Red lips, black teeth, and Betel nut toxicity

Red lips, black teeth, and Betel nut toxicity

Arecoline toxicity is rarely seen in the Emergency Department [1]; however, doctors and emergency workers should be aware of this plant and the intoxication it causes. The alkaloids associated with this intoxication are reported in multiple regions of the world. It is important to emphasize how arecoline is the fourth most consumed psychoactive substance after nicotine, ethanol, and caffeine.

What is the “Betel nut”?

The tropical Betel palm (Areca catechu) produces the Betel nut (it is not a fruit but the seed of this plant). The Betel nut contains piperidine alkaloids which have substantial psychostimulating effects. Among these alkaloids, arecoline isprimarily responsible for the muscarinic, nicotinic, and psychostimulating effects of Betel nut consumption. Other alkaloids are arecaine, arecolidine, isoguvacin, and guvacine.

Coloured areca nuts [Areca catechu] in the market. Bago, Burma [Myanmar] It is this red color that determines the color of the spits of the people who consume the “paan” (from: LBM1948 – Wikipedia – CC BY-SA 4.0)

What is the “Betel leaf”?

It is the leaf of a tropical liana belonging to the Piperaceae family. It contains phenolic aromatic compounds, such as cavibetol and cavitol, and in some plants, also a third compound called caditene. Also, it, like the paper of a candy, contain chopped Betel nut mixed with lime (calcium hydroxide, which has a preservative action) and other substances typical of the community that produces it (e.g., tobacco, tamarind, or cardamom)

How is Betel nut consumed?

The Betel nut is thinly cut, combined with lime (to extract the alkaloids), and wrapped in a Piper beetle leaf, giving it its aroma and increasing salivation. It is consumed through chewing, which is usually not accompanied by swallowing, instead being spat out.

Photograph of an areca nut vendor on the island of Hainan, China. (from: Rolfmueller – Wikicommons – CC BY-SA 3.0)

Where is Betel nut chewed?

About 200 million people around the world consume Betel nuts. Primarily produced in Southeast Asia (Myanmar, Thailand, Laos, Cambodia, and Taiwan), it is consumed in Southern China (Yunnan, Xingtan, Hainan Island), Ceylon, Micronesia (Saipan, Guam, Palau, Mariana Islands), Papua, New Guinea, the Indian subcontinent (India, Pakistan, Bangladesh), and the Philippines.

New consumption territories are Melanesia, New Zealand, Australia, and immigrants living in Europe and North America [2].

Why is Betel nut consumed?

The consumption of Betel nut is voluptuous, and the reasons given by consumers are many. In general, it is consumed to “stay awake” and therefore “work harder” and the sensation of heat and energy during chewing. The reasons also include supposed medical and health reasons, such as “strengthening the teeth”, “helping digestion”, and “freshening the breath”. The cultural aspect of its consumption should not be underestimated in Buddhist culture and during some marriage ceremonies in Maharashtra. Betel leaf and Areca nut consumption are common. At the same time, in many countries, it is convivial to consume Betel at the end of the meal.

What is arecoline?

It is a potent agonist of muscarinic and nicotinic receptors [3]. In addition, the calcium hydroxide in the product causes the arecoline to be hydrolyzed into arecaidine, which is a potent inhibitor of Gaba uptake. The result is a strong excitation of the nervous system due to the release of catecholamines (adrenaline and noradrenaline). Pregnant women who chewBetel nuts can transfer the active ingredients via the placenta to the fetus [4].

What are the symptoms of acute Arecoline intoxication?

It is a rare event [5].

The psychological acute arecoline intoxication symptoms are:

  • increased heart rate/palpitations
  • increased systemic pressure
  • increased temperature
  • increased sweating
  • increased salivation
  • nausea, vomiting

In some cases, it can lead to coma, respiratory failure, myocardial infarction.Therefore it is recommended that the patient be monitored closely and treated for cholinergic, neurological, cardiovascular, and gastrointestinal manifestations.

The psychological acute arecoline intoxication symptoms are [6]:

  • well-being
  • euphoria
  • increased alertness
  • increased ability to support hard work
  • feeling of heat

From the EEG point of view, we have widespread cortical desynchronization. So, in case of high consumption, psychosis can arise [7].

Woman with red gingivas chewing paan in Don Det in Laos. Paan is a preparation combining betel leaf with areca nut and tobacco. It is chewed for its stimulant and psychoactive effects. (from: Basile Morin, Wikipedia, CC BY-SA 4.0)

What symptoms does chronic arecoline intoxication give?

Chewing Betel nut leads to discoloration of normal dental enamel, similar to that observed in those who chew tobacco (often Tabac and Betel nut are chewed together). The saliva in the chewing of this nut becomes red and with a markedly alkaline pH. The mucous membranes, gums, and teeth take on this color. Consumption is associated with the development of necrotizing ulcerative gingivitis (ANUG), which is a bacterial infection of the periodontal tissue that can also cause systemic symptoms, such as lymphadenopathy and malaise.

What are the risks of chronic exposure to arecoline?

Betel consumers have an increased risk of cancer of the oropharynx, liver, and uterus [8] . Chronic consumption leads to evident stains on the dental enamel (black tartar) and marked red salivation for the release of tannins. Also, its consumption is predisposing for the development of oropharyngeal carcinoma as nitrogenous compounds deriving from the alkaloids are released. About 60% of oro-pharyngeal cancers occur in areas where people chewed Betel nut.


