168 Türk Kardiyol Dern Arş - Arch Turk Soc Cardiol 2012;40(2):168-170 doi: 10.5543/tkda.2012.01703 Complete atrioventricular block after self-ingestion of Nerium oleander for relief of hemorrhoidal complaints Hemoroit yakınmaları nedeniyle zakkum kullanan bir hastada tam atriyoventriküler blok Zekeriya Küçükdurmaz, M.D., Hekim Karapınar, M.D., İbrahim Gül, M.D., Ahmet Yılmaz, M.D. Department of Cardiology, Medicine Faculty of Cumhuriyet University, Sivas Summary - Nerium oleander is a plant native only in Özet - Zakkum (Nerium oleander), her ne kadar Akdeniz the Mediterranean region, but it can also be cultivated bölgesine özgü bir bitki olsa da, bilhassa ılıman bölge- worldwide, particularly in warm areas. Biologically active lerde olmak üzere tüm dünyada yetiştirilebilir. Biyolojik oleander compounds may be used for therapeutic pur- olarak aktif olan oleander bileşenleri terapötik amaçlarla poses. However, when used for self-medication, it may kullanılabilmektedir. Ancak, bitkisel tedavi amaçlı kişisel cause serious problems including death. We present a kullanımı, ölüm dahil birçok ciddi soruna yol açabilir. Bu 30-year-old otherwise healthy man who developed com- yazıda, hemoroit yakınmaları nedeniyle kişisel bitkisel plete atrioventricular block after taking a syrup of N. ole- tedavi amacıyla zakkum yapraklarından hazırladığı şu- ander leaves for self-medication to relive hemorrhoidal rubu içtikten sonra tam atriyoventriküler blok gelişen, complaints. The patient was treated by oral administra- 30 yaşında, başka sağlık sorunu olmayan bir erkek has- tion of charcoal combined with sodium sulfate as well ta sunuldu. Hastaya sodyum sülfat ile birlikte ağızdan as electrolyte solutions and transient use of an external kömür tedavisi, elektrolit sıvı desteği ve geçici kalp pili cardiac pacemaker. The atrioventricular block reverted to tedavisi uygulandı. Atriyoventriküler blok 30 saat sonra sinus rhythm in 30 hours and he was discharged in good sinüs ritmine döndü ve hasta hemodinamik ve genel du- hemodynamic status and general condition. rumu düzelmiş şekilde taburcu edildi. erium oleander is an evergreen plant native only malaise, and lightheaded- Abbreviation: in the Mediterranean region, but it can also be ness. He had no history of AV Atrioventricular block cultivatedN worldwide, particularly in warm areas. Bio- cardiometabolic diseases logically active oleander compounds exhibit insecti- and was not on any medica- cidal, antimycotic, cardiac properties, and recently tion including negative inotropic agents. His heart rate have been proposed for oncologic therapeutic pur- was 35 bpm and blood pressure was 140/100 mmHg. poses.[1] Many people consider it useful and thus use it The rest of the cardiac examination and other system in the context of herbal therapy. However, it may also examinations were unremarkable. The electrocardio- have many side effects including cardiac effects that gram revealed complete atrioventricular block with may be lethal. We report on a patient who presented atrial fibroflutter (Fig. 1a). Laboratory findings in- to our hospital with bradycardia and atrioventricular cluding electrolytes, inflammation markers, liver en- block after usage of oleander leaves for treatment of zymes, creatinine, blood count, and cardiac enzymes hemorrhoid. were normal. Upon questioning the patient on the pos- sible etiology of the condition, he explained that, on CASE REPORT an advise of an herbalist to treat his hemorrhoid, he had drunk a homemade syrup of N. oleander leaves (a A 30-year-old man was admitted to our emergency mid-size package of leaves boiled in water) for eight service with nausea, vomiting, atypical chest pain, hours before admission. The patient was treated by oral Received: June 23, 2011 Accepted: December 2, 2011 Correspondence: Dr. Zekeriya Küçükdurmaz. Cumhuriyet Üniversitesi Tıp Fakültesi, Kardiyoloji Anabilim Dalı, 58140 Sivas, Turkey. Tel: +90 342 - 360 60 60 / 77513 e-mail: [email protected] © 2012 Turkish Society of Cardiology Complete atrioventricular block after self-ingestion of Nerium oleander for relief of hemorrhoidal complaints 169 A B Figure 1. (A) Admission electrocardiogram with complete atrioventricular block and atrial fibroflutter. (B) Normal sinus rhythm on the electrocardiogram on the day of discharge. administration of charcoal combined with sodium sul- glucosyloleandrin, gentiobiosyloleandrin, nerigoside, fate as well as electrolyte solutions. An external car- odorosides, oleasides) at various concentrations. A diac pacemaker was temporarily attached because of dose of 5 to 15 leaves of oleandrin may be lethal for the complete AV block and bradycardic episodes. The adults, but in children a single leaf may be lethal.[3] AV block reverted to sinus rhythm in 30 hours. The Parts of the plant can be ingested accidentally, used in patient’s hemodynamic status and general condition suicide attempts[4] or for therapeutical aims,[5] leading improved and he was discharged on Day 6. Delayed to oleander poisoning. The first signs are gastrointes- discharge was due to the close follow-up of atrial extra tinal discomfort, nausea, and vomiting, followed by systoles that occurred in decreasing frequency. At the neurological symptoms that include weakness, men- first follow-up visit 10 days later, he was free of car- tal confusion, and cardiac involvement that presents diac symptoms with normal sinus rhythm on the elec- as cardiac arrhythmias (atrial and ventricular ecto- trocardiogram (Fig. 1b). The patient was referred to pic arrhythmias) and conduction disturbances (sino- the gastroenterology department for his hemorrhoid. atrial and AV node conduction disturbances) usually manifesting as bradycardia which may progress to AV DISCUSSION block and asystole. In some cases, ectopic beats may be followed by ventricular tachycardia and fibrilla- Oleandrin was formerly used as a cardiac tonic and di- tion. The triad of gastrointestinal distress, circumoral uretic, and its extracts are still used in homeopathy.[2] erythema and cardiac dysrhythmia should alert to the N. oleander [6] All parts of this plant, including the sap, either fresh, possibility of poisoning. dried or boiled, are toxic. Oleander leaves and seeds Nerium oleander produces typical clinical signs of contain more than 30 different cardiac glycosides cardiac glycoside poisoning. The physiological action (e.g. oleandrin, oleandrigenin, desacetyloleandrin, of cardenolides are attributed to their binding to the 170 Türk Kardiyol Dern Arş Na+/K+-sensitive membrane-bound enzymes, thereby patients with conduction abnormalities in the presence disturbing the Na+/K+ transport and leading to in- of permanent disappearance of the AV block and the creased intracellular Ca2+ levels. Intoxication rates are absence of a convincing alternative diagnosis during higher in tropic and subtropic regions of the world. hospitalization. In the context of public awareness, In a study of 170 cases in Sri Lanka, it was reported people should be warned about the appropriate use of that the majority of the cases were due to suicide at- herbal therapies which might be useless, harmful, and tempts;[7] however, in recent years, herbal medication sometimes lethal. has also become an important source for plant poi- Conflict­-of­-interest­ issues­ regarding­ the­ authorship­ or­ soning including that associated with N. oleander.[8] article:­None­declared In all cases of plant poisoning, the identification of the plant involved is the first and most important di- agnostic step especially if the patient arrives early af- REFERENCES ter ingestion of the plant, before the onset of systemic symptoms other than vomiting. Measurement of digi- 1. 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