Human & Experimental Toxicplogy (2002) 21, 579-586

www.hetjournal.com

Traditional medicine poisoning inZimbabwe: clinical presentation.

. and management in adults=

D Tagwireyi1, DE Ball*,1 and CFB Nhachi2

.1Drug and Toxicology Information Service, Department of Pharmacy,Avondale, Harare, Zimbabwe; 2Department of Clinical Pharmacology,Avondale, Harare, Zimbabwe

~aditional medicines (TMs) have been reported as major~uses of hospital admissions in some African countries

including Zimbabwe. There is, however, still a paucity ofinformation with regards to their clinical presentations. Wecarried out a retrospective case series of all cases oftraditional medicine poisoning (TMP) at eight main referralhospitals in Zimbabwe Oanuary 1998-December 1999inclusive) to describe the most common signs and symp-toms, reasons for, and management of TMP in adults.Where the reasons for taking the TM were known, mostcases had taken the medicine for either abdominal pains oraphrodisiac purposes. Nonspecific adverse effects includ-ing vomiting, abdominal pains, and diarrhoea were the

Introduction

The use of traditional medicines (TMs) is still widelypractised within most parts of Africa. This has beenattributed to long-standing traditional beliefs in theefficacy of these preparations and because they pro-

-'ide a cheaper alternative to orthodox medicine.1~lthough the active constituents of most African

TMs are not known, the bulk of them is of plantorigin but may incorporate mineral or animal prod-uctS.2,3 However, it is known that various potentially

. toxic agents are used in TMs including extracts ofEuphorbia, Solanum, and Datura species and Riciniscommunis as well as cantharides. The prevalent use

- 'of TMs in the African continent has impacted on thepatterns of poisoning in these countries, which tendto be different from those of their developed worldcounterparts. Whilst pharmaceuticals and relatedsubstances account for most toxic ingestions in devel-oped countries such as the UK,4 TMs have been

'Correspondence: Dr Douglas E. Ball, Drug and Toxicology Infor.mation Service, Medical School, University of Zimbabwe, PO BoxA178, Avondale, Harare, Zimbabwe.E-mail: dhall@healthnet.zw

Received 19 December 2001; revised 28 June 2002; accepted 29 July2002

@ Arnold 2002

University of Zimbabwe, Box A178,University of Zimbabwe, Box A178,

most commonly encountered. A large proportion ofpatients with TMP also suffered from genito-urinary tractadverse outcomes especially haematuria and dysuria.Intravenous fluids were the most commonly employedtherapeutic modality for TMP, probably in an effort todilute or increase excretion of the toxins. Further researchis required to elucidate the toxic components responsiblefor the observed ill effects and whether these effects aredue to the medicines themselves or to co-existing illnesses.Human &'Experimental Toxicology (2002) 21, 579-586.

Key words: clinical management; clinical presentation; traditionalmedicine poisoning; Zimbabwe

reported as major causes of hospital admissions insome African countries1.5 including Zimbabwe.6 A10-year retrospective study describing the pattern ofhospital admissions due to poisoning in Zimbabwerevealed that TMs (known as 'muti') accounted for22.9% of these cases7 - the highest single cause ofacute poisoning hospital admissions in the studywith a mortality rate of 15.2%.6 A more recentstudy, of which this work is a part, found that alldeaths from 'natural toxins' (16 in 192 hospitaladmissions over two years) resulted from TMs.8The relatively high mortality and morbidity fromtraditional medicine poisoning (TMP) have beenattributed to the fact that, in most cases, there isno rationalization of doses administered.9 Dosagesprescribed and dispensed by the Zimbabwean tradi-tional medical practitioner (n'anga) are described asbeing vague and not related to the age or weight ofthe patient. 9 However, poisoning may also occur as aresult of incorrect self-therapy or failure to followinstructions.

