Health Drink Poisoning – An Unusual Case of Bottle Gourd Toxicity

Abstract

Bottle gourd, popularly known as “Lauki” is a commonly used vegetable throughout the world including India. Its juice is considered a “health tonic” for chronic ailments by practitioners of alternate therapy and nutritionist. It is essential for emergency physicians to be aware of this toxicity, especially in tropical countries like India, where alternate therapy practices are prevalent. We present the case of a 35-year-old man who consumed concentrated bottle gourd juice and subsequently experienced multiple episodes of vomiting, bloody diarrhea, and giddiness. The patient was resuscitated and stabilized with crystalloid fluids, proton.pump inhibitors, and antiemetics, and admitted to the critical care unit. The patient was discharged in stable condition after 4 days of hospitalization. Bottle gourd toxicity treatment is symptomatic, and there is no specific antidote for this toxicity. It is important to early diagnose bottle gourd toxicity, especially in countries where it is commonly used as a health tonic.

INTRODUCTION

Bottle gourd, also known as “Lauki,” is a commonly used vegetable in India.[1] Bottle gourd juice is considered a “health tonic” for chronic ailments by alternate therapy practitioners.[2] The bitter taste of the juice is imparted due to a cytotoxic compound called cucurbitacin, which is a tetracyclic triterpenoid.[1,3] The toxic reaction can show symptoms such as abdominal pain, vomiting, diarrhea, hematemesis, hematochezia, shock, and death.[2,3] Over the last few years, there have been cases of toxicity due to the consumption of bottle gourd juice, leading to multiple episodes of vomiting and upper gastrointestinal (UGI) bleeding. It is essential for emergency physicians to be aware of this toxicity, especially in tropical countries like India, where alternate therapy practices are prevalent.

CASE REPORT

Patient information

A 35-year-old male with a history of multiple episodes of vomiting, with streaks of blood and food particles, and complaints of loose stools 8–10 episodes with frank blood. The vomitus was nonprojectile and nonbilious. The patient had developed severe giddiness by evening and presented to the Emergency Department of Manipal Hospital Whitefield, Bengaluru, at 21:45 h of December 25, 2022.

Timeline

The patient gave a history of consuming approximately 200 ml of concentrated bottle gourd juice on the same day morning, which was bitter in taste, and developed symptoms 30 min following consumption. The patient has a past medical history of psoriasis and has been taking homeopathic medicine for the past 4 years. The medication was provided by a homeopathic practitioner in a nonlabeled form, so the patient was unaware of the composition of the prescribed homeopathic medicine.

There is no history of fever, abdominal pain, breathing difficulty, chest pain, loss of consciousness, seizures, headache, transient obscuration of vision, or diplopia.

Clinical findings

On examination, the patient was conscious and oriented with cold and clammy extremities. Peripheral pulses were feeble with tachycardia (heart rate: 114/min), blood pressure was 70/50 mmHg, capillary refilling time was >2 s, respiratory rate was 28 breaths/min, and oxygen saturation was 99% at room air. There was no rash, edema, ecchymosis, clubbing, cyanosis, or lymphadenopathy. Systemic examination revealed mild abdominal distension.

Diagnostic assessment

The initial evaluation of ultrasound scan and 2D echo was unremarkable. Electrocardiogram showed sinus tachycardia, and blood gas analysis showed metabolic acidosis. Computed tomography abdomen revealed mild wall thickening of the gastric body and anterior pyloric antrum [Figure 1]. The initial blood reports upon admission revealed impaired renal function [Table 1]. The urine routine exhibited a turbid appearance with mild proteinuria, while the urine culture report was negative. In the following days, we focused on monitoring the patient's clinical improvement and only repeated the creatinine and hemoglobin tests.

Figure 1.

Endoscopy images - Diffuse edema in the pyloric antrum and gastric body of the stomach, respectively

Table 1.

Description of investigation on respective admission days

Test	Day 1	Day 2	Day 3	Day 4
WBC count (/mm3)	18,120
Hemoglobin (g/dL)	19.6	14.2
Hematocrit (%)	59.7
Platelet count (/mm3)	214,800
Neutrophils (%)	94.3
C reactive protein (mg/L)	4.75
Urine routine protein/albumin	Present
BUN (mg/dL)	19	17.57
Serum creatinine (mg/dL)	2.26	2.44	2.14	2.09
Serum sodium (mmol/L)	137
Serum potassium (mmol/L)	4.5
Total bilirubin (mg/dL)	1.38
SGOT (IU/L)	272
SGPT (IU/L)	276
ALP (IU/L)	99
GGT (IU/L)	110

WBC: White blood cell, BUN: Blood urea nitrogen, SGOT: Serum glutamic-oxaloacetic transaminase, SGPT: Serum glutamic-pyruvic transaminase, ALP: Alkaline phosphatase, GGT: Gamma-glutamyl transferase

Therapeutic intervention

Two wide-bore cannulas were inserted and intravenous crystalloids were started. An empirical broad-spectrum antibiotic (piperacillin with tazobactam) was administered, along with antiemetics, proton-pump inhibitors (PPIs), and other supportive measures. Right radial arterial cannula was secured following hospital protocol. He was resuscitated with 2000 ml crystalloids, after which blood pressure was improved to 100/60 mmHg.

