Background: Yellow oleander (Thevetia peruviana) is known to contain the cardioactive steroid thevetin which inhibits cellular Na /K - ATPase. Ingestions of yellow oleander are most commonly reported in cases of intentional self-harm in Southeast Asia. Brady- and tachydysrhythmias are the manifestations of life threatening cardiotoxicity. We report a case of cardiotoxicity following ingestion of a fragment of yellow oleander seed purchased in the United States from a natural practitioner treating for weight loss in the Mexican community. Case: A 30-year-old Hispanic female presented to the Emergency Department with vomiting and diarrhea nine hours after ingesting part of a nut. This nut was identified by the patient and obtained at a Mexican herbal store for constipation and weight loss. The patient was noted to have sinus bradycardia with heart rate 30 . 60 beats per minute (bpm), occasional premature supraventricular complexes, and hypotension with systolic blood pressure (SBP) 70 . 80 mmHg. Her electrocardiogram had QRS and QTc of normal duration and did not show ST segment changes typical of cardiac glycoside toxicity. She was not found to have electrolyte abnormalities. Digoxin concentration was 0.3 ng/mL, however the assay used at our institution is not known to cross-react with other cardioactive steroids found in plants. She was treated with intravenous fluids and repositioning. She was then admitted to the Medical Intensive Care Unit (MICU). She received one dose of activated charcoal with sorbitol. The patient did not require atropine or cardiac pacing. Digoxin-specific antibody fragment administration was deferred, as the patient tolerated the bradycardia and she improved to SBP 120 . 140 after fluid administration. The patient was observed in the MICU for 36 hours and did not suffer additional arrhythmias. She was discharged in sinus rhythm with a pulse of 79 bpm and BP of 120/74, asymptomatic. Case discussion: Manifestations of yellow oleander ingestion include abdominal pain, vomiting, diarrhea, and a variety of dysrhythmias. Activated charcoal reduces systemic absorption of thevetin and enhances elimination by interfering with enterohepatic circulation. Severe yellow oleander toxicity has been treated successfully with digoxin-specific antibody fragments, though in this case they were not necessary. Conclusions: Consumption of Yellow oleander, which contains the cardioactive steroid thevetin, is well documented to cause lethal dysrhythmias, especially in suicidal ingestion. Clinicians should note that its seed is marketed as a weight loss supplement and laxative in certain Latino communities with potential toxicity as illustrated by this case.
