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Cardiac Glycoside Plant Poisoning

Cardiac Glycoside Poisoning with Undetermined Intent


Presentation

  • Because of the competitive nature of the immunoassay as well as the complexity of the mixture of cross-reacting cardiac glycosides present in the plant material, the measured apparent digoxin concentration is not linearly related to the cardiac glycoside[ncbi.nlm.nih.gov]
  • Get the information you need in the most organized way with infectious agents arranged by syndromes, as they typically present.[books.google.de]
  • Case report A 26-year-old male patient presented to the emergency room with vomiting, disorientation, and increased tone of muscles (spasticity) in lower limbs.[roaic.eg.net]
  • These dysrhythmias include the following: Tachydysrhythmia, such as atrial tachycardia with block Junctional tachycardia Paroxysmal atrial tachycardia with block Bidirectional ventricular tachycardia More than a single dysrhythmia may be present.[emedicine.medscape.com]
  • Two cases of Nerium Oleander poisoning were presented. Clinical picture included gastrointestinal, cardiovascular and central nervous system effects.[degruyter.com]
Pain
  • In acute toxicity, the following may be present: GI symptoms - Usually evolve within minutes to hours, are nonspecific, and include nausea, vomiting, and abdominal pain Neurologic symptoms - Often are nonspecific and include weakness and altered mental[emedicine.medscape.com]
  • Signs and Symptoms: In children cardiac glycoside ingestion causes severe abdominal pain, diarrhea, nausea and vomiting. Additional symptoms include lethargy, circumoral flush, dialated pupils, drooling, sweating, shaking, and ashy coloring.[sites.google.com]
  • Symptoms: Nausea, vomiting, salivation, drowsiness, abdominal pain, diarrhea, weakness, and respiratory depression.[people.uwec.edu]
  • The initial signs of poisoning are headache, confusion, dizziness, vomiting or stomach pain. Later, effects on heart rate and blood pressure occur. Examples of plants which contain cardiac glycosides: Foxglove Lily-of-the-Valley Oleander Squill[chop.edu]
  • Contact  tingling and numbness Odour has narcotic action Pollen causes pain and swelling of the eyes Symptoms immediately or within min GI Salivation  dry and difficulty in swallowing Limbs weak, paraestheisa, ataxia, slurred speech 45.[slideshare.net]
Congestive Heart Failure
  • It is used in modern medicine to increase the force of the systolic contractions and prolong duration of the diastolic phase in congestive heart failure.[poisonousplants.ansci.cornell.edu]
  • Description of the problem Digoxin is commonly used for the treatment of atrial fibrillation, especially with co-existing congestive heart failure.[clinicaladvisor.com]
  • Foxglove was originally used for congestive heart failure and atrial fibrillation (chaotic contractions across the atrium of the heart).[encyclopedia.com]
  • References: [1] [3] [7] [5] [6] Indications Congestive heart failure (symptomatic patients with NYHA II despite pharmacotherapy) Atrial fibrillation Supraventricular tachycardia References: [4] [8] Contraindications References: [7] [8] We list the most[amboss.com]
  • This is not necessarily a bad thing, and these compounds have been used in medicine since the ancient Roman Empire to treat arrhythmia and congestive heart failure (today, the drugs Lanoxin, Digitek, and Lanoxicaps are made from a purified cardiac glycoside[mentalfloss.com]
Weight Loss
  • GI symptoms are nonspecific and include the following: Anorexia Nausea Vomiting Diarrhea Abdominal pain Weight loss Neurologic symptoms include the following: Confusion Drowsiness Disorientation Delirium Headache Hallucinations Seizures Visual disturbances[emedicine.medscape.com]
