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

Fatal poisoning due to ingestion of boiled oleander leaf extract

Nerium oleander is an ornamental evergreen shrub belonging to the family Apocynaceae. The Apocynaceae family includes the attractive evergreen shrub known as oleander. The cardiotoxic glycoside, oleandrin, is present in all portions of the common oleander plant. Oleander consumption can result in deadly situations accidentally or as a suicide attempt. After consuming kettle-boiled oleander leaf extract as part of a suicide attempt, an 80-year-old man was discovered comatose in his home and taken to our emergency room. The patient's heart rate was 30 beats per minute, and he had hypotension. Arterial blood gas analysis revealed remarkable metabolic acidosis and hyperkalemia (K: 7.7 mEq/L). An electrocardiogram showed a wide QRS wave, similar to a sine curve. The patient collapsed following cardiac arrest soon after hospital arrival. Veno-arterial extracorporeal membrane oxygenation was initiated; however, the patient eventually died. The serum level of oleandrin at hospital arrival, subsequently measured by LC-MS/MS, was found to be 33.4 ng/mL, far above the levels reported in previous fatal cases.

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.

Laurel but Hardy: unintended poisoning, a case report of oleander misidentification as bay laurel

Introduction

Nerium oleander is a toxic plant containing cardiac glycosides throughout all its parts, thereby posing severe health risks upon ingestion. The clinical manifestations of oleander poisoning closely resemble those of digoxin toxicity, encompassing a spectrum of gastrointestinal symptoms, neuropsychiatric disorders, and cardiac disturbances. This scientific case report describes a case of accidental intoxication resulting from the consumption of an oleander leaves infusion misidentified as bay laurel leaves.

Case report

An 84-year-old patient consumed an oleander leaves infusion, and after four hours experienced gastrointestinal symptoms. He contacted the poison control center (PCC) and was advised to go to the emergency department (ED). Upon arrival, the patient presented stable vital signs without cardiac irregularities. The PCC recommended the administration of activated charcoal, vigilant monitoring, including electrocardiography (ECG). Subsequent ECGs assessments revealed the presence of third-degree atrioventricular block; in consultation with the PCC, digoxin-specific antibodies and external pacing were necessary. The patient was discharged on the eighth day in good hemodynamic condition, and outpatient follow-up visits showed clinical stability.

Discussion

This study offers insights for the management of similar cases. The limitations of conventional assays in measuring oleander cardiac glycosides were observed, emphasizing reliance on clinical evaluation. The patient's trajectory, remaining asymptomatic despite severe ECG changes post-ingestion, underscores the importance of prolonged clinical monitoring.

Deliberate Self-Poisoning with Plants in Southeastern France, a Poison Center 20-Year Report

INTRODUCTION

In a few regions of the globe, deliberate botanical intoxication may induce significant rates of toxicity and fatality. The objective of this report was to describe plant self-intoxication using the experiences of the southeastern France poison control center (PCC) between 2002 and 2021.

RESULTS

During those 20 years, 262 deliberate plants poisonings were reported involving 35 various plants. In most of the cases, poisoning was caused by Nerium oleander (n = 186, 71%), followed by the Datura genus (4.2%), Ricinus communis (3.8%), Taxus baccata (1.9%), Digitalis purpurea (1.2%), Aconitum nape (1.9%), Myristica fragans (1.5%), and Pyracantha coccine (1.2%). Through the 262 plants poisonings, 19 patients among the 186 Nerium oleander poisonings received Digifab as an antidote and 1 patient received physostigmine among the 11 Datura poisonings. Only four deaths were reported for this review, each involving Nerium oleander.

DISCUSSION

The first involved species was Nerium oleander (71% of all plants poisonings), then Datura sp and Ricinus communis. It is explained by this native local species' important repartition. Most patients must be admitted to an emergency department for adapted medical care; however, only 41 of them described severe poisonings symptoms. Even fewer needed an antidote, only 20 patients. There is no protocol for the use of a specific treatment, and it might be interesting to develop one for this purpose.

