Curcuma zedoaria ppt

Zedoary-Induced Cardiovascular Disorders

case report

Usama M. El-Barrany*Magdy A. Ismail**

Forensic Medicine and Toxicology Department, Faculty of Medicine, Cairo* and Al-Azhar

“Boys” ** Universities

intoduction

intoduction

• Many people use traditional remedies as a first line medication.

• Some herbal toxicity is predictable, based on known botanical content.

• Many other adverse effects are idiosyncratic or not commonly appreciated.

• Zedoary (Curcuma Zedoaria) is one of these commonly used herbs.

Zedoary (Curcuma Zedoaria)


• Species: Curcuma zedoaria.

• Family: Zingiberaceae (ginger family).

• Origin: The plant is native to India and Indonesia. but today is widely cultivated in India, South-East Asia and China.

• It was introduced to Europe by Arabs around the sixth century.

• Etymology: The European names for zedoary originate from Arabic jadwār and Farsi zedwaar.


• Characteristics:• A rhizomatous herb with a 6-foot tall leafy stem.

• The leaves are 1 foot long and 3 inches across.

• The flowers are white or yellowish with a lip that is pale yellow-shaded, with a deeper yellow color near the base.

• The fruits have 3-valved capsules.

• The rhizome is short, firm, and of externally wrinkled gray, ash-colored appearance, but with a brownish red color from the inside.


• Active ingredients:

• Curcumin, berberine, hydrastine, canadline, zingiberine, dihydrocurdione, ar-turmerone, beta-turmerone, some volatile oils, and resins.

• The highest concentrations of these constituents are in the root (rhizomes), the lowest, in the leaves and stem.


• Uses: The used part is the rhizomes.

• Food:

• It has a fragrant smell (more similar to ginger, except with a very bitter taste).

• Due to its bitter taste, its use as a spice today is rare, having been replaced by ginger.

• Although it is seldom used today as an individual spice, it may be employed in spice mixtures.


• Food:

• In Indonesia & Thailand, the young rhizomes are often eaten as an aromatic vegetable, zedoary can also be ground to a powder and added to curry pastes.

• In India, it tends to be used fresh or in pickling.


• Medicinal uses:• Zedoary is used in the form of powdered root,

tincture, fluid and solid extract; the medicinal substance obtained has a fragrant smell, and a warm bitter aromatic taste.

• It is much used as a medicine in China and Japan. It has been used as an antivenom for the Indian cobra.

• It has been also used in traditional eastern medicines to help digestion, relieve colic, as a laxative, antifungal, analgesic and anti-inflammatory agent.


• Medicinal uses:

• Dihydrocurdione, the major component of Zedoary has anti-inflammatory potency related to its antioxidant effect.

• The anti-inflammatory and cancer chemopreventive effect of some components of Zedoary might be due to decreased prostaglandin and nitric oxide production through respective inhibition of cyclooygenase 2 (COX-2) and nitric oxide synthase, which have been implicated as important mediators in the processes of inflammation and carcinogenesis.


• Medicinal uses:• Zedoarin, kurdiona and kurkumol are substances that

can be also found in Zedoary. • These substances have anti-neoplastic functions

through breaking ribosome formation in cancer cells and wild tissue.

• They enhance the formation of fibroblast tissue around the cancer and form a layer of lymphocytes in the cells of cancer & wrap it.

• So, the tissue cells of cancer can not grow, eventually the cancer cells will die.


• Medicinal uses:

• Zedoary has been used to treat some liver and coronary heart disease.

• It has been used to treat anemia, prevent leukopenia due to cancer therapies and as an agent for purifying the blood.

• It has been also applied locally as poultice for skin lesions and eyes.


• Others:

• The essential oil produced from the dried roots of Zedoary is used in perfumery as well as an ingredient in bitter tonics.


• On the other hand, a protein flour, prepared from rhizomes of Zedoary ,proved to be highly toxic to 5-week-old rats and caused 100% mortality within 6 days when given at 320 g/kg diet.

• When a meal formed of fresh minced and dried rhizomes of Zedoary was given to weanling rats at 400 g/kg diet, all the animals lost weight rapidly, and two of the five rats died within 4 days.

Case Report

Case Report

• This study describes 2 cases of Zedoary-induced bradyarrhythmias and severe prolonged hypotension (during our work in Center of Poison Control and Clinical Forensic Chemistry, in Holy Makkah region, Saudi Arabia).

CASE I

CASE I

• A 20-year-old woman was admitted to Al-noor special hospital in Holy Makkah region, Saudi Arabia at 3/11/2003 after ingestion of an unknown quantity of Zedoary extract to reduce pain (the history was taken from her father).

• On admission, she was unresponsive except for painful stimuli, with diaphoresis, cyanosis, and respiratory depression.

• Pupils were slightly dilated; systolic blood pressure was 50 mmHg, with a third degree heart block and a ventricular rate 40 beats/minute.

CASE I

• Following intubation, gastric lavage was done, and activated charcoal was given 3 times (every 4 hours).

• Routine toxicological screening using, immunoassay techniques (AxSYM), was negative for alcohol, opiates, barbiturates, benzodiazepines, amphetamines, cocaine, cannabis, tricyclic antidepressants (TCAs), digoxin, theophylline, salicylates, acetaminophen, phenytoin, carbamazepine as well as valproic acid.

