Bottle gourd (Lagenaria siceraria) is believed to have many health benefits and with the increased practice of traditional medicine, it is used as alternate therapies to treat ailments . However, a handful of reports have been published regarding toxicity due to consumption of this juice . We report a case of bottle gourd juice toxicity diagnosed in the Emergency Department, review the literature in general, discuss the mechanism of toxicity and other substances that may present similarly. To the best of our knowledge, this is the first locally reported case of bottle gourd toxicity arising in our population.
Bottle gourd is also known as bottle gourd, white-flowered gourd, long melon, birdhouse gourd, is a member of Cucurbitaceae family. It is cultivated throughout the tropical and subtropical regions of the world. Consumption of bottle gourd juice is thought to work as a health tonic and part of traditional healthy living practices in controlling diabetes mellitus, hypertension, cardiovascular diseases, liver diseases and weight loss. It is believed to have cardioprotective, diuretic and nutritive properties . The ethanolic extract also showed to have antihepatotoxic and antihyperlipidemic activities in rats . People usually prepare the juice by blending bottle gourd pieces in a blender. Black pepper, salt, mint leaves or lemon can be added to enhance the taste. It should be served fresh and not to be stored by refrigerating it .
However, toxic level of Cucurbitacin can accumulate in bottle gourd or when it is inappropriate processed. Consumption of such juice can result in serious toxic reactions which may potentially be fatal . Cucurbitacin is a tetracyclic triterpenoid which has been shown to have cytotoxic effects in animals and humans. It has anti-tumorigenic and cytotoxic effect by inducing apoptosis and cell cycle arrest. It was also found to be associated with persistent hypotension, pleural effusion and ascites in mice due to increased capillary permeability, and is lethal in small doses in mice and rabbits. In vitro studies suggested that Cucurbitacin inhibits binding of cortisol to glucocorticoid receptors in a dose-dependent manner, this mechanism may potentiate other causes of hypotension in bottle gourd toxicity such as fluid and blood loss. .
Members of the Cucurbitaceae family (cucumber, zucchini, eggplant, squash, pumpkin and bitter melon) have been cultivated for food. Occasionally poisoning can occur due to toxic constituents accumulating in cultivated ones, or when wild species are mistaken for cultivated ones. Plants tend to accumulate this toxin with maturation and hence over-ripened ones produce more Cucurbitacin. Compared with other plants in the family, bottle gourd has higher content of Cucurbitacin and when it is grown under environmental stress such as extreme temperature and poor soil quality, they produce elevated level of Cucurbitacin .
The extreme bitterness of Cucurbitacin should hinder humans from being exposed to substantial quantities of the compounds. Nevertheless, there have been a few reports of toxicity due to consumption of bitter bottle gourd juice leading to severe gastrointestinal complications. Most patients present with abdominal pain, vomiting, diarrhoea, upper gastrointestinal bleeding and hypotension within 30 minutes to one hour after ingesting bitter bottle gourd juice and the symptoms may last up to 2 to 7 days . In recent years, researchers in India reported a few cases of patients experienced severe haematemesis and hypotension requiring inotropic support from this toxicity . There were also lethal cases reported due to consumption of the juice .
There is no well described antidote for this toxicity and management is mainly supportive such as replacement of fluid deficits, correction of electrolyte abnormalities, symptomatic treatment of vomiting, control of upper gastrointestinal bleeding, management of shock and blood transfusions if necessary .
Although gastrointestinal bleeding after consumption of plant material can arise if there is severe vomiting leading to Mallory-Weiss tear, but consumptions of certain plant species are often reported to lead to gastrointestinal bleeding due to inherent toxicity. Other than plants with high concentration of cucurbitacin from the Curcurbitacae family, consumption of plants with toxalbumin such as Abrus precatorius, Ricinus communis can also lead to gastrointestinal bleed. Some members of the Fabaceae family like Phaseolus genus and Wisteria sinesis also contain toxic lectins that can lead to gastrointestinal bleeding when consumed . Plants with anthraquinone can also lead to severe diarrhoea with bleeding . Members of Thuja, Psoralea, Daphne and Phytolacca genera have also been reported to cause gastrointestinal bleeding . In general, there is no antidote for these poisoning and the management for gastrointestinal bleeding is supportive, in the case of toxalbumin, multi-organ failure and cardiovascular collapse should be anticipated .
In conclusion, early recognition of this rare presentation of bottle gourd toxicity is important in our local context especially where traditional medicine is widely prevalent nowadays. Treatment is supportive. Public awareness of dangerous effects from the consumption of bitter bottle gourd juice and complementary medicine without proper consultation with practitioner plays a crucial role to prevent further cases. Physicians need to advise patients on the use of traditional medicine and their potential side effects.