Rom J Leg Med [24] 308-311 [2016]

DOI: 10.4323/rjlm.2016.308
© 2016 Romanian Society of Legal Medicine 

Datura poisoning, clinical and laboratory findings. Report of five cases

Mohammad Arefi1, Nasrin Barzegari1, Mahboubeh Asgari2, Siamak Soltani3, Naeimeh Farhidnia3, Fardin Fallah3,*

_________________________________________________________________________________________
Abstract: Introduction. Plants of Datura species contain belladonna alkaloids that can cause central and peripheral
anticholinergic effects. Abuse of Datura plants for their hallucinogenic effects is growing among adolescents and young adults.
Datura poisoning has caused a diagnostic challenge in medical emergency wards. In this article we report 5 cases of Datura
toxicity at Clinical Toxicology Emergency of Baharloo Hospital, Tehran, Iran during Summer-Fall 2015, and discuss their clinical
presentations and laboratory findings.
Cases. All 5 cases with Datura toxicity were young males and had intentionally used the plants. Mean duration of
hospitalization was 3.2 days. Three cases were multiple-drug abusers. Mydriasis, tachycardia, tachypnea and flushing alongside
with psychotic-like signs and symptoms were observed in all cases. Elevation of liver enzymes was present in three of cases but
without clinical significance. Raised LDH or CPK in four patients were without myoglobinuria and evidence of rhabdomyolysis
and these biomarkers returned to normal levels by supportive care. All patients discharged with complete recovery and there was
no need to ICU admission.
Discussion. With the absence of routine laboratory diagnostic tests for alkaloids and complex and confusing presentations
of Datura intoxication, diagnosis of such cases is difficult. Physicians' clinical suspicion and sufficient knowledge play the mainstay
roles in appropriate and timely diagnosis and management of cases with Datura toxicity. Since regulatory legislation wouldn't be
successful in halting the availability of natural plants, the best strategy to prevent Datura abuse is informing people about the
adverse effects of these plants.
Key Words: datura stramonium, poisoning, abuse, anticholinergic, laboratory findings, liver function tests, rhabdomyolysis.

N ew features of drug abuse and addiction

are emerging rapidly. Many alternatives
for traditional drugs are being introduced, based on
demands of abusers [1]. Besides chemicals, some of
natural substances like plants are also being used as
alternatives for illicit drugs with similar desired effects
like hallucinogenic, sedative or stimulating effects [2].
The abuse of some of these herbals are welcomed by
consumers because of their availability, low prices, lack of
regulatory legislation and the commonly accepted idea of
their higher safety compared to man-made or chemical
preparations [2]. "Datura stramonium" species - also
called "Jimson Weed" or "Angel's trumpet" - comprises
of plants that are being abused as herbal psychoactive
substances, usually by adolescents or youth [3]. Datura
plants contain belladonna alkaloids (like Atropine,
Scopolamine and Hyoscyamine), which cause central
and peripheral anticholinergic effects [4-6]. Diagnosis
and management of Datura poisoning is a challenge for
emergency wards due to its confusing clinical picture,
unavailability of routine laboratory diagnostic tests and
physicians' unfamiliarity with this form of drug abuse
[2].
In this article we report 5 cases of intentional

1) Tehran University of Medical Sciences, Baharloo Hospital, Department of Clinical Toxicology, Tehran, Iran
2) Forensic Pathology Organization, Tehran, Iran
3) Iran University of Medical Sciences, Department of Forensic Medicine and Toxicology, Tehran, Iran
* Corresponding author: Email: fardin.fallah@gmail.com

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Datura poisoning, admitted to Baharloo Hospital - a received 10mg of intravenous Diazepam at Emergency
referral center of toxicology in Tehran, Iran - during Room for sedation and hospitalized at Clinical
Summer-Fall 2015. We describe their presentation, Toxicology Ward for supportive care. After 48 hours, he
clinical course and laboratory findings. discharged with recovery of symptoms. His raised LDH
had been steadily declining at repeated laboratory tests.
Case Descriptions Mild elevation of Liver Function Tests was persistent
and he was advised on further outpatient follow-up for
Case 1 underlying liver diseases.
A 29-year-old man developed hallucination,
vomiting and diarrhea two hours after drinking a cup Case 2
of herbal tea containing “Datura flower” taken from A 23-year-old male patient was referred to
his friend for breakfast. At admission, he had mydriatic General Emergency Ward with nausea and vomiting,
pupils, flushing, persecutory delusions, vomiting and disorientation, delusions, agitation, tachycardia and
dry mouth. Vital signs at admission are available in mydriasis. He was first admitted at Psychiatric Emergency
Table 1. There was no previous history of any substance Ward but after hours, referred to Clinical Toxicology
abuse. Findings of our routine laboratory studies (CBC, Emergency with suspicion of substance poisoning. In
Ionograms, Liver Function Tests, Renal Function Tests, detailed history, his friends reported ingestion of powder
Lactate Dehydrogenase or LDH, Creatine Phosphokinase of Datura seeds for stimulation effects, before the onset
or CPK and Urine Screening Test for common toxins) of symptoms. There was no previous history of drug
are available in Table 2. Due to evident history of Datura abuse or addiction. Vital signs and important laboratory
intoxication, there was no diagnostic challenge. He findings are summarized in Tables 1 and 2. He received
Table 1. Important clinical and paraclincial findings of five cases of Datura poisoning at Clinical Toxicology Emergency of
Baharloo Hospital, Tehran, Iran, during Summer-Fall 2015.
Case Pulse Rates/ Axillary Respiratory Blood ABG Findings
EKG Findings O2 Saturation
Number min Temperature (°C) Rates/min pressure(mmHg) at admission
Sinus
1 108 37.8 17 121/70 98% Normal
tachycardia
Sinus Respiratory
2 120 38.4 23 150/80 97%
tachycardia acidosis
Sinus Respiratory
3 119 38 19 120/80 98%
tachycardia acidosis
Sinus Respiratory
4 110 38.2 18 143/70 98%
tachycardia acidosis
Sinus
5 105 37.5 15 130/75 97% Normal
tachycardia
All findings have been documented at the time of admission to Clinical Toxicology Emergency.

