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Brandenberger L, Silva KW, Macheret F, Badulak J, Lebin JA. Woman With Syncopal Episode and Seizure-like Activity. Ann Emerg Med 2023; 82:216-218. [PMID: 37479398 DOI: 10.1016/j.annemergmed.2022.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 11/16/2022] [Accepted: 11/16/2022] [Indexed: 07/23/2023]
Affiliation(s)
| | | | - Fima Macheret
- Section of Electrophysiology, Division of Cardiology, University of Washington, Seattle, WA
| | - Jenelle Badulak
- Department of Emergency Medicine, University of Washington, Seattle, WA; Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Jacob A Lebin
- Department of Emergency Medicine, University of Colorado, Aurora, CO; Washington Poison Center, Seattle, WA
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2
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Buetler VA, Braunshausen AM, Weiler S, Klukowska-Rötzler J, Exadaktylos AK, Liakoni E. Characteristics of emergency department presentations following ingestion of Taxus baccata (yew). Clin Toxicol (Phila) 2023; 61:104-109. [PMID: 36594830 DOI: 10.1080/15563650.2022.2158097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Presentations of Taxus baccata (yew) poisoning can range between asymptomatic cases and life-threatening cardiotoxicity - depending on the amount ingested. This study aimed to describe emergency department (ED) presentations after yew exposure, and covers their clinical presentation, diagnostic and specific treatment, to contribute to optimising intreatment and prophylaxis. METHODS Retrospective observational study of cases (≥ 16 years of age) presenting at the ED of the University Hospital of Bern, Switzerland, from 1 May 2012 to 31 May 2020 following reported yew exposure. Cases were retrieved from the electronic patient database using full-text terms. RESULTS During the study period, 55 presentations (11 patients) of the 350,381 ED attendances were included. All patients were female and the median age on first presentation was 22 years (range 16-48). All 10 patients with intentional intake had previous diagnoses of psychiatric disorders. Commonly reported symptoms on presentation were gastrointestinal disturbances (31 presentations, 56%), neurological (six presentations, 11%) and subjective cardiovascular symptoms (five presentations, 9%). The most frequent clinical findings on presentation were tachycardia (15 presentations, 27%) and hypotension (11 presentations, 20%). In 52 presentations (95%), gastroscopic extraction of the leaves was performed, activated charcoal was administered in 25 cases (45%), and there were no fatalities. In the majority of the cases (40, 73%), the patient was admitted to psychiatric care and in 10 (18%) the patient was discharged home. CONCLUSION ED presentations after yew exposure appear to be rare, but potentially life-threatening and commonly observed in this study in young female patients with underlying psychiatric diseases. In this case series, gastroscopic extraction and activated charcoal application were commonly performed and there were no fatalities.
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Affiliation(s)
- Vanessa Alexandra Buetler
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Stefan Weiler
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jolanta Klukowska-Rötzler
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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3
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Schreiber N, Manninger M, Pätzold S, Reisinger AC, Hatzl S, Hackl G, Högenauer C, Eller P. Cardiogenic shock due to yew poisoning rescued by VA-ECMO: case report and literature review. Channels (Austin) 2022; 16:167-172. [PMID: 35942511 PMCID: PMC9367666 DOI: 10.1080/19336950.2022.2104886] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Ingestion of leaves of the European yew tree (Taxus baccata) can result in fatal cardiac arrhythmias and acute cardiogenic shock. This cardiotoxicity derives from taxine alkaloids that block cardiac voltage-gated sodium and calcium channels. Prompt initiation of venoarterial extracorporeal membrane oxygenation is essential to bridge these critically ill patients to recovery, as there is no antidote available. We here report a 39-year old patient with toxic cardiogenic shock after yew poisoning, who was successfully rescued by venoarterial extracorporeal membrane oxygenation and had a full neurological recovery. This report emphasizes the role of intoxications as reversible causes of cardiac arrest and adds further evidence to the body of existing literature thus encouraging the early use of venoarterial extracorporeal membrane oxygenation in patients with yew poisoning and cardiogenic shock.
