79 J Gandhara Med Dent Sci April - June 2025 : : CASE REPORT INTOXICATION BY THE BERRIES OF CORIARIA MYRITFOLIA - A CASE REPORT Mohsin K han 1 Abdur Rehman 2 Faiza K han 3 Naima Khan 4 ABSTRACT Coriaria Myritfolia is a shrub that grows 2 - 3 meters tall. The exact local n ame of the plant is unknown, but in Hindi, some species of Coriaria are called “Divi - Divi”. We report a case of intoxication following ingestion of fruits of Coriaria Myritfolia. A 6 - year - old boy, the previously healthy child, was brought to the pediatric emergency department after accidentally ingesting red berries from a tree growing wild in district Haripur. On inquiry, the parents of the child reported that after the ingestion of an unknown quantity of fruit, the child felt nauseated and vomited. We so ught care from a local Physician who treated the outpatient as a case of food poisoning. The child didn’t get better and, after 4 - 6hr from the ingestion of berries, felt a generalised - tonic - clonic seizure with up rolling of the ball and incontinence. The p arents immediately brought the child to a tertiary care hospital. Upon arrival at the hospital, the patient was somnolent with generalised hypotonia. The Prophylactic 10mg Diazepam (0.4mg/kg) is given per rectal. The peripheral intravenous line passed. Ini tial labs were not conclusive except for hypokalemia and metabolic acidosis. He was started on the prophylactic antiseizure elixir of Phenobarbital 5mg/kg/day and levetiracetam 400mg/ day. CT brain was normal. The patient was discharged after 3 rd day of ad mission on anti - seizure medications. We concluded that the intoxication with the fruits of Coriaria Myritfolia could be managed successfully if the patient came to the hospital within 6 - 8 hours with anti - seizure medications. KEYWORDS: Divi - Divi, Coriaria Myritfolia, Pakistan, Toxicity, Sweet Poison How to cite this article Khan M, Rehman A, Khan F, Khan N . Intoxication by the Berries of Coriaria Myritfolia - A Case Report . J Gandhara Med Dent Sci. 2025;12(2): 79-81. http://doi.org/10.37762/jgmds.627 Date of Submission: 26 - 01 - 2025 Date Revised: 19 - 03 - 2025 Date Acceptance: 20 - 03 - 2025 1 Resident, Department of Pulmonologist , Ayub Teaching Hospital , Abbottabad 2 Resident, Department of Physician , Ayub Ayub Teaching Hospital, Abbottabad 4 Resident, Department of Gynecologists and Obstetric, Ayub Teaching Hospital , Abbottabad Correspondence 3 Faiza Khan, Internee at Ayub Teaching Hos pital , Abbottabad +92 - 343 - 9289701 faezakhan999@gmail.com INTRODUCTION Coriaria myrtifolia is known by a variety of different names; it is also called sweet poison due to its sweet berries; it produces reddish, attractive, shiny berries which are love ly. Africa criteria is commonly known as Redoul or Redoulin in Europe and North Africa - the most common name used in botanical and horticulture context. 1 In America and the Caribbean, this plant is known by the name Divi - Divi. The name divi - divi originated from Hindi, which means - to split . Khyber Pakhtunkhwa is commonly known as Nagar or Nagari, while in some areas of Pakistan, it's known as Kharay. 2,3 Coriaria myrtifolia is a 2 - 3 meters tall shrub found in the Himalayas, usually between 1000 - 2500 meters a bove sea level. This plant is distributed in some areas of all provinces of Pakistan. In Khyber Pakhtunkhwa, the common areas where this shrub grows and is found are Swat, Dir, Malakand, Buner, Shangla and Kohistan. Both the leaves and the fruit contain a neurotoxin called coriamyrtin and didehydrocoriamyrtin. 3,4 These toxins have multiple actions on neurons; these toxins inhibit acetylcholine esterase (AChE), which in return increases the level of acetylcholine in the brain. Coriamyrtin also has antagonist ic activity on GABAA receptors. 4 We report a rare case of coriaria myrtifolia, which gets complicated by brain toxicity. The case was managed successfully in the emergency department of Ayub Medical Teaching Institute Abbottabad. CASE REPORT: A 6 - year - o ld boy, the previously healthy child, was brought to the pediatric emergency department after accidentally ingesting red berries from a tree growing wild in district Haripur. The family bring the branch of the shrub shown in figure 01. On inquiry, the pare nts of the child reported that after the ingestion of an unknown quantity of fruit, the child felt nauseated and vomited. We sought care from a local Physician who treated the outpatient as a case of food poisoning. The child didn’t get better and, after 4 - 6hr from the ingestion of berries, felt a generalized - tonic - clonic - seizure with up rolling of the ball and incontinence. The parents immediately brought the child to a tertiary care hospital. Upon arrival at the hospital, the patient was somnolent (GCS: E 3, V4, M5), generalised hypotonia, but the hemodynamic status was good. The weight of the baby was 25 kg at presentation. The Prophylactic 10mg Diazepam (0.4mg/kg) is given per rectal. The peripheral intravenous line passed. Appropriate labs were ordered, including Complete blood count, blood sugar, and electrolytes, including calcium. The patient felt another
