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Show !ourllal of Clinical Neuro-ophthallllology 7(1): 34-37, 1987. © 1987 Raven Press, New York Accidental Mydriasis from Blue Nightshade "Lipstick" Roy S. Rubinfeld, M.D. and Jon N. Currie, F.R.A.C.P. A 7-year-old girl presented with bilaterally dilated pupils, nausea, and vomiting 2 days after head trauma. Pilocarpine pupil testing led to the correct diagnosis of pharmacologic pupillary dilation from an unexpected and unusual source of plant poisoning, Solanum dulcamara (blue nightshade). In patients with internal ophthalmoplegia, awareness of the possibility of pharmacologic mydriasis and correct use of topical pilocarpine testing can preclude the necessity for neuroradiologic and invasive diagnostic studies, even in cases with atypical or complex presentations. Key Words: Accidental mydriasis-Pilocarpine pupil testing-Plant pOisoning-PupiVdrug effect-Solanum species. From the Center for Sight (R.5.R.), Georgetown University Medical Center, Washington DC and the Neuro-ophthalmology Section a.N.c.), National Eye Institute, National Institutes of Health, Bethesda, Maryland. Address correspondence and reprint requests to Dr. Jon N. Currie, Neuro-ophthalmology Section, National Institutes of Health, Building 10, Room 105227, 9000 Rockville Pike, Bethesda, Maryland 20892. Dr. Rubinfeld is currently at the Wills Eye Hospital, Philadelphia, Pennsylvania. 34 For the clinician, the finding of a fixed, dilated pupil raises the specter of serious intracranial pathology, particularly when associated with headache, vomiting, altered mental state, or a history of head trauma. However, pharmacologic mydriasis should never be overlooked as a possible diagnosis and can arise from a number of unexpected sources. Pilocarpine testing of the dilated pupil remains an extremely useful office procedure that can help to avoid unnecessary anxiety and neuroradiological investigation (1). We report an initially worrisome case of unexplained bilateral mydriasis that was resolved when application of these principles led to the diagnosis of intoxication by the plant Solanum dulcamara (2). CASE REPORT A 7-year-old girl sustained a blow to her occiput that left her briefly dazed without loss of consciousness. Two days later she complained of severe nausea and vomited twice. When examined by her pediatrician, she was found to have bilaterally dilated pupils and was immediately admitted to hospital. Ten weeks prior to this she had undergone an outpatient evaluation for tachycardia, including Holter monitoring, with no obvious cause found. She had no history of previous ophthalmic problems, denied taking any medications, and no member of her household had recent access to any anticholinergic medications. On examination she was quiet, withdrawn, and slightly flushed. Her temperature was 98°F, pulse 100/min and regular, blood pressure 110/70, and respiratory rate 24/min. Uncorrected visual acuity was 20/25 in each eye at distance and 20/400 at near. Pupils were both dilated to 7 mm and were unreactive to light or accomodative effort, with no segmental contraction under slit lamp examination. There was mild conjunctival injection in both ACCIDENTAL MYDRIASIS FROM BLUE NIGHTSHADE 35 • Modified from Haddah and Winchester (3). TABLE 1. Effects of anticholinergic toxicity" recently undergone extensive investigation for an unexplained tachycardia, and her current presentation, which was preceded by head trauma, was accompanied by nausea, vomiting, and altered mental state. She also had mild conjunctival injection, which was at first disregarded. Concern about intracranial pathology lead to neuroradiological investigation, but in fact her signs and symptoms could all have been attributed to anticholingeric toxicity (3) (Table 1). Isolated internal ophthalmoplegia without ptosis or eye movement abnormality is exceptionally rare with intracranial third nerve compression or ischemia (4-10). Whether unilateral or bilateral, the etiology of isolated pupil mydriasis is most likely to be a tonic pupil, local ocular disease, or pharmacologic