A fatal case of oleandrin poisoning

Antidote use for cardiac arrest or hemodynamic instability due to cardiac glycoside poisoning: A narrative review

Introduction

Cardiac glycosides comprise medications such as digoxin and digitoxin, plants, and even certain toad venoms. Intoxication with cardiac glycosides can lead to hemodynamic instability and cardiac arrest. With this narrative review, our objective was to determine if any therapy used in a near-cardiac arrest state due to cardiac glycoside poisoning could improve survival with favourable functional and neurological outcomes.

Methods

We searched the Medline, PubMed, EMBASE and Cochrane Library databases up to February 2022 for controlled trials, observational studies, and case reports. We reviewed studies if participants were exposed to a cardiac glycoside, had hemodynamic instability, and an intervention was attempted to reverse the toxicity. The effect of interventions on (1) survival with favourable functional and neurological outcomes and (2) correction of hemodynamic instability was assessed.

Results

Of the 2422 studies found, 73 were included for analysis, of which 58 were case reports or series, and 15 were observational cohorts. Most patients were intoxicated with medication (60 individual cases and 11 observational cohorts). Administration of digoxin immune-Fab fragments was associated with improved hemodynamic status and survival in medication patients. Administration of magnesium, cardioversion, and cardiac pacing was associated with favourable outcomes, while administration of atropine, antiarrhythmics, or calcium was not.

Conclusion

In patients with hemodynamic instability due to cardiac glycoside intoxication, digoxin immune-Fab fragments should be given, and magnesium administration, cardioversion, and cardiac pacing can reasonably be attempted.

A suicide attempt by ingestion of oleander leaves and treatment with digoxin-specific Fab antibody fragments

Natural cardiac glycosides have positive inotropic heart effects but at high, toxic doses they can cause life-threatening cardiac arrhythmias. Here we present the first Croatian case of a 16-year-old girl who attempted suicide by eating dried oleander leaves, which contain natural cardiac glycosides, and her treatment with a specific antidote. The girl presented with an oedema of the uvula indicating local toxicity, severe bradycardia, first-degree atrioventricular block, drowsiness, and vomiting. Having taken her medical history, we started treatment with atropine, intravenous infusion of dextrose-saline solution and gastroprotection, but it was not successful. Then we introduced digoxin-specific Fab antibody fragments and within two hours, the patient's sinus rhythm returned to normal. Cases of self-poisoning with this oleander are common in South-East Asia, because it is often used as a medicinal herb, and digoxin-specific Fab fragments have already been reported as effective antidote against oleander poisoning there. Our case has taught us that it is important to have this drug in the hospital pharmacy both for digitalis and oleander poisoning.

Accidental fatal poisoning in a child due to ingestion of Nerium oleander leaf

Nerium oleander is an ornamental plant that belongs to the family Apocynaceae. It contains a cardiac glycoside named oleandrin, which is present in all parts of the oleander plant. Suicidal and medication-related deaths due to Nerium oleander poisoning are not uncommon. However, accidental deaths due to oleander leaf ingestion are most commonly encountered. We are reporting a case of an accidental ingestion of Nerium oleander leaf in a child by mistaking it for a guava leaf. The child presented to the casualty with vomiting, poor sensorium, hypotension, and shock. The child developed hyperkalemia, acute kidney injury, myocardial dysfunction, and bleeding manifestations. The urine output was decreased (< 0.5 ml/kg/h). Later, the child died after 36 h. On autopsy examination, periorbital puffiness and bluish discoloration of the nail beds were present. Petechial hemorrhages were present in the heart, kidney, and mesentery. The stomach mucosa was hemorrhagic. Histopathologically, the lung showed interstitial congestion, the liver showed centrilobular necrosis, and the kidney showed acute tubular necrosis. Toxicology analysis was positive for oleander poisoning. This case highlights the toxic nature of Nerium oleander ingestion and the importance of avoiding such plants around residential areas.