80 J Gandhara Med Dent Sci April - June 2025 was weaned gradually. episode of seizures, which was aborted with 2.5mg (100 microgram/Kg) of intravenous midazolam diluted in 5cc normal saline. The patient was admitted to the pediatric unit. The nasogastric tube was passed, and air was placed in the mouth. He was started on a prophylactic antiseizure elixir of Phenobarbital 5mg/kg/day (Elixir Debritone 20mg/5ml) and oral solution of levetiracetam 400mg/ day in 2 divided doses (syrup race 100mg/ml). The serum chemistry shows calcium of 7.8 mg/dl, sodium of 129mg/dl, potassium of 2.8mg/dl and chloride of 98mg/dl. The Atrial blood gases show a PH of 7.30, HCO3 of 19mg/dl, oxygen of 75mmof hg and CO2 of 42mm of Hg. The finge r - stick glucometer shows a reading of 5.5 milli mole. On the next day, the brain CT was ordered to rule out an intracranial lesion, which also turned out to be expected. The patient was oriented to time and place, and his oral intake improved, but he comp lained of perioral numbness and flickering movements in the facial muscles. His chewing strength was expected, and the cranial nerves were intact. The rest of the examination was unremarkable. The patient was discharged after 3 days, and a follow - up was ma de after 4 days. The patient was continuing on antiseizures for 4 days. On the follow - up visit, the patient’s examination was regular. No adverse event was noted. The syrup Levetiracetam was stopped, and the phenobarbital dose Figu re 1: Berries of Coriaria Myritfolia Bought by Patients’ Parents DISCUSSION Coriaria myritfolia is a shrub which bears fruit (toxic berries) from June to September. The child usually confuses the berries of criteria with other edible berries, so poison i s common in the young age group. 5,6 Both the leaf and fruit intoxication are reported in the literature, but in our case, intoxication occurs due to fruit. The toxic dose is not quantified precisely, but 2 - 3 berries are enough to produce the neurological s ymptoms and can require admission to the hospital. 4 Some studies have suggested that intoxicated chemical decreases the GABA levels in the brain, which leads to seizures. 7,8 Children are the most common victims of this plant because its berries (fruit) ar e attractive, charming and sweet; hence, it is also called sweet poisoning. We observe only seizures as a neurotoxicity of Coriaria, while other studies also reported trismus, opisthotonus, apnea and coma. 4 In this case, we successfully treated the neuroto xicity with Diazepam, Phenobarbital and levetiracetam. In a case reported by de Haro L et al., an intoxication of 8 years old child was treated successfully with benzodiazepine. In a letter to the editor by Yen - Chin Chen, he reported the successful treatme nt of 2 such cases with diazepam. Our case delineated the neurological toxicity of Coriaria species, which is potentially life - threatening if it cannot be intervened in a timely. We provided the details of local names, geographical areas, and pictorials t o identify them earlier and help the emergency physician identify poisonous plants early. LIMITATIONS This report is limited by the lack of confirmatory toxicological analysis, reliance on clinical presentation, and absence of long - term follow - up. Furthe r studies are needed to establish standardized management protocols. CONCLUSIONS The delayed toxicity of sweet poison led to an imbalance in neurotransmitters in the brain. This led to seizure genic activity in the brain, which could lead to irreversible brain damage, especially in young children. The fruit(berries) is toxic, and 2 - 3 can produce harmful effects. Patients should be admitted after intoxication because the neuronal side effects are delayed. Early management within 6 - 8 hours can prevent furth er seizures and permanent brain damage. CONFLICT OF INTEREST: None FUNDING SOURCES: None REFERENCES 1. Coriaria myrtifolia. CABI Compendium: CABI Publishing; 2019. 2. Ammad Waheed Q, Zafeer S, Muhammad Z - u - H. Diversity and Distribution of Endemic Fl ora in Pakistan. Proceedings of the Pakistan Academy of Sciences: B Life and Environmental Sciences. 2023;60(2). doi: 10.53560/ppasb(60 - 2)777. Intoxication by the Berries of Coriaria
81 J Gandhara Med Dent Sci April - June 2025 3. Awasthi P, Bargali K, Bargali SS, Khatri K, Jhariya MK. Nutrient Partitioning and Dynamics in Coriaria nepale nsis Wall Dominated Shrublands of Degraded Hills of Kumaun Himalaya. Frontiers in Forests and Global Change. 2022;5. doi: 10.3389/ffgc.2022.913127. 4. de Haro L, Pommier P, Tichadou L, Hayek - Lanthois M, Arditti J. Poisoning by Coriaria myrtifolia Linnaeus : a new case report and review of the literature. Toxicon. 2005;46(6):600 - 3. doi: 10.1016/j.toxicon.2005.06.026. 5. Abdel - Massih RM, El Beyrouthy M. Plants used in Lebanon and the Middle East as Antimicrobials. Medicinal Plants as Anti - Infectives: Elsevie r; 2022. p. 59 - 101. 6. Boudkhili M, Greche H, el Cadi MA, Meddah B, Zellou A, Bounihi A, et al. ACUTE AND SUB - CHRONIC TOXICITY STUDY OF CORIARIA MYRTIFOLIA LEAVES EXTRACT IN RODENTS. 2014. 7. Chen Y - C, Chen H - Y, Huang L - C, Yu J - H. Sweet poison: seizures in two patients with <i>Coriaria intermedia</i> poisoning. Clinical Toxicology. 2020;59(6):533 - 4. doi: 10.1080/15563650.2020.1832677. 8. Coriaria arborea (tree tutu). CABI Compendium: CABI Publishing; 2019. CONTRIBUTORS 1. Mohsin K han - Concept & Design 2. Abdur Rehman - Critical Revision 3. Faiza K han - Drafting Manuscript 4 . Niama K han - Final Approval LICENSE: JGMDS publishes its articles under a Creative Commons Attribution Non-Commercial Share-Alike license ( CC-BY-NC-SA 4.0 ). COPYRIGHTS: Authors retain the rights without any restrictions to freely download, print, share and disseminate the article for any lawful purpose.It includes scholarlynetworks such as Research Gate, Google Scholar, LinkedIn, Academia.edu, Twitter, and other academic or professional networking sites. Intoxication by the Berries of Coriaria