blockade (4). This differential diagnosis is outlined in Table 2 (11-29). Acute angle closure, iris trauma, and posterior synechiae as causes of mydriasis are usually evident on examination. There are several clinical features that will often suggest that the mydriasis is due to a tonic pupil (5,17). These include segmental iris sphincter palsies, exaggerated and tonic near response (light-near dissociation), and asymmetric loss of deep tendon reflexes (Adie's syndrome) (17). However pilocarpine hydrochloride eye drops provide a relatively simple test to distinguish the pharmacologically dilated pupil from paralytic dilation due to partial third nerve lesion or tonic pupil (1,27). One or two drops of 0.5% or 1% pilocarpine solution will constrict the normal pupil and will also constrict the pupil in cases of paralytic mydriasis due to both pre- or postganglionic nerve damage. However, 0.5% or 1% pilocarpine will not constrict a pharmacologically dilated pupil, and pupils with incomplete or resolving blockade will not respond to weaker eyes. There was no ptosis, and ocular motility was completely normal, as were the optic discs and fundi. The remainder of the neurological and general physical examination was unremarkable. Computerized tomographic head scan before and after contrast was normal, as were routine blood chemistry and hematology tests. When Ys% and 1% pilocarpine drops, instilled into both eyes, produced no change in pupil size, it was felt that the fixed and dilated pupils were of pharmacologic origin and did not indicate intracranial pathology. She was, therefore, discharged following a brief hospital stay, and after several more days her pupils returned to normal. Subsequently, after an extensive study of the child's play habits, it was found that together with several of her friends she had set up a makeshift kitchen in her backyard using discarded pots and pans. In this "kitchen" she had concocted a mixture of mashed red berries and leaves which she had painted on her lips and face to produce a facsimile of lipstick and other makeup. A sample of this plant bearing the red berries was obtained and identified taxonomically as Solanum dulcamara (blue nightshade or European bittersweet) (2) (Fig. 1). DISCUSSION This case illustrates the importance of carefully considering pharmacologic mydriasis in patients with fixed dilated pupils. Our young patient had / ) I ---. .' -.... ~ '", - I I. -IJ' ,1 .. "- ;,:\ .:,..- .. • .. r 'r ._- L. '" ,)1 ~. ~ ,., .... .J '. ... »" ·l~ ...." FIG. 1. The red berries and yellow and purple flowers that are characteristic of the blue nightshade (Solanum dulcamara) plant. This plant was growing in the neighborhood of the children's play kitchen, and its leaves and berries were used to make "lipstick." Peripheral (muscarinic blockade) Tachycardia Dry, flushed skin Dry mucous membranes Dilated pupils HyperpyreXia Urinary retention Decreased bowel sounds Hypertension Hypotension (late) Central Confusion Disorientation Loss of short-term memory Ataxia Incoordination Psychomotor agitation Picking or grasping movements Extrapyramidal reactions Visual/auditory hallucinations Frank psychosis Coma Seizures Respiratory failure Cardiovascular collapse I Clill Neuro-ophthalmol, Vol. 7, No.1, 1987 R.S. RUBINFELDAND J. N.CURRIE TABLE 2.CaiJseso( Isolated int'ernai ofJhthalfTIoplegiCJ~ 1. Damage to dor~al midbrain (prete~tal and E~inge;-West~halnuclei an~connectiO"-s) . isolated pupil defect israr~; light-m~ar dissociation mayoccur . .... .'. Ischemia,tumor,demyelination, infectiol'l~ (1,5,6). .' ....' C ?lctal,(1'l,-13) rnigraine(5,14) (?sympathetlc hyperactivIty} • •............. ..........••...... 2. Damage to the preganglionic oculomotor nerve (fro III Jnterpedunc~.I.ar fossa :toCtliary .·ganglion)'·.. . ". . . ' ' '.. . fsolatedpupil defect extremely rare (inCluding internal carotid.-postenor comnlunicatirig artery aneurysm) (6-:8) . Except'· . ..........• . ' Basal. meningitis (e,g. tuberculosis) (15,16). uncal herniation(early) (9) •• . ..... '" Basilar a'neurysm (rare) (10)" ..''