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Summary:We report a 36-year-old woman, without any past or family histories of epilepsy, who presented frequent vomiting and generalized convulsions. About 4 h before the convulsion, she had consumed ∼70-80 gingko nuts, seeds of Gingko biloba, in an attempt to improve her health. It is important to know that convulsion may be induced if a large amount of gingko nuts is consumed. The neurotoxicity of gingko nuts, particularly their convulsion-inducing effect, should be recognized. Key Words: Gingko biloba-Gingko nutConvulsion-Neurotoxicity.Leaf extracts of Gingko biloba have various useful pharmacologic actions, such as improvement of cerebral blood flow (1), and neuroprotection against ischemic brain damage (1). Conversely, it must be noted that seeds of Gingko biloba (gingko nuts or gin-nan) also have dangerous poisoning effects (2). Because Japanese, as well as Chinese, often eat gingko nuts as an ordinary food, there is a tendency to be less cautious of their toxicity. We encountered an adult patient who had convulsions after consuming a large amount of gingko nuts. Here, we report on the patient and emphasize the clinical importance of recognizing the neurotoxicity of gingko nuts. CASE REPORTA previously healthy 36-year-old woman without any past or family histories of epilepsy had frequent vomiting and generalized tonic and clonic convulsions. During the first 24 h, she experienced generalized convulsions twice and vomiting several times. About 4 h before the onset of her first episode of convulsion, she had consumed ∼70-80 gingko nuts during lunch, after cooking them in a microwave oven, because she had heard of a favorable effect of ginkgo nuts on health. Soon after the first episode of convulsion, she was transferred to the emergency room of our hospital in an ambulance. During the transfer, her consciousness had returned.In the emergency room, her general conditions were normal, and no neurologic abnormality was noted. Results of routine blood tests, chest and abdominal radiographs, and ECG were all normal. The brain computed tomography (CT) scan was also normal. However, she soon again experienced a generalized convulsion for a period of 10 s with vomiting. Then a possible diagnosis of epileptic seizure was made, and 100 mg of phenobarbital (PB) was administered intramuscularly in the emergency room. The next morning, she was transferred to the neurologic section. On admission, she was alert and oriented, but complained of a dull headache. Her neurologic examination result was normal. Her EEG and cerebrospinal fluid (CSF) were normal. Results of magnetic resonance imaging (MRI) and MR angiography of the brain were all normal. Because she experienced generalized convulsions twice in 1 day, carbamazepine (CBZ) was administered to prevent further convulsions, but she stopped taking the medication within a few days because of marked daytime sleepiness. After stopping the medication, EEGs were repeatedly taken but were found to be normal, and there has been no recurrence of convulsions for 2 years ever with...

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D iphtheria is a serious childhood disease with a high mortality rate (1). After a diphtheria-tetanus-pertussis vaccine (DTP) was introduced in the early 20th century, the number of cases dramatically decreased. Incidence reached a low of 4,333 cases in 2006, but more recently, the number of reported cases has increased, with incidence reaching 16,648 cases in 2018 (2). In 1981, Vietnam introduced a vaccination program in which participants received 3 primary doses of DTP (DTP3) vaccine; in 2011, a booster shot (DTP4) to be given 18 months after the initial doses was added (3). Although diphtheria cases had become sporadic by 2010, beginning in 2013, outbreaks occurred in the western and central highland areas of Vietnam, which prompted our study (4). The Study During June 2015-April 2018, the Pasteur Institute in Nha Trang, Vietnam, and the provincial health authority investigated 46 cases involving patients with suspected diphtheria, 8 of whom died, and 49 asymptomatic contacts in the provinces of Quang Nam and Quang Ngai in the central highlands region of Vietnam (Figure 1). We used standard case investigation forms to collect demographic and clinical information. We collected throat swab specimens from 93 patients and contacts but were unable to collect samples from 2 patients who had died. No cutaneous diphtheria was reported. We used sheep blood agar and tellurite medium cultures to identify Corynebacterium diphtheriae and extracted DNA with a QIAGEN DNA Mini Kit (QIA-GEN, https://www.qiagen.com), following a standard protocol. We used 2 sets of primers, Tox1/Tox2 and Dipht6F/Dipht6R, for PCR testing (5). The Elek test for diphtheria is not available in Vietnam. Laboratory testing confirmed diphtheria in 22 of 46 suspected cases: 17 patients, including 4 who died, tested positive in both culture and PCR tests, whereas 5 patients, including 1 who died, tested positive only