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Affiliation(s)
- Nikolaus Schreiber
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Martin Manninger
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Sascha Pätzold
- Department of Internal Medicine, Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Alexander C Reisinger
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Stefan Hatzl
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Christoph Högenauer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Philipp Eller
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
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4
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Ward C, Meeks D, Trimlett R, Alçada J. Taxine alkaloid poisoning successfully supported with venoarterial extracorporeal membrane oxygenation: a case report. Eur Heart J Case Rep 2022; 6:ytac039. [PMID: 35187392 PMCID: PMC8851931 DOI: 10.1093/ehjcr/ytac039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/23/2021] [Accepted: 01/19/2022] [Indexed: 12/03/2022]
Abstract
Background Ingestion of the berries of the European yew tree can result in fatal cardiac arrhythmias. Case summary A 53-year-old female presented to our emergency department following ingestion of ∼200 European yew tree berries. At presentation, she was in cardiogenic shock due to a mixture of tachy- and bradyarrhythmias including ventricular tachycardia, atrial fibrillation with slow ventricular response and prolonged ventricular conduction, and periods of asystole. She was referred to a specialist cardiac centre and promptly established on mechanical circulatory support with venoarterial extracorporeal membrane oxygenation (V-A ECMO) by a retrieval team. Following resolution of her arrhythmias, she was weaned from V-A ECMO after 4 days of support and was discharged home with full neurological recovery on Day 12. Discussion Poisoning can lead to acute reversible but potentially fatal cardiogenic shock. We believe that access to prompt initiation of V-A ECMO was key to this patient’s survival.
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Affiliation(s)
- Catherine Ward
- Department of Critical Care, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Daveena Meeks
- Department of Critical Care, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
| | - Richard Trimlett
- Department of Cardiothoracic Surgery, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Joana Alçada
- Department of Intensive Care, Adult Intensive Care Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK
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5
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Alarfaj M, Goswami A. Cardiotoxicity in yew berry poisoning. Am J Emerg Med 2021; 50:812.e1-812.e4. [PMID: 34049761 DOI: 10.1016/j.ajem.2021.05.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 05/08/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022] Open
Abstract
Yew plants (Taxus species) represent a genus of plants known to be highly toxic, though lethal intoxication is rare. The majority of deaths in yew berry poisonings occur due to its cardiotoxic effect, mediated through generation of a number of fatal tachy- and brady-arrhythmias. However, there are no guidelines on the most effective management in these cases, and interventions vary greatly between published reports. Here we report a case of a 20-year-old female who presented with refractory lethal arrythmia and shock refractory to conventional therapy. She presented to the emergency department and promptly required airway management and hemodynamic support necessitating intensive care unit management. She received many antiarrhythmics, digoxin immune Fab, lipid emulsification, and eventually transvenous pacemaker insertion for overdrive pacing. Despite our interventions, our patient ultimately died after a decision to withdraw care. We also reviewed 43 reports of yew poisoning cases described in the literature. We discuss the most common strategies used to treat such patients including gastric decontamination, antiarrhythmics, electrical pacing, extracorporeal life support and other therapies. We need better understanding of this condition, to identify which therapies offer maximal benefit and to optimize outcomes for this rare but often devastating toxidrome.
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Affiliation(s)
| | - Ankur Goswami
- Department of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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6
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Hermes-Laufer J, Meyer M, Rudiger A, Henze J, Enselmann K, Kupferschmidt H, Müller D, Herzog A, Bettex D, Keller DI, Krüger B, Engeler J. Extracorporeal life support as bridge to recovery in yew poisoning: case reports and literature review. ESC Heart Fail 2020; 8:705-709. [PMID: 33232574 PMCID: PMC7835583 DOI: 10.1002/ehf2.12828] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 04/28/2020] [Accepted: 05/21/2020] [Indexed: 12/21/2022] Open
Abstract
Aims This short communication aims to review the treatment of cardiogenic shock in patients with yew poisoning based on two case reports from our institution, focusing on the use of extracorporeal life support (ECLS). Methods and results We report two cases of Taxus baccata poisoning treated with ECLS at our institution and review the literature based on a search in PubMed and Google Scholar on the topic of yew poisoning and ECLS. All cases were combined for analysis of demographics, ECLS therapy, and outcome. Case 1: A 35‐year‐old woman developed polymorphic ventricular tachycardia followed by cardiovascular arrest 5 h after orally ingesting a handful of yew needles. Successful resuscitation required ECLS for 72 h due to ongoing cardiac arrhythmias and cardiogenic shock. The patient left the hospital without neurological sequelae after 10 days. Case 2: A 30‐year‐old woman developed refractory cardiac arrhythmias and circulatory arrest. Resuscitation included ECLS for 71 h. T. baccata needles found by gastroscopy confirmed the diagnosis. The patient had no neurologic deficits and was transferred to psychiatry after 11 days. Review of the literature: Nine case reports were found and analysed along with our two cases. Five out of the 11 (45%) patients were female. Median (range) age was 28 (19–46) years. T. baccata needles were ingested with a suicidal intention in all patients. Median (range) duration of ECLS was 70 h (24–120 h). Eight (73%) patients had full neurological recovery. Conclusions Yew poisoning is a differential diagnosis in young psychiatric patients presenting with polymorphic ventricular tachycardia and cardiogenic shock. A characteristic cardiac contraction pattern in echocardiography may present a diagnostic clue. The early use of ECLS is a valuable bridge to recovery in most of these patients.