.. ' 3. Damageto the Ciliary ganglia and postganglionic short ciliary nerves Usuallycauses:'tonic pupil"; may havehght-neardissociation' .a. Idiopathic (Aqies)lonic pupilb.l1,17) .' _. b.' Local tonic pupil (1).. .. . . '. . .' ViraL infection (e,g., hl?rPElS zoster)" Orbitallraurna;Jumor,surgery .. Retrobulbar anesthesia Ctloroidaltrauma, tUrrior . . Blunt trauma to theglob~(Ciliaryplexusdama.ge) . Temporal.arteritisb (18) '.' . .' . Episodic unilateralrnYdriasis(springing.pupil) (19) Panrefinal photOcoagulationc (20) Rheumatoid Cirteritis with episcleritiS(2.1). c: Neuropathic tonicpupiIC.(1)·· Syphilis' .. Diabetes Amyloidosis .Sarcoidosis ..' '. . . FarTIili~land acyte dysautonomias (22) . . . Guillain-Bgrre syndrome .(23) 4_Damgge to theiris'(l) Iritis and posterior synechiaec , .. '. ...• . "Angle cTosureglaucoma(iris sphincter ischemia)C (24) .' . Blunt injury to the .globewith.sphinctertear (traumatic iridoplegia)'.~ . Ipsilateral internal carotid artery occlusion (including Takayasu'sdisease}---,ins ischemia and atr()phy(15) . .......•.....••.• .' . Corneal transplantation (Urrets-Zavalia syndrome) (25) .5: Pharmacologic blockade byatropinic SUbstances :.'. '. ".:. .... :. Accidental mydriatic drops (e.g:; hand contamination in medical personneljC (1.,5) Deliberate (factitibus)mydriasisc•.. . . '.' Jirnsonweed("C6rnpickers pupil")C (26) and other plantmaterialsc .(1 ,27) PertumEls andCOsmelicsc (1) . . . '.' . Scopolarninepatches (28) ? Nutmegintoxicationc (29) 6:-8evereor .c.ornpleie foss of vision.' MaY.have Ijght-near ·dissociation. . Retinal detachment, degeneration, ischemlac ' : Opticnerv~ compressiO~. trauma,}nflammation; ischerniac Nurnbers. in ·.parentl"1eses. refer to References: "Modified from Thompson.(l). . ..b UsuallY. bilateral. . CMay be bilateral. s()luti~ns (e·.g.,Va%)..'that still .ieadiIyc()nstrict meclical;oul"nai~tatingJhat"thediag~osis'ofsc()-" normal. and denervated pupils ( 1), Atropinic polaminecontaminationcan. be confirmed by in· agents arecompetittveantagonists of the action. of' ... stillation o{ 0.5% to 1% piloca~pine hydrochloride pilocarpine, while bpth pr,e~~nd~postgangl~o~ic.inthe affected eye with prompt and'eifenslvec;onstric-nerve lesions cause'denervation supersensitivity' tion of the pupil"[ouremphasis] (31). . . (30) 'andgieater thann'ormaL piIocaq)inemioSis," .M~nyplants,s'uchas' deadly nightshadeand .' A.lthough this O.S....l%pilgcarpinetest for pharma- . Jimson weed, containbelladonr\aandother'atro~ coIogicmydriasis. was dearly·.:documented by. . .... pine-like alkaloids. (27,32)::Eye contamination with, Thompson and associates in 1971 (1), it·neve!the-. .small leaf fragmentscan'cause striking mydriasis less remains poorly understoodbymanY'clini~ (26): Our patient brought Solanum dulcamara (blue. dans', as evidenced recent report in a major ··nightshade,.Eur'op~anbittersweetj''into' cOIlt,itt ACCIDENTAL MYDRIASIS FROM BLUE NIGHTSHADE 37 with both her lips and eyes, and appears to have suffered both peripheral and mild central effects of atropinization (3). There is controversy regarding the toxicological effects of this common plant (2,32,33). Among the biologically active compounds it contains are solanine, <x, ~, 'V, and 8-solamarines; soladulcidine; solasadine; tomatine; and tomatidenol (32,34), but the pharmacologically active alkaloid and glycoalkaloid content of each strain and plant varies greatly with factors such as geographic location, time of year, available moisture, and temperature (34). Even though the ripe berries contain much less of the toxic agents than the leaves and unripe berries (34), there were clearly sufficient active compounds in the "makeup" to cause symptoms. We were unaware of any similar reports involving this plant, and so its contribution could easily have been overlooked. This reiterates the need for awareness of pharmacologic mydriasis from unexpected sources and the importance of verification by pilocarpine testing. Acknowledgment: The authors thank Dr. Peter Chen of Georgetown University and Ms. Debbie Bell of the Smithsonian Institute for their help with taxonomic identification and Mrs. Iris Kivitz of the National Institute of Health for her excellent editorial and secretarial assistance. REFERENCES 1. Thompson HS, Newsome DA, Lowenfeld IE. The fixed dilated pupil. Sudden iridoplegia or mydriatic drops. A simple diagnostic test. Arch Ophthalmol 1971;86:21. 