Fatal Yellow Oleander Poisoning Masquerading as Benign Candlenut Ingestion Taken for Weight Loss.

BACKGROUND: Candlenuts (Aleurites moluccana) and yellow oleander seeds (Thevetia peruviana) bear a physical resemblance to one another. Candlenuts are benign and marketed as weight loss supplements. Yellow oleander seeds, however, contain toxic cardioactive steroids; as few as 2 seeds may cause fatal poisoning. Because of their physical similarities, the potential for a lethal substitution exists. CASE REPORT: A 63-year-old woman presented to the emergency department with vomiting after ingesting 5 of what she believed to be candlenuts that were ordered online under the colloquial name "Nuez de la India" for the purpose of weight loss. She was bradycardic (nadir pulse of 30 beats/min) and hyperkalemic (serum potassium 7.3 mEq/L). Within hours of presentation she suffered a ventricular fibrillation arrest, followed by a terminal asystolic arrest. Postmortem analyses of liver tissue and the seeds were consistent with fatal T. peruviana poisoning. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: T. peruviana seeds contain toxic cardioactive steroids; their physical resemblance to candlenuts poses a risk of potentially fatal substitution. Therapy with high-dose digoxin specific immune fragments (20-30 vials) may be helpful.

Unintentional ingestion of bupropion in children.

BACKGROUND: The incidence of seizures after unintentional bupropion ingestion in children aged < 6 years has been reported as 0.2%. However, in many poison centers, > 80% of these patients are referred to the Emergency Department (ED) for evaluation. OBJECTIVE: To evaluate if all unintentional pediatric bupropion ingestions require referral to a health care facility (HCF), or what fraction of these could be managed safely at home. METHOD: A retrospective chart review was conducted of all bupropion ingestions in children aged < 6 years for 2000-2006 from four regional poison centers. Exclusion criteria were lack of follow-up or multiple drug ingestion. RESULTS: Of 407 patients, 209 (51%) were male. Mean age was 2.2 years (SD +/- 1.0). There were 329 patients (81%) seen in a HCF, of which 143 (35%) were hospitalized; 77 patients (19%) were observed at home. Symptoms occurred in 73 patients (18%): sinus tachycardia (n = 50), nausea/vomiting (n = 32), hyperactivity (n = 17), seizure (n = 3), hallucinations (n = 2), and hypertension (n = 2). The mean heart rate of patients with sinus tachycardia (n = 50, 12.3%) was 137 beats/min (SD +/- 13), with a range of 112-172 beats/min. Mean dosage of those with tachycardia was 24 mg/kg. In the 2 patients with hypertension, the maximum recorded blood pressures were 145/80 mm Hg (2-year-old boy) and 137/90 mm Hg (2-year-old girl), with heart rates of 122 and 125 beats/min, respectively. Dose ingested and patient weight was known for 218 patients. Mean dosage ingested was 12.2 mg/kg, with a range of 2.6-64 mg/kg. Eighty-eight percent of patients with a known dosage ingested < 20 mg/kg. DISCUSSION: A high percentage of children continue to be seen in a HCF. Concern from the higher incidence of severe effects seen with intentional adult exposures may be one of the reasons for this cautious approach. CONCLUSION: Unintentional pediatric bupropion ingestions resulted in clinical effects that rarely required any HCF intervention. Isolated unintentional bupropion ingestion of