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Affiliation(s)
- Julia Hermes-Laufer
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland.,Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Martin Meyer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Alain Rudiger
- Institute of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Julian Henze
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Kai Enselmann
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Hugo Kupferschmidt
- National Poisons Information Centre, Tox Info Suisse, Associated Institute of the University of Zurich, Zurich, Switzerland
| | - Daniel Müller
- Institute of Clinical Chemistry, University Hospital Zurich, Zurich, Switzerland
| | - Aline Herzog
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Dominique Bettex
- Institute of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Bernard Krüger
- Institute of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Judith Engeler
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
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7
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G N, Chan M, Gue YX, Gorog DA. Fatal heart block from intentional yew tree ( Taxus baccata) ingestion: a case report. Eur Heart J Case Rep 2020; 4:1-4. [PMID: 32128497 PMCID: PMC7047065 DOI: 10.1093/ehjcr/ytz226] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 08/15/2019] [Accepted: 11/21/2019] [Indexed: 11/14/2022]
Abstract
BACKGROUND Taxus baccata, also known as English yew, is a poison that causes cardiac arrhythmias and can result in death from cardiogenic shock. CASE SUMMARY A 49-year-old gentleman was admitted following yew ingestion with suicidal intent. He was bradycardic at 30 b.p.m. and hypotensive on arrival. Electrocardiography revealed complete heart block with broad complex ventricular escape rate of 30 b.p.m. Bedside echocardiography revealed severe global impairment of right and left ventricular systolic function. Urgent temporary transvenous pacing was instituted, and the patient was considered for veno-arterial extracorporeal membrane oxygenation. Unfortunately, he deteriorated rapidly and cardiorespiratory arrest ensued, and despite prolonged in-hospital resuscitation, the patient died. Post-mortem examination revealed small needle-shaped plant leaves together with seeds found in the stomach. Ante mortem serum sample analysis sent to the Royal Botanical Gardens and revealed the presence of taxine Type B alkaloids in the patient's blood. DISCUSSION Yew poisoning is a rare occurrence, and there is currently no effective antidote. Treatment involves supportive management, comprising prolonged effective cardiopulmonary resuscitation, pacing, and mechanical cardiac support. This case illustrates the importance of prompt recognition of yew poisoning, alongside early consideration of pacing and mechanical cardiac support. Due to the rarity of this cause of heart block, and since patients may not always volunteer a history of yew ingestion, yew poisoning is something that physicians should be aware of and this should be considered in the differential diagnosis in patients with unexpected heart block. Serum analysis for taxine alkaloids can be used to confirm the diagnosis.
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Affiliation(s)
- Natasha G
- Department of Cardiology, Lister Hospital, East and North Hertfordshire NHS Trust, Coreys Mill Lane, Stevenage SG1 4AB, UK
| | - Mark Chan
- Department of Cardiology, Lister Hospital, East and North Hertfordshire NHS Trust, Coreys Mill Lane, Stevenage SG1 4AB, UK
| | - Ying X Gue
- Department of Cardiology, Lister Hospital, East and North Hertfordshire NHS Trust, Coreys Mill Lane, Stevenage SG1 4AB, UK.,Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, Hertfordshire AL10 9AB, UK
| | - Diana A Gorog
- Department of Cardiology, Lister Hospital, East and North Hertfordshire NHS Trust, Coreys Mill Lane, Stevenage SG1 4AB, UK.,Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, Hertfordshire AL10 9AB, UK.,Faculty of Medicine, National Heart & Lung Institute, Imperial College, Dovehouse Street, London SW3 6LY, UK
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8
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"Chaotic Arrhythmia" During Successful Resuscitation After Ingestion of Yew (Taxus baccata) Needles. Pediatr Emerg Care 2019; 35:e223-e225. [PMID: 28590987 DOI: 10.1097/pec.0000000000001196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The study aims to describe the management of a case of life-threatening yew (Taxus baccata) intoxication. BACKGROUND The needles of the yew tree contain highly cardiotoxic taxines. Intoxication with taxines, typically as part of suicide attempts, may lead to potentially lethal arrhythmias which often require prolonged cardiopulmonary resuscitation and other supportive measures. No specific therapy has been described. In some cases, extracorporeal life support has been used. CASE After an attempted suicide with yew needles and out-of-hospital cardiac arrest, a female adolescent was resuscitated for 6 hours according to Advanced Cardiovascular Life Support guidelines. Complex ventricular tachycardias were treated by repeated direct current shocks and broad complex bradycardia managed with transvenous cardiac pacing. Antiarrhythmic drugs (amiodarone, lidocaine), magnesium sulfate, and supportive measures (intravenous lipids, sodium bicarbonate) were provided. The arrhythmias finally resolved, and the patient did not show any significant neurological or cardiac short-term sequelae after 24 hours. RESULTS The authors describe the successful management of a case of severe taxine intoxication by prolonged conventional advanced cardiac life support lasting for more than 6 hours. CONCLUSIONS In life-threatening yew intoxication, prolonged cardiopulmonary resuscitation is absolutely essential owing to the long duration of the cardiotoxic action of taxines and can lead to an outcome without cardiac or neurological sequelae.