2. Pammel LH. A manual of poisonous plants. Cedar Rapids, Iowa: The Torch Press, 1911:718-9. 3. Haddah LM, Winchester JF. Clinical management of poisoning and drug overdose. Philadelphia: Saunders, 1983:484-5. 4. Thompson HS. The pupil. In Lessell S, Van Dalen JTW, Eds. Neuro-ophthalmology, VoJ. 3. New York: Elsevier, 1984:280-91. 5. Glaser JS. The pupils and accomodation. In Glaser JS Ed., Neuro-ophthalmology, Hagerstown, Maryland: Harper and Row, 1978:169-84. 6. Miller NR. Walsh and Hoyt's clinical neuro-ophthalmology, 4th Edition. Baltimore: Williams and Wilkins, 1985;2:664-5. 7. Crompton JL, Moore CEo Painful third nerve palsy: How not to miss an intracranial aneurysm. Aust 1 Ophthalmol 1981;9:113. 8. Payne JW, Adamkiewicz J. Unilateral internal ophthalmoplegia with intracranial aneurysm: report of a case. Am 1 Ophthalmol 1969;68:349. 9. Sunderland, S. Mechanism responsible for changes in the pupil unaccompanied by disturbances of extra-ocular muscle function. Br 1Ophthalmol 1952;36:638. 10. Gale AN, Crockard HA. Transient unilateral mydriasis with basilar aneurysm. 1 Neural Neurosurg Psychiat 1982; 45:565. 11. Pant SS, Bentron JW, Dodge PRo Unilateral pupillary dilatation during and immediately following seizures. Neurology 1966;16:837. 12. Zee DS, Griffin I, Price DL. Unilateral pupillary dilatation during adversive seizures. Arch Neural 1974;30:403. 13. Jammes JL. Fixed dilated pupils in petit-mal attacks. Neuroophthalmology 1980;1:155. 14. Edelson RN, Levy DE. Transient benign unilateral pupillary dilation in young adults. Arch Neural 1974;31:12. 15. Fisher CM. Some neuro-ophthalmological observations. 1 Neural Neurosurg Psychiat 1967;30:383. 16. Sandyk R. Pupillary signs in tuberculous meningitis (Letter to the Editor) 5 Afr Med lI982;61:69. 17. Thompson HS. Adie's syndrome: some new observations. Trans Am Ophthalmol Soc 1977;75:587. 18. Currie IN, Lessell S. Tonic pupil in giant cell arteritis. Br 1 OphthalmoI1984;63:135. 19. Hallet M, Cogan DG. Episodic unilateral mydriasis in otherwise normal patients. Arch OphthalmoI1970;84:130. 20. Rogell GD. Internal ophthalmoplegia after argon laser panretinal photo coagulation. Arch OphthalmoI1979;97:904. 21. Victor D, Green WR, Stark WI, Walsh FB. A non-permanent tonic pupil in rheumatoid arteritis. Can 1Neural Sci. 1977;4:209. 22. Young RR, Asbury AK, Corbett JL, Adams RD. Pure pandysautonomia with recovery: Description and discussion of diagnostic criteria. Brain 1975;98:613. 23. Williams D, Brust JCM, Abrams G, Challenor Y, Devereaux M. Landry-Guillain-Barre syndrome with abnormal pupils and normal eye movements: a case report. Neurology 1979;29:1033. 24. Charles ST, Hamasaki DJ. The effect of intraocular pressure on pupil size. Arch OphthalmoI1970;83:729. 25. Saraux H, Offret H, Binaghi M. A propos du syndrome d'Urrets-Zavalia. Bull Soc Ophthalmol Fr 1978;78:579. 26. Thompson HS. Cornpicker's pupil: Jimson week mydriasis. 1Iowa Med Soc 1971;71:425. 27. Thompson HS. Current concepts in ophthalmology, Chap. 6. St. Louis: C. V. Mosby, 1972:76-90. 28. McCrary JA, Webb NR. Anisocoria from scopolamine patches. lAMA 1982;248:353. 29. Ahmad A, Thompson HS. Nutmeg mydriasis. lAMA 1975;234:274. 30. Ponsford JR, Bannister R, Paul EA. Methacholine pupillary responses in third nerve palsy and Adie's syndrome. Brain 1982;105:583. 31. Price BH. Anisocoria from scopolamine patches. lAMA 1985;253:1561. 32. Gibbs RD. Chemotaxonomy of flowering plants. Montreal: McGill-Queen's University Press, 1974:348-349. 33. Hardin JW, Arena JM. Human poisoning from native and cultivated plants. Durham, North Carolina: Duke University Press, 1974:143. 34. Schreiber K. The steroid alkaloids of Solanum. In Hawkes JG, Lester RN, Skelding AD, Eds., The biology and taxonomy of the Solanaceae, New York: Academic Press, 1980:211-8. I Clin Neuro-ophthalmol, Vol. 7, No.1, 1987 |
