Ackee Fruit Toxicity


Article Author:
Ryan Surmaitis


Article Editor:
Richard Hamilton


Editors In Chief:
David Wood
Andrew Wilt
Mary Cataletto


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
7/13/2019 5:22:19 PM

Introduction

Ingestion of the unripened Ackee fruit (Blighia sapida) may result in the metabolic syndrome known as "Jamaican vomiting sickness." Clinical manifestations may include profuse vomiting, altered mental status, and hypoglycemia. Severe cases have been reported to cause seizures, hypothermia, coma, and death. Medical treatment is primarily supportive care with intravenous fluids and dextrose.[1][2]

Etiology

The Ackee fruit matures into three sections, each consisting of a large black seed and a fleshy yellow aril. The aril, the edible portion of the fruit, initially contains high levels of the toxin, hypoglycin. However, over time, as the fruit ripens, the hypoglycin levels drop to ranges allowing for safe human consumption. Toxicity only occurs with ingestion of the unripe Ackee fruit. Differentiating ripe versus unripe Ackee fruit is necessary to prevent any potential adverse health effects. Ripe Ackee fruit may be identified by a yellow-red to red color and wide-open appearance (seeds easily visible). Unripe fruit is green to yellow and has a closed appearance (seeds are difficult to visualize). Cooking an unripe fruit does not reduce its potential for toxicity. The seeds remain toxic and should not be ingested. Risk factors for Ackee fruit toxicity include eating an unripe Ackee, purchasing tampered Ackee, or the reusing of water that has been previously used to cook unripe Ackee.[3][4]

Epidemiology

The Blighia sapida tree is native to West Africa. In 1778, it was imported to Jamaica where it has remained the national fruit of the country and an essential part of the Jamaican diet. The epidemiology of the disease has not been well established in Jamaica, but mortality and morbidity are thought to be underreported. There are more cases of the illness in during Jamaican winter months when the fruit is not yet ripe. Blighia sapida also is found in southern Florida, several Caribbean countries, and Cental America. Ackee imported into the United States is regulated by the Food and Drug Administration (FDA) to limit products containing dangerous amounts of the toxin, hypoglycin A. Only a few cases of toxicity have been reported within the United States. Pediatric patients and the malnourished are at greatest risk for toxicity.[5]

Pathophysiology

The Ackee fruit contains both hypoglycin A and hypoglycin B. Hypoglycin A is the toxin primarily responsible for causing Jamaican vomiting sickness. The exact mechanism of hypoglycin A is not known; however, hypoglycemia most likely results from the inhibition of gluconeogenesis. Metabolism of hypoglycin also produces a toxic byproduct, methylene cyclopropyl acetic acid (MCPA-CoA) which inhibits long-chain fatty acid beta-oxidation, resulting in glycogen store depletion. It is impossible to predict what patients will develop symptoms following ingestion as the minimum toxic dose is not currently known. Hypoglycin may be hepatoxic, with liver pathology resembling a Reyes Syndrome-like pattern. Chronic ackee fruit ingestion has been reported to cause cholestatic jaundice among adults.[6]

Toxicokinetics

The onset of hypoglycemia is delayed for a few hours, but once present rapidly progresses. Deaths have been reported within 12 to 48 hours. 

History and Physical

Gastrointestinal (GI) symptoms typically develop within six to 48 hours of ingesting of an unripe Ackee fruit, although they may develop more rapidly in severe cases. An apparent period of recovery (approximately 10 hours) may follow the initial GI symptoms. It is important to note that while vomiting is common, an absence of vomiting does not rule out the diagnosis. Diarrhea is usually absent which may help differentiate Jamaican vomiting sickness from other acute GI infections. Seizures may be a predictor of disease severity as they were present in 85% of reported fatal cases. Other neurological manifestations may include altered mental status, tremors, and paresthesias. A thorough history of the patient's recent meals may be necessary to identify recent Ackee fruit ingestion accurately. Toxicity is dose dependent; therefore, it is important to quantify the amount ingested. If recovery occurs, it happens within one week of ingestion.

Evaluation

Patients with clinical suspicion for Jamaican vomiting sickness should be evaluated in a hospital and admitted for observation. Intravenous access should be obtained to administer fluids and dextrose if needed. Diagnostic evaluation should include blood glucose, serum electrolytes, liver function tests, renal function, lactate, ketones, and blood gasses. Symptomatic patients will require close monitoring of laboratory tests, especially glucose and serum electrolytes. An early ECG may show evidence of electrolyte abnormalities before laboratory diagnostic results. Hypoglycin and its metabolite MCPA may be tested for in blood and urine; however, they may be undetectable secondary to rapid elimination. Other diagnostic tests that help confirm the diagnosis include elevated serum/urine carnitine concentrations and elevated concentrations of urinary dicarboxylic acid.

