Correspondence Address:
Subramanian Senthilkumaran
Departments of Accident, Emergency and Critical Care Medicine, Sri Gokulam Hospital and Research Institute, Salem - 636 004, Tamil Nadu
India

Full Text

Sir,

Traditional practitioners in rural areas use plant parts or extracts to treat various ailments. These herbal medicines are gaining popularity throughout the world as they are considered to be safe and effective. Here, we report a case of massive alopecia caused by Gloriosa superba poisoning.

A 20-year-old male presented to the emergency department with a history of bloody diarrhea (10-15 times per day), vomiting, and abdominal pain. The symptoms started three days earlier following consumption of some plant tuber for deworming as advised by a traditional practitioner. On examination, he was fully conscious, well-oriented, and hemodynamically stable with adequate room air saturation, but for toxic, dehydrated, and febrile status.He had abdominal distension and diffuses abdominal tenderness. Other systems were unremarkable. On the third of his admission, diffuse loss of scalp-hair was observed. It started insidiously as shedding of hairs in bunch while combing and on gentle pull. In addition, his hair became thinner, shorter, sticky, and unruly compared withearlier. There was no scarring, atrophy, graying, or exclamation mark hairs. A gentle pull of hair caused painless extraction of cluster of hairs comprising more than 30 hairs. Other body hairs were spared and were in normal in density. A trichogram revealed 95% of the hairs in anagen phase with dystrophic follicles. Within next two days, most of the hair on his scalp had fallen and he became totally denuded bald scalp [Figure 1]. His hematological profile revealed pancytopenia, whereas bloodsugar, electrolytes, thyroid profile, serum ferritin, testosterone, and chest X-ray were normal. He had altered renal and liver functions. His electrocardiogram showed a sinus tachycardia and arterial blood gas analysis revealed high anion gap metabolic acidosis. He had sonographic evidences of hepatic steatosis.The stool sample was positive for Benzidine test, but negative for ova or cyst, culture, and Clostridium difficile serotoxin. He improved with symptomatic treatment. His altered renal and liver functions settled to normal status by 10 th day of admission and got discharged on 12 th day. Meanwhile, the tuber which was consumed by him was identified as that of Gloriosa superba. Colchicine, the major active alkaloid of Gloriosa superba, is attributed for the toxicity. Alopecia caused by colchicine has been known for a long time [ 1] but is rarely observed today because of its restricted use. At follow-up after 3 months, hairs started to grow. Toxin-induced alopecia is usually described as a diffuse nonscarring alopecia which is reversible upon detoxification.{Figure 1}

The frequency and severity of alopecia depend on the toxin as well as on individual predisposition. Colchicine has anti-mitotic properties that arrests mitosis in metaphase. Cells with a high turnover and metabolic rate, like the intestinal epithelium, hair follicles, bone marrow cells, etc., are susceptible as seen in this case. It may affect the hair follicles by inducing an abrupt cessation of mitotic activity in rapidly dividing hair matrix cells (anagen effluvium). Gooneratne [2] had documented massive generalized alopecia in a female 11 days after poisoning by Gloriosa superba. Clinicians should always consider the possibility ofingestion of Gloriosa superba when the patient develops shedding of hairs and alopeciain a case of unexplained gastroenterocolitis. It is also important for the practitioners to consider the adverse effects of traditional medicines in the differential diagnosis, when the symptoms and signs are perplexed and do not fit in with conventional or common conditions.

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