| Abstract|| |
Background: Local communities in tropical regions, mainly in Africa, have used traditional herbal medicines as means of preventing and treating malaria with unrealistic experimental analysis. Aims: The safety and effectiveness of traditional dosage forms of dried seed of Aristolochia elegans mast. Was therefore assessed on 20 respondents who had been using the seed of this medicinal plant for over 1-2 years against malaria. Toxicological and pharmacological properties of ethanol and ether crude extracts of dried seed were also examined on 45 male Balb c mice. Materials and Methods: The methods used were personal interview schedule to assess safety and effectiveness of traditional dosage, evaluation of documented information, extraction of test medicinal substance, investigation of pharmaco-toxicological properties and qualitative chemical analysis. Statistical analysis was performed using data master sheets and scientific calculator. Results: The effectiveness of this seed was highly encouraging against malaria as compared to conventional antimalarial drugs. According to the respondents, relapse of malaria could usually happen with the conventional antimalarial drugs at normal doses, whereas relapse of malaria was rarely happening with the seed of A. elegans at the traditional dose taken. There were no health disorders discovered in 20 respondents who had been using the seed of this medicinal plant for over 1-2 years against malaria. However, laboratory mice died with a single dose of crude extracts at 1000-5000 mg/kg within 4-9 days after the dose was given orally. Histopathological examination showed that both crude extracts caused severe damage to the kidney and liver of Balb c mice. Four out of 10 treated Balb c mice also developed hemorrhages in the stomach, which was a strong indication of carcinogenic property of this plant material. Conclusion: A person using this herbal preparation is therefore at a higher risk of getting stomach cancer and renal and hepatic diseases.
Keywords: Antimalarial drugs, Aristolochia elegans Mast., health hazards, histopathological examination, interview schedule, medicinal plant, pharmaco-toxicological properties, qualitative chemical analysis
|How to cite this article:|
Belay Y. Study of safety and effectiveness of traditional dosage forms of the seed of Aristolochia elegans Mast. against malaria and laboratory investigation of pharmaco-toxicological properties and chemical constituents of its crude extracts. Ann Trop Med Public Health 2011;4:33-41
|How to cite this URL:|
Belay Y. Study of safety and effectiveness of traditional dosage forms of the seed of Aristolochia elegans Mast. against malaria and laboratory investigation of pharmaco-toxicological properties and chemical constituents of its crude extracts. Ann Trop Med Public Health [serial online] 2011 [cited 2018 Nov 17];4:33-41. Available from: http://www.atmph.org/text.asp?2011/4/1/33/80534
| Introduction|| |
Importance of malaria
Malaria is an infectious disease causing many deaths and more morbidity in the tropical and sub-tropical zones.  Various interventions have been employed in public health program to eradicate malaria, such as treatment of cases using tissue and blood scizonticidal agents, chemoprophylaxis of high risk population, reduction of malaria endemicity in a region, etc. However, formidable obstacles slowed the speed of progress.  Drug resistance of malaria parasites, lack of biological information on vector species habits and transmission capacity, insecticide resistance of mosquitoes, political and economic difficulties, and limitation of means and resources to combat this protozoan disease are the main obstacles for worldwide eradication. 
As the result of emergence of multidrug-resistant strains of malaria which has accompanied each new class of antimalarial drugs, there is a need for planning fresh approach to the prevention and treatment of malaria. New families of compounds with antimalarial activity are needed to improve treatment efficacy and to slow development of resistance. 
Medical importance of Aristolochia species
Although there was not much experimental work carried out on Aristolochia elegans Mast. to discover safe medical importance to humans, many other species of the genus Aristolochia were highly regarded as medicinal plants during the time of ancient Egyptians, Greeks and Romans, and also play a minor role in traditional Chinese medicine (TCM).  Some of the species are, however, notable for containing toxic aristolochic acid, sometimes in quantities fatal to humans, e.g., Aristolochia clematitis.
The leaves of A. elegans, which are pounded and diluted in water, are used to treat intestinal parasitism in cattle in Democratic Republic of Congo (Kivu),  and east coast fever of cattle in Bulamogi county, Uganda. 
Traditional medicinal plant has an important role to play in combating new and re-emerging diseases. Global priority is currently placed on combating malaria and HIV/AIDS, and new partnerships between the communities of traditional medicine, public health and health research are being formed. 