A provisional diagnosis of gastrointestinal (GI) sepsis with multi-organ involvement (renal and hepatic) and UGI bleeding, with a history of bottle gourd juice consumption, was considered. The patient was subjected to endoscopy by the gastroenterology team. The patient significantly improved after initial resuscitative measures in the Emergency Department. The patient was admitted to critical care for overnight monitoring and was transferred to the ward the following day as he was symptomatically better. The patient had no diarrhea for the next 2 days with good urine output. He was discharged on the 4^th day of hospitalization on December 29, 2022, with oral PPIs. The rest of the hospital stay was uneventful.

DISCUSSION

The drinking of bottle gourd juice to control hypertension and hyperlipidemia, treat skin lesions, and control sugar and thyroid levels is a commonly misused practice supported by various alternate medical practitioners without realizing the side effects among the population.[1] The prevalence of rapid solutions found on the Internet without scientific evidence is a real-time problem for modern medicine.[1] It is observed to have a lack of standardization in the preparation of such juices.[1] A handful of endoscopic reports and evidence of bottle gourd toxicity on humans have been published. We publish one such case report with GI sepsis with multi-organ involvement in shock and UGI bleeding, a one-of-a-kind case witnessed and diagnosed in our Emergency Department.

Bottle gourd (scientific name: Lagenaria siceraria), also known as “Lauki,” is used in Indian households for cooking. It is a member of the Cucurbitaceae family and is cultivated widely in tropical and subtropical regions. It is believed to have cardioprotective, diuretic, and antihyperglycemic properties by alternate therapy practitioners. Bottle gourd contains a toxic tetracyclic triterpenoid compound called cucurbitacin.[2,4] Cucurbitacin is a pheromone that mainly imparts a bitter taste. Many derivatives (Types B, D, G, and H)[1,3] increased in concentration are seen in plants grown in poor soil quality, extreme temperature, and dehydration.

Cucurbitacin compounds have been shown to possess properties that can interfere with the binding of cortisol to glucocorticoid receptors in HeLa cells, leading to cytotoxic activity within the cells. Specifically, cucurbitacin D, which falls under the category of cucurbitacin compounds, has been observed to induce an increase in capillary permeability. As a result, this increase in capillary permeability can potentially lead to hypotension (low blood pressure) and, in severe cases, even shock.[2,5]

The bottle gourd is believed to have cardioprotective, diuretic, and nutritive properties by practitioners of alternate therapy.[2,3,6]

In our patient, the hemoglobin level was 19.6, which was attributed to hemoconcentration. The patient also had a high total leukocyte count with neutrophilia, indicating an infection and sepsis. The patient had a normal blood urea nitrogen level but elevated creatinine values, suggesting renal toxicity, which improved with the administration of intravenous fluids. Although no literature indicates renal toxicity from bottle gourd consumption, there is a possibility of a cross-reaction between the homeopathic medication and bottle gourd. However, such cross-reactions are rarely reported in the literature, making it difficult to establish a definite connection.

Humans who consume the bitter juice of bottle gourd present with abdominal pain, hematemesis, hematochezia, melena, hypotension, followed by oliguria, and elevated liver enzymes. Symptoms usually start within 30 min to 9 h of consumption.

The other differential diagnoses we considered were as follows:

Sepsis with multi-organ dysfunction with septic shock – foci of infection in the GI tract[1,7] – due to abdominal symptoms and systemic inflammatory response syndrome response with shock.[8] Food poisoning or foodborne illness[1,7] and GI bleeding (bleeding peptic ulcer, esophageal variceal bleeding, etc.) with hemorrhagic shock and organ dysfunction[1,8] were also thought and considered differentials.

It is important to be aware of this uncommon clinical presentation in countries like India due to the widespread use of traditional medicines without any knowledge about their side effects, which can manifest in the Emergency Department. Therefore, as a physician, it is crucial to diagnose bottle gourd toxicity based solely only on the patient's symptoms and medical history, as no specific test is available.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.

Declaration of patient consent

We certify about having obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.