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9
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Pilija V, Djurendic-Brenesel M, Miletic S. Fatal poisoning by ingestion of Taxus Baccata leaves. Forensic Sci Int 2018; 290:e1-e4. [DOI: 10.1016/j.forsciint.2018.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 07/17/2018] [Indexed: 11/30/2022]
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10
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Abstract
Objectives: Yew plant materials contain highly toxic taxine alkaloids. Serious ingestions can result in life-threatening toxicity. The purpose of this article is to summarize the literature on the treatment of acute yew poisoning. Data Sources: PubMed (January 1946 to November 2017) was searched using the search terms “taxus/po”. EMBASE (1980 to November 2017) was searched using the search terms “taxus/to” and “yew.mp.” Web of Science (1945 to November 2017) was searched using the text words taxus, taxine, and yew. Study Selection and Data Extraction: Available English language articles involving case reports, epidemiology, treatment, and outcomes were included. Data Synthesis: Although not uncommon, unintentional yew poisoning rarely results in significant morbidity or mortality. A total of 26 case reports of yew poisoning were evaluated along with 4 case series articles (totaling 22 additional cases). Only 4 of the 48 total cases (8%) were accidental poisonings, the rest being deliberate ingestions. In 20 patients (42%), it resulted in fatalities. Severe, acute yew poisoning results in symptomatology largely resistant to pharmacotherapy intervention. Conclusions: Most nonintentional ingestions of yew plant constituents are asymptomatic and require little intervention. Severe poisoning can result in life-threatening cardiac toxicity and require aggressive supportive care. Therapeutic interventions, such as sodium bicarbonate, digoxin immune fab, and hemodialysis that have been utilized in case studies and case series in the literature have little proven benefit. Extracorporeal life support should be considered in severe yew poisoning.
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Affiliation(s)
| | - Dennis F. Thompson
- Southwestern Oklahoma State University, College of Pharmacy, Weatherford, OK, USA
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11
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Dela Cruz M, McCloskey K, Mostafa A, Ershad M, McKeever R, Vearrier D. Cardiotoxicity resulting from yew plant ( Taxus canadensis) ingestion. TOXICOLOGY COMMUNICATIONS 2018. [DOI: 10.1080/24734306.2018.1532677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Maricel Dela Cruz
- Division of Medical Toxicology, Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Kristen McCloskey
- Division of Medical Toxicology, Department of Emergency Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Ahmed Mostafa
- Division of Medical Toxicology, Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Muhammed Ershad
- Division of Medical Toxicology, Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Rita McKeever
- Division of Medical Toxicology, Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
| | - David Vearrier
- Division of Medical Toxicology, Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
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12
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Reijnen G, Bethlehem C, van Remmen JM, Smit HJ, van Luin M, Reijnders UJ. Post-mortem findings in 22 fatal Taxus baccata intoxications and a possible solution to its detection. J Forensic Leg Med 2017; 52:56-61. [DOI: 10.1016/j.jflm.2017.08.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 05/01/2017] [Accepted: 08/23/2017] [Indexed: 11/16/2022]
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13
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Hughes A, Johnson NJ, Mazor SS. Extracorporeal Life Support: Indications and Use in Severely Poisoned Patients. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Vardon Bounes F, Tardif E, Ruiz S, Gallart JC, Conil JM, Delmas C. Suicide attempt with self-made Taxus baccata leaf capsules: survival following the application of extracorporeal membrane oxygenation for ventricular arrythmia and refractory cardiogenic shock. Clin Toxicol (Phila) 2017; 55:925-928. [PMID: 28494178 DOI: 10.1080/15563650.2017.1321763] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
CONTEXT Yew intoxication has been known for many years; high dose ingestion of Taxus baccata leads to cardiac toxicity mediated by calcium and sodium channel blocking properties. We present a case report of a patient who attempted suicide after T. baccata ingestion, causing refractory cardiogenic shock requiring temporary circulatory assistance by veno-arterial extra corporeal membrane oxygenation (VA ECMO). CASE DETAILS A 28-year-old man was admitted to the critical care unit of a university hospital for arrhythmia after ingestion of self-made T. baccata leaf capsules. He rapidly developed cardiovascular collapse requiring mechanical ventilation, high dose intravenous catecholamines and electrical cardioversion. A femoro-femoral VA ECMO was implanted due to severe biventricular dysfunction and ventricular arrhythmia, associated with continuous renal replacement therapy. Taxol A, taxol B and baccatin III were detected and measured in both blood and urine samples by high-performance liquid chromatography tandem mass spectrometry, and kinetics suggested urinary excretion. Two days after hospital admission, VA ECMO and continuous renal replacement therapy were removed with full recovery of cardiac function. DISCUSSION Our experience suggests that circulatory assistance by VA ECMO and continuous renal replacement therapy seem to be effective safe second-line therapeutic options in critically ill cases of severe yew intoxication with refractory cardiogenic shock due to arrhythmia.