There is an increasing pool of information onpharmacologically active plants as well as theiractive constituents,10 although much of the re-search is concentrated on flora used in Western

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Traditional medicine poisoningD Tagwireyiet a/.

herbal medicine. Whilst relatively few of Africa'sindigenous poisonous plants have been investigatedand analysed, there are certain plants that areknown to be used in TM and whose toxicityis known. Examples include the root of Boophanedistica (Amaryllidaceae), which contains numerous

toxic alkaloids used as arrow poisons but is prizedfor analgesic and narcotic effects, and variousStrychnos species (Loganiaceae), which contain

strychnine and related alkaloids but are used forgastro-intestinal (GI) and other complaints.ll How-ever, despite Gelfand et aJ. describing in somedetail the use of common herbal medicines in

Zimbabwe,2 little is yet known of their active com-ponents, and such information is seldom helpful tothe clinician or toxicologist in an acute situation 12

where patients are unaware of the ingredients ofany concoction they have taken and the traditionalhealers are unwilling to divulge their 'secrets'.l Insuch circumstances, an alternative approach is towork backwards, observing adverse effects asso-ciated with TM, then tracing which plant(s) maybe responsible, and intervening so as to limit theiruse. In Zimbabwean TM, a similar approach hasbeen reported to be used successfully with can-tharides (N Nyazema, personal communication);nephrotoxicity was attributed to the use of can-tharides and educational sessions then held with

traditional healers helped to reduce its application.This approach is more clinically relevant than justdescribing the pattern of TMP6 as it concentrates onthe clinical presentation and links this to the in-dications for use as a means of working back topotential remedies. In view of this, we carried out alarge retrospective case series describing the rea-sons for taking, most common signs and symptoms,and management of TMP in adults in Zimbabwe aswell as investigating any 'toxidromes' to assistmedical management. This is part of a large studydescribing the 'toxicoepidemiology'13 of poisoningin Zimbabwe. It is hoped that results of thepresent work will provide a platform for furtherresearch into this underinvestigated area of clinicaltoxicology.

Methods

The structure of the health delivery system forZimbabwe has been described elsewhere,7 with atotal of 11 major referral hospitals - four Centraland seven Provincial Hospitals. Although the ori-ginal intention of this study was to include all theabove hospitals, data could not be obtained fromthree of these, namely Masvingo, Chinhoyi, andMarondera Hospitals, due to insurmountable diffi-

culties associated with the isolation and retrieval ofrelevant case notes.

Retrospective case reviews were, therefore, con-ducted at the remaining hospitals, which included allCentral Hospitals (Parirenyatwa, Harare Central,Mpilo, and United Bulawayo Hospitals) and fourProvincial Hospitals (Bindura, Mutare, Gweru, andGwanda Hospitals) for the period January 1998-December 1999 inclusive. Data from Harare Hospitalwas incomplete for the months September and Octo-ber 1999 due to inadvertent deletion of records fromthe record department computer.

Retrieval of case notesThe methods used in retrieving the case recordsvaried from hospital to hospital. In some cases,records were traced by using relevant ICD-9 codes'and patient notes were retrieved from the hospitalYrecord departments by their staff (Parirenyatwa,Mpilo, Harare, Mutare Hospitals) or by one of theinvestigators (Gwanda and United Bulawayo Hospi-tals). In the remaining hospitals, i.e., Bindura andGweru hospitals, patient case notes were traced byobtaining the hospital medical ward registers andrecording patient hospital numbers for all cases ofpoisoning from these. The hospital numbers werethen used to retrieve the records by the investigatorwith the help of a staff member of the recordsdepartment.

Selection of casesAfter all records of poisoning had been collected,cases due to TM as recorded by the attending doctorswere separated. For the purposes of this study, onlycases of TMP occurring in patients aged 12 year!'and above were included. This separation was mad\...-so as to represent results from homogenous group ofpatients with a similar physiology and probablyreceiving similar doses. Moreover, according to theliterature, the reasons for taking TMs as well asthe routes of administration vary, with childrenreceiving therapy mainly for sunken fontanelle6.15.16through inhalation and adults for a variety of rea-. .sons through the oral route.

Data collection

At all hospitals included in the study, a preformatteddata collection form was utilized to record the rele-vant information, namely, patient demographicdetails, the toxin involved including site of exposure,any co-existing illnesses, reasons for ingesting TM('muti'), clinical presentation of patients, manage-ment afforded to the patient, toxicologic laboratorytests done and results where available, and outcomeof exposure.

Traditional medicine poisoningD Tagwireyiet al.

35 --------------------------------------------------------------------------------------------------------------------581

30 1-----------------------------------

~ 25'tI

~'s 20'tI- I'CI

. g:

:a 15u..c- GIUi 10a.

------------------------ ----------

------------------------ ----------

------------------------ ----------

------------------------ ----------

5 ------------------------ ----------

~ 0f 1 .

