[Multidisciplinary management of voluntary pink oleander poisoning: How to estimate the quantities ingested?] / Prise en charge multidisciplinaire d'une intoxication volontaire au laurier rose : comment estimer les quantités ingérées ?

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.

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.

A case of Mobitz type II atrioventricular block due to Nerium oleander poisoning successfully managed with digoxin-specific Fab antibody fragments.

Nerium oleander is a popular ornamental plant grown in many tropical and subtropical countries and in the Mediterranean region. It is dangerous because it has been shown to contain several types of cardiac glycosides, and hence can cause cardiac arrhythmias resembling digoxin in their toxicologic manifestations. We report a patient presenting to our hospital with Mobitz type II atrioventricular block after drinking herbal tea prepared from oleander leaves. Three hours after admission, a 200-mg empiric dose of digoxin-specific Fab antibody fragments was administered intravenously over 30 minutes. A 12-lead electrocardiogram (ECG) revealed sinus rhythm at the end of infusion. After 72 hours, the patient was discharged without any symptoms.

Eating seeds from the 'be still' tree, yet having lucky nut poisoning: a case of acute yellow oleander poisoning.

A 25-year-old woman was evaluated and treated for ingestion of Thevetia peruviana seeds and flower petals-a natural digoxin cross reacting cardinolide-with intent to cause self-harm. The following case report provides the clinical presentation, treatment and management of acute yellow oleander poisoning.

Manifestaciones neurológicas por intoxicación por adelfa / Oleander intoxication: Neurologic manifestations

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False positivity of gamma-glutamyl transpeptidase measurement in urine.

Although enzymuria tends to be associated to renal injury, there are no studies that have evaluated the presence of the enzyme gamma-glutamyl transpeptidase (GGT) spectrophotometry in the urine using a non-nephrotoxic agent (Nerium oleander) in order to evaluate the possibility of false positive results. The urinary GGT/urinary creatinine concentration ratio (uGGT/uCr) of 10 healthy dogs was calculated and posteriorly confronted with data from clinical evaluation, hematological and serum biochemical profiles, creatinine clearance (CrC), urinalysis, urine protein/creatinine ratio (UPC), electrocardiogram, systemic blood pressure (SBP) and light and electron microscopy. The results for kidney histology, SBP, UPC and CrC were not significantly different in any of the time-points analyzed. However, uGGT/uCr was significantly higher when measured 4 hours and 24 hours after administration of N. oleander. The measurement of the urinary GGT enzyme, as performed in many studies, yielded false positive results in dogs poisoned by a non-nephrotoxic agent.

A bittersweet story: the true nature of the laurel of the Oracle of Delphi.

It is known from ancient sources that "laurel," identified with sweet bay, was used at the ancient Greek oracle of Delphi. The Pythia, the priestess who spoke the prophecies, purportedly used laurel as a means to inspire her divine frenzy. However, the clinical symptoms of the Pythia, as described in ancient sources, cannot be attributed to the use of sweet bay, which is harmless. A review of contemporary toxicological literature indicates that it is oleander that causes symptoms similar to those of the Pythia, while a closer examination of ancient literary texts indicates that oleander was often included under the generic term laurel. It is therefore likely that it was oleander, not sweet bay, that the Pythia used before the oracular procedure. This explanation could also shed light on other ancient accounts regarding the alleged spirit and chasm of Delphi, accounts that have been the subject of intense debate and interdisciplinary research for the last hundred years.

Prophylactic and therapeutic effects of garlic extract on Nerium oleander-induced arrhythmia: a new approach to antiarrhythmic therapy in an ovine model.

CONTEXT: Oleander is a potent cardiotoxic plant and is a common cause of poisoning in human and animals. There is no affordable and cost-effective treatment for oleander poisoning. Objective. To evaluate the prophylactic and therapeutic effects of garlic extract (Allium sativum) on Nerium oleander (a potent cardiotoxic plant) intoxication in sheep. MATERIALS AND METHODS: Eight sheep were intravenously infused with an unsterilized hydro-ethanol extract of garlic (50 mg/kg) before or after receiving a lethal dose of dried leaves (as a powder) of oleander (100 mg/kg, orally). The cardiac rhythm was continuously monitored using biopotential wireless transmitters and telemetry system. For evaluation of therapeutic effects, six sheep received the lethal dose of oleander and were administered with garlic extract after development of cardiac arrhythmias. Subsequently, the survived animals from the therapeutic study (four sheep) were administered with oleander without receiving any medication. Some blood constituents, including total antioxidant capacity, malondialdehyde, and troponin I, were compared between treated and untreated animals. RESULTS: Pretreatment with garlic extract reversed the arrhythmia caused by oleander to its previous normal rhythm in seven sheep, but, one sheep died of ventricular fibrillation. On therapeutic treatment, four sheep survived while two died of ventricular fibrillation. Dosing with oleander without receiving garlic extract resulted in death of all sheep due to ventricular fibrillation. Blood constituents did not show any significant changes between treated and untreated sheep, and before and after intoxication. CONCLUSIONS: Garlic extract reduced the case fatality from 100% to 12.5% and 33.3% as a prophylactic or therapeutic agent, respectively. Additionally, garlic extract delayed the time of onset of arrhythmias and prolonged the interval between intoxication and death of the animals. Garlic extract could be considered to be a potential and affordable antidote in oleander poisoning. However additional studies with a larger sample size and in other species need to be performed to confirm the results in this study.

