Fatal oleander poisoning in a child

Background. Nerium oleander is a common worldwide plant. All its parts contain toxic digitalis-like glycosides. Fatal accidental poisoning of humans has been described. Children are a major risk group. Case presentation. A girl aged 2 years 8 months was admitted following an episode of vomiting, pallor and cyanosis. Positive findings were hypotension, irregular breathing, cyanosis, petechias, splenomegaly and signs of upper respiratory tract infection. Abnormal laboratory tests were: leucopenia, thrombocytopenia, abnormal liver tests and metabolic acidosis. Supportive and broad spectrum antibiotic treatment was initiated. One day after admission the child felt well while laboratory results changed towards normal. On the third day the patient developed cardiorespiratory collapse. Resuscitation was unsuccessful. Autopsy examination findings were consistent with fulminant viral infection of the lungs. Bacterial and viral cultures of body fluids were negative. Tests for toxic substances were negative except for traces of oleandrin in the liver, stomach and kidney. Implication for practice. The principal clinical signs of oleander poisoning include abdominal pain, nausea, vomiting, visual disturbances, neuritis, dyspnea, diarrhoea and fatal hyperkalaemia and dysrhythmias. The digitoxin assay demonstrates cross-reactivity between oleandrin and digoxin; thus in cases of suspected oleander poisoning, some measure of circulating oleandrin levels can be determined using this assay. Treatment of oleander poisoning should include decontamination methods, supportive treatment, careful monitoring of potassium levels and management of dysrhythmias. Fab fragments from specific antibodies directed against digoxin may also be utilized to remove circulating oleandrin.