Table 2. Laboratory findings of five cases of Datura poisoning at Clinical Toxicology Emergency of Baharloo Hospital, Tehran,
Iran, during Summer-Fall 2015.
Rhabdomyolysis
Blood Kidney Liver Function Tests
Case Indicators
Sugar Function Ionogram AST ALT ALKP LDH CPK CBC Findings Urine Screening Test
Number
(mg/dL) Tests (U/L) (U/L) (IU/L) (U/L) (U/L)
WBC=10200/
1 122 Normal Normal 64‫٭‬ 48‫٭‬ 137 501‫٭‬ 119 Negative
mcl (PMN=88%)
2 100 Normal Normal 36 69‫٭‬ 188 523‫٭‬ 73 Normal Negative

WBC=12200/
3 93 Normal Normal 30 27 285 560‫٭‬ 233‫٭‬ THC and Tramadol
mcl (PMN=86%)

4 97 Normal Normal 38 54 217 180 220 Normal THC and Tramadol

5 102 Normal Normal 44‫٭‬ 48 310 488‫٭‬ 1204‫٭‬ Normal THC and Tramadol

All tests have been applied on the blood samples of patients obtained at the time of admission to Clinical Toxicology Emergency. AST(SGOT) = Aspartate transaminase.
ALT(SGPT) = Alanine transaminase. ALKP = Alkaline Phosphatase. THC = Tetrahydrocannabinol. * Points to the elevated laboratory test values, based on the age-
standardized normal ranges of our tests.

