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Severe Hyponatremia After Drinking Horsetail Juice

Background: Horsetail (Equisetum) refers to a genus of perennial plants that reproduce by spores instead of flowers. This family is the only surviving member of an order of plants that was prevalent in forests of the late Paleozoic Era. Different species grow in all parts of the world except Australasia. Horsetail has been used as an herbal remedy for edema since at least early Greek and Roman times. Objective: To alert clinicians to a potential adverse effect of horsetail juice. Case Report: A 32-year-old woman presented to the emergency department because she felt restless. Two hours earlier, the patient drank juice made by crushing horsetail plants in a blender. She had harvested the plants in the local woods after attending a course on edible plants. Respiratory rate was 18 breaths/min, blood pressure was 139/75 mm Hg, and pulse was 89 beats/min. The patient was anxious and walking around restlessly but spoke coherently. Physical examination and findings on electrocardiography were unremarkable. We consulted the Dutch National Information Centre for Poisoning, which cited a case of hyponatremia, leukocytosis, and muscle weakness after long-term use of large amounts of horsetail. Because this patient had consumed a small amount, we reassured her and discharged her with instructions to return if symptoms worsened. She returned 6 hours later because she had a headache and was lethargic and acting strangely. Before she could be examined, the patient had a tonicclonic seizure lasting approximately 30 seconds that terminated spontaneously. The physical examination was otherwise unremarkable, as were the vital signs. Within an hour of the seizure, the patient was able to open her eyes in response to speech and localized pain as a motor response but could not follow commands or communicate verbally. We began treatment with 500 mL of intravenous 0.9% sodium chloride until laboratory studies revealed severe hypotonic hyponatremia (sodium level, 118 mmol/L) and hypokalemia with a high urinary osmolality (702 mmol/kg of body weight) (Table). We administered 100 mL of 2.5% hypertonic saline and 14 mmol of potassium chloride intravenously, but plasma sodium levels increased by only 1 mmol/L and computed tomography showed diffuse cerebral edema. More hypertonic saline was infused, and the patient was transferred to the intensive care unit. Twenty-eight hours later, plasma sodium levels increased to 134 mmol/L after 900 mL of 2.5% hypertonic saline was administered. The patient regained full consciousness. The subsequent hospital course was uneventful, and she was discharged 5 days later. At follow-up 12 days after drinking the horsetail juice, the patient had fully recovered. Table. Results of Monitoring During the Acute Phase of Illness and Treatment Discussion: To our knowledge, this is the first case of such severe, acute hyponatremia after consuming horsetail juice. The patient's hyponatremia was probably exacerbated by the large amount of water that she drank within a brief period at home after being discharged the first time in an attempt to excrete the horsetail juice. The horsetail also probably acted as a diuretic. In some South American countries, horsetail plants (members of Equisetaceae) are used as diuretics to reduce edema or lose weight. The diuretic effect is believed to be caused by flavonoids, phenolic compounds, and mineral salts (1). In mice and healthy humans, horsetail increases urinary volume and urinary electrolyte excretion and has similar effects to hydrochlorothiazide (2). We believe that this patient's clinical course required the inappropriate secretion of antidiuretic hormone, which may have been secondary to symptoms caused by horsetail (such as nausea) or to a direct effect of horsetail itself.