Subject: Paraguay Tea -- A Warning

From: [email-masked] (jac)
Date: Tue, 28 Mar 1995 12:57:03

The following article is from MORBIDITY AND MORTALITY WEEKLY REPORT, 3/24/95, 
Vol. 44 #41, p. 193-195.

"ANTICHOLINERGIC POISONING ASSOCIATED WITH AN HERBAL TEA - NEW YORK CITY, 1994

Inadvertant anticholinergic poisoning can result from consumption of foods 
contaminated with plants that contain belladonna alkaloids.  During March 
1994, the New York City Department of Health (NYCDOH) investigated seven cases 
of anticholinergic poisoning in members of 3 families; 3 of the 7 ill persons 
required emergency treatment for characteristic manifestations.  For all 
cases, manifestations occurred within 2 hours after drinking tea made from 
leaves purchased commercially and labeled as Paraguay tea -- an herbal tea 
derived from the plant Ilex paraguariensis, which is native to South America.  
This report summarizes the investigation of these cases.

On 3/20, a 39-yr. old man and his 38-yr. old wife shared a pot of Paraguay 
tea.  Within 30 min. after drinking the tea, both developed acute symptoms 
(including agitation and flushed skin).  They were transported by ambulance to 
a local hospital.  In the emergency department, the man was disoriented and 
agitated.  Findings on examination included fever (101.2 F [38.4 C]), dilated 
and nonreactive pupils, and dry skin and oral mucous membranes; bowel sounds 
were absent.  Anticholinergic poisoning was diagnosed based on clinical 
findings, and the New York City Poison Center (NYCPC) was notified.  After 
treatment with 2 doses of intravenous physostigmine (2 mg each over 5 min.), 
signs and symptoms completely resolved.  Findings on examination of the woman 
included fever (100.8 F [38.2 C]), dilated and nonreactive pupils, and dry 
skin and oral mucosa.  Her symptoms resolved without treatment.

On 3/21, a 20-yr old woman drank approx. 1 cup of Paraguay tea; approx. 1 hr. 
later, she presented to a locak emergency department with agitation, 
disorientation, and aphasia that progressed to stupor.  Findings on 
examiniation included increased pulse (120 beats per minute), oral temperature 
of 98.2 F (36.8 C), dilated pupils, dry skin, and absent bowel sounds.  
Anticholinergic syndrome was diagnosed, and the NYCPC was notified.  She 
received gastric lavage, activated charcoal, and a cathartic.  Her menta 
status gradually improved, and she was discharged after 10 hours of 
observation.

On 3/23, 4 family members shared a pot of tea.  Approx. 1 hr. later, the 10-yr 
old son was transported by his parents to a local emergency department because 
of agitation and restlessness.  Findings on examination included increased 
pulse (120 beats per min.), dilated and nonreactive pupils, flushed skin, dry 
mucous membranes, and hypoactive bowel sounds.  Anticholinergic syndrome was 
diagnosed, and the NYCPC was notified.  After treatment with 2 doses of 
intravenous physostigmine (0.5 mg each over 5 min.), his manifestations 
resolved.  Because the boy's 35-yr old mother and 40-yr old father reported 
symptoms, including dry mouth, the emergency department physician 
presumptively diagnosed anticholinergic syndrom in both parents.  Their 
symptoms resolved without treatment.  The boy's 18-yr. old brother had left 
home for school immediately after drinking the tea.  On returning home during 
the evening of 3/23, he reported confusion and no knowledge of his whereabouts 
during the day.

At the request of the NYCPC, the emergency dept. physicians obtained samples 
of the tea from each family for analysis.  Samples consisted of packages of 
dried and chopped leaves and stems wrapped in clear cellophane; the package 
label identified a NYC distributor of South American foods.  Analysis involved 
soaking 5 g of tea in 50 mL of methanol for 4 hrs.  From 1 ul of the liquid 
extract, the belladonna alkaloids atrophine, scopolamine, and hyoscyamine were 
identified by gas chromatography/mass spectrometry.  Quantitative analysis was 
not performed.

Investigations of the NYCDOH, the NYCPC, and the Food and Drug Administration 
(FDA) indicated that the distributor had purchased the tea directly from 
farmers and had shipped it in bulk to NYC for packaging.  Five cases of 24 
packs had been delivered to one grocery store specializing in South American 
foods.  Only one case had been sold; the remaining 4 cases were subsequently 
quarantined in accordance with NYC health statutes.  The grocer store had no 
reccord of persons who had purchased the tea.  On 3/24, the NYCDOH issued a 
news release to educate the public about the hazards of drinking contaminated 
Paraguay tea.  No additional cases of anticholinergic poisoning associated 
with Paraguay tea were reported.

<Physicians references omitted.>

Editorial Note:  Paraguay tea is made from the leaves of I. paraguariensis, a 
20' tall holly tree indigenous to Argentina, Brazil, and Paraguay.  Common 
names for the plant include mate', yerba mate', and South American holly.  The 
leaves contain caffeine, theophylline, and a nontoxic volatile oil but do not 
contain belladonna alkaloids.  

The dominant clinical features of the cases describe in this report (i.e., 
tachycardia, fever, dilated pupils, and flushed skin) are characteristic of 
the anticholinergic effects associated with poisoning by belladona alkaloids 
(1).  In addition, patients responded to physostigmine, the treatment of 
choice for anticholinergic poisoning.  The most likely explanation for the 
cases in this report is contamination of the Paraguay tea with leaves from a 
plant containing belladonna alkaloids.  Previous reports of inadvertent 
anticholinergic poisoning resulting from contamination of foods with plants 
containing belladonna alkaloids have included consumption of hamburger 
seasonings with seeds from Angels' trumpet (Brugmansia X candida) (2) and 
onsumption of contaminated honey (3), Chinese herbs (4), or porridge (5).

This report underscores the need for persons who use herbal products to report 
any adverse reactions immediately to health authorities.  In 1993, a total of 
959 incidents of anticholinergic poisoning associated with consumption of 
plants containing belladonna alkaloids were reported to poison-control centers 
in the U.S. (6); 15 persons had symptoms requireing hospitalization.  Because 
a large number of plants throughout the U.S. contain belladonna alkaloids, 
plants harvested for human consumption must be correctly identified.  The 
public should be aware that all herbal products have the potential to be 
misidentified when collected, mislabeled, contaminated, or adulterated.  
Physicians and the public should report adverse reactions to herbal products 
to FDA's MedWatch Program, telephone (800) 332-1088 ([301-738-7553]).

<References omitted.>

MMWR is now available on the Internet:

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