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Affiliation(s)
- Fanny Vardon Bounes
- a Anesthesiology and Critical Care Unit , University Teaching Hospital of Toulouse , Toulouse , France
| | - Elsa Tardif
- a Anesthesiology and Critical Care Unit , University Teaching Hospital of Toulouse , Toulouse , France
| | - Stéphanie Ruiz
- a Anesthesiology and Critical Care Unit , University Teaching Hospital of Toulouse , Toulouse , France
| | - Jean-Christophe Gallart
- b Poison Control and Toxicovigilance Center , University Teaching Hospital of Toulouse , Toulouse , France.,c Department of Emergency , SAMU 31, University Teaching Hospital of Toulouse , Toulouse , France
| | - Jean-Marie Conil
- a Anesthesiology and Critical Care Unit , University Teaching Hospital of Toulouse , Toulouse , France
| | - Clément Delmas
- a Anesthesiology and Critical Care Unit , University Teaching Hospital of Toulouse , Toulouse , France.,d Cardiology Intensive Care Unit , University Teaching Hospital of Toulouse , Toulouse , France
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15
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Wang GS, Levitan R, Wiegand TJ, Lowry J, Schult RF, Yin S. Extracorporeal Membrane Oxygenation (ECMO) for Severe Toxicological Exposures: Review of the Toxicology Investigators Consortium (ToxIC). J Med Toxicol 2016; 12:95-9. [PMID: 26013746 DOI: 10.1007/s13181-015-0486-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Although there have been many developments related to specific strategies for treating patients after poisoning exposures, the mainstay of therapy remains symptomatic and supportive care. One of the most aggressive supportive modalities is extracorporeal membrane oxygenation (ECMO). Our goal was to describe the use of ECMO for toxicological exposures reported to the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC). We performed a retrospective review of the ACMT ToxIC Registry from January 1, 2010 to December 31, 2013. Inclusion criteria included patients aged 0 to 89 years, evaluated between January 2010 through December 2013, and received ECMO for toxicological exposure. There were 26,271 exposures (60 % female) reported to the ToxIC Registry, 10 (0.0004 %) received ECMO: 4 pediatric (< 12 years), 2 adolescent (12-18 years), and 4 adults (>18 years). Time of initiation of ECMO ranged from 4 h to 4 days, with duration from 15 h to 12 days. Exposures included carbon monoxide/smoke inhalation (2), bitter almonds, methanol, and several medications including antihistamines (2), antipsychotic/antidepressant (2), cardiovascular drugs (2), analgesics (2), sedative/hypnotics (2), and antidiabetics (2). Four ECMO patients received cardiopulmonary resuscitation (CPR) during their hospital course, and the overall survival rate was 80 %. ECMO was rarely used for poisoning exposures in the ACMT ToxIC Registry. ECMO was utilized for a variety of ages and for pharmaceutical and non-pharmaceutical exposures. In most cases, ECMO was administered prior to cardiovascular failure, and survival rate was high. If available, ECMO may be a valid treatment modality.