DNA barcoding as new diagnostic tool to lethal plant poisoning in herbivorous mammals

Reliable identification of plant species in the digestive tract of a deceased animal often represents the major key to diagnose a lethal intoxication with poisonous plants in veterinary pathology. In many cases, identification of the species is challenging or even impossible because the diagnostic morphological features have been degraded, and because the interpretation of such features requires a considerable expertise in plant anatomy and biodiversity. The use of DNA barcoding markers can support or even replace classical morphological assessment. While these markers have been widely used for plant taxonomy, their forensic application to clarify causes of animal poisoning is novel. In addition, we use specific single-nucleotide polymorphisms as fingerprints. This allows for a clear decision even in cases, where the conventionally used statistical e-values remain ambiguous. In the current work, we explore the feasibility of this strategy in a couple of exemplary cases, either in concert with anatomical diagnostics, or in cases where visual species identification is not possible, or where chemical toxin detection methods are not well established, complex, time consuming and expensive.

Quantitative evaluation of cardiac glycosides and their seasonal variation analysis in Nerium oleander using UHPLC-ESI-MS/MS

INTRODUCTION

Nerium oleander is an eminent source of structurally diverse cardiac glycosides (CGs), plays a prominent role in the treatment of heart failure, and inhibits the proliferation of cancer cell lines. CGs exert their cardiotonic action by binding to the extracellularly exposed recognition sites on Na⁺ /K⁺ -ATPase, an integral membrane protein that establishes the electrochemical gradient of Na⁺ and K⁺ ions across the plasma membrane.

OBJECTIVE

We aimed to quantitatively determine CGs and their seasonal variation in leaf and stem samples of N. oleander utilizing UHPLC-ESI-MS/MS techniques.

METHODS

The UHPLC-ESI-MS/MS analytical method was developed utilizing multiple reaction monitoring (MRM) mode. The Waters BEH C18 (150 mm × 2.1 mm, 1.7 μm) column was used with a 22-min linear gradient consisting of acetonitrile and 5 mM ammonium acetate buffer.

RESULTS

In total 21 CGs were quantitatively determined in the seasonal leaf and stem samples of N. oleander along with the absolute quantitation of the three chemical markers odoroside H (244.8 μg/g), odoroside A (231.4 μg/g), and oleandrin (703.9 μg/g). The season-specific accumulation of chemical markers was observed in the order of predominance odoroside A (summer season, stem), odoroside H (winter season, stem), and oleandrin (rainy season, leaf). Besides this, the remaining 18 CGs were relatively quantified in the same samples.

CONCLUSION

The developed method is simple and reliable and can be used for the identification and quantification of multiple CGs in N. oleander.

Oleandrin: A Systematic Review of its Natural Sources, Structural Properties, Detection Methods, Pharmacokinetics and Toxicology

Oleandrin is a highly lipid-soluble cardiac glycoside isolated from the plant Nerium oleander (Apocynaceae) and is used as a traditional herbal medicine due to its excellent pharmacological properties. It is widely applied for various disease treatments, such as congestive heart failure. Recently, oleandrin has attracted widespread attention due to its extensive anti-cancer and novel anti-viral effects. However, oleandrin has a narrow therapeutic window and exhibits various toxicities, especially typical cardiotoxicity, which is often fatal. This severe toxicity and low polarity have significantly hindered its application in the clinic. This review describes natural sources, structural properties, and detection methods of oleandrin. Based on reported poisoning cases and sporadic animal experiments, the pharmacokinetic characteristics of oleandrin are summarized, so as to infer some possible phenomena, such as enterohepatic circulation. Moreover, the relevant factors affecting the pharmacokinetics of oleandrin are analyzed, and some research approaches that may ameliorate the pharmacokinetic behavior of oleandrin are proposed. With the toxicology of oleandrin being thoroughly reviewed, the development of safe clinical applications of oleandrin may be possible given potential research strategies to decrease toxicity.

Protective Effect of Nerium Oleander Distillate and Tarantula Cubensis Alcoholic Extract on Cancer Biomarkers on Colon and Liver Tissues of Rats with Experimental Colon Cancer

BACKGROUND

Colon cancers are among the three major cancer types that result in death. The research for effective treatment continues.

OBJECTIVE

The aim of this study is to determine the effects of Tarantula cubensis alcoholic extract (TCAE) and Nerium oleander (NO) distillate on the levels of midkine, TGF-β, VEGF, AFP, COX-2, IGF and caspase 3 in liver and colon tissues of experimentally induced colon cancer in rats.