12-19 20-29 30-39

Figure 1 Age distribution of cases admitted with TMP (n=60)

Statistical analysisRelationships between recorded patients' reasonsfor taking the TM and clinical presentation wereinvestigated using the Chi-squared test or Fisher'sexact test.

Results

Patient demographic details""'here were a total of 63 cases diagnosed as due to

\ i.MP, of which 52 were males and the sex of twocases was not recorded. The ages in these casesranged from 12 to 72 years (n=60; median, 35.5years), with only one case below 20 years (Figure 1).

": The length of hospital stay ranged from 0 to 12 days(n=61; median, two days). Six patients died in thiscase series, yielding a mortality rate of 9.5 deaths

- -per 100 cases admitted. The length of hospital stayin these cases ranged from 0 to 12 days (n=6;median, two days). In none of the cases was thenature of the TM recorded in the notes. Only twocases (one male, one female, both 25 years old)involved known deliberate poisoning - the formersuffered symptoms of abdominal pains and vomitingand was simply observed overnight, whilst the latterpresented with vomiting and was violent, havingalso ingested alcohol, and remained in hospitalfor two days. There was nothing remarkable intheir clinical presentations or management. Thesecases were analysed together with the rest due to

---------------------------------------------------------------

----------------------------------------------------------------

1 --------------------------------------------

1 --------------------------------------------

1 --------------------------------------------

1 ---------- -------- -

40-49 50-59 >60

Age (yr)

their small number and since attending clinicianswill not always be aware of cases when poisoningis not accidental.

Reasons for taking 1MOf the 63 cases, the reasons for ingesting the TMwere not known or recorded in 18 cases (28.6%).Most of the patients took the TM for conditionsrelated to the gastro-intestinal tract (GIT; 31.7%)and the genito-urinary tract (GUT; 17.5%), withthe bulk of these ingesting the medicine for thetreatment of abdominal pains (19.0%) and for aph-rodisiac purposes (7.9%) (Table 1). Other reasons for

Table 1 Common reasons for taking TM resulting in poisoning

Organ systeminvolved

Conditionunder treatment

Abdominal painsDiarrhoeaConstipationEpigastric painStomach cleansingUnspecifiedabdominal disorderAphrodisiacSTIsAbortionGenital ulcerColds and/or flu

Number ofcases (n=63)

1232111

GIT (n=20)

GUT (n=l1) 53212Respiratory

tract (n=4)Pulmonary tuberculosisChest pains

11

Traditional medicine poisoningD Tagwireyiet al.

582

taking TM included for the treatment of skin con-ditions (two cases), headache (one), backache (two),and in a suicidal attempt (two). One patient took theTM for a combination of both a headache and abackache. Of the deceased cases, two had taken theTM for unknown reasons. Other indications associ-

ated with death included: as an aphrodisiac (one),constipation (one), tuberculosis (one), and abdomi-nal pains (one).

Signs and symptoms of poisoningForty-one cases (65.1%) presented with at least oneGIT symptom, with 34 (54.0%) and 22 (34.9%) casespresenting with at least one GUT symptom and cen-tral nervous system (CNS) symptom, respectively. Abreakdown of the most common specific symptomstoward these organ systems is shown in Table 2.Other recorded common complaints included dysp-noea (four cases), constipation (three), oliguria(three), incontinence (two), pupillary changes (two),unconsciousness (three), and violent behaviour(three).

Available laboratory valuesRoutine urea and electrolytes laboratory results wereavailable in 32 cases,of which 17 (53.1%) of thesehad abnormal values. Thirteen had high creatininevalues and 14 had high urea values with 11 havingboth. Serum sodium and potassium levels were nor-mal in all casessave for two - one with marginallylow serum sodium (129 mmol/L) and the other witha marginally high sodium level (145 mmol/L) and ahigh serum potassium level (6.7 mmol/L). In boththese cases, the urea and creatinine levels wereelevated with values of 11.6 and 463, and 62.78 and2113 mmol/L,respectively.

Results for full blood count were available in 20cases (31.7%), and seven of these (35%) had abnormalvalues, five with elevated white cell counts.

Table 2 Common clinical presentationsa of TMP

Organ system Clinicalinvolved presentation

Number ofcases (n=63l

Abdominal pains 34Vomiting 27Diarrhoea 13Haematuria 20Dysuria 18Increased frequency 7Suprapubic pain 5Confusion 11Restlessness 6Dizziness 5Headache 5Drowsiness 5

aThose occurring in five or more cases. bSome cases had more thanone presenting symptom.