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Affiliation(s)
- G S Wang
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, 13123 E 16th Ave B251, Aurora, CO, 80045, USA. .,Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO, USA.
| | - R Levitan
- Department of Emergency Medicine and Medical Toxicology, University of Arizona, Banner Good Samarian Medical Center, Phoenix, AZ, USA
| | - T J Wiegand
- Department of Emergency Medicine, University of Rochester Medicine, Rochester, NY, USA
| | - J Lowry
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy, Kansas City, MO, USA
| | - R F Schult
- Department of Emergency Medicine, University of Rochester Medicine, Rochester, NY, USA.,Department of Pharmacy, University of Rochester Medicine, Rochester, NY, USA
| | - S Yin
- Cincinnati Drug and Poison Information Center, Cincinnati, OH, USA
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16
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Arens AM, Anaebere TC, Horng H, Olson K. Fatal Taxus baccata ingestion with perimortem serum taxine B quantification. Clin Toxicol (Phila) 2016; 54:878-880. [DOI: 10.1080/15563650.2016.1209765] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Ann M. Arens
- Department of Emergency Medicine, University of California, San Francisco, CA, USA
- San Francisco Division, California Poison Control System, San Francisco, CA, USA
| | - Tiffany C. Anaebere
- Department of Emergency Medicine, Alameda Health System/Highland Hospital, Oakland, CA, USA
| | - Howard Horng
- Department of Laboratory Medicine, University of California, San Francisco, CA, USA
| | - Kent Olson
- San Francisco Division, California Poison Control System, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, CA, USA
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Combination of veno-arterial extracorporeal membrane oxygenation and hypothermia for out-of-hospital cardiac arrest due to Taxus intoxication. CAN J EMERG MED 2015; 16:504-7. [DOI: 10.1017/s1481803500003559] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
A young woman presented with cardiac arrest following ingestion of yew tree leaves of the Taxus baccata species. The toxin in yew tree leaves has negative inotropic and dromotropic effects. The patient had a cardiac rhythm that alternated between pulseless electrical activity with a prolonged QRS interval and ventricular fibrillation. When standard resuscitation therapy including digoxin immune Fab was ineffective, a combination of extracorporeal membrane oxygenation (ECMO) and hypothermia was initiated. The total duration of low flow/no flow was 82 minutes prior to the initiation of ECMO. After 36 hours of ECMO (including 12 hours of electrical asystole), the patient’s electrocardiogram had normalized and the left ventricular ejection fraction was 50%. At this time, dobutamine and the ECMO were stopped. The patient had a full neurologic recovery and was discharged from the intensive care unit after 5 days and from the hospital 1 week later.
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de Lange DW, Sikma MA, Meulenbelt J. Extracorporeal membrane oxygenation in the treatment of poisoned patients. Clin Toxicol (Phila) 2013; 51:385-93. [DOI: 10.3109/15563650.2013.800876] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Grobosch T, Schwarze B, Felgenhauer N, Riesselmann B, Roscher S, Binscheck T. Eight cases of fatal and non-fatal poisoning with Taxus baccata. Forensic Sci Int 2012; 227:118-26. [PMID: 23265441 DOI: 10.1016/j.forsciint.2012.11.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 11/21/2012] [Accepted: 11/23/2012] [Indexed: 10/27/2022]
Abstract
This paper describes two fatalities, three non-fatal intentional and three accidental oral ingestions of yew (Taxus baccata) leaves. In all cases the post-mortem external examinations showed no signs of violence. Internal examinations revealed small green, needle-like particles on the tongue, in the esophagus and in the stomach. Yew leaves were also identified in the stomach contents, whereas Taxus leaves were cut into small pieces and then ingested in one case. The analytical method used was based on a liquid-liquid-extraction under alkaline conditions followed by LC-MS/MS analysis (QTRAP 5500). Chromatographic separation was achieved by HPLC on a Kinetex C18 2.6u (100×3) mm. The analytical method allows the simultaneous identification and quantification of the commercially available yew alkaloids taxoids (m/z): paclitaxel (854.2→105.0/286.1), 10-deacetyltaxol (10-DAT: 812.2→105.0/286.1), baccatin III (BAC III: 604.0→105.0/327.0), 10-deacetylbaccatin III (10-DAB III: 562.1→105.0/327.0), cephalomannine [taxol B] (562.1→105.0/327.0) and of 3,5-dimethoxyphenol (3,5-DMP: 155.0→111.9/122.9) also encompassing the qualitative analysis of the alkaloidal diterpenoids (Q1→194.0/107.0); reference mass spectra obtained from a yew leaves extract: monoacetyltaxine (MAT: 568.4), taxine B (584.2), monohydroxydiacetyltaxine (MHDAT: 626.4), triacetyltaxine (TAT: 652.4), monohydroxytriacetyltaxine (MHTAT: 668.4). In both fatalities, paclitaxel, 10-DAT and cephalomannine were not identified in urine, cardiac and femoral blood but all taxoids and 3,5-DMP were present in stomach content and excreted into the bile. In urine, highest 3,5-DMP concentration was 7500 μg/L and 23,000 μg/L after enzymatic hydrolysis, respectively. In intentional and accidental poisonings, when electrocardiogram (ECG) examinations revealed ventricular tachycardia and/or prolonged QRS intervals, taxines were identified in plasma/serum, even after the ingestion of a few number of yew leaves, when 3,5-dimethoxyphenol was not even found. According to the data from one near-fatal intentional poisoning, elimination half-life of MAT, TAXIN B, MHDAT and MHTAT in serum was calculated with 11-13 h and taxines were detected up to t=+122 h post-ingestion of approximately two handfuls of yew leaves.
