Plants are responsible for 5% poisoning recorded by Poison Control Centers. Among all known toxic plants, some present a real danger if ingested. We report the case of a five years old child, who presented, after ten bitter almonds ingestion, consciousness disorders progressing to coma with generalized tonic-clonic seizures, miosis and metabolic acidosis. Bitter almonds and nuclei of stone fruits or other rosaceae (apricot, peach, plum) contain cyanogenic glycosides, amygdalin, that yields hydrogen cyanide when metabolized in the body. Swallowing six to ten bitter almonds may cause serious poisoning, while the ingestion of fifty could kill a man. The binding of cyanide ions on cytochrome oxidase lead to a non hypoxemic hypoxia by blocking the cellular respiratory chain. Therapeutic measures include, oxygen support, correction of acidosis and cyanide antidote by hydroxocobalamin in case of serious poisoning.
Keywords: Bitter almonds, cyanide, poisoning
|How to cite this article:
Mouaffak Y, Zegzouti F, Boutbaoucht M, Najib M, El Adib A G, Sbihi M, Younous S. Cyanide poisoning after bitter almond ingestion. Ann Trop Med Public Health 2013;6:679-80
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Mouaffak Y, Zegzouti F, Boutbaoucht M, Najib M, El Adib A G, Sbihi M, Younous S. Cyanide poisoning after bitter almond ingestion. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Sep 26];6:679-80. Available from: https://www.atmph.org/text.asp?2013/6/6/679/140262
Plants are responsible for 5% poisoning reported to Poison Control Center of Strasbourg in France.  In the 2003 annual report of the American Association of Poison Control Centers, plants are responsible for 3.2% poisoning. Among all those known toxic plants, some present a real danger if ingested. 
We report a pediatric case of cyanide intoxication after bitter almond ingestion, and we discuss pathophysiological elements and clinical management of this poisoning.
A 5-year-old boy, with no significant medical history, has been brought by his mother at the pediatric emergency department because developing since 2 h dizziness, confusion, somnolence, and vomiting. Thereafter, he had generalized tonic-clonic seizures and became comatose. Five hours earlier, the child had deliberately ingested about 10 bitter almonds.
On arrival in the emergency room, the patient was unconscious, spontaneously mobilizing its members. He has a Glas gow coma scale at 10 and miosisof the pupilsintight. He was tachypneic, with peripheral oxygen saturation at 98%. He has normal pulse and blood pressure. He was afebrile and has no stiff neck. Cardio thoracicauscultation had shown no abnormality except for bilateral sonorous rales. The laboratory test shad revealeda metabolic acidosis (bicarbonatemia at 15mmol/l), with renal function and blood count normal. In the absence of aninfectious syndrome and another calling point explaining the neurological distress of the child, atoxic origin was strongly suspected. The child has been transferred to the intensive care unit. He was monitored and supported on oxygen. Three hours later, he recovered with normal breathing and neurological status.
Bitter almonds contain cyanogenic glycoside called amygdalin. Its hydrolysis releases in the body hydrocyanic acid.  Some cases of poisoning by ingestion or inhalation of bitter almonds’s oil have been reported. Some were fatal. , Swallowing sixto ten bitter almonds may cause serious poisoning, while the ingestion of 50 could kill a man.  Cyanogenic compounds are found in several plants, including nuclei of other rosaceae fruits (apricot, peach, cherry, plum) or cassavaroot. Ingestion of this starch seems to be a real public health problem in some tropical countries, where it constitutes a staple food of the diet. It causes every year acute cyanide poisoning with several deaths in those countries. ,
Several cases of poisoning by ingestion of bitter almonds have been reported in literature. Some with a fatal issue. ,, The first case has been reported by T. R. Heywoon. Thomsom in 1856 about a 48-year-old woman, a cook, died after ingestion of almonds essence sold as flavor by the druggist of her city. 
Bitter almonds contain up to 5.3% amygdalin. The toxicity of amygdalin is directly attributable to the release of hydrogen cyanide. This release occurs through the action of enzymes (hydrolase). Chewing the amends increases production of cyanide.  Hydrolysis is slow in acidic conditions but fast and complete in alkaline ones. This chemical feature probably explains the delay of onset of symptoms in cyanide poisoning. It is the time necessary of passage of the bolus from the stomach to the duodenum, which means from the acid to the alkaline medium. ,
Toxic action is an on specific inhibition of many enzyme (mitochondrial cytochrome oxidase), anearly impairmentof calcium homeostasis and intra cellular peroxidation of nerve membranes. Accordingly, clinical manifestations of acute cyanide poisoning are often nonspecific and mainly reflect oxygen deprivation of heart and brain such as confusion, dizziness, and the cardio-respiratory collapse in severe poisoning case. ,,
In our patient, neurological manifestations were the main symptoms of the clinical picture. Dizziness and confusion at first and complicated later by seizures and coma.
The diagnosis can be evoked by the characteristic bitter almond odor of the breath or the gastric lavage. It may be confirmed by the measure of cyanide in plasma. ,,, This is not possible in our context.
Literature data report the efficacy of early treatment of severe cyanide intoxication. Gastric lavage may be recommended in early diagnosis. Oxygen support and correction of electrolyte disorders should be rapidly performed. , The administration of hydroxocobalamin is recommended in severe cyanide poisoning. It constitutes the antidote of choice, which detoxifies cyanide by binding it to form cyanocobalamin, a nontoxic compound excreted in the urine. ,
Our patient was hospitalized in pediatric intensive care unit and his vital signs were strictly monitored. He rapidly responded to a treatment with oxygen and correction of his metabolic acidosis. The neurologic recovery was obtained in 3 h.
Manifestations of cyanide poisoning by ingestion of cyanogenic foods are not specific. Its severity depends on both quantity of cyanogenic food ingested and the delay of management. Medical professional should be able to recognize cyanide poisoning despite its rare occurrence because early diagnosis and treatment are the successful way to reduce morbimortality. Oxygen administration should be rapid as well as specific antidotes in severe poisoning.
|1.||Flesch F. Intoxications d′origine végétale. Encyclopédie médico-chirurgicale 2005;2:532-46.|
|2.||Baert A, Danel V. Armes chimiques. Encyclopédie médico-chirurgicale. Toxicol Pathol 2004;1:117-23.|
|3.||Geller RJ, Barthold C, Saiers JA, Hall AH. Pediatric cyanide poisoning: Causes, manifestations, management, and unmet needs. Pediatrics 2006;118:2146-58.|
|4.||Kovalevsky P, Bengler C. Intoxication cyanhydrique par ingestion d′amandes amères. Réansoinsintens. Med URG 1996;12:149-53.|
|5.||Ruangkanchanasetr S, Wananukul V, Suwanjutha S. Cyanide poisoning, 2 cases report and treatment review. J Med Assoc Thai 1999;82:S162-7.|
|6.||Shragg TA, Albertson TE, Fisher CJ Jr. Cyanide poisoning after bitter almond ingestion. West J Med 1982;136:65-9.|
|7.||Heywoon-Thomsom TR. Fatal case of poisoning by essence of almonds. Assoc Med J 1856;4:1055-6.|
Departments of Anaesthesia and Critical Care, Mother and Child Hospital, University Hospital Centre, Rue Ibn Sina, Amerchich, Marrakech, 40000
Source of Support: None, Conflict of Interest: None