[1] Deng JF, Ger J, Tsai WJ, Kao WF, Yang CC. Acute toxicities of betel nut: rare but probably overlooked events. J Toxicol Clin Toxicol. 2001;39(4):355-60. doi: 10.1081/clt-100105155. PMID: 11527229.

[2] Nelson BS, Heischober B. Betel nut: a common drug used by naturalized citizens from India, Far East Asia, and the South Pacific Islands. Ann Emerg Med. 1999 Aug;34(2):238-43. doi: 10.1016/s0196-0644(99)70239-8. PMID: 10424931.

Anaphylaxis in a Nutshell

anaphylaxis in a nutshell

Anaphylaxis can be broadly defined as a severe, life-threatening, generalized or systemic hypersensitivity reaction. Literature suggests that anaphylaxis is not always easily recognized in the Emergency Department (ED). One study indicates around 50% of cases being misdiagnosed and up to 80% do not receive appropriate first-line treatment.


The most commonly identified triggers of anaphylaxis include food, drugs and venom, but it is important to note that 30% of the cases can be idiopathic. Among drugs, muscle relaxants, antibiotics, NSAIDs and aspirin are the most commonly implicated.

Which patients are at an increased risk of anaphylaxis severity and mortality?

Extremes of age

Co-morbid conditions (asthma, COPD, cardiovascular disease)

Concurrent use of beta-blockers and ACE inhibitors

While the overall prognosis of anaphylaxis is good, the key to avoiding adverse outcomes is by prompt recognition and initiation of appropriate interventions. Below are key points to guide your management of anaphylaxis in the ED.

Recognizing Anaphylaxis in the ED

Anaphylaxis reactions vary significantly in duration and severity and a single set of criteria will not identify all anaphylactic reactions. The World Allergy Organization (WAO) has suggested the following criteria to help ED physicians be more consistent in their recognition of anaphylaxis.

Anaphylaxis is highly likely when any one of the following three criteria is fulfilled

1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized urticaria, itching or flushing, swollen lips-tongue-uvula) AND AT LEAST ONE OF THE FOLLOWING

  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)
  • Reduced blood pressure or associated symptoms of end-organ dysfunction (eg. hypotonia [collapse], syncope, incontinence) OR

2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours)

  • Involvement of the skin-mucosal tissue (eg, generalized urticaria, itch-flush, swollen lips-tongue-uvula)
  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)
  • Reduced blood pressure or associated symptoms (eg, hypotonia [collapse], syncope, incontinence)
  • Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting) OR

3. Reduced blood pressure after exposure to known allergen for that patient (minutes to several hours)

  • Infants and children: low systolic blood pressure (age-specific) or greater than 30% decrease in systolic blood pressure
  • Adults: systolic blood pressure of less than 90 mm Hg or greater than 30% decrease from that person’s baseline

Management Algorithm of Anaphylaxis in the ED

Anaphylaxis algorithm
Anaphyaxis algorithm 2

Key Points in Management

References and Further Reading

Cite this article as: Neha Hudlikar, UAE, "Anaphylaxis in a Nutshell," in International Emergency Medicine Education Project, January 31, 2020,, date accessed: October 1, 2023

Epistaxis on a Flight

Epistaxis On A Flight

A couple of days ago, a friend told me about an incident that had occurred on a plane where a middle-aged man was found to have epistaxis (bleeding from the nose) midway between a 4-hour flight. Although epistaxis has various degrees of severity and only a small percent are life-threatening, the sight of blood, no matter the amount, is a cause of panic and anxiety for everyone. Hence, the cabin crew was called and helped in managing the patient until the flight landed.

Some of the causes of epistaxis on a flight are dryness in the nose due to changes in cabin pressure and air conditioning. Other causes depend on patients’ previous health problems, which may include medications such as warfarin, bleeding disorders, nose-picking.

As important as it is to learn the emergency management of epistaxis in a hospital setting, often you come across a scenario such as this, in your daily life and its essential to know how to manage it, out of the hospital setting or even in the emergency department, while taking history or waiting to be seen.

The following are a few steps you can take for initial conservative management of epistaxis:

If the following measures fail, further medical management may be advised.


Epistaxis is acute hemorrhage from the nose, nostrils, nasopharynx, and can be either anterior or posterior, depending on the source of bleeding. It is one of the most common Otolaryngological Emergencies.

Anterior bleeds are the most common, and a large proportion is self-limited. The most common site is ‘Little’s area’ also known as Kiesselbach’s plexus (Anastomosis of three primary vessels occurs in this area: the septal branch of the anterior ethmoidal artery; the lateral nasal branch of the sphenopalatine artery; and the septal branch of the superior labial branch of the facial artery).

Posterior bleeds are less common and occur from posterolateral branches of the sphenopalatine artery and can result in significant hemorrhage.

Causes of epistaxis

Nose picking, dryness, allergic or viral rhinitis, foreign body, trauma, medications (anticoagulants), platelet disorders, nasal neoplasms, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), aspirin.

Assessment and Management

References and Further Reading

Alter Harrison. Approach to the adult epistaxis. [December 24th, 2019] from:

Cite this article as: Sumaiya Hafiz, UAE, "Epistaxis on a Flight," in International Emergency Medicine Education Project, December 27, 2019,, date accessed: October 1, 2023