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Chinese evergreen plant (Aglaonema) poisoning in a child presenting to an urban hospital in Papua New Guinea

Dear Editor, A previously healthy 5 year old boy presented to our ED an hour after he developed a swollen and painful tongue and lips. The symptoms began about 10 min after he chewed the charred but cold stem of a plant while playing unsupervised outside his house in Port Moresby. Airway assessment revealed a moderately swollen tongue and lips. The tongue was protruding out of the mouth with sialorrhoea. He had trismus with a mouth opening of 2 cm. His vital observations were BP 100/70, PR 90/min, SpO2 98% in room air, RR 28/min and temperature 36.5 C. Chest was clear with good air entry bilaterally. He had pink and warm peripheries and was alert and obeying commands. Other systems examinations were unremarkable. He weighed 20 kg. The mother brought the plant stem and leaf and it was identified using the smartphone application PlantSnap as the Chinese evergreen plant (Aglaonema spp.). A diagnosis of Chinese evergreen plant poisoning with partial airway obstruction was made. The paediatric and critical care team decided not to intubate, but admitted him to the Intensive Care Unit (ICU) and managed him conservatively with i.v. fluids, atropine (0.01 mg/kg) 0.2 mg i.v. PRN, hydrocortisone (1 mg/kg) 20 mg i.v. QID, and he was monitored for signs of progressive airway obstruction. Complete blood count, renal and liver tests, electrolytes and arterial blood gas were all within normal parameters. The patients’ symptoms improved and on the third day following admission he was asymptomatic and was discharged home to be followed up with the paediatric team. The Chinese evergreen plant (Aglaonema spp.) is a member of the Araceae family of plants. It is a perennial plant native to the tropical and subtropical regions of Asia and a popular garden and flowering plant in Papua New Guinea (PNG). Like most plants of the Araceae family, its roots, stem and leaves are poisonous. The sap contains needleshaped insoluble calcium oxalate crystals (raphides) contained in specialised cells called idioblasts. If chewed or ingested, the idioblasts fire the raphides with some force resulting in traumatic cell injury. This causes pain and oedematous swelling of the mouth, lips, tongue, pharynx, with sialorrhoea and breathing difficulties. Severe cases of poisoning that have progressed to airway obstruction in both humans and animals have been reported with the chewing or ingestion of the genera Dieffenbachia. A PubMed search revealed 37 papers of Dieffenbachia poisoning, but a search for Aglaonema poisoning returned no results. We also illustrate the utility of smartphone applications for identifying poisonous plants in resourcedeficient settings. There is no Poisons Centre in PNG, so we used the smartphone application, PlantSnap Version 2.00.16, to identify the offending plant. PlantSnap is a free application that is used to instantly identify a plant by simply taking a picture of the plants’ leaves. To further confirm its identity, we cross checked the result on the World Checklist of Selected Plant Families online (Fig. 1). The decision not to intubate the patient was based on the patients’ stable cardiorespiratory status, competing critical care patients for the limited ICU bed space with ventilators and the self-limiting nature of most calcium oxalate poisoning. However, he was admitted to the ICU because it is the only setting in our hospital where the patient could receive close airway observation and good nursing care to detect deterioration of the airway patency. Our patients’ symptoms resolved and did not require intubation. To our knowledge this is the first recorded case of Chinese evergreen plant (Aglaonema spp.) poisoning of a child in PNG. Unsupervised children are at increased risk of poisoning. Severe poisoning can cause airway obstruction and even death, but is rare. Mild to moderate poisoning can be managed conservatively. We recommend public health