Bottle gourd (Lagenaria siceraria) toxicity: A rare case report

Bottle gourd juice usage has been known to be a healthy practice in the rural parts of India. In recent times, the knowledge of fitness, exercise and practice of yoga and meditation has increased the consumption of this juice in both urban and suburban areas as well. Bottle gourd juice contains a compound called cucurbitacins. It gives a bitter taste when consumed in excessive quantity. Hypotension, haematemesis, and vomiting has been a fatal presentation of bottle gourd juice toxicity when consumed in excess due to its cytotoxic effects. Bottle gourd belongs to the Cucurbitaceae family which has over 750 species. This included plants such as cucumber, Bitter gourd, Pumpkin, Watermelon, Eggplant, Squash, Colocynth, Zucchini. Its commonly known as Lauki in Hindi, which is a common vegetable grown in India and in the tropics and subtropical worldwide. The fruit believes to have cardio protective, diuretic and nutritive properties as well. Early morning consumption on an empty stomach is considered a remedy for diabetes, heart disease, hypertriglyceridaemia, constipation, liver disease, urinary tract disease, depression, etc. The plant produces cucurbitacin which is a bitter compound that acts as a defence mechanism against insects and other herbivores. In some instances, the excess concentration of this chemical compound grown under poor / non-conducive environmental state like drought, poor soil quality and extreme temperature may alter the nutritive value of the fruit juice. Studies have shown that cucurbitacin has a promising pharmacological properties but increased levels lead to toxicity, capillary leak, hypotension, polyneuritis. The lethal dose in mice is 1.2 mg/Cuca/kg. Levels more then 130 ppm can cause symptoms in adults. In some instances, the consumption of this juice can become dangerous and even life threatening due to the lack of standardisation of the preparation. A 62 year old gentleman presented to our hospital on the 23 November 2022, from a private nursing home with symptoms of severe vomiting and loose stools. He was in a state of shock, BP was not recordable at the time of arrival and was started on IV Noradrenalin (double strength) @ 10 mL/h and with all other supportive measures. On detail history and evaluation, patient was asymptomatic until 7am on the morning on 23 November 2022, at which he consumed a glass full of bottle gourd juice. The entire event was observed by the patient's mother. He did mention that the juice was extremely bitter. This was his first glass of juice after 2 years. He was taking the juice on and off, 2–3 years prior. All juice were made fresh from the fruit which he grinded in a juice-maker. He developed symptoms within 3–5 min of consumption. The first symptom was vomiting, which occurred 5 min after consumption and continuous in nature, followed by loose motions which occurred after 1 h. There was one episode of haematemesis. Patient is a known case of Diabetes and Hypertension on regular oral hypoglycaemics, and anti-hypertensives. Our differential diagnosis Acute Gastroenteritis with Hypovolaemic shock. On examination, the patient was conscious, oriented with cold and clammy extremities. Peripheral pulse was feeble with tachycardia (PR: 160/min, low volume), Oxygen saturation was maintaining 95% on room air, systolic BP was 80 mmHg on IV Noradrenalin. Ryle's tube was inserted and frank blood aspirated, free flow. Random blood sugar was 304 mg/dL. He had oliguria (urine output /24 h <500 cc). Systemic examination revealed a soft abdomen, tenderness over epigastrium with no organomegaly, chest was clear with normal heart sounds. Electrocardiogram showing sinus tachycardia. Right internal jugular vein was canulated and patient was resuscitated with fluids and started on broad spectrum antibiotics and treatment for his diabetic state. Patient became haemodynamically unstable with a drop in GCS the next morning (24 November 2022) and was electively intubated and IV Vasopressin @ 2.5 mL was added. ABG post intubation showing metabolic acidosis which was then corrected. Patient did not show significant signs of improvement and arrested at 12.40pm the same day. Cardiopulmonary resuscitation commenced based of ACLS guidelines, four doses of adrenalin and one dose of Calcium gluconate was given. Despite our efforts, we were unable to revive the patient. With the recent outbreak of COVID in 2019, many traditional preparations of immune and general health boosters have been on the rise globally. The consumption of bottle gourd juice has been a common practice for a long time in many Asian and South East Asian countries. Cases of reported toxicity in the past have not been disclosed due to poor data gathering. In the highlights of recent events more data have been gathered and physicians and scientist alike from around the world now have access thanks to the internet. Bottle Gourd, or known by its scientific name Lagenaria siceraria, is a fruit produced by a fence creeper which dies at the end of each harvest season. The fruit has a green to pale brown colour once ripe. The best climate to grow this plant is in the tropics, with temperatures ranging from 20–25 °C and with plenty of sun light. The fruit has a pheromone known as cucurbitacin which gives it a bitter taste. It's own natural defence against insects and herbivores. There are four subtypes of cucurbitacin which is B,D,G & H. The Cucurbitacin D is most potent and has shown increase capillary permeability which in turn reduces blood pressure, causes ascites and pleural effusion(i). Toxicity in humans is primarily due to this compound. The ethanolic extract of this fruit, however, shows antihepatotoxic and antihyperlipidaemic activity in rats(ii). No study has been done on humans. Cooking the fruit however denatures all the cucurbitacin and the cooked preparation (without the skin and seeds) is said to have cardiac and hepatorenal protective properties. For traditions, this fruit has been eaten and there is no reported side effects up to date after it has been cooked well. Bottle gourd juice poisoning includes Acute gastroenteritis and commensal infections, Systemic Inflammatory Response Syndrome (SIRS), food poisoning e.g. Staphylococcus aureus and Bacillus cereus in acute presentations. Bottle gourd juice, although its consumed in various medical practices, has proven to be less harmful for the majority. However, in small percentage of people, it does produces cardiotoxicity and food poisoning associated with morbidity and mortality.