Dieffenbachia plant poisoning requiring mechanical ventilation: a case report and review of the literature

Abstract

Background

Poisoning with Dieffenbachia, a member of the Araceae family, poses serious risks, particularly with respect to oral and airway exposure. This case highlights the critical need for precautionary measures, prompt treatment, and continuous observation following such exposure, emphasizing its significant clinical implications.

Case presentation

A 3-year-old Ethiopian boy, who was previously healthy and neurodevelopmentally normal, was brought to the pediatric emergency department after inadvertently chewing and swallowing the parts of Dieffenbachia plant. Initially, he had mild symptoms and signs, including oral and throat irritation and laryngeal and pharyngeal erythema, which were neglected by the parents, leading to respiratory depression, desaturation, seizures, and airway edema on laryngoscope examination. The child’s blood counts, renal function, liver enzymes, electrolytes, and blood glucose tests were normal. His case was initially managed in the emergency department with supportive medications, including steroids, antihistamines, acid suppressants, and analgesics. Later, there was a need for immediate intubation and mechanical ventilator support, as the patient developed impending respiratory failure due to upper airway obstruction. The child eventually fully recovered after a few days, with no residual sequelae.

Conclusion

It is essential to seek immediate medical attention if individuals are exposed to the toxic Dieffenbachia plant and to closely monitor them for any late symptoms or complications for a minimum of 24 hours, particularly in cases involving the digestive system and airway.

Background

The genus Dieffenbachia (dumb cane) belongs to the kingdom Plantae and the family Araceae [1] (Figs. 1, 2). Approximately 135 species have been identified, with the majority being found in South and Central America [2]. In the late seventeenth century, owing to its toxic nature, it was used by Amazonians as a poison in arrows. They also used the oil of the plant to torture slaves by putting it in their mouths [3–5]. Typically, the Dieffenbachia plant is used as a household ornamental plant worldwide [6].

Fig. 1.

Dieffenbachia plant (from Elyssa Goins. Dumb cane plant (Dieffenbachia): plant care and growing guide. Houseplantexpert.com Published 26 October 2023. Updated 8 December 2023. Available from: https://images.app.goo.gl/a6ryZ)

Fig. 2.

Dieffenbachia plant (also known as dumb cane) (from Julie Martens Forney. Dieffenbachia: planting and care for dumb cane plant. HGTV; 9 April 2025. Available from: https://images.app.goo.gl/wx42R)

Depending on the site of exposure, the clinical presentations include dermal irritation and edema, tongue numbness and swelling, airway obstruction, and ocular pain, redness, and tearing [7–11]. According to Pedaci et al., who assessed the symptoms of Dieffenbachia species exposure via extensive search of 23 sources, oral irritation (18.2%), dermal pain (8.7%), vomiting (2.6%), erythema(2.5%), throat irritation (2.3%), dermal edema (2.2%), pruritus (2.1%), ocular irritation (1.7%), rash (1.2%), and cough/choking (1.1%) were the documented symptoms; accordingly, oral and throat irritations were the most common toxidromes when multiple symptoms occurred [10].

There is no specific toxin screening for Dieffenbachia plant poisoning, and its diagnosis relies entirely on a history of exposure and clinical presentations [5, 7–9]. Commonly ordered laboratory investigations, which include complete blood count, random blood sugar, serum electrolytes, liver and renal function tests, and arterial blood gas analysis, are used to assess organ function and the extent of poisoning. Additionally, there is no specific treatment protocol available; however, those exposed are successfully treated by supportive care and close observation for complications [5, 7–9].

Here, a 3-year-old male child was brought to the pediatric emergency department after the oral mucosa and upper airways were accidentally exposed to the plant, resulting in airway compromise. This case report describes unexpected and life-threatening clinical events during observation, highlighting the need for attention to early signs of complications and ensuring that emergency management protocols are in place. In addition, it informs parents and guardians to take necessary precautions to prevent exposure and to seek immediate medical care if exposure occurs.

