Acute cardiotoxicity following 'poppy seed tea' consumption

Summary

Insect damage to, and sub‐optimal harvesting practices of the Papaver somniferum poppy are associated with contamination of its seeds with opium alkaloids. Consumption of poppy seeds has been linked to opium‐like overdose symptoms, such as reduced consciousness and respiratory depression. However, acute cardiotoxicity secondary to ingestion of contaminated poppy seeds has not been reported previously. We report a case of a 21‐year‐old man who presented with severe biventricular dysfunction and cardiogenic shock following consumption of homemade poppy seed tea. We highlight the importance of prompt recognition of the myocardial effects of opiates along with the more common respiratory and neurological effects. In this case, the acute cardiotoxicity was fully reversed with high‐dose naloxone, milrinone and noradrenaline. In addition, we recommend offering high‐level care due to the possibility that specialist cardiac services may be required. Ergo, early transfer to an appropriate centre is recommended.

Introduction

The flowering plant Papaver somniferum, also known as the opium poppy, has been cultivated by humans for centuries as a source of poppy seeds and opium. Poppy seeds are harvested when the poppies have fully matured and are a common ingredient in a wide variety of baked goods, desserts and poppy seed oil. Poppy seeds were traditionally considered to contain little if any opiates. However, analysis of urine samples following ingestion of poppy seeds has revealed measurable quantities of codeine and morphine [1]. Furthermore, insect damage and suboptimal harvesting practices are associated with contamination with opium alkaloids [1]. Consumption of contaminated poppy seeds has been linked to opium‐like overdose symptoms, such as reduced consciousness and respiratory depression [2, 3].

In the context of alternative medicine, there are many advocates of the use of poppy seed tea as a method of analgesia or for its narcotic effects. They give tips, recipes and sell ingredients. Recently a television show and an article in the newsprint media described an individual who failed a drug test due to ingestion of poppy seed bread, potentially bringing its use to mainstream attention [4]. Despite the known health risks of contaminated poppy seeds, we are unaware of any previously reported cases in which poppy seed consumption has led to acute cardiac toxicity. Here, we present a case of a 21‐year‐old man who presented with severe acute biventricular cardiac dysfunction following ingestion of homemade poppy seed tea.

Case report

A 21‐year‐old man was found unresponsive and cyanosed by his parents at their home. He was known to suffer from depression and chronic pain, for which he was prescribed sertraline and mirtazapine. He had no previous history of deliberate self harm or suicide attempts. Assessment by paramedics revealed bradycardia (56 beats.min^‐1), normotension (111/73 mmHg), bradypnoea (3 breaths.min^‐1), a Glasgow coma scale score of 3/15, and bilateral miosis. An opioid overdose was suspected and following administration of 400 μg of naloxone i.v., his vital signs and conscious state improved. However, he remained confused and was unable to inform paramedics about possible triggers. Arterial blood gas analysis after arrival in the Emergency Department revealed severe mixed respiratory and metabolic acidosis (pH 7.05, lactate 10.4 mmol.l^‐1, pCO₂ 10.2 kPa). He was noted to have a fluctuating level of consciousness. Electrocardiogram (ECG) showed marked ST elevation in V2, widespread abnormalities of the ST segments and an intraventricular conduction defect, similar to a classical Brugada syndrome (Fig. 1).

Figure 1.

Twelve‐lead electrocardiogram from our patient showing Brugada type pattern.

Approximately 1 h after admission, a deterioration in blood pressure to 70/39 mmHg was noted. Intravenous fluid resuscitation was initiated, but despite 2 l of sodium chloride 0.9%, blood pressure remained low at 57–76 mmHg systolic and 27–47 mmHg diastolic. At this point, the patient disclosed that he ingested large quantities of homemade poppy seed tea to relieve chronic back pain. Blood biochemistry revealed a raised troponin I (1101 ng.l^‐1) and creatinine (170 μmol.l^‐1). The patient was reviewed by an intensive care physician, who advised regular administration of naloxone and magnesium supplementation. Unfortunately, no response to treatment was observed. Subsequent bed‐side ultrasound of the abdomen was unremarkable, but a transthoracic echocardiogram revealed severe, global, biventricular systolic dysfunction with no evidence of valvular pathology.

The United Kingdom National Poisons Information Service (UK NPIS) was consulted, and advised a 2 mg bolus of naloxone i.v. followed by an infusion of 2 mg.hr^‐1. They discouraged the use of vasoconstrictors given the patient's raised creatinine while encouraging mechanical cardiac support, including extracorporeal membrane oxygenation (ECMO), if necessary. The onsite ECMO team was informed about the potential need for their services. Shortly following the administration of the 2 mg bolus of naloxone, the patient's blood pressure stabilised at approximately 90/50 mmHg and he was transferred to the Cardiothoracic Critical Care Unit (CTCCU) for further management.

The patient remained in CTCCU for two days, during which he was commenced on milrinone and noradrenaline infusions. Serum troponin I levels peaked at 8724 ng.l^‐1, 24 h after initial presentation, and then gradually decreased to normal. On the second day of hospitalisation, repeat transthoracic echocardiogram showed no residual structural or functional abnormality, with normal systolic and diastolic ventricular function. His ECG, vital signs and cognition returned to normal. The patient remained in hospital two more days for observation. Upon discharge, the patient was given strict instructions to avoid strenuous exertion. Outpatient cardiac magnetic resonance imaging was arranged for three months after discharge, which showed no enduring cardiac damage. The patient's reflections on his experience are reproduced in Table 1.