MATERIAL AND METHODS

This retrospective review was realized with files managed by the southeastern France PCC based in Marseille from 2002 to 2021. Our department covers the complete French Mediterranean coast, Corsica, and tropical islands (Reunion Island, Mayotte). For every patient, toxicity was evaluated using the Poison Severity Score (PSS).

Forensic botany: who?, how?, where?, when?

Plants are a good source of biological forensic evidence; this is due to their ubiquity, their ability to collect reference material, and their sensitivity to environmental changes. However, in many countries, botanical evidence is recognised as being scientifically. Botanical evidence is not mostly used for perpertration, instead it tends to serve as circumstantial evidence. Plant materials constitute the basis, among others, for linking a suspect or object to a crime scene or a victim, confirming or not confirming an alibi, determining the post-mortem interval, and determining the origin of food/object. Forensic botany entails field work, knowledge of plants, understanding ecosystem processes, and a basis understaning of geoscience. In this study, experiments with mammal cadavers were conducted to determine the occurence of an event. The simplest criterion characterising botanical evidence is its size. Therefore, macroremains include whole plants or their larger fragments (e.g. tree bark, leaves, seeds, prickles, and thorns), whereas microscopic evidence includes palynomorphs (spores and pollen grains), diatoms, and tissues. Botanical methods allow for an analysis to be repeated multiple times and the test material is easy to collect in the field. Forensic botany can be supplemented with molecular analyses, which, although specific and sensitive, still require validation.

Detection of Highly Poisonous Nerium oleander Using Quantitative Real-Time PCR with Specific Primers

Nerium oleander is one of the most poisonous plants, and its accidental ingestion has frequently occurred in humans and livestock. It is vital to develop a rapid and accurate identification method for the timely rescue of oleander-poisoned patients and the investigation of poisoning cases. In this study, a specific and highly sensitive quantitative real-time PCR (qPCR)-based method was developed to identify oleander in mixture systems and simulated forensic specimens (SFS). First, a new pair of oleander-specific primers, JZT-BF/BR, was designed and validated. Then, a qPCR method was developed using the primers, and its detective sensitivity was examined. The results showed that JZT-BF/BR could specifically identify oleander in forage and food mixtures, and qPCR was capable of accurate authentication even at a low DNA concentration of 0.001 ng/μL. This method was further applied to the analysis of SFS containing different ratios of N. oleander. The method was confirmed to be applicable to digested samples, and the detection limit reached 0.1% (w/w) oleander in mixture systems. Thus, this study undoubtedly provides strong support for the detection of highly toxic oleander and the diagnosis of food poisoning in humans and animals.

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.

[Multidisciplinary management of voluntary pink oleander poisoning: How to estimate the quantities ingested?]

This is a case of voluntary ingestion of Nerium oleander leaves in an adolescent requiring the use of atropine and emergency chartering of antidigoxin antibodies (Digifab®) due to the difficulty of assessing oleandrin level and associated toxicity. Upon hospital admission, a digoxinemia was performed (0.44μg/mL) and the presence of oleandrine was detected. Oleandrin levels at toxic levels may be suspected by a measure of blood digoxin and explain the patient's clinical signs, which could adapt the therapeutic management.

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.

Outbreak of Oleander (Nerium oleander) Poisoning in Dairy Cattle: Clinical and Food Safety Implications

Oleander is a spontaneous shrub widely occurring in Mediterranean regions. Poisoning is sporadically reported in livestock, mainly due to the ingestion of leaves containing toxic cardiac glycosides (primarily oleandrin). In this study, 50 lactating Fleckvieh cows were affected after being offered a diet containing dry oleander pruning wastes accidentally mixed with fodder. Clinical examination, electrocardiogram, and blood sampling were conducted. Dead animals were necropsied, and heart, liver, kidney, spleen, and intestine were submitted to histological investigation. Oleandrin detection was performed through ultra-high performance liquid chromatography-tandem mass spectrometry in blood, serum, liver, heart, milk, and cheese samples. Severe depression, anorexia, ruminal atony, diarrhea, serous nasal discharge, tachycardia, and irregular heartbeat were the most common clinical signs. The first animal died within 48 h, and a total of 13 cows died in 4 days. Disseminated hyperemia and hemorrhages, multifocal coagulative necrosis of the cardiac muscle fibers, and severe and diffuse enteritis were suggestive of oleander poisoning. The diagnosis was confirmed by the presence of oleandrin in serum, liver, heart, milk, and cheese. Our results confirm the high toxicity of oleander in cattle and report for the first time the transfer into milk and dairy products, suggesting a potential risk for the consumers.