Pharyngitis
  • ENT (ear, nose, and throat) examination revealed pharyngeal edema. Steroid therapy with intravenous dexamethasone (8 mg) was started, which improved the aphasia after 28 h of steroid therapy.[roaic.eg.net]
Vomiting
  • In acute toxicity, the following may be present: GI symptoms - Usually evolve within minutes to hours, are nonspecific, and include nausea, vomiting, and abdominal pain Neurologic symptoms - Often are nonspecific and include weakness and altered mental[emedicine.medscape.com]
  • Case report A 26-year-old male patient presented to the emergency room with vomiting, disorientation, and increased tone of muscles (spasticity) in lower limbs.[roaic.eg.net]
  • The clinical symptoms were characterized by nausea, vomiting, salivation, colic, diarrhoea, ventricular tachycardia, dysrhythmia, heart block, ataxia, drowsiness, muscular tremor.[degruyter.com]
  • Two to three hours later, other signs of poisoning may occur, including nausea, vomiting, sweating, confusion, and slowing of the heart rate. There have been reports of seizures with severe overdoses.[chop.edu]
  • Signs and Symptoms: In children cardiac glycoside ingestion causes severe abdominal pain, diarrhea, nausea and vomiting. Additional symptoms include lethargy, circumoral flush, dialated pupils, drooling, sweating, shaking, and ashy coloring.[sites.google.com]
Nausea
  • In acute toxicity, the following may be present: GI symptoms - Usually evolve within minutes to hours, are nonspecific, and include nausea, vomiting, and abdominal pain Neurologic symptoms - Often are nonspecific and include weakness and altered mental[emedicine.medscape.com]
  • The clinical symptoms were characterized by nausea, vomiting, salivation, colic, diarrhoea, ventricular tachycardia, dysrhythmia, heart block, ataxia, drowsiness, muscular tremor.[degruyter.com]
  • Signs and Symptoms: In children cardiac glycoside ingestion causes severe abdominal pain, diarrhea, nausea and vomiting. Additional symptoms include lethargy, circumoral flush, dialated pupils, drooling, sweating, shaking, and ashy coloring.[sites.google.com]
  • Symptoms: Nausea, vomiting, salivation, drowsiness, abdominal pain, diarrhea, weakness, and respiratory depression.[people.uwec.edu]
  • Two to three hours later, other signs of poisoning may occur, including nausea, vomiting, sweating, confusion, and slowing of the heart rate. There have been reports of seizures with severe overdoses.[chop.edu]
Abdominal Pain
  • In acute toxicity, the following may be present: GI symptoms - Usually evolve within minutes to hours, are nonspecific, and include nausea, vomiting, and abdominal pain Neurologic symptoms - Often are nonspecific and include weakness and altered mental[emedicine.medscape.com]
  • Signs and Symptoms: In children cardiac glycoside ingestion causes severe abdominal pain, diarrhea, nausea and vomiting. Additional symptoms include lethargy, circumoral flush, dialated pupils, drooling, sweating, shaking, and ashy coloring.[sites.google.com]
  • Symptoms: Nausea, vomiting, salivation, drowsiness, abdominal pain, diarrhea, weakness, and respiratory depression.[people.uwec.edu]
  • The signs and symptoms of Lily-of-the-Valley Plant Poisoning may include: Headaches and weaknesses Nausea, vomiting, and diarrhea Abdominal pain Increased urination frequency at night Skin rashes and hives (red weals on the body) Vision abnormalities,[dovemed.com]
  • .  Contact dermatitis  Emenations Headache, dizziness, respiratpry difficulty, Nausea  Ingestion difficulty in swallowing and articulation, V, profuse frothy salivation and diarrhoea, abdominal pain  Pulse is first slow and later rapid and weak[slideshare.net]
Loss of Appetite
