**2. Uses and active compounds in** *C. sanguinolenta*

*C. sanguinolenta*, is recognized for its antimalarial [13], antimicrobial [14], antihyperglycemic [15, 16], and anti-amoebal properties. In the case of its use for the treatment of malaria, the bioactive indole alkaloid cryptolepine which is the major constituent of the root bark. It is reported to possess an anti-plasmodial property among other antiparasitic [3], anti-thrombotic [17], noradrenergic [18], vasodilator [17], hypoglycaemic [19, 20] properties. It also has anti-diabetic, anti-pyretic, antiinflammatory, hypotensive, anti-thrombotic, and anti-plasmodial properties [2].

An aqueous extract of the roots yields a N-methyl derivative of quindoline and indoloquinoline alkaloids, mainly cryptolepine [21]. The roots also contain high concentration of indologuinoline and cryptolepine which has the most potent antiplasmodial activity [22–24].

Cryptolepine was first isolated in 1931 by Delvaux and later from collected *C. sanguinolenta* accessions in Ghana [23] and Nigeria [25]. Several structurally related alkaloids found in the plant included, cryptoquindoline cryptoheptine, biscryptolepine, 11-hydroxycryptolepine, quindolinone, isocryptolepine (Cryptosanguinolentine), neocryptolepine, quindoline, and cryptospirolepine have also been isolated [21]. In prepared aqueous root extract used for the treatment of various ailments, only cryptolepine is isolated [3]. In the ethanolic root extract, the cryptolepine isomers called neocryptolepine, biscryptolepine and cryptoquindoline which are dimeric alkaloids have been isolated [26]. Research into the synthesis of the plant alkaloid cryptolepine and the development of its analogues as a way of understanding the mechanisms into its pharmacological effects have been carried out [27].

Among indigenous inhabitants where biomedicines are not readily available, herbal plants are usually the only source of remedy to treat various ailments [28]. The medicinal plant industry does not only play a major role in satisfying the health care needs of the populace but serves as a viable source of income to manufacturers and collectors of the raw herbal plant materials.

In African, *C. sanguinolenta* is widely use in the treatment of various ailments especially countries in the West African sub region. Traditional healers in Guinea Bissau use the root extract and the powdered leaf to treat fever, hepatitis and cicatrizant of wounds respectively. The boiled leaf is used as an infusion for the treatment of malaria [29]. In Uganda the prepared roots are used in the treatments of measles, hernia, snake bites and hypertension [3]. In Nigeria, the root is macerated to treat rheumatism and urogenital infection. In Ghana, the aqueous root extract is used to treat malaria, urinary, and upper respiratory tract infections [30]. It is also used for the treatment of colic, stomach complaints, amoebic dysentery, diabetes and diarrhea in other West African countries such as Senegal and DR Congo [31–33]. Due to its general use by traditional healers, it has been included in several herbal products sold on the market in Ghana, such as Class Herbaquine, Malaherb, Nibima, Phyto-Laria and Malacure. *C. sanguinolenta* is used in Central and West Africa for the treatment of infectious diseases such as amoebiasis and Covid-19 [34]. It is presently studied in clinical trials for the treatment of COVID-19 in Ghana [35, 36]. A recent study by Amissah et al. [12] reported that cryptolepine extracts from plants aged between 9 and 12 months had the most antiplasmodial activity and drug selectivity index against *Plasmodium falciparum* Dd2. These cryptolepine extracts were identified for the effective management of cancer due to its cytotoxicity to Jurkat leukemia cell lines [12].

Besides its medicinal properties, the length of *C. sanguinolenta's* branches and twining nature enables its use as a rope to construct houses in Uganda [2]. In addition, the pulverized roots contain yellow pigment, which serves as a yellow dye in the leather, textiles, and fabric industry [3, 37].

#### **2.1 Role of** *C. sanguinolenta* **as herbal medicine in the United States**

An online survey was conducted in 2018 among 133 medicinal plant practitioners and clinics in collaboration with Woodland Essence LLC Ltd. (https://woodlandessence.com) to assess the use of *C. sanguinolenta* root extracts along with the quantities required in the United States of America. Medicinal plant practitioners were asked; 1) whether they knew the plant 2) whether they use the plant in their practice, clinic or personal protocol? 3) what conditions they use *C. sanguinolenta* to treat and 4) how much of the plant is used per month.