Oleander toxicosis in equids: 30 cases (1995-2010).

OBJECTIVE: To determine clinical, laboratory analysis, and necropsy findings for equids with oleander toxicosis and to identify factors associated with outcome. DESIGN: Retrospective case series. ANIMALS: 30 equids. PROCEDURES: Medical records of equids with detectable concentrations of oleandrin in serum, plasma, urine, or gastrointestinal fluid samples and equids that had not received cardiac glycoside drugs but had detectable concentrations of digoxin in serum were identified via a medical records database search. Descriptive statistics were calculated for medical history, physical examination, laboratory analysis, and necropsy variables. Logistic regression analysis was used to identify physical examination and laboratory analysis factors significantly associated with outcome. RESULTS: 3 of 30 (10.0%) equids died before or immediately after arrival at the hospital. Of the other 27 equids, 23 (85.2%) had gastrointestinal tract abnormalities, azotemia was detected for 19 (70.4%), and a cardiac arrhythmia was ausculted for 18 (66.7%). Mortality rate for all equids was 50.0%; mortality rate for hospitalized equids was 44.4%. The most common cause of death was cardiac dysfunction. Odds of survival to discharge from the hospital were lower for equids with cardiac arrhythmias versus those without arrhythmias and decreased with increasing Hct and serum glucose concentrations. Odds of survival increased with increasing serum chloride concentration and duration of hospitalization. CONCLUSIONS AND CLINICAL RELEVANCE: Equids with oleander toxicosis frequently had simultaneous gastrointestinal tract, cardiac, and renal problems. Oleander intoxication should be a differential diagnosis for equids with colic in geographic areas where oleander is found, especially when azotemia or cardiac arrhythmias are detected concurrently.

Applied clinical pharmacology and public health in rural Asia--preventing deaths from organophosphorus pesticide and yellow oleander poisoning.

Self-poisoning with pesticides or plants is a major clinical problem in rural Asia, killing several hundred thousand people every year. Over the last 17 years, our clinical toxicology and pharmacology group has carried out clinical studies in the North Central Province of Sri Lanka to improve treatment and reduce deaths. Studies have looked at the effectiveness of anti-digoxin Fab in cardiac glycoside plant poisoning, multiple dose activated charcoal in all poisoning, and pralidoxime in moderate toxicity organophosphorus insecticide poisoning. More recently, using a Haddon matrix as a guide, we have started conducting public health and animal studies to find strategies that may work outside of the hospital. Based on the 2009 GSK Research in Clinical Pharmacology prize lecture, this review shows the evolution of the group's research from a clinical pharmacology approach to one that studies possible interventions at multiple levels, including the patient, the community and government legislation.

Experimental oleander (Nerium oleander) intoxication in broiler chickens (Gallus gallus).

Dried leaves of oleander were orally given at a single dose of 500 mg/kg body weight to 20 clinically healthy male chickens. Clinical signs of toxicosis began to appear about 1 h after receiving the oleander and included hypersalivation, vomiting, diarrhea, deep depression, and sudden death. Also, hyperemia in the combs and wattles was obviously seen. Electrocardiograms (ECG) were repeatedly recorded at 30 min intervals. ECGs findings included increasing the QRS duration in some birds and various kinds of arrhythmias. Bradycardia was the most frequently detected finding (30.43%). During necropsy, there were congestion and hemorrhages in the visceral organs particularly in heart, liver, kidney, and lung. Histopathology revealed myocardial cell necrosis with hyperemia and hemorrhage, severe diffuse pulmonary congestion and edema, severe renal congestion and hemorrhage with tubular necrosis, and coagulative necrosis of hepatocytes with hyperemia and hemorrhage. There were also congestion, mild epithelial necrosis and desquamation with infiltration of mononuclear inflammatory cells in the proventriculus of all birds. There was also mild to moderate congestion in the intestines with scattered necrosis of surface enterocytes. The lack of information about the toxicity of oleanders in poultry was the main cause for this study. The results suggest that chickens appear to respond to oleander poisoning in a manner similar to other species.

Unexpected double lethal oleander poisoning.

Nerium oleander is a very popular urban ornamental plant in Europe, but it is also extremely dangerous because it contains several types of glycosides, accidental ingestion of which can cause cardiac arrhythmias and even deaths. The rarity of such cases makes it difficult to think of oleander poisoning without evidences that suggest this possibility as the cause of the unexpected death. This report concerns the discovery of the bodies of 2 young people, a man and a woman, in a forest in conditions of extreme malnutrition. Medicolegal investigations showed neither pathologic nor traumatic causes of death, but the presence of vegetal remains in the stomach was noticed. A common toxicological analysis resulted negative, but the implementation of more detailed investigations showed the presence of digoxin in the blood of both cadavers, excluding the possibility of a pharmaceutical provenience of digoxin, this laboratory result was interpreted as evidence of ingestion of oleander, which contains oleandrine, the cross reaction of which with digoxin is widely described in the literature. Identification of the 2 subjects, which occurred after 4 years, strengthened the hypothesis of accidental poisoning by oleander because it was ascertained that the 2 young people were vegans--extreme vegetarians who reject the ingestion of foods of animal origin and live by eating only what they find in nature.