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Arefi M. et al. Datura poisoning, clinical and laboratory findings
Physostigmine at Clinical Toxicology Emergency due to
severity of his anticholinergic signs; sedatives also had
been prescribed at Psychiatric Emergency. He stayed at
Clinical Toxicology Ward for 3 days and discharged in
good health condition. At discharge, his elevated ALT
and LDH were in normal range.
Case 3
A 25-year-old male patient with the history
of multiple-drug abuse was admitted to Toxicology
Emergency Ward after smoking a preparation of
“Cannabis and seeds of Datura”. He was very agitated
and showed aggressive behaviors and tried to harm
himself. Mydriasis, flushing, nausea and thirst were
present. His vital signs and laboratory tests are available
in Tables 1 and 2. Due to severe agitation, he received 20
mg of intravenous Diazepam in two doses, one dose of
Midazolam and one dose of Haloperidol at first day of
admission. He transferred to Clinical Toxicology Ward
after sedation and was under supportive care for 4 days.
He raised concerns about probable rhabdomyolysis
among physicians. Neither myoglobinuria, nor any
indicative symptom or sign of rhabdomyolysis were
detected during hospital stay. He discharged when his
elevated LDH and CPK returned to normal.
Case 4
A 17-year-old student brought to Toxicology
Emergency by his friends due to severe agitation,
hallucination, flushing and vomiting after taking a
cup of herbal tea containing “Cannabis and Datura”.
Tables 1 and 2 show his vital signs and laboratory tests.
While there was no reported history of any drug abuse,
Urine Screening Test was positive for Tramadol and
Cannabis. He received 20 mg of intravenous Diazepam
at Emergency Room but due to uncontrollable agitation,
Midazolam was also prescribed. He stayed at Clinical
Toxicology Ward for two days and discharged in good
condition.
Case 5
A 17-year-old boy with the history of alcohol
abuse, smoking and previous drug poisoning was
brought to Clinical Toxicology Emergency Ward by his
parents because of visual and hearing hallucinations
and severe agitation. At admission, he presented with
mydriasis, flushing and other anticholinergic signs
(Table 1). Laboratory tests are summarized in Table 2. At
Emergency Room he received two doses of intravenous
Diazepam and one dose of Midazolam to control his
severe psychotic symptoms. With the elevated LDH
and CPK levels, he was suspicious for rhabdomyolysis.
He was hospitalized for 5 days and received intravenous
fluids. Fortunately, there was no myoglobinuria and
symptoms of rhabdomyolysis during hospitalization. His
raised LDH and CPK levels had been gradually reducing
310
in serial tests and mild elevated AST returned to normal
at the time of discharge.
Discussion
Datura plants grow spontaneously in most
parts of the world and have been used in folklore and
traditional medicine as herbal treatments for many
medical problems [7]. Intentional use of Datura plants
for their hallucinogenic and stimulating effects is growing
especially among adolescents and youths [8]. Different
Datura plants have various amounts and proportions of
alkaloids and therefore severity of symptoms in poisoned
patients may vary [4]. In each plant all parts contain
alkaloids, but they are greatest in ripe seeds [4, 7]. Central
effects of alkaloids are usually psychotic-like signs and
symptoms including delirium, hallucination, confusion,
disorientation, agitation, aggression, photophobia,
blurred vision, seizure and even coma [3, 4, 7, 9].
Peripheral signs of alkaloids are mydriasis, dry skin and
mouth, flushing, tachycardia, fever, hyper or hypotension
and urinary retention [4, 9, 10]. Treatment is usually
supportive care, fluid replacement and Benzodiazepines
for sedation; but in severe cases Physostigmine may be
used for the alleviation of anticholinergic symptoms [4,
9]. Patients with Datura poisoning usually recover soon,
with short duration of hospitalization [4, 5, 11]. Despite
benign nature of Datura poisoning in most cases, reports
of fatalities [12], coma [7], seizure [7], rhabdomyolysis
[13] and impairment of liver function tests [14] are also
available.
In this report, we described 5 cases of Datura
intoxication referred to Clinical Toxicology Emergency
Ward of a toxicology referral center in Tehran, Iran. All
cases were hospitalized in Clinical Toxicology Ward
with mean duration of 3.2 days. Mydriasis, tachycardia,
hyperthermia and altered mental condition were present
in all patients. Urine Screening Test showed multiple-drug
abuse in three of cases. Leukocytosis and mild elevation
of liver function tests were observed in two and three
of patients, respectively. Elevation of rhabdomyolysis
biomarkers (LDH or CPK) were observed in four cases.
There was no need to ICU admission and all patients
treated with supportive care and sedation. Just one
patient received Physostigmine due to severity of his
anticholinergic symptoms.
With the available reports of rhabdomyolysis
following Datura poisoning [13], elevation of LDH
and CPK in our patients led to physicians' concerns
for probable rhabdomyolysis. None of these patients
developed myoglobinuria and they showed reduction
of CPK and LDH in serial laboratory tests with
only conservative managements. As mentioned by
Blackford et al., [15] the rise of “Creatine Kinase” is
not uncommon in Datura ingestion but it is usually
without any clinical sign and neither accompanied with
Romanian Journal of Legal Medicine Vol. XXIV, No 4(2016)

rhabdomyolysis. Few monographs in the literature have
reported impaired Liver Function Tests in patients with
Datura poisoning [14]. Most available investigations
about the hepatotoxicity of Datura are experimental
studies on animal subjects and results are with
controversy [16-20]. Some of these experimental studies
show no effect of Datura on liver function and enzymes
[16, 17]; others report hepatic toxicity and rise of liver
enzymes in prolonged or heavy Datura exposures [18-
20]. Elevation of liver enzymes among our patients was
mild and without any clinical significance. However,
interpretation of laboratory tests among our patients
is not easy and accurate because there is no reliable
history of the duration of Datura abuse and some
cases are multiple-drug abusers. Consistent with our
cases, rise of WBC at acute phase of Datura toxicity
have been reported in experimental rats [18]. Further
methodologically-designed studies are needed to find
the impact of Datura on different human organs and
serum biomarkers.
Legislation can't easily control availability of
natural herbal substances as they grow spontaneously
anywhere; thus the most important measures to halt
Datura abuse is informing people with side-effects and
consequences of abuse and dependency. With the absence
of routine laboratory diagnostic tests for alkaloids
and complex and confusing presentations of Datura
intoxication, diagnosis of such cases is difficult and
must be made on clinical findings and high suspicion of
physicians. Physicians should have enough information
about the physiopathology, clinical and paraclinical
features of Datura poisoning to make their best diagnosis
and management. In patients with anticholinergic and
psychiatric symptoms, Datura poisoning should always
be considered.
Conflict of interest. The authors declare that
they have no conflict of interest concerning this article.
Ethical Considerations. Written informed
consent for this report was obtained from all described
patients and also from fathers of cases 4 and 5.

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