World Health Organization (WHO) estimates that the majority of the population of most non-industrial nations still relies on traditional forms of medicine for their every day health care. In Uganda, for instance, where there is only one doctor for every 20,000 people, there is one traditional health practitioner per 200-400 people and a greater percentage of population uses traditional medicine with unrealistic clinical application in tropical countries. 
Historically, local communities in tropical regions, mainly in Africa, have used local flora as a means of preventing and treating malaria.  As a result, there is a need for planning and implementing realistic experimental analysis to this local flora to discover safe and efficient medicinal product against malaria.
| Materials and Methods|| |
Data collection was conducted on different community members in Kampala city (Kawempe, Karorowe and St. Balikuddembe shed in Owino market) with the help of traditional healers who were selling traditional herbal products with unrealistic clinical analysis, to the community. The dose and dosage form of the herbal product given to the patient was obtained from three traditional healers at St. Balikuddembe shed in Owino market, Kampala city. These traditional healers were helpful to the principal investigator and research assistant in recruiting respondents who have been buying the seed of this traditional medicinal plant for malaria treatment. Identification of the scientific name of the plant was made at the Herbarium, Department of Botany, Makerere University, in January 2007. The fruit of A. elegans was collected from different places in Kampala (upper hill road, along the fence of Mulago hospital and Buganda road along the fence of Ministry of Agriculture, Animal Industry and Fisheries) by the principal investigator along with an assistant in March 2008. The seeds were separated manually and pounded using a metallic mortar in the School of Pharmacy, Mulago Paramedical Schools. The ground materials were extracted from the seed of this plant, and laboratory study on pharmaco-toxicological properties and chemical constituents of crude extract was conducted in the Department of Pharmacology and Therapeutics, Faculty of Medicine, Makerere University, from April to August 2008. Histopathological evaluation of tissues from the kidney, liver, stomach and intestines of Balb c mice was conducted in the Department of Veterinary Pathology, Faculty of Veterinary Medicine, Makerere University, from 17 th September to 20 th October 2008.
The study was longitudinal and descriptive which was conducted as four cross-sectional studies from July 2006 to October 2008.
The respondents from different communities were considered when they were coming to buy the herbal product for malaria treatment from traditional healers at St. Balikuddembe shed in Owino market, Kampala city. Twenty respondents who had been using both the seeds of A. elegans and conventional antimalarial drugs for malaria treatment for the last 1-2 years were involved in the study.
Convenient sampling technique was used on clients attending traditional healers at St. Balikuddembe shed in Owino market, Kampala city. The principal researcher along with a research assistant collected data from the traditional healers at St. Balikuddembe shed in Owino market, where they sell herbal products with unrealistic clinical analysis to the community, the residence and working places of other respondents who were buying this herbal product from traditional healers.
Data collection methods
Five data collection methods were used. These were personal interview schedule, review of documented information, extraction of plant material, investigation of pharmacological and toxicological properties and qualitative chemical analysis.
Personal interview schedule
This method of data collection was used to assess safety and effectiveness of the seed of A. elegans on the respondents mentioned earlier. The interview schedule was designed with guiding questions which were written in English. One field research assistant was used to translate the questions to local language during the study. Answers were written in English on the interview schedule, using a pencil.
The interview schedule included the period of use, the health disorders probably encountered during and after the course of medication using the seed of this plant, such as nausea, vomiting and gastric upset, mental confusion and headache, sleeplessness, allergic reaction and physical disorders corresponding to the respondent's name. The dose and dosage forms used by the respondents were also included in the interview schedule. In addition to interview schedule, folder, Hb pencil and rubber were required.
Documented information on the dose and dosage forms of the seed of A. elegans used by different communities and its adverse effect on humans and animals were reviewed from different sources (traditional healers, Internet and records of THETA - Uganda).