  • Symptoms such as depression, loss of appetite, and halos in the vision are typically only present in cases of chronic or severe poisonings.[homeguides.sfgate.com]
  • An overdose of foxglove may also cause diarrhea, headache, loss of appetite, and vomiting. More serious and potentially deadly reactions to an overdose affect the heart and the central nervous system.[encyclopedia.com]
Abdominal Cramps
  • Acontium spp and Delphinum spp, may be in Asian herbal medicines sodium channel activator GI symptoms: N&V, abdominal cramps, diarrhoea tachycardia, dysrhythmia, shock CNS effects: paresthesiae, paralysis, coma, seizures MODS, lactic acidosis Belladona[lifeinthefastlane.com]
Photophobia
  • […] and include the following: Anorexia Nausea Vomiting Diarrhea Abdominal pain Weight loss Neurologic symptoms include the following: Confusion Drowsiness Disorientation Delirium Headache Hallucinations Seizures Visual disturbances manifest as follows: Photophobia[emedicine.medscape.com]
Muscle Spasticity
  • Case report A 26-year-old male patient presented to the emergency room with vomiting, disorientation, and increased tone of muscles (spasticity) in lower limbs.[roaic.eg.net]
Renal Impairment
  • Host-specific factors include advanced age, renal impairment, myocardial ischemia, hypothyroidism, hypoxia, and electrolyte abnormalities (eg, hypokalemia, hyperkalemia, hypomagnesemia, hypercalcemia).[emedicine.medscape.com]
Confusion
  • GI symptoms are nonspecific and include the following: Anorexia Nausea Vomiting Diarrhea Abdominal pain Weight loss Neurologic symptoms include the following: Confusion Drowsiness Disorientation Delirium Headache Hallucinations Seizures Visual disturbances[emedicine.medscape.com]
  • Two to three hours later, other signs of poisoning may occur, including nausea, vomiting, sweating, confusion, and slowing of the heart rate. There have been reports of seizures with severe overdoses.[chop.edu]
  • Confusion, dizziness, drowsiness, weakness, visual disturbances, and mydriasis are the central nervous system manifestations of toxicity [4], [8].[roaic.eg.net]
  • […] vomiting, diarrhea, salivation Oleander ( Nerium oleander, Thevetia peruviana ) Toxins: oleandrin, folinerin, digitoxigenin, nerium Signs and symptoms: Abdominal pain, visual disturbances, hypotension, bradycardia and heart block, tachydysrhythmias, confusion[sites.google.com]
  • Poison hemlock (Conium maculatum) Poison hemlock ( Conium maculatum ) Hemlock is sometimes confused with other species in the Apiaceae family such as cow parsley. It’s a large plant up to 2m tall, with hollow, purple-blotched stems.[woodlandtrust.org.uk]
Aphasia
  • Steroid therapy with intravenous dexamethasone (8 mg) was started, which improved the aphasia after 28 h of steroid therapy. ECG showed irregular rhythm with first-degree atrioventricular block.[roaic.eg.net]
Dysarthria
  • Abnormal findings may include the following: Altered level of consciousness Hypotonia Hyporeflexia Dysarthria Ataxia Horizontal nystagmus Generalized seizures Author Coauthor(s) Mark Su, MD, MPH, FACEP, FACMT Consulting Staff and Director of Fellowship[emedicine.medscape.com]
Nystagmus
  • Abnormal findings may include the following: Altered level of consciousness Hypotonia Hyporeflexia Dysarthria Ataxia Horizontal nystagmus Generalized seizures Author Coauthor(s) Mark Su, MD, MPH, FACEP, FACMT Consulting Staff and Director of Fellowship[emedicine.medscape.com]
Hyporeflexia
  • Abnormal findings may include the following: Altered level of consciousness Hypotonia Hyporeflexia Dysarthria Ataxia Horizontal nystagmus Generalized seizures Author Coauthor(s) Mark Su, MD, MPH, FACEP, FACMT Consulting Staff and Director of Fellowship[emedicine.medscape.com]