METHOD

The liver and colon tissues of the rats were divided into Control, Colon Cancer (AZM), AZM+TCAE and AZM+NO groups and they were homogenized. The levels of midkine, TGF-β, VEGF, AFP, COX-2, IGF and caspase 3 in the colon and liver tissues were measured by ELISA kits.

RESULTS

All parameters levels of colon and liver tissues in the AZM group were generally higher (p<0.05) than the Control group. TCAE and NO prevented (p<0.05) the increases in midkine, TGF-β, VEGF, AFP, COX-2, IGF and caspase-3 levels in the colon. NO prevented increase of all parameters except for IGF level, while TCAE prevented (p<0.05) the increase of all values apart from COX-2 and IGF levels in the liver.

CONCLUSION

NO and TCAE may prevented at the specified marker levels of colon in the AZM induced colon cancer. The increases the level of parameters in the liver are not as severe as in the colon, due to the 18-week study period may not be sufficient for liver metastasis formationIn the future molecular studies should be done to determine the mechanisms and pathways of them more clearly.

New Cardenolides from Biotransformation of Gitoxigenin by the Endophytic Fungus Alternaria eureka 1E1BL1: Characterization and Cytotoxic Activities

Microbial biotransformation is an important tool in drug discovery and for metabolism studies. To expand our bioactive natural product library via modification and to identify possible mammalian metabolites, a cytotoxic cardenolide (gitoxigenin) was biotransformed using the endophytic fungus Alternaria eureka 1E1BL1. Initially, oleandrin was isolated from the dried leaves of Nerium oleander L. and subjected to an acid-catalysed hydrolysis to obtain the substrate gitoxigenin (yield; ~25%). After 21 days of incubation, five new cardenolides 1, 3, 4, 6, and 8 and three previously- identified compounds 2, 5 and 7 were isolated using chromatographic methods. Structural elucidations were accomplished through 1D/2D NMR, HR-ESI-MS and FT-IR analysis. A. eureka catalyzed oxygenation, oxidation, epimerization and dimethyl acetal formation reactions on the substrate. Cytotoxicity of the metabolites were evaluated using MTT cell viability method, whereas doxorubicin and oleandrin were used as positive controls. Biotransformation products displayed less cytotoxicity than the substrate. The new metabolite 8 exhibited the highest activity with IC₅₀ values of 8.25, 1.95 and 3.4 µM against A549, PANC-1 and MIA PaCa-2 cells, respectively, without causing toxicity on healthy cell lines (MRC-5 and HEK-293) up to concentration of 10 µM. Our results suggest that A. eureka is an effective biocatalyst for modifying cardenolide-type secondary metabolites.

The Need for Antiviral Drugs for Pandemic Coronaviruses From a Global Health Perspective

Respiratory failure due to SARS-CoV-2 has caused widespread mortality, creating an urgent need for effective treatments and a long-term need for antivirals for future emergent coronaviruses. Pharmacotherapy for respiratory viruses has largely been unsuccessful with the exception of early treatment of influenza viruses, which shortens symptom duration and prevents infection in close contacts. Under the rapidly evolving circumstances of the COVID-19 pandemic, most clinical trials of experimental treatments in the United States have focused on later stages of the disease process. Worldwide, the clinical studies of the most impactful drugs, remdesivir and dexamethasone in ACTT-1, RECOVERY, and Solidarity, have studied hospitalized patients. Less than half of clinical trials in the U.S. have investigated oral agents, and the majority have taken place in hospitals at a disease stage where the viral load is already decreasing. The limited success of treatments for respiratory viruses and the viral dynamics of COVID-19 suggest that an antiviral therapy with the greatest impact against pandemic coronaviruses would be orally administered, well-tolerated, target a highly conserved viral protein or host-coronavirus interaction and could be used effectively throughout the world, including resource-poor settings. We examine the treatment of respiratory viral infections and current clinical trials for COVID-19 to provide a framework for effective antiviral therapy and prevention of future emergent coronaviruses and call attention to the need for continued preclinical drug discovery.

