Bottle gourd, also known as Calabash, is used as a culinary vegetable in South East Asia. Toxicity mediated by the accumulation of cucurbitacins is most commonly associated with the ingestion of the juice as a tonic in India, where it is thought to provide health benefits in diabetes, hypertension, liver disease and depression.[[1–4]] More recently, there is significant interest in the use of cucurbitacins in the treatment of cancer.[[5]] We report a case of a patient admitted with bottle gourd toxicity following ingestion of the vegetable as a home-grown, home-cooked meal.

Case report

A 66-year-old Vietnam-born New Zealander was admitted to General Medicine  via the Emergency Department with a diarrhoeal illness following the ingestion of bottle gourd, which he had grown in his garden and cooked by stir-fry. This was consumed for his evening meal, and symptoms of severe abdominal pain and diarrhoea without blood or mucus began six hours later, attending hospital 18 hours following ingestion. He had shared his garden produce with his son, who declined the meal because it tasted very bitter. On the onset of symptoms, the son ascertained the likely diagnosis of bottle gourd toxicity by means of an internet search.

Vomiting was absent. Pain was limited to the upper-abdomen and noted to be stabbing. The pain was cyclical and would occur for two hours then resolve spontaneously for an hour or two. His past medical history comprised type 2 diabetes mellitus (on Metformin), diverticulosis and hypertension.

Examination revealed a man of normal build in some discomfort. Abdomen was soft with epigastric tenderness. Bowel sounds were normal. Observations at presentation were BP 154/100, pulse 115, afebrile.

Laboratory investigations revealed acute kidney injury (AKI)  stage 1, mild elevation of hepatic enzymes (ALT 50U/L), compensated metabolic acidosis with a serum lactate of 2.9mmol/L and base excess of -6. Haemoglobin was raised at 184g/L. C-reactive protein (CRP) was not significantly elevated. Electrocardiograph (ECG) demonstrated a sinus tachycardia but was otherwise normal. Stool culture was not possible as diarrhoea was not witnessed in hospital, with a return to normal stool the morning following presentation.

The patient was admitted for observation, rehydrated with intravenous fluids, and commenced on Omeprazole. Metformin was withheld. The following day his biochemical abnormalities had resolved. He was discharged with a prescription for Omeprazole 20mg once daily for two weeks and instructions to withhold his Metformin until well again. He has subsequently made a full recovery.

Discussion

Bottle gourd (Lagenaria siceraria), or Calabash, is known by number of other names internationally. Harvested early it can be eaten, and as a more mature fruit can be used to make containers and utensils.[[2]]

When the gourd is over ripe or stored improperly, they accumulate cucurbitacins, which are toxic at high concentrations.[[1]]

There is a preponderance of case reports from India,[[1,3,4,6]] though a Canadian case has been reported relating to juice toxicity.[[7]] Severe toxicity causes upper gastro-intestinal bleeding.[[6]]

It is important to enquire about bottle gourd ingestion in patients presenting with gastroenteritic illness, and to educate patients on the dangers of eating fruit that is over ripe or has been stored improperly. We would also recommend that patients presenting with this toxidrome following bottle gourd ingestion should commence proton-pump inhibitor therapy to reduce the risk of acute upper gastrointestinal bleeding.

This is an important case to highlight because it is the first report of poisoning mediated by ingestion of the fruit as opposed to the juice. Additionally, the impact of global climate change, the move to home-grown vegetables, and the evolving ethnicity of New Zealand make it possible that this toxicity may be encountered more frequently in the future.

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