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Affiliation(s)
- Thomas Grobosch
- Labor Berlin - Charité Vivantes GmbH, Laboratoriumsmedizin & Toxikologie, Oranienburger Str. 285, 13437 Berlin, Germany.
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Burcham GN, Becker KJ, Tahara JM, Wilson CR, Hooser SB. Myocardial fibrosis associated with previous ingestion of yew (Taxus sp.) in a Holstein heifer. J Vet Diagn Invest 2012; 25:147-52. [PMID: 23166182 DOI: 10.1177/1040638712466729] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Twenty-six 5-month-old Holstein calves were accidentally exposed to discarded branches of yew bushes ( Taxus sp.). Several calves were found dead approximately 24 hr after exposure; however, a few calves died several days after exposure. One calf died 18 days after the initial exposure to Taxus sp. and was examined on the farm via necropsy. Gross lesions included ascites, and dilated and flaccid myocardial ventricles. Sections of formalin-fixed heart were submitted to the Indiana Animal Disease Diagnostic Laboratory for histopathologic examination; fresh rumen contents were submitted for toxicologic testing. Histologically, large areas of myocardium were replaced by fibrous connective tissue, suggesting previous myocardial necrosis. Taxus alkaloids were identified in the rumen contents using gas chromatography–mass spectrometry. Based on the clinical history, the gross and histologic lesions, the identification of Taxus alkaloids in the rumen contents, and lack of exposure to other known cardiotoxic agents, yew toxicity was considered the cause of death in this calf. Ingestion of taxines is known to cause acute and subacute toxicity in human beings and animals; however, a chronic clinical course and severe histologic lesions have not been previously associated with yew toxicity. Although only 1 calf was examined, this case suggests that yew toxicity can result in a prolonged clinical course in cattle and can cause histologic myocardial lesions.
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Affiliation(s)
- Grant N. Burcham
- Department of Comparative Pathobiology, Purdue University, West Lafayette, IN (Burcham, Wilson, Hooser)
- private practitioner, Mooreland, IN (Becker)
- California Animal Health and Food Safety Laboratory, University of California–Davis, Davis, CA (Tahara)
- Animal Disease Diagnostic Laboratory, West Lafayette, IN (Wilson, Hooser)
| | - Kyle J. Becker
- Department of Comparative Pathobiology, Purdue University, West Lafayette, IN (Burcham, Wilson, Hooser)
- private practitioner, Mooreland, IN (Becker)
- California Animal Health and Food Safety Laboratory, University of California–Davis, Davis, CA (Tahara)
- Animal Disease Diagnostic Laboratory, West Lafayette, IN (Wilson, Hooser)
| | - John M. Tahara
- Department of Comparative Pathobiology, Purdue University, West Lafayette, IN (Burcham, Wilson, Hooser)
- private practitioner, Mooreland, IN (Becker)
- California Animal Health and Food Safety Laboratory, University of California–Davis, Davis, CA (Tahara)
- Animal Disease Diagnostic Laboratory, West Lafayette, IN (Wilson, Hooser)
| | - Christina R. Wilson
- Department of Comparative Pathobiology, Purdue University, West Lafayette, IN (Burcham, Wilson, Hooser)
- private practitioner, Mooreland, IN (Becker)
- California Animal Health and Food Safety Laboratory, University of California–Davis, Davis, CA (Tahara)
- Animal Disease Diagnostic Laboratory, West Lafayette, IN (Wilson, Hooser)
| | - Stephen B. Hooser
- Department of Comparative Pathobiology, Purdue University, West Lafayette, IN (Burcham, Wilson, Hooser)
- private practitioner, Mooreland, IN (Becker)
- California Animal Health and Food Safety Laboratory, University of California–Davis, Davis, CA (Tahara)
- Animal Disease Diagnostic Laboratory, West Lafayette, IN (Wilson, Hooser)