GIT

GUT

CNS

Table 3 Cross-tabulation of clinical presentations of TMP andreason for use

Clinical

presentationReasons for taking 'muti'

Unknown Abdominal pains Aphrodisiac(n=18) (n=12) (n=5)

164771

2 17 14 3

42

GIT painVomitingDiarrhoeaHaematuriaDysuriaFrequencySuprapubic painConfusionRestlessnessDrowsinessDizzinessHeadache

54

A cross-tabulation of the most common reasons f("--'taking TM against the most common clinical presen-tations of TMP is shown in Table 3. There were no

significant associations between the recorded reasonsfor taking the TM and grouped GI, GU, and CNSpresenting signs (P>0.05 in all cases).A specific testof association between the presence of GUT symp-toms and taking the TM for abdominal pains was alsonot significant (P>0.05).

Drug managementForty-three cases (68.2%) received intravenous fluidswith 5% dextrose, normal saline, Darrow's half-strength with dextrose, and Ringer's lactate beingthe most common. Antibiotics were the most com-monly used drugs with 22 cases (34.9%) receiving atleast one antibiotic. Eleven cases (17.5%) receivedfurosemide, with 10 of these (91.1%) receiving in-travenous stat doses. None of these cases harco-existing illnesses, save for one patient who wa~also hypertensive. The breakdown of the antibiotics

Table 4 Drugs used in the management of TMP in Zimbabwea

Drug class Individual drug Number of casesreceivingdrug - -

Antibiotics Ampicillin 5Doxycycline 5Amoxicillin 3

Procaine penicillin 3Chloramphenicol 3Magnesium trisilicate 14Cimetidine 3Furosemide 11Pethidine 8Paracetamol 6

Diazepam 6Chlorpromazine 5ProcWorperazine 4

Corticosteroids Hydrocortisone 4

aAntibiotics used in less than three cases are excluded from thetable.

Antacids

DiureticsOpiatesSimple analgesicsBenzodiazepinesPhenothiazines

12 4- 23 1- 22 1

used as well as other frequently used drugs (used inmore than three cases) is shown in Table 4. Therewas no specific clinical management protocol asso-ciated with any of the reasons for taking muti orparticular clinical presentations.

Discussion

Toxicity related to TMs is becoming widely recog-, nized as these remedies become increasingly popular.in developed countries.12 Furthermore, with in-creased immigration from African countries to thedeveloped world, clinical and medical toxicologistsin these regions are more likely to encounter patientspresenting with African TMP. In view of this, there is a

'ed for work in this area of poisoning to be con-'-..:-dcted and published to assist clinicians handlingcases of poisoning from African TM. Unfortunately,with a few exceptions, patients are unaware of thecontents of traditional remedies they may have con-sumed and all that is available to the attendingphysician is usually the clinical picture on presenta-tion, together with information on the indication forthe traditional treatment that the patient or relativesmay be able to recount. The use of this informationneeds to be maximized and potential toxins identifiedand their use or that of their parent plants minimized.

Poisoning due to TMs has been said to occurmainly in adult males because, traditionally, menresort to TM and also have easier access to traditionalhealers compared to their female counterparts.6 Inthe present study, there was a disproportionatelyhigher number of male patients (85%) as comparedto females. This figure was much higher than that

'ported previously for Zimbabwe (67% males).6~hese results are, however, not directly comparable

since the latter study did not separate adults fromchildren. In addition, the present work included twohospitals that were not included in the other study.

- However, our results support the observation madeby the previous authors.

Only one case in this series was below the age of-20 years. The relatively small proportion of caseswithin this age group may suggest that most teenagersdo not utilize TMs to the same extent as older

persons, possibly a consequence of urbanization.However, it is also possible that since these teenagersare still of school-going age, they tend to follow thedosage schedule given to them more closely and areless likely to receive an overdose. This presupposes acertain amount of standardization of the TM, some-thing which is not common in Zimbabwe2 but ismore advanced in other African countries. Therewere also few cases of poisoning in people abovethe age of 50 years. It would have been expected that

Traditional medicine poisoningD Tagwireyi et a/.