Findings from the survey revealed that majority of the respondents (131) representing 98.5%, were familiar with *C. sanguinolenta* whereas only 2 respondents representing 1.5% were not. It was revealed that 133 respondents (95.5%) used *C. sanguinolenta* in their practice, clinic or personal protocol whereas 6 respondents (4.5%) answering that they did not.

Regarding its uses, respondents mentioned Babesia (73.7%; 98 respondents), followed by Lyme disease (*Borreliosis burgdorferi*) (57.9%; 77 respondents), Bartonella (43.6%; 58 respondents), and as a systemic anti-bacterial (33.8%; 45 respondents) as the top four (4) conditions Cs is used to treat. Other conditions treated with *C. sanguinolenta* included anti-fungi infection (17.3%; 23 respondents), methicillin-resistant *Staphylococcus aureus* (MRSA) (14.3%; 19 respondents), urinary tract infections (11.3%; 15 respondents), external treatments (6.0%; 8 respondents), cancer (1.5%; 2 respondents), diabetes (1.5%; 2 respondents), and hepatitis (0.8%; 1 respondent) (**Figure 2**). Twenty-four (24) respondents representing 18.1% mentioned that *C. sanguinolenta* was used to treat conditions such as mold and deep lung infections, general antimicrobial, systemic anti-viral, prophylaxis with embedded deer tick, strep infections, gut bacterial outgrowth and recurring gastrointestinal (GI) tract

**Figure 2.** *Responses to the health conditions treated with* C. sanguinolenta*.*

infections (**Figure 2**). According to the survey, medicinal plant practitioners and clinics testified to the efficiency of *C. sanguinolenta* in treating the medical conditions listed in (**Figure 2**).

"I suffered for over 8 months with recurrent Methicillin-resistant Staphylococcus aureus (MRSA) infections in the outer and middle ears. I tried over 6 different antibiotics (all resistant) and was getting ready to start IV antibiotics. My functional medicine practitioner had me take *C. sanguinolenta* in tincture form. Within a couple of weeks, I was cured! I have had a couple of flare up and the same protocol does the trick, and quick." (Respondent No. 12, personal communication).

"It is the only thing that has been effective in treating long-term staph infection." (Respondent No. 9, personal communication).

"It is literally saving my life from chronic GI tract bacterial infections, where no other medicine helps" (Respondent No. 11, personal communication).

Regarding dosage use, some respondents indicated using 40 drops twice a day for 14 days on and 14 days off (Respondent No. 25), 3/4 of a dropper of the CSA formula (Respondent No. 30) while another respondent (Respondent No. 41), reported its use in combination with other medicinal plants such as *Sida acuta* and *Alchornea cordifolia* as per Steven Buhner's protocols [38]. Respondent No. 51 indicated that patients usually take 1table spoon three times a day for approximately 4 months. In response to the duration of its use, respondent No. 50 reported a cycle of usage of 1–4 months on and 6 months to a year off.

Monthly quantities (ounces/milliliters) of *C. sanguinolenta* used by the respondents were indicated as follows; 1–4 ounces/ (54.9%; 73 respondents), followed by 4–40 ounces (34.6%, 46 respondents). Five percent (5.0%) and 2.3% of the respondents reported the use of larger quantities of between 40 and 162 and > 162 ounces respectively (**Figure 3**).

Findings from the survey point to the multipurpose use of *C. sanguinolenta* to treat ailments other than malaria including Babesia, Lyme disease (*Borreliosis burgdorferi*) and Bartonella among others. This confirms the importance of the herb on the US market, cementing the need for its conservation by encouraging its cultivation. *C. sanguinolenta* has since been tested with other botanical and natural products used by Lyme disease patients and found to be very active *in vitro* against stationary phase *Borrelia burgdorferi* [39] and *Babesia duncani* [40].

**Figure 3.** *Quantities of* C. sanguinolenta *used per month as indicated by respondents.*