Fatal poisoning by ingestion of a self-prepared oleander leaf infusion

An unusual case of poisoning by the ingestion of oleander leaves is reported. A 71 year old male laboratory technician committed suicide at home in this unusual manner. At the death scene a steel pan and other paraphernalia, used for the extraction of oleandrin and other cardiac glycosides from the leaves of the Nerium oleander plant were found.Toxicological investigations for oleandrin, oleandrigenin, neritaloside, and odoroside were performed by LC-MS/MS on all biological samples (peripheral blood, vitreous humor, urine, liver, gastric contents) and on the yellow infusion found at the death scene.In all samples, toxic levels of oleandrin were detected (blood 37.5 ng/mL, vitreous humor 12.6 ng/mL, urine 83.8 ng/mL, liver 205 ng/mg, gastric content 31.2 µg/mL, infusion 38.5 µg/mL). Qualitative results for oleandrigenin, neritaloside, and odoroside were obtained. Oleandrigenin was present in all tissue samples whereas neritaloside and odoroside were absent in the blood and vitreous humor but present in urine, liver, gastric content, and in the leaf brew.The purpose of this study was the identification of oleandrin and its congener oleandrigenin, detected in the vitreous humor. The blood/vitreous humor ratio was also calculated in order to assess of the likely time interval from ingestion to death. According to the toxicological results death was attributed to fatal arrhythmia due to oleander intoxication. The manner of death was classified as suicide through the ingestion of the infusion.

Development and Validation of a UHPLC-ESI-MS/MS Method for Quantification of Oleandrin and Other Cardiac Glycosides and Evaluation of Their Levels in Herbs and Spices from the Belgian Market

Cardiac glycosides (CGs) are naturally occurring plant secondary metabolites that can be toxic to humans and animals. The aim of this work was to develop a targeted analytical method utilizing liquid chromatography-tandem mass spectrometry (LC-MS/MS) for quantification of these plant toxins in a herbal-based food and human urine. The method included oleandrin, digoxin, digitoxin, convallatoxin, and ouabain. Samples of culinary herbs were extracted with acetonitrile and cleaned using Oasis® MAX solid-phase extraction (SPE), while samples of urine were diluted with acidified water and purified on Oasis® HLB SPE cartridges. Limits of quantification were in the range of 1.5-15 ng/g for herbs and 0.025-1 ng/mL for urine. The mean recovery of the method complied with the acceptable range of 70-120% for most CGs, and relative standard deviations were at maximum 14% and 19% for repeatability and reproducibility, respectively. Method linearity was good with calculated R² values above 0.997. The expanded measurement uncertainty was estimated to be in the range of 7-37%. The LC-MS/MS method was used to examine 65 samples of culinary herbs and herb and spice mixtures collected in Belgium, from supermarkets and local stores. The samples were found to be free from the analyzed CGs.

A Probable Fatal Case of Oleander (Nerium oleander) Poisoning on a Cattle Farm: A New Method of Detection and Quantification of the Oleandrin Toxin in Rumen

Oleander (Nerium oleander) is an ornamental plant common in tropical and sub-tropical regions that is becoming increasingly widespread, even in temperate regions. Oleander poisoning may occur in animals and humans. The main active components contained in the plant are cardiac glycosides belonging to the class of cardenolides that are toxic to many species, from human to insects. This work describes a case of oleander poisoning that occurred on a small cattle farm and resulted in the fatality of all six resident animals. Furthermore, the investigation of the poisonous agent is described, with particular focus on the characterization of the oleandrin toxin that was recovered from the forage and rumen contents. The innovation of this study is the first description of the detection and quantification of the oleandrin toxin by liquid chromatography-high resolution mass spectrometry (LC-HRMS) in rumen.

A fatal case of self-poisoning through the ingestion of oleander leaves

BACKGROUND

Benefits and even dangers of plants are known since time began. The ancients used plants and herbs because of their effects on the human body. Poisoning is a logical consequence of their use: history is full of episodes of plants and herbs poisoning, whether intentional or accidental.

AIM

Oleander poisoning is generally accidental; an intentional assumption of its leaves to commit suicide is uncommon because the population is not aware of the harmfulness of its cardiotoxic glycosides, therefore we report a fatal case of self-poisoning through the voluntary ingestion of oleander leaves.