Extraction of test medicinal substance
The dried fruits of A. elegans were collected and seeds were isolated manually. The isolated seeds were pounded using a metallic mortar and ground materials were extracted using ether and ethanol. Four hundred grams of pounded seeds was soaked in ether for 48 hours and filtered in a dark brown chemical free bottle, using Whatman filter paper 46 × 57 cm. After drying the marc from the ether extraction, it was also soaked in ethanol for 48 hours and filtered in a bottle of the same type, using a Whatman filter paper 46 × 57 cm. Ether was removed using simple distillation at 40°C, and ethanol was removed using rotary evaporator and water bath at 90°C. Both soluble extracts were concentrated to dryness at room temperature for 1.5 days (36 hours) and stored in different containers to be tested differently.
The pharmacological and toxicological properties of test extract were investigated using 45 male Balb c mice of about 4 months old, which were procured from Faculty of Veterinary Medicine, Makerere university. These investigations included the following: investigation of toxicity property on Balb c mice and histopathologic evaluation of tissues of the visceral organs of treated and control Balb c mice.
Toxicological study of test extracts on male Balb c mice:
The toxicity of extracted test compound was evaluated on 30 laboratory Balb c mice by dividing them into two groups (15 mice each) in which the ethanol and ether crude extracts were tested. Four mice were selected by non-probability sampling from each group and kept in separate cages. One mouse from each group was also selected by non-probability sampling and kept in another cage for control test. All sampled mice had been starved overnight before weighing them and calculating the right dose. The mice from each group were weighed separately and labeled at the head, back, thigh and tail with different colors, i.e., black and blue. First, the mouse was picked from the cage by holding its tail and put in a plastic bottle (with its tail off) which w as already measured. Each mouse was weighed using an electronic balance and the weight was recorded in a notebook, from which the right dose per body weight was calculated.
The calculated doses of both crude extracts were also measured using electronic balance, weighing boat and spatula [Figure 1]A. A solution of soluble extract at different concentrations (500, 1000, 2000, 3000, 4000 and 5000 mg/kg) was prepared and administered orally to the first, second and third groups of eight laboratory mice each (two mice for each dose) and the control solutions (0.5 ml) were also administered orally to the last group of six laboratory mice (two mice for each dose) using intragastral tube and 1 ml syringe [Table 1] and [Figure 1]B. The ethanol crude extract was dissolved in 0.5 ml of distilled water and tested on black labeled mice, while the ether crude extract was dissolved in 0.5 ml of cooking oil and tested on blue labeled mice. The effects of each administered dose to Balb c mice were monitored three times a day (in the morning, at noon and in the evening) for 10 days by providing food (layer's mash) and water to both treated and control mice on a daily basis.
|Figure 1: (A) Weighing of calculated dose per body weight to prepare the dosage form; (B) Oral administration of prepared dosage form; (C) Red labeled control mice for histo-pathological examination (control solutions); (D) Black labeled mice for histo-pathological examination (ethanol crude extract); (E) Blue labeled mice for histo-pathological examination (ether crude extract)|
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|Table 1: Weight of laboratory mice labeled for toxicity evaluation and orally administered doses of extracted test compounds and control solutions|
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Histopathologic evaluation of tissues of Balb c mice
Histopathologic examination was also done to establish the effect of test extract on the kidney, liver, stomach and intestines of Balb c mice. First, 15 male laboratory mice were divided into three groups of five mice each by non-probability sampling, and weighed, labeled with different colors and kept in separate cages. The first group of five mice was labeled black on the ear, head, back, thigh and tail and treated with 5000 mg/kg of ethanol crude extract which was dissolved in 0.5 ml of cooking oil. The second group of five mice was marked blue on the ear, head, back, thigh and tail and treated with 5000 mg/kg of ether crude extract which was also dissolved in 0.5 ml of cooking oil. The third group of five mice was test control laboratory mice, labeled red on the ear, head, back, thigh and tail [Figure 1]C-E.
The effect of each administered dose to laboratory Balb c mice was also monitored three times a day (in the morning, at noon and in the evening) by providing food (layer's Mash) and water to both treated and control mice on a daily basis. Dissection was performed immediately after death and visceral organs (kidney, liver, stomach and intestines) of Balb c mice were removed and preserved in 10% formalin using one specimen container for each dissected mice. The control Balb c mice were sacrificed by breaking the neck, and visceral organs (kidney, liver, stomach and intestines) were also removed and preserved in 10% formalin [Figure 2]. The specimens were labeled and transported to the Department of Veterinary Pathology, Faculty of Veterinary Medicine, Makerere University, for histopathologic examination.
|Figure 2: Visceral organs (kidney, liver, stomach and intestines) of Balb c mice preserved in 10% formalin|
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Kidney, liver, stomach and intestine, which were fixed in 10% formalin, were processed for microscopic examination. Each of the samples was given a number for identification and trimmed to small sizes and placed in tissue cassettes along with their corresponding numbers. They were then dehydrated with graded alcohol, cleared impregnated with paraffin wax and finally embedded in paraffin block. The sections were then cut into 3-5μ thick slices, collected onto a slide and stained with Hematoxylin-Eosin and examined under the light microscope.
