Ackee

JUN 2008

Blighia sapida , K. Konig. Family: Sapindaceae

Ackee , akee , aki , arbre a' fricasser , ¹ seso vegetal , ² yeux de crabe , ¹ merey del diablo , ¹ ris de veau , ¹ fruto de huevo , ¹ arbol de seso , ¹ pero roja , ¹ pan y quesito ¹

Uses

The ackee is a major food in Jamaica. In South America, the fruit has been used to treat colds, fever, and diseases as varied as edema and epilepsy, although there are no clinical trials to support these uses.

Dosing

The ripe fruits are edible, however, the unripe fruits are toxic due to hypoglycins A and B.

Contraindications

The unripened ackee fruit is toxic, causing severe hypoglycemia often accompanied by convulsions and death.

Pregnancy/Lactation

Information regarding safety and efficacy in pregnancy and lactation is lacking. Avoid use.

Interactions

Hypoglycemia caused by ackee may be masked in patients on beta-blockers because these suppress epinephrine-mediated warning signs of imminent hypoglycemia; monitor patients with diabetes.

Adverse Reactions

No data.

Toxicology

Symptoms of ackee poisoning include cholestatic jaundice, vomiting, hypoglycemia, convulsions, coma, and potentially death. Six to 48 hours may elapse between ingestion of the unripened fruit and the onset of symptoms.

Ackee is the national fruit of Jamaica and is widely found throughout the West Indies and has been naturalized to parts of Central America, Florida, and Hawaii. This tall, leafy tree grows to approximately 12 meters and produces fruit 2 times/year, between January and March, and June and August. ^1, Its oval, compound leaves have 5 pair of leaflets, the longest of which is approximately 15 centimeters at the tip. The plant produces small, greenish-white flowers. The red fruit pods split open at maturity, exposing 3 shiny, black seeds embedded in a white, waxy aril. ²

The ackee tree was imported to Jamaica from West Africa in the late 1700s and is often grown as an ornamental. ^3, Although the unripened walnut-like seeds are toxic, the ripe fruits are used in traditional island cooking. ^2, The ackee is a major food in Jamaica and is noted for its high protein and fat content. ^4, Fresh ackee berries are available in season in markets and canned fruit is available throughout the year. Poisonings have long been associated with the use of the ackee, and published reports of Jamaican intoxications date back to 1904. ^5, In South America, the fruit is used to treat colds, fever, and diseases as varied as edema and epilepsy. ³

Hypoglycin A and hypoglycin B are potent hypoglycemic compounds. ^1, The most toxic is the cyclopropyl amino acid hypoglycin A and its metabolite methylenecyclopropylacetic acid, found in the aril and the seeds of the unripe ackee fruit. ^1, , ^6, , ^7, The unripe ackee fruit contains hypoglycin A at concentrations 100 times higher than those in ripe ackee fruit. ^7, , ^8, In addition, other hypoglycemic compounds, including hypoglycin B and other cyclopropanoid amino acids, are found in the seed. CNS active carboxycyclopropylglycines found in the unripened fruit are reported to be potent group II metabotrophic glutamate receptor agonists. ⁹

The ackee is a major food in Jamaica. In South America, the fruit has been used to treat colds, fever, and diseases as varied as edema and epilepsy.

Animal data Research reveals no animal data regarding the use of ackee for the treatment of colds, fevers, edema, or epilepsy.

Clinical data Research reveals no clinical data regarding the use of ackee for the treatment of colds, fevers, edema, or epilepsy.

The ripe fruits are edible, however, the unripe fruits are toxic due to hypoglycins A and B.

Information regarding safety and efficacy in pregnancy and lactation is lacking. Avoid use.

Hypoglycemia caused by ackee may be masked in patients on beta-blockers because these suppress epinephrine-mediated warning signs of imminent hypoglycemia; monitor patients with diabetes.

Because ackee has no data supporting a medicinal use, all adverse reactions are addressed under Toxicology.

