A 30 yo woman with no past medical history was burning leaves and became sob.

What happened?

Our patient was exposed to burning sumac smoke while clearing out her yard .  Toxicodendron vernix is a woody shrub or tree which can grow to 30 ft. It contains urushiol which is the same resin in poison ivy and poison oak but is more toxic in sumac.  Poison ivy has a C15 side chain, poison oak has a C17 side chain and poison sumac has a C13 side chain.   Whensumac  burned, the smoke can cause breakdown in the lining of the lungs causing ARDS. 

This is not a new problem.  In fact, the Iroquois used sumac in warfare.  By setting fires with sumac upwind of their enemies they caused respiratory distress and even death in their enemies.  The following is a quote from a book by Thevet in 1557.

“They also used poisons made from the leaves of trees, herbs, and fruits, which are dried in the sun, and placed amongst the faggots and branches, then they set fire when they see the enemy approaching.”  A smoke emerges which is so thick, black and dangerous to breathe, as much for the fetid odor as for the poison mixed in these faggots, that several  are suffocated. 

poisonous sumac with white berries and a red stem

non poisonous sumac

non poisonous sumac

Teaching point:

Not all sumac is poisonous.  In fact sumac with red berries is used in Middle Eastern cooking and to make a kind of lemonade. However, beware the sumac with white berries, since it contains urushiol.

Our patient had an initial sat of 66% and was unable to be ventilated.  She was placed on veno-venous ecmo 10/20/16  and remains in the ICU on ecmo.   Her last arterial blood gas was O2 52, CO2 56 and pH 7.38.