Qualitative chemical analysis
The constituents of extracted test compounds were investigated using test tube identification reactions based on color, precipitate and ultraviolet light determinations [Figure 3].
|Figure 3: Test - tube identification reactions based on colour and precipitation|
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Data processing and analysis
Data from different data collection techniques were recorded manually in notebooks, digital camera and field diaries. Then, the data were systematically arranged, processed and analyzed manually and using a computer package (Microsoft office excel 2003, Microsoft office word 2003 and HP photosmart essential along with calculator) for content. Subject matters of the study were identified and organized into meaningful categories and subcategories. For comprehensiveness, data from different data collection techniques were compiled to validate and complement the findings from each of the sources.
The analyzed data from each of the sources were presented in form of tables, pictures, graphs and use of descriptive statements in a thematic approach.
The researcher was given an introduction letter from the School of Medical Entomology and Parasitology to seek permission and conduct research. Traditional healers at Owino market and Heads of Departments in Makerere university were contacted. The norms and rules of the community and institutions were strictly observed.
| Results|| |
Description of A. elegans
A. elegans is a species of evergreen and deciduous woody vines and herbaceous perennial plant.  It has irregular flowers, the perianth tube is yellowish green, leaves alternate, simple estipulate, often heart shaped at the base and trilobed. Flowers are usually large, variously patterned, brown or purple in color. 
It is widely cultivated and naturalized in tropical and temperate regions of the world in evergreen riverine forest margins, usually in disturbed areas.  The plant, which climbs over other plants, fences and buildings, is mainly used as environmental ornamentation and medicinal plant against malaria by different communities in Uganda.
The fruit of this plant is oblong, cylindrical in shape, and composed of six approximately paralleled and closed pockets in which the seeds are contained. When the fruit dries, the capsule of the seed opens, and the seeds, which are ovate and flattened in shape, are released by the wind and rain to the ground. Seeds are numerous, have a very unpleasant smell (evil smelling) and are dark-yellowish in color. Once the plant reaches flowering stage, the plant continuously produces fruit and seed throughout the year, including dry and rainy season. Since rain washes away most of the seeds during rainy season, adequate seeds could be harvested from a particular habitat of the herb during dry season than rainy season.
Traditional dose and dosage forms of the seed of A. elegans, used by the people
The traditional dosage form of the seed of A. elegans used by the people differs from community to community. A teaspoonful of seeds was added to 1 l of warm water and 0.5 l of this solution was taken twice a day.  On the other hand, three members of the society at Kawempe and Karorowe in Kampala city took about a teaspoonful of the seed sandwiched in peeled banana or millet flour and swallowed it with incomplete chewing [Table 2]. These few members of the society preferred the second dosage form to the first one because of the bitter taste of the solution of the seed in warm water. However, traditional healers at St. Balikuddembe shed in Owino market, Kampala city, were opposed to this kind of dosage form. According to them, the seed is not easily digested by the enzymes of alimentary canal and it might stick to the mucous membranes of gastrointestinal tract and caused tumor. As a result, they prescribed three teaspoonfuls of the seed added to one cup of warm water, taken three times a day (tid) and this solution was given to children suffering from malaria fever. In the case of adults, they prescribed half tea cup of the seed added to two cups of warm water and the solution was to be taken three times a day (tid) against malaria (traditional healers at St. Balikuddembe shed, July-August 2008).
|Table 2: The different dosage forms of the dried seed and number of users in percentage against malaria (n = 20)|
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Safety and effectiveness of the dried seed of A. elegans
The safety of the seed of this traditional medicinal plant was assessed on 20 respondents who used it two to three times against malaria fever. Except a few cases of nausea and vomiting during the course of medication, there was no other health hazard discovered in the respondents. However, ethanol and ether crude extracts of the dried seed killed all sampled Balb c mice at a single dose of 1000-5000 mg/kg within 4-9 days, depending on the amount of dose administered orally. The patients were feeling the bitter taste of the seed in the saliva for over 48 hours after the dose was taken orally. The sweat and urine of these patients also smelled like that of the seed the following day (Kikomba John, personal information, 11 December 2006).
