Crataegus mexicana overdose
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Various toxicities: case report A 16-year-old girl developed multiple toxicities, including nausea, vomiting, diarrhoea, drowsiness, dizziness, altered mental status, falsely elevated digoxin levels, respiratory depression in the form of bradypnoea, and cardiotoxicity, involving sinus bradycardia, prolonged PR interval, Mobitz type-1 second-degree atrioventricular (AV) block and dysrhythmia after ingesting an overdose of her mother’s Crataegus mexicana, in an attempt to loose weight. The girl presented to a hospital about 8 hours after consuming eight pieces of her mother’s Crataegus mexicana [Tejocote] root weight-loss supplement in an attempt to lose weight [exact ingested dose not stated]. She developed nausea, vomiting and diarrhoea, accompanied by drowsiness after waking up due to discomfort. At the time of the presentation, she was afebrile, normotensive and had normal respirations, with a PR of 57 bpm. Her blood chemistries were significant for an elevated digoxin assay; however, her potassium levels were normal. She and her family denied access to or ingesting digoxin. She exhibited bradycardia (HR 38 bpm) and bradypnoea (RR 4 breaths/min), with intermittent desaturations to 70% during sleep (respiratory depression). The girl received oxygen by a nasal cannula, after which her bradypnoea and saturation improved. ECG revealed sinus bradycardia with prolongation of PR interval. Therefore, she was transferred to another hospital for further evaluation and monitoring. Upon arrival to the other hospital, about 18 hours after ingestion, she reported persistent drowsiness, with dizziness on standing. Physical examination was non-focal. ECG revealed severe bradycardia with Mobitz type-1 second-degree AV block. After consultation with the regional poison control centre and a discussion with her, it was suspected that she had ingested digoxin. However, it was also possible that the substance she consumed was structurally similar to digoxin, since it cross-reacted with the digoxin immunoassay and appeared to exert a similar toxicity. Therefore, she received two vials of anti-digoxin polyclonal antibody [Digoxin Immune Fab] as an antidote, because of her severe bradycardia; however, her HR did not improve, and her dysrhythmia did not normalise. Therefore, she was admitted to the paediatric ICU for observation. Additional doses of the antidote were withheld due to the perceived futility and its high cost. About 29 hours after ingestion, ECG returned to normal sinus rhythm. Her subsequent hospital course was uneventful. Her bradycardia resolved about 3 days after ingestion, and she was subsequently discharged in a stable condition. Palmer KG, et al. Crataegus mexicana (Tejocote) Exposure Associated with Cardiotoxicity and a Falsely Elevated Digoxin Level. Journal of Medical Toxicology - official 803498540 journal of the American College of Medical Toxicology 15: 295-298, No. 4, Oct 2019. Available from: URL: http://doi.org/10.1007/s13181-019-00727-w
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