Anaesthesia, 2001, 56, pages 11781180

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C A S E R E P O RT
Poisoning due to Abrus precatorius (jequirity bean)

C. Fernando
Consultant Anaesthetist, General Hospital (Teaching), Kandy, Sri Lanka

Summary
The management of a patient with poisoning due to ingestion of the jequirity bean (Abrus precatorius)
is presented. The clinical features of this case included pulmonary oedema and hypertension; this has
not been recorded previously in the literature associated with jequirity bean poisoning.

Keywords Toxicity. Complications: hypertension.

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Correspondence to: C. Fernando
E-mail: dirghk@slt.lk
Accepted: 28 June 2001

A 13-year-old boy was admitted to the intensive care unit breath.min21, a heart rate of 150 beat.min21, arterial
requiring intermittent positive pressure ventilation (IPPV) blood pressure at this stage had decreased to 70/
for drug-resistant pulmonary oedema. 40 mmHg. Oxygen saturation (Sao2) was 72%. He was
He had previously been admitted to a medical ward 6 h intubated using a 6-mm tracheal tube and ventilated with
earlier with vomiting, watery diarrhoea and colicky a tidal volume of 300 ml, respiratory rate 12 breath.-
abdominal pain of 3 h duration. At that time, he had a min21 and FIo2 was 0.5. The Sao2 increased with
sinus tachycardia 164 beat.min21, arterial blood pressure ventilation, and shortly afterwards reached 96%. Fruse-
of 160/90 mmHg, and bilateral crepitations and rhonchi mide 1 mg.min21 and nifedipine 0.15 m g.kg21.min21
in his lung fields. He was treated with frusemide 40 mg were administered. In addition, an infusion of dobuta-
intravenously, oxygen was administered using a low flow mine was commenced. Investigations revealed a serum
mask and nebulised salbutamol was given as he had a potassium 6.0 mmol.l21 and blood urea 12.6 mmol.l21.
history of childhood asthma. Blood gas analysis showed an uncompensated metabolic
There was no improvement, and 1 h later his arterial acidosis with pH of 7.199, bicarbonate 13.5 mmol.l21
blood pressure had increased to 180/120 mmHg. Nifedipine and base excess of 213.4. One hundred millilitres of 8.4%
10 mg sublingually was administered and frusemide 40 mg sodium bicarbonate was administered, and subsequent
intravenously was repeated. White cell count, haemoglobin blood gas analysis showed a pH of 7.48, bicarbonate of
concentration, packed cell volume, blood urea and serum 22.3 mmol.l21 and a base excess of 0.6. Although a chest
electrolytes were all within normal limits. Two hours later, X-ray was requested, there was a delay and it was taken
arterial pressure had increased to 190/110 mmHg and the 8 h later, by which time his lungs were clear.
patient was peripherally cyanosed (oxygen saturation was not Five hours following his admission to the ICU arterial
measured as there was no pulse oximeter available). pressure was 110/70 mmHg, Sao2 was 99% and arterial
Following further doses of frusemide and nifedipine and oxygen tension was 165 mmHg on an inspired oxygen
venesection to remove 150 ml of blood he was transferred to concentration of 40%, and the lung fields were clear to
the cardiology unit, where frusemide and nitroglycerine auscultation. Nasogastric aspirate at this time was the
intravenous infusions were started and an intravenous bolus colour of coffee grounds and in view of this, the following
dose of 0.25 mg digoxin was administered. As there was no investigations were carried out: bleeding time, clotting
response to drug therapy, he was transferred to the intensive time prothrombin time, serum bilirubin, alanine transa-
care unit (ICU) for positive pressure ventilation. minase (ALT), aspartate transaminase (AST), alkaline
On admission to the ICU, he was drowsy and slow to phosphatase, creatinine phosphokinase (CPK), creatinine
respond to commands. His respiratory rate was 40 kinase myocardial band (CKMB) and dengue antibodies.