According to the respondents, relapse of malaria fever usually happened with the conventional antimalarial drugs at normal doses and most of the clients [16 (80%)] were subjected to additional doses to heal malaria. However, relapse of malaria fever was rarely happening with the seed of this traditional herbal medicine at a single traditional dose taken orally [Table 3].
|Table 3: Comparison of effectiveness of the seed of A. elegans and conventional antimalarial drugs for malaria treatment (n = 20)|
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Amount of crude extract obtained
Of the 400 g pounded dry seed of A. elegans which was first soaked in ether for 48 hours and then in ethanol for 48 hours, a viscous residue of 9.11 and 11.43 g of the extract, respectively, was obtained.
Acute toxicity studies on Balb c mice
The acute toxicity of oral administration of both ethanol and ether crude extracts at different concentrations was evaluated on 30 Balb c mice for a maximum period of 10 days for each administered dose. There was no appearance and behavioral change observed in the first batch of laboratory mice, which was given a single dose of 1000 mg/kg for the first 3-4 days.
However, the appetite of these mice was gradually suppressed and they eventually started dying 7 days after the dose was given. All treated mice died as if they were sleeping peacefully without any vigorous movement against the death. The first sampled and treated laboratory mice died on the 7 th , 8 th and 9 th days after the dose was administered orally [Figure 4]C.
|Figure 4: The length of time at which the crude extracts caused lethal effect on laboratory Balb c mice at different doses; (A) 4000 mg/kg and 5000 mg/kg; (B) 2000 mg/kg and 3000 mg/kg; (C) 500 mg/kg and 1000 mg/kg|
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The second batch of eight Balb c mice, which were given a single dose of 2000 and 3000 mg/kg body weight of both ethanol and ether extracts, started dying on the 5 th day after the dose was administered in the same route. All the treated mice died on the 6 th and 7 th days after treatment [Figure 4]B.
The first two mice from the third batch of eight Balb c mice, which was given a single dose of 4000 and 5000 mg/kg body weight of both ethanol and ether extracts died on the 4 th day and the remaining six mice died on the 5 th and 6 th days after the dose was administered orally [Figure 4]A. But no sampled mice died within 72 hours even with the highest dose administered in this route.
The length of time at which lethal effect of test extract was observed on sampled mice was dose related. Even if the effect of these extracts was dose related and became magnified within a short period of time when large amounts were administered orally, the effect of these extracts also remained after a long period of time when small amounts were administered in the same route. As a result, it was difficult to determine the lethal dose (LD 50 ) and effective dose (ED 50 ) of these extracts precisely.
Histopathologic evaluation of mice tissues
The effects of both ether and ethanol crude extracts on the kidney, liver, stomach and intestines of Balb c mice were investigated by histopathologic examination. This examination showed that all the sections from the kidney of the mice given a single dose of 5000 mg/kg of both the crude extracts revealed marked degeneration and necrosis of tubular epithelial cells. Hyaline casts were observed in the lumen of the tubules. Focal parenchymal hemorrhages were also observed. The lesions were all similar with minor variations in their severity. Sections from the liver showed mild to moderate hepatocellular degeneration, and vacuolar to fatty degeneration with hepatocellular necrosis of individual cells. In general, the liver damage was less severe than the kidney damage. Hemorrhages in the stomach were seen in 4 out of 10 mice given a single dose of 5000 mg/kg of these crude extracts. The stomach of other mice showed no significant lesions. Examination of the intestine of all the 10 mice given a single dose of 5000 mg/kg of these crude extracts revealed no significant lesions.
