Skip to main content

Catharanthus roseus intoxication mimicking acute cholangitis



Catharanthus roseus, a Madagascar native flowering plant, is known for its glossy leaves and vibrant flowers, and its medicinal significance due to its alkaloid compounds. As a source of vinblastine and vincristine used in chemotherapy, Catharanthus roseus is also employed in traditional medicine with its flower and stalks in dried form. Its toxicity can lead to various adverse effects. We report a case of Catharanthus roseus juice toxicity presenting as acute cholangitis, emphasizing the importance of healthcare providers obtaining detailed herbal supplement histories.

Case presentation

A 65-year-old woman presented with abdominal pain, fever, anorexia, and lower limb numbness. Initial diagnosis of acute cholangitis was considered, but imaging excluded common bile duct stones. Further investigation revealed a history of ingesting Catharanthus roseus juice for neck pain. Laboratory findings showed leukocytosis, elevated liver enzymes, and hyperbilirubinemia. The patient developed gastric ulcers, possibly due to alkaloids in Catharanthus roseus. No bacterial growth was noted in blood cultures. The patient recovered after discontinuing the herbal extract.


Catharanthus roseus toxicity can manifest as fever, hepatotoxicity with cholestatic jaundice, and gastric ulcers, mimicking acute cholangitis. Awareness of herbal supplement use and potential toxicities is crucial for healthcare providers to ensure prompt diagnosis and appropriate management. This case emphasizes the need for public awareness regarding the possible toxicity of therapeutic herbs and the importance of comprehensive patient histories in healthcare settings.

Peer Review reports


Catharanthus roseus is a species of flowering plant classified within the family Apocynaceae. Belonging to the genus Catharanthus, this plant is characterized by its glossy leaves and vibrant, pinwheel-like flowers. Native to Madagascar, it has been widely cultivated for its ornamental value and is also recognized for its alkaloid compounds, giving it medicinal significance in various cultures. The components of Catharanthus roseus known as vinblastine and vincristine has been widely used for chemotherapy in clinical practice [1]. Catharanthus roseus can be easily found on street in Taiwan and is accessible in traditional Chinese herbal store. It is widely used in traditional Chinese medicine to treat diabetes, gastrointestinal diseases and also used as anti-cancer drug with its flower and stalk portions in dried form for the cooking of herbal soup [2]. However, Catharanthus roseus toxicity can lead to bone marrow suppression, gastrointestinal toxicity, paresthesia, stomatitis, fever, and even cause multi-organ failure [3, 4]. We herein report a case of Catharanthus roseus juice toxicity presenting as acute cholangitis. To our best knowledge, this might be the first case of Catharanthus roseus poisoning in the literature. Our case highlights the importance of the healthcare providers in obtaining detailed patient histories of herbal or plant supplement use, and the awareness of its potential toxicities.