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Anaesthesia, 2001, 56, pages 11781180 Case report
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Of these, alkaline phosphatase, CPK and CKMB were Not all parts of a plant are poisonous. For instance,
increased. Blood was negative for dengue immunoglobu- rhubarb leaves are toxic due to their high oxalic acid
lin (Ig)M and IgG antibodies. Ranitidine was adminis- content, although the stalks are edible [1]. The vast
tered and the nitroglycerine infusion was reduced and majority of plants are harmless, a small number may be
frusemide decreased to 40 mg twice a day. mildly toxic, and a few can be fatal if ingested in even
As the presenting symptoms were primarily gastro- small quantities. The jequirity bean (Abrus precatorius) falls
intestinal, the parents were questioned closely about the into this latter category.
food ingested on the day prior to admission, however, no Poisoning due to ingestion of jequirity beans is
significant features were identified in the history. extremely rare in Sri Lanka with only nine inquiries
On day 2, he was weaned from ventilatory support, a being made at the Poisons Centre in Sri Lanka over the
history of ingestion of two or more jequirity beans was last 10 years. As far as we were able to ascertain, none of
given by his parents who had obtained this history from his these cases have been reported in the literature.
classmates. It was revealed that he had bitten at least one of The very low incidence of poisoning is surprising as
the seeds before swallowing it, and had commented on its the plant is widely distributed in Sri Lanka. The seeds are
bitter taste. Ingestion had taken place 5 days prior to the easily accessible to children and are in fact used in
onset of symptoms. In the light of this information, the traditional games played in Sri Lanka during the Sri
treatment already given was reviewed. An alkaline diuresis, Lankan New Year.
which is recommended for jequirity bean poisoning, had The jequirity bean is known by various names such as
been carried out, although inadvertently. The urine output the rosary pea, prayer bead, Buddhist rosary bead, crabs
over the last 24 h was 1650 ml, blood urea was eye, weather plant or lucky bean [2]. It belongs to the
12.3 mmol.l21, and he had albuminuria with granular casts. Leguminoceae family, it is a slender creeper with pods
On day 3 he was extubated, the albuminuria persisted containing ovoid scarlet polished seeds with a black spot at
and blood urea increased to 22 mmol.l21. An echocar- the hilum. The seeds, roots and leaves are all poisonous,
diogram revealed only a mild mitral valve prolapse. He toxicity occurs only if the hard outer covering is pierced
was discharged from the ICU on day 4 with Sao2 of 97% by chewing or drilling holes in the seeds as is done for
breathing air, a heart rate of 108 beat.min21, and an beadwork, ornaments or jewellery [3].
arterial pressure of 120/80 mmHg. An ultrasound scan of This allows the toxin to leak out into the intestinal
the abdomen suggested early renal parenchymal disease. secretions and be absorbed. In five cases reported from
He was discharged from hospital his blood urea having Boston, the beans had been used as Christmas tree ornaments
decreased to 4.6 mmol.l21, with instructions to return for and jewellery [3]. The immature bean is pink in colour and
a repeat echocardiogram and ultrasound scan. the covering is soft, and can be chewed easily. The seeds are
extremely toxic with half to one seed being sufficient to cause
toxicity in children. The toxins found in the seeds are abrin (a
Discussion
lectin) and abric acid (a glycoside) [4]. Lectins are
Poisoning by plants is not common. Most plant ingestions glycoproteins that are known for their ability to agglutinate
occur in young children, and are due to berries and erythrocytes in vitro. The toxic effects of abrin consist of
houseplants. Older children may eat berries, fruits and seeds haemagglutination. There is also a direct action on
found in gardens, the latter being the case in this patient. In parenchymal cells, severe gastroenteritis and focal necrosis
adults, poisoning can be either accidental or intentional. in the liver and kidneys. There may occasionally be retinal
Plant poisons in Sri Lanka that are commonly ingested with haemorrhage [2, 4]. In spite of these toxic effects, extracts of
suicidal intent are nerium oleander and yellow oleander this plant have been used in Zimbabwe as a traditional herbal
which contain several cardiac toxins, and the tuber of the remedy in the treatment of urinary schistosomiasis, as it has
vine Gloriosa superba. The latter is also often ingested been found to be lethal to adult schistosomes [5]. Extracts
accidentally due to erroneous identification as an edible from the roots have been shown to exhibit potent antiplatelet,
tuber. The leaves of the plant Datura stramonium which anti-inflammatory and anti-allergic properties [6].
contain an alkaloid with anticholinergic properties is Following ingestion of jequirity beans there is a latent
another accidentally ingested poison. Poisoning due to period of < 3 days [1] and symptoms may persist for
mushrooms is extremely uncommon in Sri Lanka as they . 10 days [2]. Mortality rate is 5% and death may occur
are rarely used in traditional Sri Lankan food. Plant poisons up to 14 days after poisoning [4].
may also be ingested accidentally due to their use as herbal Patients usually present with nausea, vomiting, diar-
preparations in indigenous medicine, and ingestion of rhoea, abdominal cramps, haematemesis and melena,
plants sprayed with agricultural chemicals or contaminated which occur due to the irritant effects of abrin on the
with atmospheric pollutants can also lead to poisoning [1]. gastrointestinal mucosa. Acute renal failure may occur due