CASE I

• Color tests, TLC & Toxi-Lab System showed –ve results for other common substances such as phenothiazines, antihistamines, beta blockers, calcium channel antagonists, NSAIDs, SSRIs, organophosphates as well as carbamates.

• Bradycardia and hypotension were unresponsive to atropine, infusion of dopamine, saline, or even pacemaker insertion.

• She died within 24 hours after admission from cardiovascular collapse.

CASE Ii

CASE Ii

• An 18-years old woman was admitted to Al-noor special hospital in Holy Makkah region, Saudi Arabia at 4/11/2003 after ingestion of a large quantity of Zedoary extract as a tonic. (the history was taken from the patient).

• On admission, she was alert, but had nausea, vomiting, abdominal pain, dizziness and lethargy.

• Systolic blood pressure was 60 mmHg, with junctional bradycardia (as slow as 27 beats/minute) but without evidence of myocardial infarction.

CASE Ii

• Following spontaneous emesis, gastric lavage was done, and activated charcoal was given 3 times (every 4 hours).

• Routine toxicological screening, using immunoassay techniques (AxSYM), was also negative for alcohol, opiates, barbiturates, benzodiazepines, amphetamines, cocaine, cannabis, TCAs, digoxin, theophylline, salicylates, acetaminophen, phenytoin, carbamazepine as well as valproic acid.

CASE Ii

• Color tests, TLC & Toxi-Lab System showed also –ve results for other common substances such as phenothiazines, antihistamines, beta blockers, calcium channel antagonists, NSAIDs, SSRIs, organophosphates as well as carbamates.

• Dopamine, intravenous saline, and 20 ml of 10% calcium gluconate intravenously were administered, and a pacemaker was placed.

• Calcium gluconate was repeated and pressor agents were infused for additional 18 hours.

• Blood pressure became normal after 24 hours, and sinus rhythm returned after 35 hours from admission. The patient was discharged free 5 days post-admission.

Discussion

Discussion

• The rapid course of the two cases pushed the team of center to work in two ways:

• One way was the analysis of biological fluids from the two patient as well as the possible analysis of Zedoary.

• The other one was getting all possible data about the mentioned herb.

Discussion

• In the two cases, routine toxicological screening for the previously mentioned substances was done to exclude any of them as a cause of toxicity.

• Many substances such as beta blockers, antihistamines, CCAs, NSAIDs or SSRIs are not analyzed routinely as one group but as individual drugs in the group, meaning that getting –ve results for some drugs in the group does not exclude the presence of other + ve unknown drugs or substances belonging to the same group.

Discussion

• Although HPLC-MS needed for analysis of zedoary into their different components was available in the center, we did not have the special method for detection of this herb.

• In addition to that, the rapid course of the two cases especially the first one enforced all the team of the center to depend on the available data received from our search about Zedoary.

Discussion

• Some of these data included that Curcuma herbs have showed hypotensive and protective effect on the endothelium in spontaneously hypertensive rats.

• Especially, C. Zedoaria was more effective than C. Longa, and its mechanism was thought to be related to a radical scavenging effect and improvement of hemorheology.

• Hemorheology is the study of flow properties of blood and its elements (plasma and formed elements, including red blood cells, white blood cells and platelets).

Discussion

• Dihydrocurdione, the major component of Zedoary has calcium channel antagonist-like effects.

• Zedoary contains both hydrastine and berberine, which cause a decrease in blood pressure.

Discussion

• Berberine is thought to be seven times as potent as hydrastine in producing hypotension.

• A dose of 1mg/kg of Zedoary extract will produce a slight increase then decrease in blood pressure, while 2mg/kg will produce significant prolonged hypotension.

Discussion

• On the other hand, hallmarks of CCAs overdose include bradyarrhythmias, myocardial depression, peripheral vasodilatation, hypotension, and syncope.

• These symptoms and signs of toxicity coincided with the two cases of Zedoary toxicity, presently reported, whereas their main manifestations were cardiovascular disorders in the form of severe prolonged hypotension and bradyarrhythmias.

Discussion

• Although plasma concentrations of CCAs correlate well with cardiovascular depression in the experimental setting, plasma concentrations in humans show no significant correlation with the amount of drug reportedly ingested by patients.

• Moreover, fatal verapamil overdose has occurred with a peak plasma concentration slightly higher than the high-therapeutic range (687 ng/mL).

Discussion

• Thus, managing patients with suspected herbs having signs and symptoms similar to CCA overdose should be based on clinical features rather than analysis.

• Based on these data, calcium gluconate 10% was given to the second patient to treat the refractory hypotension and to avoid death as in the first case.

Conclusion AND RECOMMENDATIONS


• There is no logic supporting the popular conception that herbal products are safer or more natural than pharmaceutical medications.

• The use of herbs by most individuals should be put under strict medical regulations.


• More studies are needed regarding the clinical manifestations as well as the chemical analysis of most commonly-used herbs.

• Toxicology centers should be equipped with modern analytical facilities as well as information centers to help clinicians in managing different toxic cases.

يابالدي يابالدي أنا باحبك يابالدي

لحسن ًشكرا

استماعكم

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Curcuma zedoaria ppt

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