[A poisonous spring smoothie with wild herbs: accidental intoxication with foxglove (Digitalis purpurea)]. / Een giftige lente-smoothie van wilde kruiden.

BACKGROUND: At a time when self-sufficiency and health are becoming increasingly important in society, the chances of intoxications with wild plants are increasing. Foxglove contains poisonous cardiac glycosides such as digoxin, digitoxin and gitoxin. The levels vary greatly and depend on the season and the location of the plants. The "non-digoxin" cardiac glycosides show a limited cross-reaction with the digoxin assay. This means that a low or therapeutic digoxin level does not rule out a severe foxglove intoxication. Due to the long half-life of the different cardiac glycosides, toxic symptoms can be persistent. CASE DESCRIPTION: A 43-year-old woman arrived at the Emergency Department with persistent vomiting and specific ECG-abnormalities. The day before, she drunk a smoothie made from wild plants picked in the woods. Patient appeared to have mistaken foxglove for common sorrel. CONCLUSION: In case of persistent gastrointestinal complaints with specific ECG abnormalities after ingestion of plant material, clinicians should be aware of a foxglove intoxication.

[Vincent Van Gogh and Giovanni Pascoli, foiled by the foxglove.] / Il giallo digitale di Van Gogh e Pascoli.

Vincent Van Gogh and Giovanni Pascoli were artists who shared many aesthetic and biographical affinities. Both were somehow intoxicated by digitalis, the painter literally in a pharmacological sense, the poet symbolically or in a literary sense. In the paper we propose an original theory on how digital affected the last works of the Dutch painter and in particular the portrait of doctor Gachet, which differs from the previous theories, that attribute the chromatic style of Van Gogh to the xanthopsia caused by digitalis overdose. The Italian poet dedicated a short poem to the Foxglove, inspired by the popular wisdom that centuries ago already recognized the poisonous power of Foxglove.

Alternans during fascicular ventricular tachycardia due to digitalis toxicity.

This report describes a digitalis-induced regular fascicular ventricular tachycardia characterized by marked QRS alternans a manifestation not usually associated with this arrhythmia. The striking alternation of QRS configuration suggested alternating ventricular activation from either a single focus with two exits in distal branches of the left anterior fascicle or 2 different foci localized in the Purkinje-myocardial network of the left anterior fascicle.

Fatal cardiac glycoside poisoning due to mistaking foxglove for comfrey.

CONTEXT: Accidental ingestion of foxglove (Digitalis purpurea) can cause significant cardiac toxicity. We report a patient who ingested foxglove mistaking it for comfrey and developed refractory ventricular arrhythmias. The patient died despite treatment with digoxin-specific antibody fragments (DSFab) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). CASE DETAILS: A 55-year-old woman presented to the emergency department with nausea, vomiting and generalized weakness eight hours after drinking "comfrey" tea. She had bradycardia (54 beats/min) and hyperkalemia (7.6 mEq/L). Electrocardiogram revealed a first-degree atrioventricular conduction block with premature atrial contractions, followed by polymorphic ventricular tachycardia three hours after arrival. A serum digoxin level was 151.2 ng/mL. The patient developed ventricular fibrillation while waiting for Digibind infusion. Resuscitation was performed and an emergent VA-ECMO was set up. A total of eight vials of Digibind were given over the next 16 hours. She temporarily regained consciousness, but remained hemodynamically unstable and subsequently developed lower limb ischemia and multiple organ failure, and she expired on hospital day seven. A botanist confirmed that the plant was foxglove. CONCLUSIONS: The diagnosis of cardiac glycoside plant poisoning can be difficult in the absence of an accurate exposure history. In facilities where DSFab is unavailable or insufficient, early VA-ECMO might be considered in severely cardiotoxic patients unresponsive to conventional therapy.

Comfrey herbal remedy causing second-degree heart block: do not be outfoxed by digitalis.

A previously well woman aged 63 years presents to the emergency department with vomiting, palpitations and 3 presyncopal episodes. She had no previous medical or cardiac history, with the patient stating that she tried a herbal remedy of boiled comfrey leaves for insomnia 18 hours before arrival to the department. Her ECG showed multiple abnormalities, including bradycardia, second-degree atrioventricular node block, Mobitz Type 2, a shortened QT interval, downsloping ST depression and presence of U waves. After viewing the images of comfrey and foxglove, it highlighted the possibility of mistaken ingestion of Digitalis, containing the organic forms of cardiac glycosides, such as digoxin and digitoxin. Raised serum digoxin levels confirmed this. The patient was haemodynamically stable, and given digoxin-binding antibodies. After 5 days of cardiac monitoring, her ECG returned to normal rhythm, and she was discharged home.

[Antidigitalis Fab-fragment for treating poisoning from a foxglove plant]. / Antidigitalis Fab-fragment til behandling af forgiftning med fingerbølplanten.

Plant poisonings are rare in Denmark, but can have fatal consequences. We present a case in which a woman went into cardiac arrest after having ingested leaves from the foxglove plant. Sinus rhythm was not restored until Digibind was administered. Literature in this field is sparse, but we conclude that the following advice can be given: 1) assessment of the degree of poisoning should be based on clinical features and changes of the electrocardiogram; 2) activated charcoal should be given; 3) in case of malignant arrhythmia or cardiac arrest, the use of Digibind should be considered.