Table 1.

Patient’s experience following ingestion of homemade poppy seed tea and remarks following discharge from hospital.

“I ingested a perfunctory daily dose of opium tea from a recipe I acquired from the internet, … purchased from a different popular supermarket chain from the one I usually bought from. The following 20 min were very hazy and unrecallable. However, I did experience significantly more nausea and vomiting than usual. I was later discovered by my family, unconscious, barely breathing and unresponsive, after which they dragged me downstairs and called an ambulance. I became acutely aware of how poorly my heart was performing and did not honestly for a second think I was going to survive the ordeal. After initial treatment, I regained most of my consciousness and was moved to the cardiothoracic unit. I received the best of care and could not fault the staff. However, I could not seem to relax, likely due to rapid precipitated withdrawal, combined with shock and the shame of being found in this predicament by my family, including my younger brother. Despite being highly traumatic, somewhat embarrassing, and extremely burdensome to both the lives of my family and me, the experience had ironically been a character‐building and valuable one. I believe this because this was the incident that inspired me to receive help from narcotics anonymous and other support groups.”

Discussion

Poppy seed tea is easily available and has been the subject of promotion online and in the print media. Over 40 different alkaloids have been extracted from poppy seeds, with five substances accounting for nearly all detectable alkaloid content: morphine; codeine; thebaine; papaverine; and noscapine [5]. The degree of opioid alkaloid contamination is based on several factors, including cultivation techniques, harvesting practices and food processing [1]. Cases of highly contaminated poppy seeds with associated morbidity have been reported [1, 3].

Global, biventricular, systolic dysfunction with gross conduction abnormalities on ECG and a Brugada syndrome‐like pattern have not been reported with either morphine or codeine toxicity. The consensus in our case, following discussion with UK NPIS, was that the patient's cardiac dysfunction was due to sodium channel abnormalities in the myocyte cell membrane. Neither morphine nor codeine is known to significantly alter myocardial sodium channel function at high levels. However, papaverine and other substances belonging to the opioid family – such as propoxyphene – have been associated with myocardial depression and prolonged refractory periods with subsequent conductivity depression [6]. Given that over 40 different alkaloids have been identified in contaminated poppy seeds it is postulated that contamination of poppy seeds with opium (dried latex obtained from immature seed capsules of the opium poppy) may lead to cardiotoxicity.

In keeping with a Brugada pattern, the clinical findings in our case suggest that opioid alkaloids may have had a significant inhibitory effect on voltage‐activated sodium channel function in our patient’s cardiac myocytes [6]. Sodium channel function is essential to excitability and the generation of a normal cardiac rhythm leading to synchronous ventricular contraction. Impaired sodium inflow currents trigger a prolonged refractory period with subsequent cardiac conductivity delays, which could result in asynchronous contraction and contribute to profound biventricular failure. Given the rapid observed response to naloxone and subsequent improvement in cardiac function, we suggest that the underlying cause for this patient’s presentation was indeed opioid‐induced. Interestingly, despite marked hypotension and biochemical evidence of myocardial ischemia, organ damage was limited, and normal cardiac function was restored within 48 h. A possible explanation for the rapid resolution of significant cardiac dysfunction with no apparent residual damage may be the cardioprotective effects of opioids. Studies on isolated cardiac myocytes demonstrate that endogenous and exogenous activation of δ‐ and κ‐opioid receptors located on the myocardium is associated with reduced cardiac damage during ischemic events [7]. Therefore, morphine contained within the extract ingested by the patient may have prevented permanent cardiac damage and long‐term complications.

Another factor that may have contributed to the patient's state was his regular medications. Sertraline is a selective serotonin reuptake inhibitor (SSRI) and is a standard firstline pharmacotherapy in depression. Despite their widespread use, SSRIs are known to have significant cardiovascular side‐effects, including myocardial conduction abnormalities [8]. In addition, while mirtazapine has few cardiovascular adverse effects, Brugada syndrome has been observed in a mirtazapine overdose [9]. Although our patient did not exceed his prescribed dose of either sertraline or mirtazapine, they may have contributed to his presentation. Establishing the contribution of opioid alkaloids in poppy seeds, mirtazapine or sertraline to the clinical state of our patient was complicated by our not performing toxicological analysis of urine or blood during his stay. Consequently, it was not possible to definitively identify a causative agent for the observed acute cardiotoxicity. Despite the lack of laboratory evidence, the positive response to high‐dose naloxone suggests that opioid toxicity played a significant role [10].

Poisoning from 'poppy seed tea' may become an increasing problem due to the easy access to ingredients, online recipes and advocates on social and print media. Although not a typical presentation, the myocardial effects of opiates should be considered, along with the more common respiratory and neurological effects. In this case, high‐dose naloxone was required, with no improvement seen at standard doses. Early discussion with UK NPIS was invaluable. The poisoning was completely reversed, but we would nevertheless recommend ensuring affected patients have immediate access to high‐level cardiac care including mechanical circulatory support. Early transfer to an appropriately credentialed and equipped centre is recommended if necessary.