Chemical constituents of extracted test compounds
Both ether and ethanol extracted test compounds were analyzed by test tube identification reactions and ultraviolet light determination. All the samples of ether extracted test compound were found to be rich in steroids/triterpenoids (strong), flavonoid aglycones (strong), anthraquinone aglycones (trace), basic alkaloids (trace) and saponins (very strong). Tannins (very strong), coumarins (trace) and steroids/triterpenoids (strong) were the components of ethanol extracted test compound.
| Discussion|| |
Investigation of safety and effectiveness of traditional dosage forms
The potential adverse effect of the seed of A. elegans, which might have occurred during and after the course of treatment, was assessed in the respondents. Except a few cases of nausea and vomiting, none of them presented any of the adverse effects mentioned in the interview schedule, and despite the fact that the seed tasted bitter, all of the participants preferred the seed of this medicinal plant to conventional antimalarial drugs for malaria treatment. Sixteen (80%) of them said that they usually failed to respond to the normal dose of conventional antimalarial drugs and they normally went to the pharmacy for additional doses. However, a single traditional dose of the seed of A. elegans (e.g., teaspoonful of seeds sandwiched in peeled banana or millet flour, or three teaspoonfuls of seeds added to one cup of warm water taken three times a day) was quite enough for them to treat malaria and they remained free of malaria sickness for longer period of time.
Pharmacological and clinical property
The oils from the dried seed of A. elgans were bioassayed on Balb c mice (aged about 4 months) at different doses per body weight. Even if the sampled mice did not die within 72 hours after the administration of prepared dosage form orally, they started dying as if they were sleeping peacefully on the 4 th day at the highest dose per body weight (5000 mg/kg). It seemed that the lethal effect of both ether and ethanol extracts was abnormal stimulative effect against the biological process of cells in the stomach, liver and kidney of treated laboratory mice which leads to haemorrhages and necrosis. The effects of both extracts on mice were similar to the effects of adrenocortical steroids (endocrine drugs) which cause permissive side effects on human beings. Of the chemical constituents of the extracted test compound from the dried seed, steroids/triterpenoids were one of the strong ingredients identified using test tube identification reaction.  Studies by Shimoyama et al. (2003) in Japan, Latif et al. (1997) in USA and Bühler et al. (1991) in Germany discovered the selective inhibition of hepatic and renal systems in rats  and kidney in sheep,  by this chemical compound and its derivatives.
Even though there was not any health hazard identified in the respondents who had been using the dried seed of A. elegans in different dosage forms against malaria for the last 1-2 years in Uganda, two cases of nephropathy associated with the use of Chinese botanical preparations, which contain aristolochic acid, were reported in the United Kingdom in July 1999.  In 1993, a series of end-stage renal disease cases had been reported from Belgium, associated with a weight loss treatment where Stephania tetrandra in a herbal preparation was suspected of being substituted with different plant species, especially Aristolochia fangchi.  More than 105 patients were identified with nephropathy following the ingestion of this preparation but the part of the plant from which the preparation was formulated was not specified.  The undesired effect of this preparation was much related to the effects of steroids/triterpenoids and its derivatives on mice, rats and sheep, which were studied by different investigators mentioned earlier.
The dried seed of A. elegans was intensively used by different community members in Uganda against malaria fever, with unrealistic clinical analysis [Figure 5]. The effectiveness of the traditional dosage forms of the seed against malaria was encouraging as compared to conventional antimalarial drugs. However, histopathologic investigation of processed tissues from different visceral organs (kidney, liver, stomach and intestine) of Balb c mice showed that these crude extracts have caused severe damage to the tissues of kidney and liver. Hemorrhages in the stomach of 4 out of 10 treated mice were also found, which is a strong indication of carcinogenic property of this plant material. A person using the seed of this plant for treatment purposes orally is therefore at a higher risk of acquiring stomach cancer and hepatic and renal diseases as well.
|Figure 5: The dried seed of Aristolochia elegans mast for sell at St. Balikuddembe shed in Owino market|
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Further investigations, mainly epidemiological studies, need to be conducted to discover the health status of the population that has been using these herbal remedies against malaria parasites for considerable period of time. If safe medicinal and commercially important products are desired out of this crude extract, separation of harmful component (steroids/triterpenoids) needs to be performed and re-evaluation has to be conducted to determine the dose, dosage forms, safety and effectiveness of the new ingredients.
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School of Medical Entomology and Parasitology, Mulago Paramedical Schools, PO Box 34025, Kampala
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]