A Case of Strychnine Poisoning from a Southeast Asian Herbal Remedy

Strychnine is a highly toxic alkaloid found in both naturally occurring compounds and commercial products. Extracts of fruits from the strychnine plant have been used in Southeast Asia as remedies for various illnesses. We describe strychnine poisoning from ingestion of a Southeast Asian herbal supplement quantitatively confirmed by serum and urine analysis.

A 40-year-old Cambodian woman presented to the emergency department with a complaint of jaw pain and spasms. The patient was staying with a relative and drank 2 oz from an unmarked bottle that she thought contained vodka. She then developed trismus and abdominal cramping, after which a family member said the bottle contained a compound called "slang nut." Her vital signs were as follows: heart rate 102 beats/min, blood pressure 142/72 mm Hg, respiratory rate 20 breaths/min, and oxygen level 100%. The physical examination revealed no significant abnormalities. Serum toxicologic screens were negative except for strychnine levels that revealed a serum concentration of 350 ng/mL and a urine concentration >200 ng/mL. The patient was observed for 2.5 h and discharged with no long-term complications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Strychnine is a well-known compound that has been used in poisons, rodenticides, and performance enhancing drugs for years. In the Western world, strychnine is a much less common poisoning given that its use has been restricted because of the potential for severe toxicity; however, given its potentially high mortality, it is important to be aware of other sources of exposure, including those from herbal and homeopathic remedies.