Diagnostic dilemma: A woman's homemade juice led to life-threatening 'toxic squash syndrome'

The patient: A 64-year-old woman in Canada

The symptoms: Paramedics brought the patient to the emergency department after she developed sudden weakness, nausea, vomiting, diarrhea and lower abdominal pain.

What happened next: The woman told doctors she'd developed the symptoms minutes after consuming two cups of homemade juice made from pureed calabash (Lagenaria siceraria), also known as bottle gourd. She said she'd made and drunk juice from store-bought calabash every day for years, according to a report of the case. However, on this occasion, she noted that it tasted "abnormally bitter," rather than having its more typical mild squash flavor.

Tests revealed that the woman's heart rate and breathing rate were high, and her blood pressure was initially high and then fell concerningly low. Her extremities were also unusually cool to the touch, indicating she had poor circulation. Meanwhile, one of the chambers of her heart was pumping very forcefully, and an echocardiogram suggested she was having other heart issues.

The medical team restored the woman's blood pressure to normal levels by giving her intravenous fluids, but she still subsequently had several episodes of "profound" low pressure. She also continued to experience diarrhea and vomited blood several times.

She was then transferred to the intensive care unit (ICU), where doctors examined her gastrointestinal tract via gastroscopy, in which a thin tube with a camera in it is inserted into the mouth and guided into the throat and stomach. They found that her stomach lining was inflamed and bleeding as a result of tissue damage, which was likely caused by poor oxygen delivery to the tissue.

The diagnosis: The patient was diagnosed with shock, a life-threatening condition in which blood flow starkly declines and ultimately injures organs. In this case, the shock stemmed from toxins in the squash juice. This "bitter bottle gourd poisoning" is a type of "toxic squash syndrome," which is caused by eating toxic substances sometimes found in squashes and gourds.

Calabash is specifically a "cucurbit," meaning it belongs to the Cucurbitaceae family that includes cucumbers, pumpkins, watermelon and zucchini. Cucurbits produce bitter-tasting chemicals called cucurbitacins, which can have toxic effects if consumed in large enough quantities. Domesticated varieties of these plants have been bred to contain minimal quantities of cucurbitacins so that they're both palatable and safe for humans to eat. But in some cases, cucurbits may accumulate these chemicals as they ripen, posing a rare risk to people who consume them.

"If ingested, cucurbitacin is toxic to humans by various purported albeit uncertain mechanisms," the report authors noted. The toxin is thought to disrupt signaling in cells and make blood vessels more permeable, and it ultimately injures mucous membranes in the body, especially in the digestive tract.

"It is suspected that the gourd’s degree of bitterness correlates with its cucurbitacin concentration and thus toxicity; however, this is not definitively supported in the literature," the authors added.

The treatment: There is no specific antidote to bitter-gourd poisoning, so the medical team continued to monitor the patient's vital signs and stabilize them as needed. Her shock and associated symptoms went away after she'd spent five days in the ICU.

The patient was then discharged, and on a follow-up call, she reported sudden and progressive hair loss that set in about two weeks after she'd been admitted to the hospital. The doctors noted that this is another likely symptom of "bitter bottle gourd poisoning and further supported this diagnosis." Hair loss has been reported in other cases of the syndrome.

What makes the case unique: Toxic squash syndrome is considered very rare, and this was the first such case ever reported in Canada. Similar cases had previously been reported in other countries, such as India, where calabash juice is used in some forms of traditional medicine.

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