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Ecbalium elaterium, a rare cause of uvular angioedema
Ecbalium elaterium or squirting cucumber, is a plant species that belongs to the Cucurbitaceae family and grows in Mediterranean region. The root and fruit of this plant have been used in traditional medicine since ancient times. The fruit juice of E. elaterium has been used in the Anatolia region for inflammatory diseases like rhinosinusitis because of its potent cathartic, analgesic, and anti-inflammatory effects1. However, it may cause allergic, toxic, and systemic adverse reactions in some users. We present a case who developed uvular angioedema after applying a few drops of the fresh fruit juice of E. elaterium into his nostrils to cure his chronic rhinosinusitis.
A 36-year-old male patient applied to the emergency service with complaints of burning sensation, sore throat, and difficulty in breathing. It was learned that due to recurrence of his rhinosinusitis in spite of repeated medical treatment, he applied two drops of fresh fruit juice of E. elaterium plant into his nostrils without diluting it. His symptoms began in about 10~20 minutes. When applying the same treatment on two prior occasions, he had experienced no similar symptoms. The medical and family histories were unremarkable, and he had no history of drug use. Erythema and edema were observed in uvula and soft palate and other physical examination findings were normal (Fig. 1a). On laboratory examination, complete blood count and blood biochemistry were within normal limits. In the light of the history, physical examination and laboratory findings, E. elaterium-induced angioedema was diagnosed for the patient. The patient's symptoms regressed with standard angioedema treatment in the next few hours.
Rhinosinusitis is one of the most common medical problems throughout the world. Long periods of antibiotics, surgical or supportive treatment methods are the usual treatment. However, none of these approaches have been found successful long term2. This leads people to search for alternative treatment methods as in our case.
The fruit of E. elaterium is ovoid, fleshy, pale green in color, approximately 3 cm in length, and the surface is covered with hairs (Fig. 1b). Elaterium is the fluid obtained from the fruit of E. elaterium. The most known active component of elaterium is elaterin. Elaterin is a cathartic agent with potent hydragogue effect, and for this reason it has been used in traditional medicine. Another component of elaterium is cucurbitacine B which is a derivative of triperten and acts as an active anti-inflammatory agent1. It has been reported that besides chronic rhinosinusitis, elaterium is also used in the treatment of diseases considered to be inflammatory like rheumatism and infections3. An experimental study conducted by Uslu et al.4 investigated the anti-inflammatory effect of aqueous extracts of E. elaterium used topically in treatment of rhinosinusitis, showing that E. elaterium extracts reduce inflammation considerably in rabbits suffering from rhinosinusitis compared with the control group. Elaterin and cucurbitacins may cause allergic reactions, direct toxic reactions or systemic side effects. Uvular angioedema, which is one of the most prevalent adverse reactions, manifests as sore throat, hoarseness, and dyspnea. It may progress and lead to complete airway obstruction if treatment is delayed5. Uvular edema may either be an immunoglobulin E (IgE)-mediated allergic reaction or may result from direct toxic effect. Since no reaction developed in earlier uses of undiluted form of elaterium, the uvular edema in our case was considered to be an IgE-mediated hypersensitivity reaction resulting from earlier sensitizations. In their series with 42 cases where allergic edema developed due to the use of E. elaterium, Kloutsos et al.6 have reported that the edema was most frequently observed in uvula and 39 cases had a history of allergic reaction. The patient reported here had no history of allergy. Eken et al.7 have reported a case with nasal mucosa necrosis caused by direct toxic effect of E. elaterium. One case who developed renal failure after systemic intake of the plant has also been reported in literature8.
Although the effect of E. elaterium on rhinosinusitis has been demonstrated experimentally, care must be taken in using herbal treatments for which therapeutic doses, effects and side effects are not fully understood, since using undiluted forms may cause serious adverse reactions.