583

this age group would have the highest number ofpoisoning cases as it is generally believed that olderpeople tend to use more TMs and are more sensitiveto adverse effects of medications due to compromisedliver and renal function and changed pharmaco-dynamics. It is possible that the relative deficit ofpoisoning cases in this age group may mean that,through experience, they get to know and to take theright doses of the medicines prescribed to them. Theyare also more likely than the younger generation tocollect the correct herbs in the case of self-medica-tion. However, the data were not standardized for ageand the lower incidence of cases is likely to partlyreflect the national adult age distribution.

The mortality rate seen in this work (9.5%) waslower than that reported by an earlier study in Zim-babwe (15.2%), which also involved a survey ofhospital records over a 10-year period.6 It is not clearwhether this is a real decrease in mortality perhaps asa result in changes in TM prescribing, or is simply aresult of normal variation. Only two patients in thisseries took TMs in a deliberate attempt to poisonthemselves, suggesting that muti is not commonlyused for such purposes. This observation is consis-tent with anecdotal accounts that pesticides andpharmaceuticals are more often used in deliberateself-poisoning, perhaps due to traditional remediesbeing more associated with healing or because ac-cess to them is more strictly controlled through thehealers or community elders.

From the results of the present study, most TMsthat led to poisoning admissions in Zimbabwe areconsumed for complaints related to the GIT (31.7%)and the GUT (17.5%), especially 'muti' taken for thetreatment of abdominal pains and for aphrodisiacpurposes. This is consistent with data for Parire-nyatwa Hospital alone, which had been publishedpreviouslyY

The most common clinical signs and symptoms ofpatients admitted with TMP were directed toward theGIT, exhibiting mainly as abdominal pains, vomiting,and diarrhoea (Table 2). These signs and symp-toms, unless very severe, are nonspecific and mosttoxins taken orally would lead to anyone or a com-bination of them. They may also be related to theoriginal indication for the TM. It would, therefore,be incorrect to attribute these as being specific toTMp'17 However, some plants, such as seeds ofRicinus communis and Jatropha curcas, are well do-cumented as a major cause of severe symptoms ofabdominal pains, diarrhoea, and vomiting.2 Symp-toms associated with the GUT were the next mostcommon clinical presentation, with haematuriaoccurring in 31.7% of all cases. In addition, 27%of all patients had abnormal urea and electrolytevalues, characterized mainly by elevations in urea

Traditional medicine poisoningD Tagwireyiet a/.

584

and/or creatinine. The GUT effects of TMP havebeen of interest in recent years in Zimbabwe9.17.18and elsewhere on the African continent.1 A number

of plants contain soluble oxalates which, if absorbedin large enough quantities, may precipitate in thekidneys and/or bladder, leading to renal pathology.19The observed renal effects may also be a result ofcantharides, which are used in traditional medicalpractice in Southern Africa,2,20,21 or could alsoresult from heavy metal contamination of the TMas reported in other countries.22,23 It is, however,also possible that the TMs utilized may themselveshave inherent nephrotoxic effects, e.g., Securidacalongependunculata and Euphorbia species,18 whichare widely used in TM practice in Zimbabwe. FUr-ther investigation is required to confirm this. Thereare high costs associated with the use of sophisti-cated analytical methods used in the identificationof potential toxins in TM, a situation that would beunsustainable for most developing countries. Toovercome this hurdle, we suggest investigation ofthe presence of oxalates and heavy metals, whichcan be easily detected using simple, cost-effective,qualitative techniques.24

A number of herbs are documented as a cause ofCNS effects especially confusion and/or restlessnessincluding Datura stramonium and Solanum speciesamongst others.2,25 As these are used in Zimbabwean

TM practice, it is--possible that they contributed to fo~.,

.:::;- the CNS. effects. !:leavy metal contamination of TI4s>'-could also result in the CNS symptoms.26 However,the possibility that the recorded symptoms were aresult of dehydration secondary to vomiting anddiarrhoea, or other medical complaints cannot beoverlooked.

