Abstract
Introduction
Taxus species are known to be toxic and may result in significant dysrhythmias. Treatment of taxus induced cardiac dysrhythmias is based largely on case reports. We describe a case of a 24-year-old male withTaxus cuspidate (yew berry) toxicity initially treated with amiodarone bolus and infusion and subsequently managed with sodium bicarbonate boluses and continuous infusion.
Case Report
The patient was found at home by his parents with witnessed “seizure-like” activity 2 hours after reportedly chewing and swallowing 168 yew seeds. The initial prehospital rhythm strip demonstrated ventricular tachycardia (VT); the patient was hypotensive with fluctuating levels of alertness. Prehospital cardioversion was attempted without success.
Staff at the local presenting emergency department (ED) consulted toxicology for management of the presumed yew berry ingestion, complicated by cardiac dysrhythmias and mental status change with seizure. Amiodarone 300-mg IV and diazepam 5-mg IV were given. Cardioversion was attempted 4 times without change in the wide complex tachycardia, presumed to be VT, at a rate of 166. An amiodarone drip at 1 mg/min was initiated. The patient was transferred to an intensive care unit (ICU) at a regional toxicology center.
On arrival to the toxicology center the patient was alert and verbally appropriate without complaints. Initial heart rate was 76 and regular with premature ventricular contractions (PVCs). A wide complex tachycardia associated with hypotension recurred; however, normal mental status was maintained. A bolus of 100 mEq of sodium bicarbonate (NaHCO3) was given intravenously followed by sodium bicarbonate infusion at 37.5 mEq/hr. The amiodarone drip was discontinued. Subsequent electrocardiograms (EKG’s) revealed a prolonged, but steadily narrowing QRS complex. Ultimately, the QRS complex closed to 92 ms, with a rate of 94, PR 154 and a QT/QTc of 390/487.
Conclusion
This case describes successful treatment of an isolatedTaxus cuspidate (yew berry) ingestion with significant toxicity initially with amiodarone bolus and infusion. Due to lack of significant change in telemetry recordings with amiodarone, treatment with sodium bicarbonate bolus and infusion was initiated. While the QRS narrowed significantly temporally related to the bicarbonate, it is difficult to determine if correction of the cardiac dysrhythmias was solely due to the sodium bicarbonate, or the synergism of sodium bicarbonate and amiodarone, or possibly spontaneous improvement due to taxine clearance. One should use caution while drawing conclusions from a single case; however, based on the clinical improvement of this patient, both with EKG recordings and vital signs, this report would suggest that isolatedTaxus cuspidate ingestion from yew berry plants can be treated with sodium bicarbonate.
Keywords: taxus toxicity, yew berry toxicity, digoxin-specific antibody fragments, sodium bicarbonate
Full Text
The Full Text of this article is available as a PDF (1.4 MB).
Footnotes
The information contained in the case report has not been presented previously.
There was no outside funding of any kind used for this study.
References
- 1.Nora M, Elsner G, Purdy C, et al. Wide QRS rhythm due to taxine toxicity. J Cardiovasc Electrophysiol. 1993;3:59–61. doi: 10.1111/j.1540-8167.1993.tb01212.x. [DOI] [PubMed] [Google Scholar]
- 2.Wilson CR, Sauer JM, Hooser SB. Taxines: a review of the mechanism and toxicity of yew (Taxus spp.) alkaloids. Toxicon. 2001;39:175–185. doi: 10.1016/S0041-0101(00)00146-X. [DOI] [PubMed] [Google Scholar]
- 3.Lowe JE, Hintz HF, Schryver HF, et al. Taxus cuspidata (Japanese yew) poisoning in horses. Cornell Vet. 1970;60(1):36–39. [PubMed] [Google Scholar]
- 4.Tekol Y, Gõgüsten B. Comparative determination of the cardiosensivity of taxine and verapamil in the isolated aorta, atrium, and jejunum preparations of rabbits. Arzneim-Forschung. 1999;49(8):673–678. doi: 10.1055/s-0031-1300481. [DOI] [PubMed] [Google Scholar]
- 5.Musshoff F, Jacob B, Fowinkel C, et al. Suicidal yew leaf ingestion—phloroglucindimethylether (3,5-dimethoxyphenol) as a marker for poisoning from Taxus baccata. Int J Legal Med. 1993;106(1):45–50. doi: 10.1007/BF01225024. [DOI] [PubMed] [Google Scholar]
- 6.Tekol Y, Kamayama M. Elektrophysiologische Untersuchungen über den Wirkungsmechanisms des Eibentoxin Taxin auf das Herz. Arzneim.-Forschun. 1987;37(4):428–431. [PubMed] [Google Scholar]
- 7.Ruha AM, Tanen DA, Graeme KA, et al. Hypertonic sodium bicarbonate for Taxus media-induced cardiac toxicity in swine. Acad Emerg Med. 2002;9(3):179–185. doi: 10.1111/j.1553-2712.2002.tb00241.x. [DOI] [PubMed] [Google Scholar]
- 8.Gustafson DL, Long ME, Zirrolli JA, et al. Analysis of doctaxel pharmacokinetics in humans with the inclusion of later sampling time-points afforded by the use of a sensitive tandem LCMS assay. Cancer Chemother Pharmacol. 2003;52(2):159–166. doi: 10.1007/s00280-003-0622-z. [DOI] [PubMed] [Google Scholar]
- 9.Alloatti G, Penna C, Levi RC, et al. Effects of yew alkaloids and related compounds on guinea-pig isolated perfused heart and papillary muscle. Life Sci. 1996;58(10):845–854. doi: 10.1016/0024-3205(96)00018-5. [DOI] [PubMed] [Google Scholar]
- 10.Cummins RO, Haulman J, Quan L, et al. Near fatal yew berry intoxication treated with external cardiac pacing and digoxin-specific FAB fragments. Ann Emerg Med. 1990;19:38–43. doi: 10.1016/S0196-0644(05)82138-9. [DOI] [PubMed] [Google Scholar]
- 11.Miller MB, Eng J, Curry SC. Sodium bicarbonate for taxus-induced dysrhythmia. Dewitt, MI: Ingham Regional Medical Center; 2000. [Google Scholar]