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Our new case report in @jem_journal:
"Fatal Yellow Oleander Poisoning Masquerading as Benign Candlenut Ingestion Taken for Weight Loss" https://authors.elsevier.com/c/1cDE22dT1CnqEB#.X9Iqdq3YQlM.twitter
"Fatal Yellow Oleander Poisoning Masquerading as Benign Candlenut Ingestion Taken for Weight Loss" https://authors.elsevier.com/c/1cDE22dT1CnqEB#.X9Iqdq3YQlM.twitter
Candlenuts (Aleurites moluccanus) are purported to aid in weight loss. The mechanism is dubious, but actual candlenuts are probably benign.
Candlenuts contain phorbol esters and saponins, which are basically just mild GI toxins (vomiting, diarrhea, etc.)
Candlenuts contain phorbol esters and saponins, which are basically just mild GI toxins (vomiting, diarrhea, etc.)
Yellow Oleander (Thevetia peruviana) is also purported to cause weight loss (also dubious).
In contrast to candlenuts, Yellow Oleander contains the potent cardiac glycosides thevetin and peruvoside. Ingestion of as few as two seeds can cause fatal poisoning.
In contrast to candlenuts, Yellow Oleander contains the potent cardiac glycosides thevetin and peruvoside. Ingestion of as few as two seeds can cause fatal poisoning.
Yellow Oleander is such a potent poison that in some parts of the world it is one of the most common methods of suicide. https://pubmed.ncbi.nlm.nih.gov/12932405/
Unfortunately, both of these two "seeds" look very similar.
They are both also sometimes (perhaps erroneously) referred to by the common name "nuez de la India."
They are both also sometimes (perhaps erroneously) referred to by the common name "nuez de la India."
Because they are both purported to cause weight loss, and look similar, one may be substituted for the other.
This substitution (whether it is intentional or not) has occurred at least since 2011. https://www.productsafety.gov.au/recall/lumsden-health-products-pty-ltd-also-trading-under-balanced-opinion-pty-ltd-and-lsm-pty-ltd-the-latin-seed
This substitution (whether it is intentional or not) has occurred at least since 2011. https://www.productsafety.gov.au/recall/lumsden-health-products-pty-ltd-also-trading-under-balanced-opinion-pty-ltd-and-lsm-pty-ltd-the-latin-seed
As such, a patient thinking they are taking a benign "natural weight loss supplement" could easily inadvertently ingest a fatal dose of Yellow Oleander if this substitution is made. We believe this is what occurred in our case.
The learning point from our case is that when a patient presents with evidence of cardiac glycoside poisoning after ingesting a "natural weight loss" agent (especially if "candlenuts" or "nuez de la India" are mentioned), immediately consider the usual indications for DigiFab.
One last important point - it's probably wise to use the usual indications for DigiFab for Yellow Oleander, but not the usual dose.
Yellow Oleander is a bit different than digoxin in that it likely needs a larger dose of DigiFab - as many as 20-30 vials. https://pubmed.ncbi.nlm.nih.gov/10768435/
Yellow Oleander is a bit different than digoxin in that it likely needs a larger dose of DigiFab - as many as 20-30 vials. https://pubmed.ncbi.nlm.nih.gov/10768435/
This can be a real problem because the average wholesale price of DigiFab is about $4,500/vial (an almost 10-fold increase over the last 10 years). This cost, combined with new evidence that digoxin poisoning might not need full reversal, has led hospitals to stock fewer vials.
Therefore, if such a patient arrives and DigiFab is indicated, plans for acquisition of additional vials should be enacted immediately. Coordination with your pharmacy is key.
Very last point - if enough DigiFab cannot be rapidly obtained, remember cardiac glycoside poisoning can be treated with extreme measures, such as ECMO. https://pubmed.ncbi.nlm.nih.gov/32697480/
TL:DR
sick "candlenuts" patients are probably occult Yellow Oleander, use DigiFab in higher doses, consider ECMO as a final bail-out
sick "candlenuts" patients are probably occult Yellow Oleander, use DigiFab in higher doses, consider ECMO as a final bail-out
Thanks to co-authors @J_Corky @StaceyBangh and everyone at @MNpoisoncenter who made this paper happen.