Case presentation

A 3-year-old Ethiopian male child, who was neurodevelopmentally normal, devoid of chronic illness, and perfectly well before presentation, was brought by his parents to the pediatric emergency unit 6 hours after chewing and ingesting the plant Dieffenbachia (also known as dumb cane). As per the mother, he was in the household compound playing with his peers when she saw the child chewing and swallowing the leafy part of Dieffenbachia plant, which was placed ornamentally in the compound. The mother tried to remove the plant from the toddler’s mouth with her fingers, but the child had already swallowed, and she was unsure of the amount consumed. A few minutes later, he started to develop mild lip swelling, and subsequently, he began to feel a burning sensation on his tongue and throat. The mother ignored the symptoms and believed that they would disappear on their own. He experienced these symptoms for 6 hours, and by the time he became irritable and speechless, he was brought to the emergency unit. Upon arrival, his vital signs were as follows: pulse rate of 100 beats per minute, radial, regular, and full volume; respiratory rate of 24 breaths per minute and regular; temperature of 36.2 °C; and pulse oximetry showing O₂ saturation of 97% on atmospheric air. Head, ear, eye, nose, and throat (HEENT) evaluation revealed lip swelling and tongue erythema, whereas other physical examination findings were normal.

The lab results of the patient revealed normal total white blood cell counts and differential counts. Serum electrolytes, blood glucose levels, liver function tests, serum bilirubin, and renal function tests were all within the normal range. Taking into consideration the Dieffenbachia plant ingestion poisoning, he was then kept nil per os except for medications, put on intravenous maintenance fluid, and given an antihistamine (cetirizine 2.5 mg orally daily (0.25 mg/kg/day), dexamethasone 3.6 mg intravenously twice per day (0.6 mg/kg/day), analgesics with paracetamol 7.5 mL orally four times per day (15 mg/kg/day), and cimetidine 200 mg intravenously three times per day (40 mg/kg/day) and was kept in the emergency room for close observation.

A total of 2 hours later, he started to drool saliva, had depressed respiration, and experienced two episodes of generalized tonic–clonic seizure lasting 2–3 min. His physical examination revealed a pulse rate of 144 beats per minute, at full volume and regularity; a respiratory rate of 16 breaths per minute, with slow and irregular respiration with the use of accessory muscles and poor air entry on auscultation of the chest; a mild fever with a temperature of 38.1 °C; and an O₂ saturation of 86% on the face mask. The seizures were managed with 1.8 mg of intravenous diazepam statim, and with a working diagnosis of impending respiratory failure secondary to upper airway obstruction with airway edema secondary to Dieffenbachia plant poisoning and meningitis in question, he was immediately transferred to the intensive care unit (ICU) for immediate intubation. In the ICU, a pre-intubation examination using a laryngoscope was done and revealed pharyngeal erythema and laryngeal edema with visible vocal cords and narrowing of the glottis opening. Considering the airway edema and poor air entry upon auscultation of the chest and the desaturation on the face mask, the child was then intubated with rapid-sequence intubation and put on mechanical ventilation with the following settings: The mode of ventilation used was volume assist/control (V-A/C), at a rate of 20 and a inspiratory/expiratory (I:E) ratio of 1:2; the tidal volume was initially 105 and was then titrated to 72; the fraction of inspired oxygen (F_IO₂) was initially 70 and was then titrated to 40; and the positive end-expiratory pressure (PEEP) was initially 5 and was then titrated to 4. With the above settings, his oxygen saturation was maintained within the range of 95–97%, and his other vital signs were within the normal range. A standing dose of dexamethasone 3.6 mg intravenously twice daily (0.6 mg/kg/day), cetirizine 2.5 mg orally daily (0.25 mg/kg/day), and cimetidine 200 mg intravenously three times daily (40 mg/kg/day) was continued. Antibiotics with a meningeal dose of ceftriaxone 600 mg intravenously twice daily (100 mg/kg/day) and vancomycin 180 mg intravenous four times daily (60 mg/kg/day) were also initiated empirically, as a lumbar puncture was not able to be performed and rule out meningitis as a result of respiratory compromise. Blood samples were sent for testing for hemoparasites and for culture and sensitivity.

After 3 days, he was off intubation and required minimal support with intranasal oxygen for a few hours. He later maintained oxygen saturation on atmospheric air. He was transferred to the wards with stable vital signs, and after 2 days of stay in the ward, it was noted that he produced clear and loud sounds. Examinations of the lips, tongue, and pharynx were free of inflammation signs. The throat irritation that caused him to avoid feeding also completely subsided, and he was able to consume food orally. There were no seizures after the initial episodes, and the respiratory, neurological, and other examinations were normal.

