IAP Case Report Submission
  • Title of the article: A  case of Neem Oil Poisoning
  • Short running title:  Neem Oil Poisoning
  • Authors :

            Dr Ramchandra K. Dhongade
            MD DCH, Professor and Head
            Sant Dnyaneshwar Medical Education & Research Centre
            Dr. Sandeep G. Kavade,
            Senior Resident, DNB Pediatrics
            Dr. Rushikesh S. Damle
            Senior Resident, DNB Pediatrics   

  • Contribution of the authors:

Dr. Sandeep Kavade manuscript design and writing.
Dr. Rushikesh Damle data compilation and manuscript drafting.
Dr. R. K. Dhongade guarantor overall coordinator and guide.

  • Name of Institute :

      Sant Dnyaneshwar Medical Education & Research Centre, Pune.

  • Disclaimer: None

Address of correspondence:

C/o Dr R. K. Dhongade
      Sant Dnyaneshwar Medical Education & Research Centre,
      Shaishav clinic, 695/A Sadashiv Peth,
      Opp. Vijay Talkies, Laxmi Road,
      Pune - 411030. Maharashtra
      Phone nos- 020-24457234, 09822037483
      Fax no-02066021423
      E-mail- sandeepkavade@gmail.com

  • Competing interests : None
  • Source of Funding : None
  • Word Count : 718 words

Dr. Ramchandra K. Dhongade
M.D. (Paed), D.C.H. (Bom)

Dr. Ashalata R. Dhongade
MBBS, DA (Secretary)

Dr. Vaijayanti Bapat (MD DCH)
Vice President & HOD UNIT II



Neem oil as a cause of poisoning is rare. Even small doses of neem oil can cause severe metabolic acidosis along with seizures which can be refractory. Late neurological sequelae are also known.

Key words:   Neem oil, Poisoning, Status epilepticus


Neem oil has been used from times immemorial in Indian folk medicine. We are reporting an unusual case of neem oil poisoning which has caused serious neurological sequelae in a previously normal child.

Case Report

            A 5 yrs previously healthy boy brought in status epilepticus an hour after accidental ingestion of neem oil. On admission his GCS was 5 with pupils dilated sluggishly reacting to light, and brisk reflexes. Patient had tachycardia and dyspnea. Management was immediately started but patient did not respond. He went into cardio respiratory arrest. Resuscitation was done and taken on mechanical ventilator. Midazolam drip was started which controlled convulsions.

On admission BSL was 300 mg / dl, hemogram showed marked neutrophilic leucocytosis, Serum Calcium 8.2 mg/dl, Serum electrolytes, liver function tests, prothrombin time, activated partial thromboplastin time were normal. Arterial blood gases showed partially compensated metabolic acidosis.

The patient was gradually weaned off ventilator. On 3rd day patient was conscious with GCS 12 with reflexes normal. MRI scan of brain was normal. EEG done 7th day was also normal. Other investigations repeated showed improvement except for raised SGPT (816 U/L) and Blood Ammonia (102 mcg / dl) marginally high. Though he showed improvement in general condition neurodeficits remained. Higher functions were disturbed. Patient did not recognize parents, was unable to sit without support and no bladder or bowel control. There were choreoathetoid movements of all limbs; speech was of incoherent sounds. Follow up after 2 months showed no improvement.


            Neem oil also known as margosa oil is obtained from neem plant (Azadiracta indica Juss). Oil is extracted from neem seed kernels. It contains neutral oils such as palmitic and stearic acids. Active ingredients are terpenoids such as azadirachtin, nimbin, picrin and sialin(1). It also contains Aflatoxin but in very low concentrations. Azadirachtin is attributed with pesticide action of neem oil (2). Neem oil is used as base for many herbal medicines and also in cosmetic products (3). It is also said to be effective as a contraceptive in males (4).
            There are few similar reported cases. (5, 6, 7) Practice of instilling neem oil in infants and small children having ARI, seen in South India and Indians in South East Asia(6), is the causative factor in these cases. The usual features are vomiting, drowsiness, tachypnea and recurrent generalized seizures. (5, 6) The severity of symptoms is dose dependent. Exact toxicity level doses are not known. Leucocytosis and metabolic acidosis are significant laboratory findings (5, 6). Leucocytosis is usually of neutrophilic type and resolves within first few days. Liver biopsy of 1 case showed fatty infiltration and Reye’s like syndrome is attributed to neem oil toxicity (5). Though liver enzymes are elevated in some cases hepatic failure does not seem the major toxicity in most cases. 
            No specific antidote is available. Management is aimed primarily towards the control of convulsions. Gastric lavage is not recommended. Cases with only mild vomiting and gastrointestinal features fared better than those with CNS manifestations. Supportive management is equally important. Prognosis is usually good but fatalities and neurological deficits have been reported.(5, 6)

Key messages:

Neem oil a very potent toxin with causing both immediate and long term complications. Both presentation and management are not well defined. As the use of neem oil as pesticides and other medicines the cases of its toxicity are likely to increase.   


1) A Rahman and F. A. Talukder Bioefficacy of some plant derivatives that protect grain against the pulse beetle; Callosobruchus maculatesJournal of Chemical Ecology 1993; 19:2463–247

2) H. Vatandoost1 and V.M. Vaziri. Larvicidal activity of a neem tree extract (Neemarin) against mosquito larvae in the Islamic Republic of Iran.Eastern Mediterranean Health Journal 1995, 26: 180–2.

3) Charmaine Lloyd AC, Menon T, Umamaheshwari K. Anticandidal activity of Azadirachta indica. Indian Journal Pharmacology 2005; 37:386-389

4) Garg S, Talwar GP, Upadhyay SN. Immunocontraceptive activity guided fractionation and characterization of active constituents of neem (Azadirachta indica) seed extracts. Journal of Ethnopharmacology 1998; 60:235-46

5) Sinniah D, Baskaran G. Margosa oil poisoning as a cause of Reye's Syndrome Lancet 1981, 1: 487-9.

6) Sundarvalli N., Raju BB, Krishnamoorthy KA. Neem oil poisoning, Indian J Pediatr. 1982, 49: 357-9

7) Lai SM, Lim KW, Cheng HK, Margosa oil poisoning as a cause of toxic encephalopathy Singapore Med J. 1990; 31:463-5.