Case report

A 65-year-old woman presented to the emergency department with a 2-day history of acute abdominal pain and fever, anorexia, and lower limb numbness. The pain was localized in the central area of the upper abdomen and was dull in nature, with a pain score of 4 out of 10. There was no radiation of pain to the other part of the body. The patient denied any associated symptoms, such as bloating, nausea, and vomiting. Her temperature, pulse, and respiratory rate were 37.2 degrees Celsius, 74 beats per minute, 19 beats per minute, and her blood pressure was 158/85 mmHg. A physical examination showed mild icteric sclera. However, hepatomegaly, right hypochondrial tenderness, features of hepatic encephalopathy, and Murphy’s sign were all negative. Sensory tests for light touch, pinprick, and vibration were performed that showed no prominent altered sensations. Differential diagnosis at this point included acute hepatitis, acute pancreatitis, peptic ulcer disease and heavy metal intoxication. Laboratory data revealed leukocytosis (WBC: 12,060/UL), elevated liver transaminases (AST: 237 U/L; ALT: 519 U/L), alkaline phosphatase (ALP: 97 U/L), gamma glutamyl-transferase (γ-GT: 213 U/L), and hyperbilirubinemia (direct bilirubin: 0.7 mg/dL, total bilirubin: 3.8 mg/dL). Activated partial thromboplastin time (APTT), D-DIMER, urea and creatinine levels, amylase and lipase were within normal limits. She was negative for hepatitis B surface antigen (HBsAg) and Anti-HCV antibody titer. Taken into account of her clinical course, acute cholangitis was highly suspected. Empirical antibiotics treatment with intravenous cefoxitin was begun at 2 g every 8 h. The patient did not disclose taking any new drugs or traditional herbal medications on the first day of her hospitalization. Contrast computed tomography of the abdomen performed at the emergency department showed no evidence of common bile duct stones. Magnetic Resonance Cholangio-Pancreatography (MRCP) of the abdomen done on the hospital day 2 showed no choledocholithiasis, and therefore the tentative diagnosis of acute cholangitis was excluded. To further investigate her abdominal pain, gastroduodenoscopy was done that revealed two active and sharp edge gastric ulcers. On further probing her history, she reported drinking juice extract of Catharanthus roseus by boiling it as a soup, about 14 g a day for 8 consecutive days (a total consumption of 112gram, Figs. 1 and 2) before her admission for treating her neck pain caused by a cervical spinal bone spur. Serum levels of heavy metals, including copper, zinc, and mercury, were all negative. The fever subsided on the fifth day of her hospitalization with discontinuation of the use cefoxitin, and her blood culture yielded no growth of bacteria. The patient was discharged on the 8th day of hospitalization and recovered smoothly thereafter with normalized liver function and bilirubin level one week after discharge. Our hypothesis was further supported by the fact that the Naranjo ADR probability scale score for the association was “probable” (score 6; Table 1).

Fig. 1
figure 1

Catharanthus roseus flower photo provided by patient

Fig. 2
figure 2

Dried flower and stalks of Catharanthus roseus photo taken at Chinese herbal store in Ping-Tung

Table 1 Naranjo ADR probability scale score for the association of Catharanthus roseus and its intoxication


Catharanthus roseus is a raw material of anticancer drugs vinblastine, vincristine.

and vinorelbine which is widely used for chemotherapy, mainly for hematological malignancies [1]. The toxicity of Catharanthus roseus includes bone marrow suppression and gastrointestinal toxicity, similar to the toxic effects of these vinca alkaloids, but also includes paresthesia, stomatitis, fever and could lead to multi-organ failure [3, 4]. Our case presented with symptoms of lower leg numbness indicative of neurotoxicity following the ingestion of Catharanthus roseus. Alkaloids like vincristine are known to exert neurotoxic effects by interfering with microtubule formation, leading to disruption of normal cellular processes [5].

Hepatotoxicity is characterized by abnormalities in liver function tests and clinical signs of liver dysfunction. While hepatotoxicity associated with Catharanthus roseus is less commonly reported, it is plausible that certain alkaloids may exert adverse effects on hepatic tissues. According to one animal study in albino rats, a dose of 300 mg of Catharanthus roseus could cause biochemical and histopathological toxicity in liver, kidney and heart [6]. Similarly, hepatotoxicity is not a common concern in patients using vinca alkaloids as part of chemotherapy, even though it is metabolized by the liver and excreted in the bile. While the exact reason for this is unknown, it is possible that resting liver tissue is less susceptible to disruption of cell division.

The liver plays a crucial role in the metabolism and detoxification of various substances, and any disruption in its normal function can have systemic repercussions. In this case, it is conceivable that the alkaloids present in Catharanthus roseus may have contributed to hepatocellular injury, leading to the observed hepatotoxic effects [7]. Our case underscores the potential hepatotoxic effects of Catharanthus roseus, which, to our knowledge, has not been extensively documented in the literature and to our best understanding this might be first documented case in human. Another animal study in sheep with accidental poisoning of Catharanthus roseus were observed to have anorexia and marked increase in Activated Partial Thromboplastin Time (APTT), D-DIMER, hemoglobin, urea and creatinine levels with the decrease in cholinesterase activity and calcium levels [8]. However, relevant laboratory findings suggestive of disseminated intravascular coagulation (DIC) were not observed in our patient except for liver function derangement, which was seen in an albino rat study. Two reasons might be due: first, the metabolism of Catharanthus roseus in rats and sheep might be different from that in humans, which causes different abnormal laboratory findings; and second, the difference in dosages ingested among animals and humans might cause different kinds of toxicity.

