key: cord-0777117-hbqapc16 authors: Mathew, Thomas; John, Saji K.; Kamath, Vikram; Kumar R, Shiva; Jadav, Rakesh; Shaji, Asha; Nadig, Raghunandan; Sarma, Gosala Raja Kukkuta; Parry, Gareth J. title: Essential oil–related status epilepticus: A small case series study date: 2020-06-25 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12147 sha: 607d1b8b8022d10bceb615bfa3562ea93061ee5b doc_id: 777117 cord_uid: hbqapc16 OBJECTIVE: Essential oils are plant‐derived oils and are widely used as an over‐the‐counter remedy for common ailments. Many essential oils are found to have proconvulsant effects. Here we report a small case series of 3 adults with eseential oil‐related status epilepticus. METHODS: This was an observational study conducted in a tertiary care hospital in south India from January 2018 to December 2019. We collected the demographic, clinical, and imaging features of all cases of status epilepticus resulting from exposure to essential oils. Cases of status epilepticus secondary to all other causes were excluded. RESULTS: There were 3 young adults with essential oil‐related status epilepticus. Two had de novo generalized tonic–clonic status epilepticus, and 1 with posttraumatic occipital lobe epilepsy had focal‐impaired awareness status epilepticus. The first 2 cases presented with histories of ingestion of eucalyptus oil. The third case had focal‐impaired awareness status epilepticus after topical application of various balms containing eucalyptus and camphor. CONCLUSIONS: Proconvulsant essential oils of eucalyptus and camphor can cause both generalized and focal status epilepticus. Physicians dealing with patients of status epilepticus should enquire about the exposure to proconvulsant essential oils. prayers and rituals. Many essential oils are found to have proconvulsant effects and can trigger seizures. In 2017, we published a small case series of patients from 3 tertiary care hospitals who had eucalyptus oil inhalation-induced seizures. 1 Similar to eucalyptus oil, camphor also has proconvulsant properties. Camphor is a terpenoid obtained from the wood of camphor laurel and has been known for more than 500 years to have convulsant properties. 2 Camphor has been implicated in many cases of acute symptomatic seizures not only in the pediatric age group but also in adults. [3] [4] [5] Status epilepticus can have varied etiology, but essential oil-related status epilepticus has received less attention in the literature. Here we report a small case series of 3 adults with essential oil-related status epilepticus. A A 38-year-old male was a case of post-traumatic occipital lobe epilepsy for the past 6 years and was well controlled on phenytoin 300 mg orally per day. He had a headache and cold for 3 days for which he His other hematological and biochemical investigations were normal. He was treated with intravenous fosphenytoin 750 mg loading dose followed by 150 mg every 8 hours. After 12 hours, his visual auras decreased but were still persistent. Intravenous levetiracetam was added to the current treatment (1 g loading followed by 500 mg every 12 hours). His attacks completely subsided after 24 hours. He was discharged after 2 days with the advice to avoid these essential oils, which provoke seizures. On follow-up he was continued on the same dose of phenytoin 300 mg, and his levetiracetam was tapered and stopped after 2 weeks. Essential oils are plant-derived oils that contain the "essence" of the plant or its parts. The term "essence" is a misnomer as these oils are not essential to any living organism. As they have a fragrance they are used in perfumes, cosmetics, and food additives. They are claimed to have antibactericidal and antiviral properties in in vitro studies. 6 People use these essential oil-containing products as over-the-counter remedies to treat many common ailments such as the common cold, cough, headache, and so on. During the current coronavirus 2019 pandemic, many companies are selling essential oils for the prevention and treatment of coronavirus 2019 infection, claiming that they have an effect against severe acute respiratory syndrome coronavirus 2 but without any evidence. 7 Hence there is high chance of use and abuse of these potentially proconvulsant essential oils during the current coronavirus 2019 pandemic. Physicians are unaware of the side effects of these essential oils as they are not systematically studied. Many of the side effects go unnoticed as physicians rarely ask the history of essential oil exposure and are unaware of the chemical nature and adverse effects of these essential oils. Essential oils such as eucalyptus and camphor have proconvulsant potentials that are rarely recognized by the public. These essential oils are kept in houses in easily accessible areas and within the reach of everyone, including toddlers, as they are generally perceived as safe. Here we described 3 cases of essential oil-related