METHODS

A diagnosis of oleander self-poisoning was highly suspected on the basis of the circumstantial evidence and the autopsy findings. Toxicological investigations were performed on the samples collected during the autopsy and aimed at confirm the presence of oleandrin at a toxic level.

RESULTS

The autopsy revealed a piece of oleander leaf on the posterior third of the tongue's body and several plant residues, similar to the one recovered on the tongue, into the gastric content; petechiae on the deep surface of the scalp, multi-organ congestion, and pulmonary edema were also observed. The histological study corroborated the pulmonary edema macroscopically observed but did not provide any other information. The detection of oleandrin in biological cadaveric samples revealed high, fatal, concentrations.

CONCLUSIONS

Cases of voluntary ingestion of oleander with a suicidal intent prove to be uncommon: in the case reported the victim was aware about the possibility to commit suicide through the ingestion of oleander leaves.

Oleander Poisoning as an Example of Self-Medication Attempt

BACKGROUND

There is an increasing interest in herbal products as a self-medication method in recent years. Some plant extracts either turn into drugs over time or are consumed directly without treatment. One of these plants is Nerium oleander L., which is a potentially lethal plant, since it has cardiac glycosides. However, numerous researches of its extracts have been performed against cancer cell lines in recent literature. This contradiction leads to misinterpretation and induces the prevalence of intoxication or fatal cases.

CASE REPORT

This case is associated with an oleander-poisoned patient, who was admitted to the Emergency unit 20 hours after the first dose, and 8 hours after the second dose. Although she lives in a metropolis and has a higher level of education and numerous hospital facilities available, she had decided to take self-medication for her Hashimoto's thyroiditis and malignant thyroid disease which was caused by her apprehensive thoughts. Oleandrin was detected in the urine at a concentration of 3.2 ng/mL and in the serum at a concentration of 8.4 ng/mL by chromatographic analysis at the time of admission.

CONCLUSION

This case represents the misunderstanding of herbal treatments by the community. Promoting awareness of the potential toxicity of this plant among the public may help to reduce the incidence of poisoning due to Nerium species.

Acute plant poisoning: analysis of clinical features and circumstances of exposure

INTRODUCTION

Human contact with potentially toxic plants, which may occur through abuse or by accident or attempted suicide, is frequent and sometimes results in clinically significant toxicity.

OBJECTIVE

The aim of the present study was to identify which plants may lead to severe poisoning, and to define the clinical relevance of plant toxicity for humans in Switzerland.

METHODS

We analyzed 42,193 cases of human plant exposure and 255 acute moderate, severe, and lethal poisonings, which were reported to the Swiss Toxicological Information Centre between January 1995 and December 2009.

RESULTS

Plant contact was rarely responsible for serious poisonings. Lethal intoxications were extremely rare and were caused by plants with cardiotoxic (Taxus baccata) or mitosis-inhibiting (Colchicum autumnale) properties.

CONCLUSIONS

Most often, plant contact was accidental and patients remained asymptomatic or developed mild symptoms, which fully resolved within a short time.

Use of forensic methods under exigent circumstances without full validation

Forensic science can be instrumental in providing investigative leads or clues to help identify the perpetrators, and those who are innocent, of a chemical, biological, radiological, or nuclear terrorist attack, as well as identify leads during infectious outbreaks or other public health threats. Because of a need to react quickly in exigent circumstances during which the threat of continued attack persists, methods may be used that are not fully validated. A preliminary validation should be performed to evaluate the acquisition of limited test data to ensure that the interpretation of results remains within the limitations of known performance of the method. If results from a preliminarily validated method are used beyond developing an investigative lead, further validation should be considered to support its reliability for adjudication purposes.

A case of non-fatal oleander poisoning

We present a case of non-fatal poisoning with oleander blooms in a 42-year-old woman. After repeated vomiting and gastrointestinal distress, the patient was admitted to the hospital with cardiac symptoms 4 h after the ingestion. Urine and blood samples were assayed for drugs of abuse and for general toxicological screen. Blood was analysed for alcohol and volatiles. Oleandrin was detected in the blood sample at a concentration of 14.7 ng/ml. Following a review of the literature, this is the first case of oleander poisoning in which the patient recovered with only conservative treatment. Oleander poisonings occur rarely, and generally result in death.