'Muti' taken for the management of abdominalpains was associated with vomiting (58.3%), haema-turia (58.3%), abdominal pains (50%), dysuria(33.3%), and confusion (33.3%). Since patients inthis group were already taking the TM for abdominalpains, it is unclear whether the clinical signs weredue to the complaint or the TM itself. A large pro-portion of patients who took TM for abdominal painsalso suffered from GUT symptoms especially haema-turia and dysuria. However, statistical analysisrevealed that these patients were no more likely tosuffer these symptoms than those taking 'muti' forother complaints. Therefore, in view of this and incontrast to an inference made in another study,17 thenephrotoxicity of TMs is not necessarily specific toTM used for abdominal pains. However, it is alsoimportant to note that the term 'abdominal pains' isvague and patients may not be able to clearly differ-entiate between true abdominal pains and suprapubicpain related to cystitis secondary to conditions suchas sexually transmitted infections (STls). It would not

then be surprising for them to also present withGUT symptoms. This could also explain why allpatients suffering from abdominal pains also had atleast one symptom toward the GUT in the previousstudy. 17

All cases where the TM was taken for aphrodisiacpurposes also presented with at least one symptomtoward the GUT, with most cases (80%) presentingwith increased urinary frequency and only one casepresenting with haematuria. Cantharides, which arederived from 'blister beetles', have been used exten-sively for aphrodisiac purposes,21,27 resulting in the-well-documented renal adverse effects, especiallyhaematuria. The fact that only one patient who hadtaken TMs for aphrodisiac purposes had haematuriasuggests that cantharides are not used extensively inZimbabwe or do not often result in serious poisoniD~Some years back, traditional medical practitione:t-..--had been educated on the dangers of cantharides (NNyazema, pei-sonal communication) and this mayhave led to lower use of the toxin. TM practitionersin Zimbabwe are purported to have knowledge of astrong aphrodisiac of plant origin (known as 'vuka-vuka'), with anecdotal reports of prolonged priapismarising from its ingestion. It is conceivable thatpatients experiment with herbs which they believeare 'vuka-vuka', but may in fact be inherently toxic,resulting in the cases observed in this series. Acomparison of the clinical presentation of caseswhere the TM was taken for abdominal pains andthose in which the reason was unknown shows somesimilarities, with most patients presenting with vom-iting, haematuria, and dysuria, suggesting that theyform a common group or are exposed to similartoxins. However, the small numbers in the groupsmake this difficult to evaluate.

Since, in most instances, the culprit substance 0,..--TMP is not known, it has been recommended that themanagement should be largely symptomatic and sup-portive.12,28 In this case series, most patients (68.2%)received intravenous fluids. On account of the fact -that vomiting and diarrhoea are some of the mostcommon symptoms of TMP, this is probably appro-priate. Moreover, since the toxins responsible are-almost always not known, an increase in fluid intakemay have the effect of increasing urinary excretion ofthe culprit toxin from the body. Increased fluid intakemay also dilute the toxin in the kidney as withcantharides21 and oxalates,19 thus reducing nephro-toxic effects. However, caution must be taken not tolead the patient into fluid overload especially in caseswhere the kidneys cease to be fully functional. In thisstudy, antibiotics were the most commonly usedpharmacologic intervention, with 34.9% of all thecases receiving at least one antibiotic. Although anti-biotics in themselves are not specific therapy for

TMP, they may be used if there are co-existinginfectious diseases. The presence of co-existing infec-tions in this cases series is supported by the fact thatfive (7.9%) of the cases had elevated white cell va-lues. Of particular interest is the relatively high use ofthe diuretic furosemide in almost a fifth of cases. This

therapy was probably used in an attempt to increaseurinary excretion of the toxins. The fact that this

- _,therapy was almost always given intravenously as astat dose and in conjunction with intravenous fluidssupports this assumption. As there is no evidence-....

'§upporting the clinical efficacy of this therapy, whichis associated with electrolyte as well as acid-baseimbalances, this may be inappropriate. Moreover,concomitant use of loop diuretics in renal insuffi-ciency is associated with the development of seriousr' "'e effects. There is a need to further investigate the~e of furosemide in the management of TMP.

The retrieval and selection methods used in this

study ensured that all cases of poisoning due to TMswere isolated, including those that would have beenmiscoded. However, a bias could arise if physicianslabelled poisonings of unclear or unknown origin asbeing due to TMs. However, the fact that, in mostinstances, the reason for taking the medicine wasknown, Le., the patient had admitted to TM exposure,suggests that this bias is not significant. The retro-spective data were limited especially in as much asno information was available as to the nature or ingre-dients of the TMs ingested. However, this informationis usually not available even in a prospective settingsince most patients are not told such information bytraditional healers and identifiable samples are sel-

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Traditional medicine poisoningD Tagwireyiet a1.

585

dom presented. This study tried to make use of theinformation that is available to assist in the identi-fication of potential toxidromes or areas of concern.

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Acknowledgements

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