Several compounds present in Catharanthus roseus, such as alkaloids, tannins, and glycosides, have been identified as potential contributors to gastrotoxic effects. The alkaloids vincristine and vinblastine, while effective against cancer cells, can also exert toxic effects on normal cells, including those in the gastrointestinal lining. This may lead to adverse gastrointestinal reactions when consumed inappropriately. Additionally, tannins found in the plant can bind to proteins and cause precipitation, leading to irritation and damage to the mucosal lining of the digestive tract if were ingested in high concentration [9,10,11]. These might be the possible reasons causing peptic ulcer in our case.


Misuse of Catharanthus roseus herb may lead to hepato-toxicity with cholestatic jaundice and gastric ulcers presenting as abdominal pain with fever that mimicking acute cholangitis as like our case. Our case underscores the importance of public awareness regarding the potential toxicity of medicinal plants. Healthcare providers should be vigilant in obtaining detailed patient histories, including herbal or plant supplement use, to identify potential sources of toxicity.

Data availability

All data generated or analyzed during this study are included in this published article.


  1. DeVita VT, Chu E. Vinca alkaloids in the treatment of Hodgkin’s disease and other lymphomas. Ann Intern Med. 1969;69:27–43.

    Google Scholar 

  2. Man S, Gao W, Wei C, Liu C. Anticancer drugs from traditional toxic Chinese medicines. Phytother Res. 2012;26(10):1449–65.

    Article  CAS  PubMed  Google Scholar 

  3. Cooling L, Bombery M, Hoffmann S, Davenport R, Robertson P, Levine JE. The impact of recent vincristine on human hematopoietic progenitor cell collection in pediatric patients with central nervous system tumors. Transfusion. 2014;54(8):2004–14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Starobova H, Vetter I. Pathophysiology of Chemotherapy-Induced Peripheral Neuropathy. Front Mol Neurosci. 2017;10:174.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Madsen ML, Due H, Ejskjær N, Jensen P, Madsen J, Dybkær K. Aspects of vincristine-induced neuropathy in hematologic malignancies: a systematic review. Cancer Chemother Pharmacol. 2019;84(3):471–85.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Vutukuri VR, Das MC, Reddy M, Prabodh S, Sunethri P. Evaluation of Acute oral toxicity of ethanol leaves Extract of Catharanthus roseus in Wistar albino rats. J Clin Diagn Res. 2017;11(3):Ff01–4.

    CAS  PubMed  PubMed Central  Google Scholar 

  7. Grigorian A, O’Brien CB. Hepatotoxicity secondary to Chemotherapy. J Clin Transl Hepatol. 2014;2(2):95–102.

    PubMed  PubMed Central  Google Scholar 

  8. Aydogan A, Sezer K, Ozman O, Haligur M, Albay M. Catharanthus roseus toxicity in Sheep: clinical and pathological investigations of Accidental Catharanthus roseus toxicity in Sheep. Isr J Vet Med. 2015;70(4):66–71.

    Google Scholar 

  9. Kaur G, Athar M. Tannins: their beneficial role in health and disease. Phytother Res. 2014;28(11):1581–93.

    Google Scholar 

  10. Awad R, Arnason JT. Tannins: isolation from Hamamelis virginiana and pharmacological properties. J Herb Pharmacother. 2002;2(3):49–80.

    Google Scholar 

  11. Scalbert A. Antimicrobial properties of tannins. Phytochemistry. 1991;30(12):3875–83.

    Article  CAS  Google Scholar 

Download references


The authors thank Tsewang Tashi, MD from the University of Utah for providing editorial and proofreading support.


Not applicable.

Author information

Authors and Affiliations



All authors contributed equally to the review of data, drafting of manuscript, and approval of final version.

Corresponding author

Correspondence to Li-Jen Chang.

Ethics declarations

Ethics approval and consent to participate

Institutional Review Board approval was not required for this case report, because according to the national guidelines, the article is exempt from ethi cal committee approval as it is a case report of a patient previously seen.

Consent for publication

Consent to publish is required from patient to publish this report. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal

Competing interests

The author declares no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Chuah, Y.Y., Lee, Y.Y., Chou, CK. et al. Catharanthus roseus intoxication mimicking acute cholangitis. BMC Complement Med Ther 24, 139 (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: