, detoxifying and heart strengthening effect
Used in febrile convulsion, heart disease, gum bleeding and anxiety
Chemical composition: cardioactive steroids: bufalin, cinobufagin, resibufogenin and epinephrine
Chemical structure similar to digoxinOnset time : 20min – 2 hrToxic reaction can begin after 12 hours of
ingestionSymptoms of intoxication are nausea,
vomiting, headache, dizziness, limb numbness and even convulsion
Suggested approach for treating Ciansu poisoning
Breif rapid triage with history taking and clinical assessment
Basic laboratory investigations including measurement of serum potassium and digoxin concentrations
Surface ECG and telemetry monitoringReporting to and consult with the local
poison control centreGeneral life supportive measures
Treatment with digoxin specific Fab fragments
No calcium administration for hyperkalaemia
retention of sample for investigation
Xiong Huang 雄黃
Arsenic sulfide
Methical beliefs: antibacterial, detoxifying action
Acute overdose: GI: nausea, vomiting, diarrhoea CVS: hypotension, tachycardia, shock and
death Neurological: lethargy, agitation, delirium,
seizure, sensorimotor axonal peripheral neuropathy
Hematological: pancytopenia, relative eosinophillia, basophilic stippling
Dermatologic: delayed effect desquamation, periorbital edema, diffuse
maculopapular rash Transverse white striae
Long term uses: chronic arsenic poisoning Fatigue, malaise Gastroenteritis, leukopenia, anemia, sensory
predominant peripheral neuropathy, hepatic transaminase elevation, noncirrhotic portal hypertension, and peripheral vascular insufficiency.
Skin disorder: rain-drop pigmentation, hyperkeratotic changes, neuropathy, anemia
Lung, bladder, skin cancer
Treatment
DecontaminationEnhanced eliminationChelating agents:
Unithiol (DMPS) Dimercaprol (BAL) Oral succimer (DMSA)
NiuHuang 牛黃
Cow’s gall stoneMythical beliefs: strengthen heart,
tranquilizing, detoxifying and antipyreticUsed in heart disease, anemia, sepsis and
alcoholic intoxicationToxic effect: hypotensive, gastroparesis,
increase prolactin secretion in rats
SheXiang 麝香
Known as muskSecretion from gland between the
umbilicus and genitals of a deer living in Himalayas
Methical beliefs: tranquilizing, antiepileptic and heart strengthening effect
Used in anxiety and epilepsyToxic effects: uterine contraction,
antiplatelet, hypotensive
BingPiang 冰片
BorneolDerivative of the stem in Dipterocarp
(tropical tree). Ingredients of turpentine and camphorAnalgesic, anti-inflammatoryUsed in conjunctivitis, pharyngitis, cellulitis
and skin ulcerToxic effect: uterine contraction in second
and third trimester of gestation in rats
Zhen Zhu 珍珠
Tranquilizing and anti-inflammatoryUsed in insomnia, pharyngitis, cough
suppressing, skin healing and body strengthening.
Toxic effects: diuretic, decreased gastric acidity
Literature search
Chan HM. 41 cases of adverse effect caused by Liushenwan. Journal of Hubei institute for Nationalities (medical edition): 2003 Vol. 20 No.3 P.57
41 cases searched from 21 journals over 5 years
Epidemiology
Age: 8 days – 60 years oldMale : 22 cases (53.7%)Female: 19 cases (46.3%)Time of onset: 20 min – 2 hrSymptom onset: after 1 dose or multiple
repeated doses
Distribution of adverse reactions
Type of reactions
No.of cases
% Clinical manifestation
Toxidrome 23 56.1 Nausea, vomiting, milk regurgitation, dyspnea, chest pain, bradycardia, dysrhythmia, confusion, irritability, dizziness, epistaxis
Allergic response
13 31.7 skin rash, angioedema, anaphylactic shock and death
Other reactions 5 12.2 Preterm labor, priapism, skin pigmentation, keratosis
Toxidromes Enteric :
nausea, vomiting, diarrhoea, neonatal regurgitation Circulation:
cold peripheries, cyanosis, weak pulses bradycardia, dysrhythmia, atrioventricular block shock and death
Respiratory reactions: chest pain, dyspnea, tachypnea shallow breathing respiratory failure and death
Hematological system: cyanosis, epistaxis
Most of the toxic symptoms are accountable by Arsenic and Ciansu
Arsenic: Gastrointestinal upset, oral and gastric mucosa edema,
hemorrhage and necrosis. Long term use: liver and renal damage, skin
pigmentation Ciansu
Digoxin like effect blocking AV conduction pathways, causing cardiovascular and respiratory compromise in severe intoxication.
Hu M.C. Discussions on adverse reaction of LiuShenWan. Journal of Combined Chinese and Western Medicine. 1991, Vol.11, No.9, P563-4.
28 cases reported 14 cases of intoxication 8 neonates, 4 infants, 2 adults Symptom onset : 0.5-12 hrs Mortality: 5 (4 neonates); Discharged: 8; no data
available: 1 Fatal cases:
lip cyanosis, facial flushing 3rd degree atrioventricular block T wave changes, epistaxis circulatory failure
12 cases of allergy:8: allergic drug rash4: scarletiform drug rash1: eczematous drug rash1: drug rash with fixed pattern1: purpuric drug rash1: anaphylatic shock1: laryngeal edema
2 idiosyncratic responses
Discussion
Mild intoxication Symptoms correspond to ciansu and arsenic
sulphide poisoning Many brands of Liushenwan available over the
counter Mortality reported mainly in neonatal intoxication Should prohibit use of the drug in neonates Legistration required for prescription
Most fatal cases has cardiovascular manifestations including 3 degree AV block, bradycardia, circulatory shock
Atropine, adrenaline used for resuscitation Digoxin like effects Multiple atrial ectopics reported in a patient on
digoxin therapy taking the recommended dose of LiuShenWan
Synergistic effects with digoxin Treatment according to digoxin toxicity