Feud, Flower, and Fatal Electrocardiograms.

Oleander is a prevalent tropical plant used in many parts of India for deliberate self-harm. The active ingredients act in a mechanism similar to cardiac glycosides; hence, the toxicological profile is similar to digoxin toxicity. Cardiac toxicity occurs in the form of a heart block with concomitant ventricular arrhythmia. Identifying the distinct electrocardiographic pattern for early diagnosis and initiating emergency management is imperative. Here, we present two such interesting cases of oleander intoxication, one with Nerium oleander and the other with Thevetia peruviana.

Endogenous Digitalis-like Factors as a Key Molecule in the Pathophysiology of Pregnancy-Induced Hypertension and a Potential Therapeutic Target in Preeclampsia.

Preeclampsia (PE), the most severe presentation of hypertensive disorders of pregnancy, is the major cause of morbidity and mortality linked to pregnancy, affecting both mother and fetus. Despite advances in prophylaxis and managing PE, delivery of the fetus remains the only causative treatment available. Focus on complex pathophysiology brought the potential for new treatment options, and more conservative options allowing reduction of feto-maternal complications and sequelae are being investigated. Endogenous digitalis-like factors, which have been linked to the pathogenesis of preeclampsia since the mid-1980s, have been shown to play a role in the pathogenesis of various cardiovascular diseases, including congestive heart failure and chronic renal disease. Elevated levels of EDLF have been described in pregnancy complicated by hypertensive disorders and are currently being investigated as a therapeutic target in the context of a possible breakthrough in managing preeclampsia. This review summarizes mechanisms implicating EDLFs in the pathogenesis of preeclampsia and evidence for their potential role in treating this doubly life-threatening disease.

Digoxin-specific antibody fragments for the treatment of suspected Nerium oleander toxicosis in a cat.

CASE SUMMARY: A 6-year-old castrated male domestic shorthair cat presented for lethargy and gastrointestinal signs after possible exposure to Nerium oleander leaves. The cat developed a ventricular arrhythmia that responded positively to the administration of digoxin-specific antibody fragments. Underlying hypertrophic cardiomyopathy was also diagnosed after the development of congestive heart failure. Humane euthanasia was elected owing to a lack of significant response to continued therapy. RELEVANCE AND NOVEL INFORMATION: To our knowledge, this is the first report to describe the use of digoxin-specific antibody fragments in a cat. Nerium oleander toxicosis is associated with significant morbidity and mortality, and digoxin-specific antibody fragments have been used effectively in humans and animals. The development of cardiac necrosis may have contributed to worsening arrhythmias and highlights the importance of early intervention. The use of digoxin-specific antibody fragments for suspected N oleander toxicosis in a cat resulted in a rapid response and appeared to be well tolerated.

Rare Manifestation of Digoxin Toxicity: Right Bundle Branch Block.

A 76-year-old female, with medical history significant for systolic congestive heart failure, who presented to the emergency department with lethargy and abdominal pain with diarrhea for the past 3 weeks. Due to hypotension, the patient received multiple boluses of isotonic saline and was started on norepinephrine. Laboratories were significant for severe digoxin toxicity (29 ng/mL), in setting of acute kidney injury. Electrocardiogram (EKG) revealed a new right bundle branch block (RBBB). She was given Digibind and her repeat digoxin level was 20 ng/mL. Repeat EKG showed resolved RBBB. This case identifies that patients with digoxin toxicity are at risk for RBBB. This is a rare finding and is not commonly recognized. Emergency medicine physicians are often the first to encounter patients with digoxin toxicity and need to be aware of such EKG findings.

Rapid detection of the active cardiac glycoside convallatoxin of lily of the valley using LOCI digoxin assay.

OBJECTIVES: To explore the luminescent oxygen channeling technology-based digoxin immunoassay (LOCI digoxin assay) for rapid detection of lily of the valley extract and convallatoxin. The potential in vitro binding of convallatoxin with Digibind was also evaluated. METHODS: Aliquots of a drug-free serum pool and a digoxin serum pool were supplemented with lily of the valley extract or convallatoxin, and then apparent digoxin concentrations were measured using the LOCI digoxin assay. Mice were administered lily of the valley extract or 50 µg of convallatoxin, and digoxin concentrations in serum specimens were measured 1 and 2 hours after gavage. Aliquots of a serum pool supplemented with convallatoxin or lily of the valley extract were further supplemented with various concentrations of Digibind and free apparent digoxin concentrations were measured. RESULTS: Apparent digoxin concentrations were observed when aliquots of a drug-free serum pool were supplemented with convallatoxin or lily of the valley extract, and also with convallatoxin or herbal extract. Bidirectional interference of convallatoxin and lily of the valley extract with serum digoxin measurement using the LOCI assay was also observed. Digibind was capable of binding convallatoxin in vitro. CONCLUSIONS: LOCI digoxin assay can be used for rapid detection of convallatoxin, and Digibind can bind convallatoxin in vitro.

Digoxin antibody fragment, antigen binding (Fab), treatment of preeclampsia in women with endogenous digitalis-like factor: a secondary analysis of the DEEP Trial.

OBJECTIVE: Endogenous digitalis-like factors (EDLFs) are elevated in women with preeclampsia, and the use of an anti-digoxin antibody Fab (DIF) in women with preeclampsia who were remote from term reduced maternal blood pressure and preserved renal function. The objective was to determine whether DIF treatment in women with severe preeclampsia in association with positive EDLFs in maternal serum improves maternal-perinatal outcomes. STUDY DESIGN: This was a planned secondary analysis from a randomized, placebo-controlled, double-blind study of DIF in women with severe preeclampsia with positive EDLF status that was managed expectantly between 23 weeks 5 days and 34 weeks' gestation (19 women received placebo, and 17 women received DIF). Primary outcome variables were a change in creatinine clearance and the use of antihypertensives. Secondary outcomes were maternal and perinatal complications. RESULTS: Women with positive EDLFs who received DIF had an attenuated decline in creatinine clearance from baseline compared with placebo (-4.5 ± 12.9 vs -53.2 ± 12.6 mL/min; P = .005). In this same group, the use of antihypertensives (the other primary outcome) was lower but not significantly so (41% vs 63%; P = .12). However, women who were treated with DIF had a lower rate of pulmonary edema (1/17 vs 6/19 women; P = .035) and lower rates of neonatal intraventricular hemorrhage (DIF: 0/17 women vs placebo: 5/19 women; P = .015). CONCLUSION: In women with severe preeclampsia who were remote from term who were EDLF positive, the use of DIF was associated with improved maternal and neonatal outcome. These findings suggest the need for a large multicenter trial that would evaluate the benefits of DIF in the treatment of women with severe preeclampsia who are remote from term and with positive EDLF status.