title: Cardioactive steroid poisoning from an herbal cleansing preparation.
abstract: We describe a case of unintentional poisoning from a cardioactive steroid and the subsequent analytic investigation. A 36-year-old woman with no past medical history and taking no conventional medications ingested an herbal preparation marketed for "internal cleansing." Its ingredients were neither known to the patient nor listed on the accompanying literature. The next morning, nausea, vomiting, and weakness developed. In the emergency department, her blood pressure was 110/60 mm Hg, and her pulse rate was 30 beats/min. Her ECG revealed a junctional rhythm at a rate of 30 beats/min and a digitalis effect on the ST segments. After empiric therapy with 10 vials of digoxin-specific Fab (Digibind), her symptoms resolved, and she reverted to a sinus rhythm at a rate of 68 beats/min. Her serum digoxin concentration measured by means of the fluorescence polarization immunoassay (Abbott TDx) was 1.7 ng/mL. Further serum analysis with the Tina Quant digoxin assay, a more digoxin-specific immunoassay, found a concentration of 0.34 ng/mL, and an enzyme immunoassay for digitoxin revealed a concentration of 20 ng/mL (therapeutic range 10 to 30 ng/mL). Serum analysis by means of high-performance liquid chromatography revealed the presence of active digitoxin metabolites; the parent compound was not present. When the diagnosis of cardioactive steroid poisoning is suspected clinically, laboratory analysis can confirm the presence of cardioactive steroids by using immunoassays of varying specificity. An empiric dose of 10 vials of digoxin-specific Fab might be beneficial in patients poisoned with an unknown cardioactive steroid.
authors.affiliation: Department of Emergency Medicine, New York University School of Medicine and the New York City Poison Control Center, 455 First Avenue, Room 123, New York, NY 10016, USA. fbarrueto@hotmail.com
authors.forename: Fermin
authors.initials: F
authors.lastname: Barrueto
authors.forename: Saeed A
authors.initials: SA
authors.lastname: Jortani
authors.forename: R
authors.initials: R
authors.lastname: Valdes
authors.forename: Robert S
authors.initials: RS
authors.lastname: Hoffman
authors.forename: Lewis S
authors.initials: LS
authors.lastname: Nelson
mesh_terms: D000328:Adult; D001919:Bradycardia / Q000139:chemically induced*; D002301:Cardiac Glycosides / Q000506:poisoning*; D019587:Dietary Supplements / Q000506:poisoning*; D004077:Digoxin / Q000506:poisoning; D004562:Electrocardiography / Q000187:drug effects; D005260:Female; D006801:Humans; D007008:Hypokalemia / Q000139:chemically induced*; D007140:Immunoglobulin Fab Fragments / Q000627:therapeutic use; D018908:Muscle Weakness / Q000139:chemically induced; D009325:Nausea / Q000139:chemically induced; D028321:Plant Preparations / Q000506:poisoning*; D016896:Treatment Outcome; D014839:Vomiting / Q000139:chemically induced
chemical_list: D002301:Cardiac Glycosides; D007140:Immunoglobulin Fab Fragments; D028321:Plant Preparations; C050199:digoxin antibodies Fab fragments; D004077:Digoxin