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Case report Anaesthesia, 2001, 56, pages 11781180
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to haemagglutination, haemolysis of red cells, hypovo- a newspaper to coincide with the Sri Lankan New Year,
laemic shock and a direct toxic effect on the kidneys [4]. during which time these beans are used. In countries in
Hepatotoxicity may occur leading to elevated levels of which the tree is not indigenous, legislation to impose
transaminases and serum bilirubin [4]. Drowsiness and labelling and import restrictions on items made from these
convulsions may also occur [4] contact with the eyes may beans can be implemented as was done in Massachusetts
cause irritation and blindness, and skin contact may result [3].
in a rash [7].
Treatment is supportive and symptomatic with intra-
venous fluids, correction of electrolyte imbalance and Acknowledgments
blood transfusions if required. Gastric lavage and emetics
should be used with caution due to the necrotizing action I would like to thank Dr J. P. Jayasuriya MB, BS FRCA,
of abrin. An alkaline diuresis with sodium bicarbonate Department of Anaesthesia, Chorley and South Ribble
will prevent precipitation of haemoglobin and its products District General Hospital, UK, for his help and sugges-
in kidney tubules [2]. tions in the preparation of this manuscript, and also Ms
In our case, the clinical presentation was unusual Marina Jayasinghe for secretarial assistance.
making the diagnosis difficult, the history of poisoning
being obtained late on direct questioning.
Pulmonary oedema associated with hypertension as a References
presenting symptom in jequirity bean poisoning has not 1 Cooper MR, Johnson AW. Poisonous plants and fungi. In:
been recorded in the literature. A suspicion of organo- Weatherall DJ, Ledingham JGG, Warrell DA, eds, Oxford
phosphorus poisoning was uppermost in our minds at the Textbook of Medicine, 3rd edn. Oxford: Oxford University
time of admission as he presented with gastrointestinal Press, 1996;1151.
symptoms and pulmonary oedema, and as organopho- 2 Arena JM, Poisoning 2 toxicity, symptoms treatments. In:
sphorus poisoning is the most common form of poisoning Newton I, Kugelmass, eds. Poisonous Plants, Reptiles, Arthro-
in Sri Lanka. However, this patient had a sinus tachycardia pods, Insects and Fish, 3rd edn. Springfield, IL: Charles C
on presentation, whereas organophosphorus poisoning Thomas, 1976; 496.
usually causes a bradycardia. Our differential diagnosis also 3 Hart M. Hazards to health jequirity bean poisoning New
included acute glomerular nephritis, rheumatic carditis, England Journal of Medicine 1963; 268: 8856.
viral myocarditis and dengue fever. 4 Fernando R. Management of Poisoning. Colombo: National
Poisons Information Centre, 1998;1921.
The delayed history of poisoning was for several
5 Ndamba J, Nyazema N, Makaza N, Anderson C, Kaondera
reasons. First, the time interval between ingestion and
KC. Traditional herbal remedies used in the treatment of
onset of symptoms is long, and therefore, the two events urinary schistosomiasis in Zimbabwe. Journal of Ethnopharma-
are not correlated. Second, as it was ingested away from cology 1994; 42: 12532.
home, the parents were unaware of the history. Third, it is 6 Kuo SC, Chen SC, Chen LH, Wu JB, Wang JP, Teng CM.
not widely known that Abrus precatorius is so highly toxic, Potent antiplatelet, anti inflammatory and anti allergic
and medical personnel are often unaware of this. isoflavaquinones from the roots of Arbus precatorius. Plant
Prevention is better than therapy, and this can be Medicine 1995; 61: 30712.
achieved only through measures to increase public 7 Henry JA, Wiseman HM. Management of Poisoning A
awareness of its toxicity. We have published an article in Handbook for Healthcare Workers. Geneva: WHO, 1997; 279.

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