Treatment / Management

Treatment is primarily supportive as no current antidote for hypoglycin A exists. Patients require close monitoring for hypoglycemia and should be treated with dextrose. Boluses of dextrose may be given initially followed by an infusion which may be titrated to maintain euglycemia. Intravenous fluids should be provided to prevent dehydration and antiemetics to alleviate symptoms. Vomiting and dehydration may lead to electrolyte abnormalities which should be repleted. Benzodiazepines may be used for the treatment of seizures, but again it is prudent to rule out hypoglycemia as the cause of the seizures. GI decontamination, including activated charcoal and gastric lavage, may be considered if there is a concern for potential toxicity if the patient presents within a few hours of ingestion. There is not sufficient evidence to suggest GI decontamination consistently improves patient outcomes. There id no role for syrup of ipecac following acute ingestions. Riboflavin and glycine have been used for treatment as they are thought to antagonize hypoglycin A. Methylene blue has also been proposed as a treatment option for potentially fatal encephalopathy. True efficacy of these supplements is unknown. A medical toxicologist may assist in providing management and may be reached through the local Poison Control Center. Patients with persistent hypoglycemia, seizures, metabolic acidosis, altered mental status, or poor perfusion will most likely require admission to an intensive care unit (ICU). Education focusing on the health hazards of eating unripe Ackee fruits may decrease the future incidence of the disease.[7]

Enhancing Healthcare Team Outcomes

Health care provider, especially those who work in the emergency department, awareness of the potential toxicity of unripe Ackee fruit, especially in the United States, is necessary for early diagnosis and timely management. Public health education on the proper preparation of Ackee fruit may decrease rates of toxicity in areas where it is endemic.

The nursing staff should identify patients exposed in triage and communicate with the clinical emergency department staff so that clinical pharmacy and physician toxicologists can be quickly consulted. Once a working diagnosis is established, the interprofessional team of clinicians and nurses must communicate to assure that appropriate support is rendered quickly. The nurses must monitor the patient for changes in vital signs and immediately report to the clinical team so that adjustments in care can be initiated. [Level V]

The nurses and clinicians including physician assistants, nurse practitioners, and physicians must work towards educating patients and the dangers of consuming Ackee fruit. Making sure children and adults avoid exposure is the safest is the best approach to avoiding morbidity and mortality.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Ackee Fruit Toxicity - Questions

Take a quiz of the questions on this article.

Take Quiz
A 7-year-old male presents to the emergency department with vomiting and a blood glucose of 47 mg/dl. His parents state he ate a piece of Ackee fruit several hours ago. The fruit was brought by his grandmother who is visiting from Jamaica. What toxin is responsible for the patient's symptoms?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 56-year-old female presents with altered mental status 6 hours following ingestion of an unripe Ackee fruit. An EKG is ordered for the patient. What EKG finding is most consistent with this clinical presentation?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old male is experiencing stupor, coma, and hypoglycemia following ingestion of an unripe Ackee fruit. What is the most affected metabolic pathway?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following clinical scenarios more likely describes a case of gastroenteritis rather than Jamaican Vomiting Sickness?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Ackee Fruit Toxicity - References

References

Sanford AA,Isenberg SL,Carter MD,Mojica MA,Mathews TP,Laughlin S,Thomas JD,Pirkle JL,Johnson RC, Quantification of hypoglycin A and methylenecyclopropylglycine in human plasma by HPLC-MS/MS. Journal of chromatography. B, Analytical technologies in the biomedical and life sciences. 2018 Sep 15     [PubMed]
Katibi OS,Olaosebikan R,Abdulkadir MB,Ogunkunle TO,Ibraheem RM,Murtala R, Ackee Fruit Poisoning in Eight Siblings: Implications for Public Health Awareness. The American journal of tropical medicine and hygiene. 2015 Nov     [PubMed]
Grunes DE,Scordi-Bello I,Suh M,Florman S,Yao J,Fiel MI,Thung SN, Fulminant hepatic failure attributed to ackee fruit ingestion in a patient with sickle cell trait. Case reports in transplantation. 2012     [PubMed]
Barceloux DG, Akee fruit and Jamaican vomiting sickness (Blighia sapida Köenig). Disease-a-month : DM. 2009 Jun     [PubMed]
FOX HC,MILLER DS, Ackee toxin: a riboflavin antimetabolite? Nature. 1960 May 14     [PubMed]
Isenberg SL,Carter MD,Graham LA,Mathews TP,Johnson D,Thomas JD,Pirkle JL,Johnson RC, Quantification of metabolites for assessing human exposure to soapberry toxins hypoglycin A and methylenecyclopropylglycine. Chemical research in toxicology. 2015 Sep 21     [PubMed]
Golden KD,Kean EA,Terry SI, Jamaican vomiting sickness: a study of two adult cases. Clinica chimica acta; international journal of clinical chemistry. 1984 Oct 15     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatric. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatric, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatric, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatric. When it is time for the Pediatric board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatric.