A quest for oleandrin in decayed human tissue

This forensic case taught us several lessons. First, there is a need for improved sample cleanup and treatment of severely decayed tissue samples when trace determinations of target analytes are needed. With the exception of a few reports the literature is lacking in information with regard to the most modern sample preparation techniques. Second, the coupling of LC/LC with tandem MS provides an effective means of "on-line" samples cleanup for complex sample matrices. The improvements in selectivity shown in Figure 3 reveal the analytical power available when these techniques are combined. Third, once we decided to use LC/LC/MS/MS, we were able to analyze more than 50 samples in a semi-automated fashion over approximately three days. The reliability and ruggedness of the combined techniques and equipment suggest this approach may have merit for common applications in which large numbers of biological samples (e.g., plasma and urine) must be analyzed. As a postscript, when this project was completed we proposed that the use of antibodies for isolating oleandrin and its relatives might be a more selective means for trace enrichment of the target analytes. For example, a high-pressure immunoaffinity column could have been coupled on line as column 1 in Figure 4. After pumping a relatively high volume of aqueous tissue extract through an immunoaffinity column during trapping and trace enrichment conditions, the column could be rinsed with phosphate-buffered saline. Then the pH could be lowered to unfold the antibody protein and allow release of the trapped analyte from this column with subsequent trapping on column 2 in Figure 4.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute heart failure and its treatment in cardiologic drug poisoning]

The causes of sudden cardiac arrest (SCA) and its associated early death were examined in 179 patients with acute intoxications due to amitriptyline, antiarrhythmic agents and cardiac glycosides. In the first hours of intoxication, various cardiac conduction disturbances were found to occur in 39.6% of the patients, among whom 11.7% died due to SCA predominantly in complete bundle-branch block. The cause of SCA was an acute (contractile) heart failure that had run as cardiogenic shock and been associated with the specific selective action of the agents in question on cardiomyocytes. Premodulation of acute heart failure with membrane protective agents (unithiol, alpha-tocopherol, hydrocortisone), pharmacological antagonists (novodrin, alupent, isoprenaline), and the cardiotonic agent dobutamine enabled acute heart failure to be effectively treated, hemosorption to be made in early periods and cardiac events to be abolished in 80% of the patients, SCA mortality rates decreased from 11.7 to 3.2%.

Cardiac glycoside poisoning involved in deaths from traditional medicines

Autopsy cases (from all areas of South Africa except the Cape Province) are referred for chemical investigation to the Johannesburg Forensic Chemistry Laboratory of the State Health Department. Over a 1-year period in 41 autopsies where death was presumed to have been caused by a herbal medicine, the presence of cardiac glycosides was sought and was found in 44%. Most of the cases were from the Transvaal, followed by Natal. Clinical histories of the patients revealed that gastrointestinal irritation was the most common syndrome experienced after traditional medicine administration (54%). It is concluded that in patients presenting with gastro-intestinal symptoms, presumably due to poisoning by traditional medicines, cardiac glycoside poisoning should be suspected.

[Poisoning with oleander leaves]

After ingestion of seven leaves of oleander (Nerium oleander) in a suicide attempt, a 37-year-old woman was admitted to hospital with symptoms of digitalis intoxication. The serum digoxin level on arrival was 5.69 nmol/l. The course was uneventful. The usefulness of digoxin radioimmunoassay to demonstrate poisoning with oleander (but not to predict the degree of toxicity) and the potential use of digoxin-specific Fab-antibody fragments in this situation are discussed.

[Determination of zimarin in urine]

Private technique of extraction isolation and purification, chromatographic detection and photometric determination of zimarin in urine is suggested. Detection limit is 0.01 mg, determination limit is 0.1 mg of glycoside in 100 ml of urine. Method makes it possible to detect 66-80% of zimarin added to 100 ml of urine in quantities 0.5-0.1 mg.

Detection of poisoning by plant-origin cardiac glycoside with the Abbott TDx analyzer

Cardiac glycoside poisoning caused by ingestion of plant material is common in tropical and sub-tropical areas. In evaluating the use of the Abbott TDx Digoxin II assay to detect such cases of poisoning, we found it a rapid and convenient method for confirming the ingestion of glycosides from the plants Nerium oleander, Thevetia peruviana, and Adonis microcarpa, and from the toad Bufo marinus. Here we report some clinical cases illustrating our experience with the use of this assay, and describe results of cross-reactivity studies with compounds structurally similar to digoxin. 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 concentration.

Oleander poisoning: treatment with digoxin-specific Fab antibody fragments

A 37-year-old man presented two hours after the ingestion of "a handful" of oleander leaves (probably Nerium oleander) in a suicide attempt. Cardiotoxicity was evidenced by the presence of bradycardia (rate, 30 to 45) with sinoatrial nodal arrest and junctional escape consistent with a cardiac glycoside effect. The patient was treated empirically with a single dose of five vials (200 mg) of digoxin-specific Fab antibody fragments (Digibind). The pretreatment digoxin level was 1.5 ng/mL. After treatment, the patient's rhythm stabilized with residual sinus bradycardia (rate, 56). The patient recovered uneventfully and was discharged on the fifth hospital day to inpatient psychiatric care.

Cardiac glycoside poisoning in sheep caused by Urginea physodes (Jacq.) Bak. and the isolated physodine A

Urginea physodes (Jacq.) Bak., a species closely related to or possibly synonymous with U. pusilla, is described and its distribution given. Four bufadienolides were isolated from U. physodes and the approximated LD50 and cumulative effect of some of them determined in guinea pigs. The most toxic one proved to be mildly cumulative. Typical signs of acute cardiac glycoside poisoning, involving the locomotory, gastro-intestinal, respiratory and cardiac system, were seen in the field cases and/or were experimentally induced by the plant. Similar signs could also be induced by injecting the isolated bufadienolide, physodine A, to a sheep.

The toxicity to cattle and bufadienolide content of six Bryophyllum species

Cardiac glycoside poisoning was produced in calves given (in descending order of toxicity) flower heads of the hybrid Bryophyllum (Kalanchoe) daigremontianum x B. tubiflorum, of B. pinnatum, of B. tubiflorum (from previous work), whole plant of B. fedtschenkoi, flower heads of B. daigremontianum and whole plant of B. proliferum. For each plant (except B. tubiflorum), 2 calves were each given a single dose of 20 g wet weight per kg bodyweight. By using high performance liquid chromatography, the bufadienolides (cardiac glycosides) bryotoxin A, B and C were detected and assayed in the flower heads and leaf plus stem of B. tubiflorum and in the roots of B. tubiflorum, the hybrid and B. pinnatum. Only bryotoxins B and C were detected and assayed in the flower heads and leaf plus stem of the hybrid, B. daigremontianum and B. pinnatum. No bryotoxins were detected in B. fedtschenkoi. Bryotoxin A and a mixture of bryotoxins B and C from B. tubiflorum flowers were used as standards in the chromatographic assay. Comparing the results of the calf toxicity experiment with the amounts of bufadienolide measured in the plants suggests that bryotoxins A, B and C probably account for the observed disease, but that B. pinnatum and B. fedtschenkoi contain at least one other cardiac glycoside.

Oleandrin distribution in a fatality from rectal and oral Nerium oleander extract administration

In a fatal (cardiotoxic) case of oleander extract poisoning of a young female, ethanol extracts of blood and tissue homogenates were purified by lead acetate. After removal of excess lead by ammonium sulfate, oleandrin was extracted into chloroform. Oleandrin in the extract concentrates was detected by thin-layer chromatography, with location by fluorescence and chromogenically by means of p-anisaldehyde. Quantitation was performed on dried extracts reconstituted in water/methanol, reacted with hydrogen peroxide, ascorbic acid, and hydrochloric acid, and analyzed by fluorescence spectrophotometry. Excitation was at 355 nm, and fluorescence scanning from 340 to 580 nm. The fluorescence peak at 460 nm was used for the quantitative measurement. The concentrations of oleandrin measured in blood, stomach wall, colon tissue, liver, heart, lung, brain, spleen, and kidney ranged from 10 to 39 micrograms/g, with 200 micrograms/mL in the total gastric content residue submitted for analysis.

Curing experimental Bryophyllum tubiflorum poisoning of cattle with activated carbon, electrolyte replacement solution and antiarrhythmic drugs

A slurry of activated carbon (activated charcoal) in electrolyte replacement solution given by stomach tube and antiarrhythmic drugs given parenterally cured 9 of 11 calves dosed 7 to 24 h previously with a lethal amount (20g/kg) of Bryophyllum tubiflorum flower heads. Two of another 4 calves treated 26 to 36 h after dosing with flowers survived. B. tubiflorum toxins are bufadienolides (cardiac glycosides). Activated carbon was effective at a single dose of 5 g/kg. Calves were rehydrated with oral electrolyte replacement solution at 150 ml/kg in divided doses over 24 h. Tachycardia was treated with intravenous lignocaine (200 mg doses) or propranolol (5 mg doses) and atrioventricular block with atropine (0.5 mg/kg).

Herbal poisoning: a case report of a fatal yellow oleander poisoning from the Solomon Islands

A fatal yellow oleander herbal poisoning is reported in a 2 1/2-year-old Melanesian boy, who had persistent vomiting,bradycardia caused by complete heart block, hyperkalemia and cardiac glycosides detected in his serum. This is one of the few recognized clinical pictures of illness from herbal poisoning, yet herbal poisoning in infants in some Pacific and African countries is common and has a high mortality.

Poisoning by antidysrhythmic drugs

This article discusses the management of antidysrhythmic drug overdoses in children and adolescents.

Naturally occurring cardiac glycosides

Cardiac glycoside poisoning from the ingestion of plants, particularly of oleanders, occurs with reasonable frequency in tropical and subtropical areas. We have assessed a variety of plant specimens for their cardiac glycoside content by means of radioimmunoassays with antibodies that differ in their specificity for cardiac glycosides. Significant amounts of immunoreactive cardiac glycoside were found to be present in the ornamental shrubs: yellow oleander (Thevetia peruviana); oleander (Nerium oleander); wintersweet (Carissa spectabilis); bushman's poison (Carissa acokanthera); sea-mango (Cerbera manghas); and frangipani (Plumeria rubra); and in the milkweeds: redheaded cotton-bush (Asclepias curassavica); balloon cotton (Asclepias fruiticosa); king's crown (Calotropis procera); and rubber vine (Cryptostegia grandifolia). The venom gland of the cane toad (Bufo marinus) also contained large quantities of cardiac glycosides. The competitive immunoassay method permits the rapid screening of specimens that are suspected to contain cardiac glycosides. Awareness of the existence of these plant and animal toxins and their dangers allows them to be avoided and poisoning prevented. The method is also useful for the confirmation of the presence of cardiac glycosides in serum in cases of poisoning.

[The antitoxic action of triamterene in cardiac glycoside poisoning]

The antagonistic effect of triamterene on the toxicity of cardiac glycosides was investigated in conscious rabbits using the infusion method. Pretreatment with triamterene (5 mg/kg and 10 mg/kg) significantly reduces the ouabain toxicity indicated by an increase of the dose producing arrhythmia (from 61 +/- 14 to 121 +/- 17 and 178 +/- 22 micrograms/kg, resp.) and lethality (from 114 +/- 18 to 236 +/- 5 and 329 +/- 11 micrograms/kg, resp.). The triamterene induced increase of plasma potassium concentration may contribute to the antitoxic effect, however, the effect persisted after the decrease of plasma potassium concentration (by addition of NaHCO3) to pretreatment values. Under the influence of digitoxin the antitoxic effect of triamterene (10 mg/kg) is also demonstrated by the delayed appearance of arrhythmias (113 +/- 3 min compared to 78 +/- 5 min) and of lethality (125 +/- 4 min compared to 92 +/- 6 min). Triamterene is not only a prophylactic but also a curative antitoxic agent in the digitalis intoxicated rabbit.

[Glycoside poisoning in experimental heart failure and its drug correction]

It has been demonstrated in experiments on 420 rats that antiadrenergic, antihistamine, antihypoxic, anabolic, antiarrhythmic and diuretic agents have different effects on the cardiotoxicity of strophanthine K for intact animals and in experimental heart insufficiency of different genesis. The pharmacological analysis revealed some risk factors capable of provoking glycoside intoxication in circulatory failure. Approaches to the goal-oriented drug correction of the risk factors are proposed.