Dexamethasone, cetirizine, and cimetidine were given for 5 days. Considering the negative blood cultures and negative hemoparasites and because we were unable to perform lumbar puncture owing to respiratory compromise, empirical antibiotics were continued for 7 days. Finally, the child was discharged with complete improvement with no sequelae. Upon discharge, his parents were advised to follow precautionary measures to avoid exposure. Follow-up was also arranged, and it was observed that the patient was in good health condition and that no residual chronic complications were noted.

Discussion

In poison control centers, oxalate plant poisoning is common, with over 4000 exposures reported annually. The majorities of cases are mild and involve individuals younger than 6 years of age [16].

All parts of the plant are toxic, although there are claims that there is a difference in the toxicity of leafy and stalky/stem parts [19]. The mechanism behind this is attributed to the presence of calcium oxalate crystals and the proteolytic enzyme L-asparginase. If exposed, it can lead to tissue destruction and inflammation [3, 11, 12].

Accidental contact with the plant sap or oil is the reported mechanism of exposure to the skin, eye, and mucosal surfaces of the digestive system and airways [7–11]. Although intentional exposures have been reported for suicide attempts [13], abuse, and torture [14, 15], almost all exposures are accidental and unintentional, particularly in children [5, 7–9]. As in the current case, unintentional and accidental exposures are common in children, as they are more explorative, and the plant is more attractive to them.

Symptoms start within a few minutes of exposure and are caused mainly by tissue destruction and inflammation, leading to pain/irritation, edema, and redness of the exposed surfaces. Skin swelling and irritation [10, 11]; tongue swelling, mouth pain and irritation, swallowing difficulty, and drooling [8]; stridor, hoarseness, and mild airway obstruction [9]; and ocular manifestations [7] are the presenting symptoms, all of which involve local exposure resulting in local symptoms and local complications. In addition, all symptoms, with early and appropriate supportive interventions, resolved within 24 hours of exposure, except for ocular exposures and neglected and late-intervention ones. The timing and course of symptoms are consistent with those of the current case where the symptoms started within a few minutes after the exposure with lip swelling and throat irritation, which was initially neglected for a significant number of hours, resulting in a loss of sound production and later leading to respiratory compromise from airway edema.

Although there is evidence of kidney, heart, and liver toxicity in Wister albino rats after exposure [17], none of these have occurred in human exposures, nor in the current case, as evidenced by unaffected electrolyte, renal, and liver function enzyme tests.

The current case noted the presence of seizure episodes, which is unusual in Dieffenbachia plant poisoning. However, the episodes occurred while the child was desaturating because of airway-edema-induced hypoxia. Hence, the seizure can be attributed to a severe hypoxia-induced brain response.

To date, there is no specific treatment or antidotes available for Dieffenbachia plant poisoning; however, supportive measures are indicated. These include cold compression for dermal swelling, intravenous steroids to reduce inflammation and subsequent tissue destruction, antihistamines to reduce vascular leakage and subsequent edema, and minimal or advanced respiratory support [5, 8, 9]. Cases of ocular exposure were successfully treated with topical or oral steroids, topical antibiotics, analgesics, and frequent follow-up [7]. In all the previous cases, medications were given immediately following exposure, with recovery times ranging from a few hours to a few days depending on the extent of complications. The current case was managed via an identical approach, except for the delayed patient presentation, which led to the delayed provision of the drugs, particularly dexamethasone and cetirizine, which need hours to take effect. In addition, the occurrence of further complications with airway edema that require mechanical ventilation also contributes to the delayed recovery.

In contrast, prolonged and neglected exposures, especially in those who have severe symptoms at presentation, require an extended period of recovery. Some even die or require more than 2 months for full recovery, particularly for mucosal exposures [18].

Conclusion

The reporting of the current case involves a serious complication of airway compromise, requiring mechanical ventilation. It is essential to seek immediate medical attention if exposed to the toxic Dieffenbachia plant and to closely monitor for any late symptoms or complications for a minimum of 24 hours, particularly when the exposure is related to the digestive system and airways.

Author contributions

The author is responsible for conceptualization; reviewing of the literature; writing—original draft; writing—review and editing; data curation; and investigation. The author is also involved in the consultation and management of the child’s case.

Funding

None.

Availability of data and materials

All the necessary data are available within the document.

Declarations

Ethics approval and consent to participate

As per the Dilla University College of Health Sciences ethics committee guidelines, ethical approval for reporting cases was not needed. The treatment and reporting of this case was carried out in accordance with the Declaration of Helsinki.

Consent for publication

Written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images. A copy of written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

None.