Workup

First-Degree Atrioventricular Block
  • ECG showed irregular rhythm with first-degree atrioventricular block. All the routine investigations were within normal limits except for serum potassium level which was 5.7 mEq/l on day 1 of ICU admission.[roaic.eg.net]
Sinus Arrest
  • Other dysrhythmias often associated with cardiac glycoside toxicity include the following: Bradydysrhythmia Sinus bradycardia with all types of AV nodal block Junctional rhythms Sinus arrest Dysrhythmias characterized by increased automaticity and conduction[emedicine.medscape.com]

Treatment

  • The treatment of oleander poisoning is empirically based on the treatment of digitalis glycoside toxicity and consists of supporting the patient hemodynamically.[roaic.eg.net]
  • Digoxin Fab fragment treatment should be given if indicated. Fab Fragment Treatment Sheep-derived digoxin antibody Fab fragments reportedly are effective for some plant cardiac glycosides.[emedicine.medscape.com]
  • Treatment included administration of activated charcoal, symptomatic and supportive care. 1. Bessen, H. A. Therapeutic and toxic effects of digitalis: William Withering, 1785. - J. Emerg. Med., 4, 1986, 3, 243. 2. Bourgeois, B., P. Incagnoli, J.[degruyter.com]
  • Seite 327 - Holland Interuniversity Nifedipine/Metoprolol Trial (HINT) Research Group: Early treatment of unstable angina in the coronary care unit: a randomized, double-blind placebo controlled comparison of recurrent ischemia in patients treated with[books.google.de]

Prognosis

  • In such cases, the prognosis may be adversely affected. However, fatalities have generally not been reported from Lily-of-the-Valley Plant Poisoning In general, toxicities are common situations in the emergency departments.[dovemed.com]
  • Age-related differences in incidence AAPCC data from 2015 show the following age breakdowns for plant cardiac glycoside exposure [4] : Infants and children younger than 6 years - 57% Children aged 6-19 years - 18% Adults older than 19 years - 22% Prognosis[emedicine.medscape.com]
  • Prognosis The prognosis for acute digoxin toxicity directly correlates with the mortality.[clinicaladvisor.com]

Etiology

  • Etiology Exposure to plants containing glycosides can occur through ingestion of sap, berries, leaves, blossoms, or seeds, or of teas brewed from plant parts. Plant extracts also have been intentionally injected.[emedicine.medscape.com]
  • Cardiac glycoside poisoning Etiology Digoxin overdose ( iatrogenic, by nonadherence to prescribed dosages or by ingestion of plants containing cardiac glycosides) Hypokalemia Renal failure Treatment with verapamil, diltiazem, amiodarone, and/or quinidine[amboss.com]
  • Alternative diagnosis If an adequate dose of digoxin immune Fab fragments has been administered and there is no change in the hemodynamics, one should consider searching for alternative etiologies.[clinicaladvisor.com]

Epidemiology

  • Digitalis purpurea ) Woolly foxglove ( Digitalis lanata ) Ouabain ( Strophanthus gratus ) Lily-of-the-valley ( Convallaria majalis ) Common oleander ( Nerium oleander ) Yellow oleander ( Thevetia peruviana ) Squill or sea onion ( Urginea maritima ) Epidemiology[emedicine.medscape.com]
  • Epidemiology In the 1780s, the foxglove plant (from which digoxin is derived) was used in the treatment of congestive heart failure.[clinicaladvisor.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology More than 200 naturally occurring cardiac glycosides have been identified. These bind to a site on the cell membrane, producing reversible inhibition of the sodium (Na )-potassium (K )-adenosine triphosphatase (ATPase) pump.[emedicine.medscape.com]
  • Pathophysiology Ingested cardioactive steroids (CAS) are approximately 80% bioavailable. However, toxicokinetics depends on multiple factors,... References 1.[link.springer.com]
  • Pathophysiology Digoxin, like other cardiac glycosides, inhibits the sodium-potassium-ATPase. This inhibition results in a rise in extracellular potassium and a rise in intracellular sodium.[clinicaladvisor.com]

Prevention

  • Understand the common characteristics and methods of transmission for each disease, and learn all the applicable diagnosis, treatment, control, and prevention techniques.[books.google.de]
  • To prevent further absorption, oral administration of activated charcoal is recommended if no contraindications exist.[emedicine.medscape.com]
  • Centers for Disease Control and Prevention Poisoning Prevention is a resource offering tips for preventing poisonings at home, including those by pesticides and plants.[redfin.com]
  • Cardiac glycosides function by inhibiting the intercellular sodium-potassium pumps to prevent the extrusion of sodium. Raised sodium levels derange the action of the sodium-calcium pump leading to an increased intracellular calcium concentration.[sites.google.com]

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