Clinical Case Discussions
Cerbera odollam, also known as the “suicide tree” or “pong pong,” is a tree primarily found in coastal areas of Southeast Asia which yields highly toxic seeds.1 The active ingredient found in these seeds is cerberin, which has cardiotoxic effects similar to those of digitalis, including cardiac dysrhythmias and hyperkalemia.1,2 Although it has been reported to have some legitimate uses, such as in bioinsecticides,3 the highly toxic seeds have historically been used for both suicidal and homicidal purposes.1 Given the online availability of these seeds and the growing rate of suicide in the United States,4 western physicians should be aware of the presentation, diagnosis, and treatment of C. odollam toxicity.
A 33-year-old female with a history of suicide attempts presented to the emergency department with nausea and self-report of 1 episode of emesis shortly after intentionally ingesting 2 seeds of C. odollam that she purchased online. Her nausea persisted, and she had further vomiting in the emergency department. An additional seed was found with the patient, and it was disposed of after consultation with the Poison Control Center in Indianapolis. The patient was transferred to a progressive care unit with telemetry and electrolyte monitoring, and she was provided with supportive care. Her initial laboratory results showed a potassium level of 4.3 mmol/L (normal range, 3.5 to 5.5 mmol/L) and a creatinine level of 1.23 mg/dL (normal range, 0.80 to 1.50 mg/dL). Within 3 hours of admission, the patient’s electrocardiogram showed some digitalis-like effects. Figure 1 shows these minor ST segment changes in lead II. However, subsequent electrocardiograms did not have these ST segment abnormalities and were unremarkable. Digoxin immune fab (DigiBind), an antitoxin developed to treat potentially life-threatening digoxin intoxication, was kept on hand in case bradycardia, heart block, or hemodynamic compromise developed. Fortunately, our patient did not require DigiBind. After medical clearance, the patient was transferred for psychiatric treatment.
Cardiac glycoside toxic effects, including those seen with C. odollam, have been associated with the ingestion of various plant seeds commonly found in South Asia, and the Internet has facilitated the procurement of these toxic substances for suicidal purposes. The most commonly reported symptoms include nausea and vomiting, diarrhea, dizziness, bradycardia, and varying degrees of heart block developing within 24 hours of ingestion.5,6 Other studies have shown possible nervous system effects such as hyporeflexia and hypotonia.7
Diagnosing C. odollam toxicity is challenging and often depends on a report of ingestion and the clinical presentation. Urine toxicology and digitalis levels are likely to be unremarkable in patients after ingestion of the seeds due to the complete lack of or variable degrees of cross-reactivity with such testing.1 Definitive diagnosis may be made by thin-layer chromatography and liquid chromatography in conjunction with mass spectrometry.1 Although time since ingestion was reported to be the rationale for not performing gastric decontamination in this patient, the literature suggests activated charcoal should be considered in all patients regardless of the time since ingestion.8 Temporary cardiac pacing (mean duration 4.5 d) has been found efficacious when clinically indicated.5 Although atropine is not effective in all cases,9 it may partially abolish the direct vagotonic action of the glycosides. However, as the toxicity increases, the heart rate may not increase, because odollam cardenolides have direct depressant activity on the myocardial cells.2 Life-threatening hyperkalemia can be treated with intravenous glucose, insulin, and sodium bicarbonate, but calcium salts are generally avoided due to theoretical development of arrhythmias or cardiac arrest.10 Reports suggest that response to digoxin immune fab (digoxin-specific antibody) for C. odollam poisoning is limited and variable, but this finding could be due to the antibody having a lower affinity for C. odollam and/or to C. odollam having a longer half-life compared with the fab fragments.11 Mortality has been reported in 20% to 28% of patients and is likely to occur in 3 to 6 hours after ingestion.2,7
This case raises concerns for multiple reasons. First, C. odollam toxicity is difficult to diagnose and treat with conventional methods. Second, the ease of online access to C. odollam seeds, which are associated with a significantly high rate of mortality, is a noteworthy concern. Finally, there is limited awareness of and scientific research concerning C. odollam toxicity in western medicine. This case adds to the literature by describing a known intentional ingestion, which fortunately did not end with a patient death.
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