Toxicity effects of Nerium oleander, basic and clinical evidence: A comprehensive review

Introduction:

Nerium oleander is a plant that is frequently grown in gardens and public areas. N. oleander is distributed originally in subtropical Asia but is now growing in many parts of the world, such as the United States, Australia, China, and Middle East countries. Pharmacological effects of plant including antinociceptive, anti-inflammatory, and anticancer activity were reported, but the potential toxic effects of all parts of the shrub either fresh or dried on animal and human body were documented.

Method:

The data of this review article were obtained from Medline/Pubmed, Scopusand Google Scholar databases in English until September 2019. To include all publications in this field, keywords such as N. oleander and toxicity were used.

Results:

The poisoning effects of plant or their active alkaloids induced infiltration of cells with hemorrhage and sever negative changes in the lung, induce lesions, and infiltration of inflammatory cells into the portal spaces with scattered necrosis of hepatocytes in the liver, cardiac toxicity of the plant in the heart were included, induced varying degrees of hemorrhage, myocardial degeneration, and necrosis. It also induced arrhythmia, sinus bradycardia, and prolonged P-R interval in electrocardiographic records.

Conclusions:

The toxic effects of N. oleander are mostly related to its inhibitory effects on the Na+-K+ ATPase pump in the cellular membrane. However, the exact molecular mechanism involved in the toxicity of N. oleander is not clear.

Circadian sensitivity to the cardiac glycoside oleandrin is associated with diurnal intestinal P-glycoprotein expression

The cardiac glycoside oleandrin is a main active constituent of the botanical anti-cancer drug candidate PBI-05204, an extract of Nerium oleander. Here, we aimed to determine the circadian sensitivity of mice to oleandrin, and to investigate the role of intestinal P-gp in generating rhythmic drug toxicity. Toxicity and pharmacokinetic experiments were performed with wild-type, Bmal1iKO (intestine-specific Bmal1 knockout) and Bmal1fl/fl (control littermates of Bmal1iKO) mice. The cardiac toxicity (reflected by plasma CK-MB, LDH and cTn-I levels) varied significantly with the times of drug dosing in wild-type mice (a lower toxicity at ZT10 and more severe at ZT2/22). Dosing at ZT2 generated a higher drug exposure than ZT10, supporting a lower toxicity at ZT10. Intracellular accumulation of oleandrin (2.5-10 μM) was reduced in MDCKⅡ-MDR1 than in parental cells. MDR1 overexpression decreased the cell sensitivity to oleandrin toxicity. The net flux ratio (MDCKⅡ-MDR1 versus parental cells) was 2.9 for oleandrin. These data indicated oleandrin as a P-gp substrate. Both mdr1a mRNA and P-gp protein oscillated with the times of the day in small intestine of Bmal1fl/fl mice. Intestinal ablation of Bmal1 down-regulated mdr1a mRNA and P-gp protein, and abrogated their rhythms. Likewise, Bmal1 silencing led to down-regulated mdr1a mRNA and to a loss of its rhythmicity in serum-shocked CT26 cells. Based on luciferase reporter assays, Bmal1 regulated rhythmic mdr1a transcription through the clock output genes Hlf and E4bp4. Intestinal ablation of Bmal1 exacerbated oleandrin toxicity and enhanced drug exposure. Moreover, time dependency of toxicity and drug exposure were lost in Bmal1iKO mice. In conclusion, diurnal intestinal P-gp is a critical factor influencing daily oleandrin exposure and toxicity. Our findings have implications in minimizing oleandrin (and possibly Nerium oleander) toxicity and improving drug efficacy via dosing time optimization.