Transcript A case report on Liu Shen Wan Poisoning

A case report on Liu Shen
Wan (六神丸)Poisoning
History
 A 26 year old man
Accidentally taken 100 tablets of
Liushenwan
He got mild upper respiratory tract
infection
Took the pills as remedy
Symptoms started 1 hour later
Felt dizzy and nauseated
Palpitation, chest discomfort and limb
weakness
No vomiting
No epigastric pain
Physical Examination
Vitals were stable
BP 145/79
Pulse 77/min
Afebrile
Cold extremities
GCS 15/15
Abdomen soft and nontender
Bowel sound sluggish
Chest clear, equal AE
Heart sound dual, no murmur
No focal neurological signs
H’stix: normal
ECG : sinus rhythm, no ischemic changes
CXR : normal
Admit to medical ward subsequently
CBP
R/LFT
Amylase
Paracetamol, Salicylate level: normal
Symptoms subsided quickly
Discharge the next day after admission
Liu Sheng Wan 六神丸
Well known Chinese composite herbal
medication
Six 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 China
4 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:
Oral
As 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 digoxin
Onset time : 20min – 2 hr
Toxic reaction can begin after 12 hours of
ingestion
Symptoms 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 monitoring
Reporting to and consult with the local
poison control centre
General 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
Decontamination
Enhanced elimination
Chelating agents:
Unithiol (DMPS)
Dimercaprol (BAL)
Oral succimer (DMSA)
NiuHuang牛黃
Cow’s gall stone
Mythical beliefs: strengthen heart,
tranquilizing, detoxifying and antipyretic
Used in heart disease, anemia, sepsis and
alcoholic intoxication
Toxic effect: hypotensive, gastroparesis,
increase prolactin secretion in rats
SheXiang麝香
Known as musk
Secretion 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 epilepsy
Toxic effects: uterine contraction,
antiplatelet, hypotensive
BingPiang冰片
Borneol
Derivative of the stem in Dipterocarp
(tropical tree).
Ingredients of turpentine and camphor
Analgesic, anti-inflammatory
Used in conjunctivitis, pharyngitis, cellulitis
and skin ulcer
Toxic effect: uterine contraction in second
and third trimester of gestation in rats
Zhen Zhu珍珠
Tranquilizing and anti-inflammatory
Used 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 old
Male : 22 cases (53.7%)
Female: 19 cases (46.3%)
Time of onset: 20 min – 2 hr
Symptom 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.
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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 rash
4: scarletiform drug rash
1: eczematous drug rash
1: drug rash with fixed pattern
1: purpuric drug rash
1: anaphylatic shock
1: 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