status epilepticus in 3 young adults. The first 2 cases presented with histories of the ingestion of eucalyptus oil. The first young man who expired following status epilepticus and multiorgan dysfunction had consumed it accidentally. The second case had ingested eucalyptus oil for abdominal pain and had multiple episodes of generalized tonic-clonic seizures. The third case had complex partial status epilepticus (focal-impaired awareness status epilepticus) after topical application of various balms containing eucalyptus and camphor. Ingestion of eucalyptus and camphor is well known to trigger seizures, but topical application is generally perceived as safe. 8, 9 In epileptic patients, the use of the topical application of essential oils are found to precipitate seizures. 10 The dermal application of eucalyptus for head lice treatment resulted in a tonic-clonic seizure in an otherwise healthy 4-year-old child. 11 Studies have shown that camphor is also readily absorbed from all sites of administration after inhalation, ingestion, or dermal exposure. In the case of dermal application, the volume of the absorption is relatively low, but the speed of the process is very fast. 12 Essential oils such as eucalyptus, camphor, and rosemary contain aromatic monoterpene 1,8-cineole. 13,14 1,8-Cineole has a mechanism of action similar to the known proconvulsant pentylenetetrazole. 11,15 1,8-Cineole in animal models was found to induce seizures at a dosage of 0.5 mL/kg. 16 Although there have been no explicit studies outlining the mechanism by which eucalyptus oils can precipitate seizures, studies on rat models show it may be secondary to the loss of tissue sodium/potassium gradient leading to increased cellular hyperexcitability. 1, 11 The effects of eucalyptol (1,8-cineole) studied on the central neurons of the land snail Caucasotachea atrolabiata found that the excitatory and epileptogenic action of eucalyptol is most likely mediated through the direct inhibitory action on potassium channels. 17 Another study in snail neurons with camphor showed that its excitatory and epileptogenic action is also mediated through the blockade of K + channels and upregulation of the Ca 2+ inward currents. 18 Although the epileptogenic properties of plant-derived essential oils have been known for centuries, both the public and physicians are equally ignorant of these serious complications. The essential oils that are epileptogenic are those of eucalyptus, camphor, rosemary, thuja, sage, spike lavender, and turpentine. 2, 3 The route of exposure, type of essential oil, amount taken, and genetic susceptibility may be important in causing these complications. The essential oils of eucalyptus and camphor are the those that are commonly used and abused. 19 In cases of so called de novo status, epilepticus exposure to essential oils need to be sought. The public and physicians should be made aware of the epileptogenic potential of these essential oils. The proconvulsant essential oils of eucalyptus and camphor can cause both generalized and focal status epilepticus. Physicians dealing with patients of status epilepticus should enquire about exposure to essential oils. Thomas Mathew MD, DM https://orcid.org/0000-0002-3941-8020 Eucalyptus oil inhalation induced seizure: a novel under recognized preventable cause of acute symptomatic seizure Plant-induced seizures: reappearance of an old problem The effects of various essential oils on epilepsy and acute seizure: a systematic review Camphor: an herbal medicine causing grand mal seizures Campho-Phenique ingestion: an intentional overdose Essential oils as antimicrobial agents-myth or real alternative? Essential knowledge about essential oils and COVID-19 Unintentional exposure of young children to camphor and eucalyptus oils Eucalyptus oil poisoning in childhood: 41 cases in south-east Queensland Essential oils as a cause of breakthrough seizure after temporal lobectomy Seizure caused by dermal application of over-thecounter eucalyptus oil head lice preparation Camphor: risks and benefits of a widely used natural product Abstracts of the 2012 International Congress of the European Association of Poisons Centres and Clinical Toxicologists Eucalyptus oil poisoning Actions of essential oils of rosemary and certain of its constituents (eucalyptol and camphor) on the cerebral cortex of the rat in vitro Wavelet and fractal analysis of rat brain activity in seizures evoked by camphor essential oil and 1,8-cineole Eucalyptol induces hyperexcitability and epileptiform activity in snail neurons by inhibiting potassium channels Camphor elicits epileptiform discharges in snail neurons: The role of ion channels modulation Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 34th Annual Report is a distinguished neurologist in Bangalore and is currently functioning as Professor and Head of the Essential oil-related status epilepticus: A small case series study