Mixed intoxication with Aconitum nappellans (monkshood) and Digitalis grandiflora (large yellow foxglove).

BACKGROUND: Intoxications are frequent and relevant medical problems in emergency units. CASE REPORT: We report of a mixed intoxication with monkshood and large yellow foxglove. A 39-year-old mentally ill drug addict, intent on committing suicide, swallowed an undefined amount of chaffed monkshood and large yellow foxglove. The typical symptoms of an intoxication occurred, including high-grade ventricular and supraventricular tachyarrhythmias, colic abdominal pain, and peripheral paralysis. After activated charcoal was repeatedly administered as well as FAB digitalis-antibodies, a lasting normalisation of the heart rhythm set in and a release of the clinical symptoms could be observed. CONCLUSIONS: FAB antibodies are a safe antidote for herbal digitalis intoxication. Therapy of choice for an aconitum poisoning is activated charcoal and intensive monitoring.

An outbreak of foxglove leaf poisoning.

Comfrey (Symphytum officinale) leaves resemble those of foxglove (Digitalis purpurea) when the plant is not in bloom and, therefore, cardiac glycoside poisoning may occur when people confuse foxglove with comfrey. We report an outbreak of foxglove leaf poisoning following the use of alleged "comfrey" herbal tea. Nine patients were involved and initially presented with nausea, vomiting, diarrhea and dizziness. Significant cardiotoxicity developed later among the 3 patients who also had mild hyperkalemia. Peak serum digoxin concentration measured by immunoassay was elevated in all patients and ranged from 4.4 ng/mL to 139.5 ng/mL. Patients with severe cardiotoxicity were treated with temporary cardiac pacing. Moreover, 40-80 mg of digoxin-specific antibody therapy was given without any effect. All patients recovered uneventfully. Our report highlights the potential risk of misidentification of herbs; in this case, D. purpurea was mistaken for S. officinale. Physicians should be aware that cardiac glycoside poisoning could arise from such misidentification. Public education about the toxicity of D. purpurea poisoning may reduce the risk of misidentification and subsequent poisoning.

Bitter pill to swallow: a case of accidental poisoning with digitalis purpurea.

While digitoxicity secondary to therapeutic use is frequent, due to its distinctive appearance and unpleasant taste accidental ingestion of digitalis purpurea (foxglove) is uncommon. This report relates the case of two previously healthy individuals who inadvertently consumed significant quantities of digitalis in its plant form. Both men presented in first-degree atrioventricular block and had digoxin levels of 4.9 µg/litre, but were otherwise stable and made unremarkable recoveries with repeated dose activated charcoal.

Researching nature's venoms and poisons.

Our environment hosts a vast diversity of venomous and poisonous animals and plants. Clinical toxinology is devoted to understanding, preventing and treating their effects in humans and domestic animals. In Sri Lanka, yellow oleander (Thevetia peruviana, Sinhala 'kaneru'), a widespread and accessible ornamental shrub, is a popular means of self-harm. Its toxic glycosides resemble those of foxglove, against which therapeutic antibodies have been raised. A randomised placebo-controlled trial proved that this treatment effectively reversed kaneru cardiotoxicity. There are strong scientific grounds for the use of activated charcoal, but encouraging results with multiple-dose activated charcoal were not confirmed by a recent more powerful study. Venom of Russell's viper (Daboia siamensis) in Burma (Myanmar) produces lethal effects in human victims. The case of a 17-year-old rice farmer is described with pathophysiological interpretations. During the first 9 days of hospital admission he suffered episodes of shock, coagulopathy, bleeding, acute renal failure, local tissue necrosis, generally increased capillary permeability and acute symptomatic hypoglycaemia with evidence of acute pituitary/adrenal insufficiency. Antivenom rapidly restored haemostatic function but failed to correct other effects of venom toxins incurred during the 3h before he could be treated.

Capillary zone electrophoretic determination of cytochrome c in mitochondrial extracts and cytosolic fractions: Application to a digitalis intoxication study.

We describe a capillary zone electrophoretic procedure with photodiode-array detection for the determination of the apoptogenic protein cytochrome c in cytosolic fractions and mitochondrial extracts from guinea pig hearts. Optimal separation was achieved with a 100mM phosphates electrolyte solution at pH 2.05. The applied voltage was 25kV and the capillary temperature was kept constant at 25+/-0.5 degrees C. The method was linear over the concentration range of 0.2-600pM. All determination coefficients were higher or equal to 0.9989. Limits of detection and quantitation were 0.06pM (S/N=3) and 0.21pM (S/N=10), respectively. The present method offers a time-saving way to determine cytochrome c since it can be completed in 12min, compared to a time scale of days for Western blotting methods, or hours for ELISA-based methods. The procedure is illustrated by experiments that quantify cytochrome c released under control conditions and in a digitalis intoxication experimental animal model, in which cytochrome c content was successfully determined and was found to be (mean+/-standard deviation): control cytosol (0.48+/-0.01pM), digitalis-intoxicated cytosol (0.85+/-0.01pM), control mitochondria (1.11+/-0.1pM) and digitalis-intoxicated mitochondria (0.75+/-0.02pM). Recovery results ranged from 98.4 to 110.2%. Hence, the proposed analytical method could be useful to elucidate the digitalis intoxication mechanism as well as the role of cytochrome c in mediating apoptosis.