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Plantes toxiques : les dangers du retour à la nature. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0494-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Grobosch T, Schwarze B, Stoecklein D, Binscheck T. Fatal poisoning with Taxus baccata: quantification of paclitaxel (taxol A), 10-deacetyltaxol, baccatin III, 10-deacetylbaccatin III, cephalomannine (taxol B), and 3,5-dimethoxyphenol in body fluids by liquid chromatography-tandem mass spectrometry. J Anal Toxicol 2012; 36:36-43. [PMID: 22290751 DOI: 10.1093/jat/bkr012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This method development was to confirm the fatal ingestion of toxic yew plant material in postmortem samples (stomach content, urine, femoral blood, cardiac blood, bile, and brain tissue) collected from a 22-year-old man who committed suicide by ingesting yew leaves. The analytical method was based on a liquid-liquid extraction under alkaline conditions followed by LC-MS-MS analysis. Chromatographic separation was achieved by HPLC on a Kinetex C18 2.6u (100 × 3 mm) coupled to a QTRAP 5500 system. The method allows the simultaneous identification and quantification of the yew alkaloids taxoids paclitaxel (taxol A), 10-deacetyltaxol, baccatin III, 10-deacetylbaccatin III, cephalomannine (taxol B), and 3,5-dimethoxyphenol; the alkaloidal diterpenoids monoacetyltaxine, taxine B, monohydroxydiacetyltaxine, triacetyltaxine, and monohydroxytriacetyltaxine were also identified. The initial hypothesis of yew tree (Taxus baccata) poisoning was confirmed. The quantitative evaluation revealed taxoid concentrations ranging from 4.5 to 132 µg/L (stomach content), 1 to 200 µg/L (urine), <0.5 to 12 µg/L (cardiac blood), <0.5 to 7.3 µg/L (femoral blood), and 4.9 to 290 µg/L (bile). In brain tissue, none of these taxoids could be detected (<0.5 µg/L). In urine, after enzymatic hydrolysis, the concentration of 3,5-dimethoxyphenol (3,5-DMP) was 23,000 µg/L. The alkaloidal diterpenoids were found in all postmortem samples. The newly developed LC-MS-MS method enables the identification of alkaloidal and non-alkaloidal diterpenoids and 3,5-dimethoxyphenol in human body fluids and tissues for the confirmation of accidental or intentional poisonings with yew plant material.
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Affiliation(s)
- T Grobosch
- Berliner Betrieb für Zentrale Gesundheitliche Aufgaben (BBGes), Institute of Toxicology and Poison Information Centre Berlin, Berlin, Germany.
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Dahlqvist M, Venzin R, König S, Faber K, Weinmann W, Terbeck S, Ceschi A, Dünser MW. Haemodialysis in Taxus baccata poisoning: a case report. QJM 2012; 105:359-61. [PMID: 21385831 DOI: 10.1093/qjmed/hcr037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Dahlqvist
- Department of Intensive Care Medicine, Inselspital, Bern Medical University, Bern, Switzerland
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Varlet V, Augsburger M. Monitoring of aglycons of yew glycosides (3,5-dimethoxyphenol, myrtenol and 1-octen-3-ol) as first indicator of yew presence. Drug Test Anal 2012; 5:474-9. [PMID: 22371422 DOI: 10.1002/dta.391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 10/24/2011] [Accepted: 10/24/2011] [Indexed: 11/09/2022]
Abstract
The toxicity of yew (Taxus spp) is well known from ancient times and is mainly due to taxins acting as inhibitors of calcium and sodium transport across the cell membrane of cardiac myocytes. The confirmation of yew taxins in body fluids can be carried out by liquid chromatography-tandem mass spectrometry (LC-MS/MS). However, before selecting this precise but expensive technique, an orientation test should be done to ascertain yew presence as toxic agent in the organism. As the 3,5-dimethoxyphenol (3,5-DMP), myrtenol and 1-octen-3-ol appear as glycosidically bound volatile compounds and are very yew specific, the detection of 3,5-DMP and the measurement of 1-octen-3-ol / myrtenol concentration ratio constitute reliable indicators of yew presence in forensic cases. The detection of these compounds is easily performed by gas chromatography-mass spectrometry (GC-MS) (SIM) after an enzymatic hydrolysis (β-glucosidase) allowing the release of volatile compounds from yew glycosides.
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Affiliation(s)
- V Varlet
- University Center of Legal Medicine Lausanne-Geneva, CH-1011, Lausanne, Switzerland.
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