On February 1, 2013, a 58-year-old man was admitted to the Emergency Department of the Regional Hospital of Zaghouan (Tunisia), with dizziness, weakness, anorexia, and dyspnea. His blood pressure was 130/60 mmHg. The patient has a 15-pack-year history of smoking. He was a mason by occupation. He had 20-year back history of pulmonary tuberculosis and type 2 diabetes revealed one year ago. Two days before his admission, the patient experienced nausea, vomiting, anuria, and hematuria. He reported having daily consumption of a homemade drink based on Rhamnus alaternus roots, during the last 6 months, to control his blood glucose levels. On physical examination, the patient had myalgia. He had no other clinical signs.
Cytological reports and sputum smear were negative (three times) for pulmonary tuberculosis. Hepatitis B and hepatitis C serology were also negative. Chest X-ray was normal; blood and urine culture were negative. In renal ultrasonography, there was a significant difference in kidney sizes and the corticomedullary differentiation was altered. Laboratory tests showed glucose 14.44 mmol/L, creatinine 1190 mumol/L, blood urea nitrogen 66.77 mmol/L, creatine phosphokinase (CPK) 2129 UI/L, pH 7.10, a CRP of 8.7 mg/L, and a normal coagulation profile (Table 1). Three dialysis sessions were performed.
Samples of the herbal decoction were obtained from the patient's wife. It was a dark brown suspension with fine brown deposit and a clear supernatant. It smelled a strong penetrating odor. Samples of both Rhamnus alaternus root and its decoction were sent to be analyzed in the Laboratory of Toxicology in the Center for Emergency Medical Assistance of Tunis in Tunisia.
After the authenticity and the botanical identification of the species were confirmed according to the "Flore de la Tunisie" phytochemical compounds were extracted from the medicinal decoction using routine methods including liquid-liquid extraction procedures with further analysis by gas chromatography/mass spectrometry (GC-MS). The solvents used were dichloromethane, ethyl acetate, and chloroform at different pH values (1.0, 7.0, and 9.0). The different extracts were dehydrated over anhydrous sulfate. The dry residue was diluted with 2 milliliters of ethyl acetate. One or 2 muL was analyzed by GC-MS. Dried roots of "Rhamnus alaternus" were reduced to small fragments and macerated in a water-methanol mixture (1 : 2) during 4 h with magnetic stirring. 24 hours later, the extract was filtered and the alcoholic layer was evaporated. The aqueous layer was collected in a separating funnel and had been alkalinized by the addition of ammonia (NH4OH) and then extracted with dichloromethane by liquid-liquid extraction procedures. The organic phase was dehydrated over anhydrous sulfate and concentrated to 1 mL and then analyzed by GC-MS.
The gas chromatograph-mass spectrometer used was a Hewlett Packard 5890-II (Agilent Technologies) fitted with a manual injector and HP5-MS (0.25-mum) capillary column (30 m long and 0.25 mm i.d.). The injection volume was 2 muL; the compounds were separated with helium (carrier gas) at a flow rate of 1 mL/min. The operating conditions were as follows: the injector was programmed to 250 C at 10 C s-1 and held for 2 min. The oven was programmed from 50 C (2 min) to 100 C at 25 C min-1 and then to 200 C at 10 C min-1 (2 min). MS detection was achieved in scan mode for qualitative analysis. Run time was 16 min.