Hypoglycin A is a water-soluble liver toxin that induces hypoglycemia by inhibiting gluconeogenesis by limiting the activity of cofactor mimics (CoA and carnitine) that are required for the oxidation of long-chain fatty acids. ^5, Methylenecyclopropylacetyl-CoA also causes secondary inhibition of gluconeogenesis by inactivating several acyl-CoA dehydrogenases involved with the oxidation of fatty acids and several amino acids. ^10, The pink raphe (the portion of the seed that attaches to the ovary wall) and the aril in the immature plant are poisonous because of the presence of the hypoglycins. The arils become edible when the fruit ripens; hypoglycin A is efficiently removed from the edible arils when the ackee fruit is boiled in water for approximately 30 minutes. ^7, Hypoglycin A appears to be approximately twice as toxic as hypoglycin B. ^6, The powdered fruits are used in Africa as a fish poison. ³

More than 5000 people have died from ackee poisoning since 1886. ^6, , ^10, In the past, large-scale poisonings appeared to be limited to the island of Jamaica where they reached epidemic proportions during the winter months under the name of “Jamaican vomiting sickness.” ^2, In Jamaica, 28 patients who had symptoms of ackee poisoning were identified during the period between January 1989 through July 1991. Six of these patients died. The most common symptoms were vomiting, coma, and seizures. Seven of the patients had confirmed hypoglycemia. Most of the cases occurred between January and March. ⁵

A case-control, retrospective study of health-service records and interviews with family members, village chiefs, and local healers in a rural area in west Africa identified 29 cases of fatal encephalopathy in preschool children (2 to 6 years of age) during January to May 1998. All children died within 48 hours of onset of symptoms. The clinical presentation was similar to that of Jamaican vomiting sickness and toxic hypoglycemic syndrome; most common symptoms included hypotonia, convulsions, and coma. ⁸

Eighty cases with symptoms consistent of ackee poisoning (ie, continuous vomiting, abdominal pains, loss of consciousness, convulsions within 24 hours) were recorded in 2 districts of Haiti's Northern Province between November 2000 and March 2001. ^1, Retrospective analysis confirmed 31 of the 80 cases were related to consumption of ackee. The mean age of the victims ranged from 6 months to 88 years, with a median of 7 and an average of 16. The case fatality rate was 52%. ¹

Poisonings may be present in 1 of 2 distinct forms. In the first case, vomiting is followed by a remission period of 8 to 10 hours, followed by renewed vomiting, convulsions, and coma. The second type is characterized by convulsions and coma at the onset. Additional symptoms associated with chronic fruit ingestion include cholestatic jaundice, abdominal pain, and elevated liver function values. ^11, Diarrhea and fever are usually absent. Six to 48 hours may elapse between ingestion of the fruit and the onset of symptoms. ^12, Severe hypoglycemia develops ^2, and blood glucose levels as low as 3 mg/dL are observed in many cases. ⁵

Management of ackee intoxication consists of fluid therapy and the administration of glucose and electrolytes. Because patients with preexisting nutritional deficits and children may be more sensitive to the toxic effects of the fruit, vitamin and nutritional supplements should be administered. ^2, , ^5, , ¹²

1. Moya J. Ackee ( Blighia sapida ) poisoning in the Northern Province, Haiti, 2001. Epidemiol Bull . 2001;22:8-9. PubMed

2. Lampe KF. AMA Handbook of Poisonous and Injurious Plants . Chicago, IL: Chicago Review Press; 1985.

3. Duke JA. Handbook of Medicinal Herbs . Boca Raton, FL: CRC Press; 1985.

4. Ashurst PR. Toxic substances of ackee. Review. J Sci Res Counc Jam . 1971;2:4-16.

5. Toxic hypoglycemic syndrome—Jamaica, 1989-1991. MMWR . 1992;41:53-55. PubMed

6. Farnsworth NR, Segelman AB. Hypoglycemic plants. Tile and Till . 1971;57:52.

7. Golden KD, Williams OJ, Bailey-Shaw Y. High-performance liquid chromatographic analysis of amino acids in ackee fruit with emphasis on the toxic amino acid hypoglycin A. J Chromatogr Sci . 2002;40:441-446. PubMed

8. Meda HA, Diallo B, Buchet JP, et al. Epidemic of fatal encephalopathy in preschool children in Burkina Faso and consumption of unripe ackee ( Blighia sapida ) fruit. Lancet . 1999;353:536-540. PubMed

9. Natalini B, Capodiferro V, De Luca C, Espinal R. Isolation of pure (2S,1'S, 2'S)-2-(2'-carboxycyclopropyl) glycine from Blighia sapida (Akee). J Chromatogr A . 2000;873:283-286. PubMed

10. Sherratt HA. Hypoglycin, the famous toxin of the unripe Jamaican ackee fruit. Trends Pharmacol Sci . 1986;7:186-191.

11. Larson J, Vender R, Camuto P. Cholestatic jaundice due to ackee fruit poisoning. Am J Gastroenterol . 1994;89:1577-1578. PubMed

12. Henry SH, Page SW, Bolger PM. Hazard assessment of ackee fruit ( Blighia sapida ). Hum Ecol Risk Assess . 1998;4:1175-1187.