Paradise nut paradox: alopecia due to selenosis from a nutritional therapy.

Selenium is a micronutrient. It presents a nutritional conundrum because of its twin status as an essential as well as a highly toxic trace element. Here, we report a case of acute non-intentional selenium toxicity due to increased ingestion of "paradise nuts" (Lecythis ollaria) which resulted in massive alopecia.

INTRODUCTION

Selenium is a micronutrient which, in small concentrations, is an important constituent of the antioxidant enzyme glutathione peroxidase. Thus, selenium may have a role in the prevention of cardiovascular diseases and cancer.[1] These preventive effects and potential health benefits motivate people to consume dietary compounds containing selenium. However, selenium at higher concentrations can cause multiple organ toxicity, a condition called “selenosis.” Here, we report a case of acute, non-intentional selenium toxicity due to increased ingestion of “paradise nuts” (Lecythis ollaria), which resulted in massive alopecia.

CASE REPORT

A 55-year-old otherwise healthy woman presented to the emergency department with a history of headaches, dizziness, vomiting, and abdominal pain for 5 days. On examination, she was conscious, rational, febrile (100 F), dehydrated, and visibly distressed. She was hemodynamically stable and maintaining adequate saturation in the room air. She had mild abdominal distension and diffuse abdominal tenderness. Other systems were essentially normal. She was resuscitated and admitted to the hospital. On the 2nd day of admission, it was noted that she had lost a significant number of scalp hairs on her pillow. This process started abruptly but was unremitting, and she noted shedding of hairs in tufts while combing or even gently pulling her hair. There was no scarring, atrophy, graying, or “exclamation mark” hairs on close scalp examination. However, even a gentle pull of hair caused painless extraction of a bunch of hairs, typically comprising more than 50 hairs. Other body hairs were spared and were in normal in thickness. A trichogram revealed 90% of the hairs in anagen phase with dystrophic follicles. Within 2 days, most of the hair on her scalp had fallen out, and she became totally bald [Figure 1]. She also had developed greyish discoloration of the fingernails on 4th hospital day.

Figure 1

Massive alopecia after eating paradise nuts

Her complete blood count, metabolic profile, thyroid function tests, vitamin B12, folic acid, ferritin, serum iron, and hormone profile were within normal limits. Eventually, a more detailed anamnesis revealed the source of the patient's alopecia. She stated that she worked with a colleague who was suffering from breast cancer, and she learned from several websites that selenium could aid in cancer prevention. She then purchased 2 kg of paradise nuts online, and consumed 10-15 nuts per day for 20 days with the intention of preventing cancer.

The nuts were identified and compared with the existing specimen in the botany herbarium and found to be Lecythis ollaria. As paradise nuts are rich in selenium, a causal relationship was considered between her recent nutritional supplement and the clinical presentation. The patient's plasma level of selenium was found to be 512 mg/L (normal: 74-139 mg/L). She improved with symptomatic treatment. At follow-up after 2 months, her hair started to regrow.

DISCUSSION

Alopecia poses challenges to the treating physician as the causes are multiple. Massive alopecia is alarming and depressing to the patient, and most often seen in association with cancer chemotherapy. Here, we describe another cause of massive alopecia – acute selenosis – with the ironic twist that the patient's intention to treat cancer resulted in a remarkable and unique multiorgan toxidrome.

Plants have long been used as an organic source of selenium, because the high bioavailability and low toxicity in this form of the micronutrient is favorable in comparison to inorganic selenium compounds.[2] About 7-12 g of selenium/kg is available in the dry mass of paradise nuts in the form of seleno-cystathionine.[3] The clinical manifestations of selenium toxicity include alopecia, nail dystrophy, skin rashes, gastrointestinal upset, and neurologic dysfunction such as disorientation. Selenium causes telogen effluvium by disruption of structural proteins network in keratin and amalgamate. The resulting disulfide bridges make the hair shaft more fragile, with eventual generalized hair loss. Severe selenium toxicity has been reported after ingestion of seven or more of these nuts.[4] Müller and Desel[5] documented massive hair loss associated with elevated selenium concentrations in two previously healthy women who had consumed paradise nuts. Recently, over 200 patients suffered from acute selenosis as a result of a misformulated liquid dietary supplement containing more than 200 times the labeled concentration of selenium as well as a higher than labeled concentration of chromium.[6] Previously, we also reported massive alopecia following plant poisoning, in the context of colchicine poisoning.[7]

Beyond the acute and specific toxic syndrome of acute selenosis, this case provides a timely and important reminder for clinicians to explore alternative medicines and unusual dietary sources as causes of unique toxic presentations. Just because nuts are natural products, they may not necessarily be safe or good when consumed in large, uncontrolled amounts. Hair loss secondary to the use of plant materials should also be discussed in clinical teaching apart from training on alopecia, nail and cutaneous diseases. Lastly, public health education efforts should focus on the real and proven benefits as well as adverse effects of nutritional supplements and alternative therapies, in order to prevent untoward effects on vulnerable and gullible patients.