Near-fatal yew berry intoxication treated with external cardiac pacing and digoxin-specific FAB antibody fragments

doi:10.1016/S0196-0644(05)82138-9

Annals of Emergency Medicine

Volume 19, Issue 1, January 1990, Pages 38-43

https://doi.org/10.1016/S0196-0644(05)82138-9 Get rights and content

The case of a 5-year-old girl who survived a near-fatal ingestion of yew plant leaves after treatment with CPR, transcutaneous pacing, and digoxin-specific FAB antibody fragments is presented. Multiple rhythm disturbances, including profound bradycardia, occurred. She required endotracheal intubation, external chest compressions, and application of a transcutaneous pacemaker. Paced cardiac contractions produced a dramatic improvement in her blood pressure and clinical condition. Two empiric injections of digoxin-specific FAB antibody fragments were administered, after which cardiac function and rhythm gradually improved. She was discharged in her normal state of health three days later. Yew leaves and berries contain several alkaloids that can produce fatal conduction disturbances. Transcutaneous cardiac pacemakers may be lifesaving for patients with transient cardiac toxicity from drug or toxin ingestions. In addition, cross-reactivity between digoxin-specific FAB antibodies and the alkaloids in the yew plant may exist and may have therapeutic importance, although this mechanism was unlikely to have helped our patient.

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Cited by (59)

Cardiotoxicity in yew berry poisoning
2021, American Journal of Emergency Medicine
Citation Excerpt :
Most of them reported poisoning by Taxus baccata species. Only two reports for Taxus canadensis and one for each of Taxus cuspidate, Taxus brevifolia [9,13,26,27]. These reported cases included mild gastrointestinal symptoms to seizures and significant cardiotoxicity.
Yew plants (Taxus species) represent a genus of plants known to be highly toxic, though lethal intoxication is rare. The majority of deaths in yew berry poisonings occur due to its cardiotoxic effect, mediated through generation of a number of fatal tachy- and brady-arrhythmias. However, there are no guidelines on the most effective management in these cases, and interventions vary greatly between published reports.
Here we report a case of a 20-year-old female who presented with refractory lethal arrythmia and shock refractory to conventional therapy. She presented to the emergency department and promptly required airway management and hemodynamic support necessitating intensive care unit management. She received many antiarrhythmics, digoxin immune Fab, lipid emulsification, and eventually transvenous pacemaker insertion for overdrive pacing. Despite our interventions, our patient ultimately died after a decision to withdraw care.
We also reviewed 43 reports of yew poisoning cases described in the literature. We discuss the most common strategies used to treat such patients including gastric decontamination, antiarrhythmics, electrical pacing, extracorporeal life support and other therapies. We need better understanding of this condition, to identify which therapies offer maximal benefit and to optimize outcomes for this rare but often devastating toxidrome.
Extracorporeal membrane oxygenation in a patient with yew and escitalopram intoxication
2019, Cor et Vasa
Yew intoxication is an uncommon, life-threatening emergency. Patients frequently die due to refractory cardiac shock or pulseless ventricular tachycardia and ventricular fibrillation, both of which do not respond to classical treatment with antiarrhythmics and defibrillation. The cardiac toxicity is driven mainly by taxine B, both sodium and calcium channel blocker. Hemodialysis is ineffective, because of the large molecular size of taxine B. Specific antidote is currently not available, but digoxin-specific FAB antibodies can be used instead, with partial effect. Severe cases of intoxication can profit from initiation of veno-arterial extracorporeal membrane circulation (VA ECMO). We present a case of a 25-year-old patient with yew and escitalopram ingestion in a suicide attempt. He presented to the emergency department of a regional hospital with cardiology center without cardiosurgery clinic, but with VA ECMO team on site. Pulseless ventricular tachycardia and fibrillation unresponsive to usual treatment developed soon after presentation and the patient had to be placed on VA ECMO during ongoing cardiopulmonary resuscitation using Lucas CPR device. Patient survived and was successfully weaned off VA ECMO after 4 days with normalization of cardiac function and without severe liver or kidney dysfunction. Unfortunately, brain death was diagnosed after the discontinuation of sedation two days later and the patient entered the transplantation program as a donor. This propably happened due to inadequate mechanical resuscitation during transportation to the cathlab.
VA ECMO is an important option for the treatment of intoxications, with early indication being crucial.
Extracorporeal life support and digoxin-specific Fab fragments for successful management of Taxus baccata intoxication with low output and ventricular arrhythmia
2017, American Journal of Emergency Medicine
Citation Excerpt :
Catecholamine infusion is generally reported to be ineffective in treatment of bradycardia and hypotension [7,8,13,14]. In some cases of therapy-resistant cardiogenic shock, ECLS has been successfully applied [8,9,13,15]. Digitalis and yew alkaloids have previously been shown to cross-react on serum digoxin assays [16].
Yew plants are evergreen shrubs which are widely spread throughout the northern hemisphere. Taxane alkaloid derivatives, mainly taxine B, represent the main toxins of Taxus baccata and are highly cardiotoxic. Due to the lack of randomized clinical trials, case reports on accidental or suicidal yew intoxications build the only source of knowledge of clinical treatment options.
We report the case of a suicidal yew ingestion admitted to our hospital under prolonged cardiopulmonary resuscitation due to pulseless electrical activity. Extra-corporeal life support (ECLS) was established to maintain adequate organ perfusion. Repeated administration of digoxin-specific Fab antibody fragments, which cross-react with taxine, was associated with an immediate conversion from asystole to broad-complex bradycardia and a gradual normalization of the electrocardiogram (ECG). This was paralleled by a recovery of the cardiac function and weaning from the ECLS. The taxine metabolite 3,5-dimethoxyphenol could be detected by mass spectrometry before but not after the first Fab-fragment treatment. In contrast, the total amount of taxine (including the neutralized, Fab fragment-bound fraction) was increased after each Fab fragment administration, suggesting an accumulation of neutralized, since antibody-bound taxine in the blood by anti-digoxin Fab fragments.
In conclusion, the successful clinical course of this case suggests a benefit of an early anti-digoxin Fab-fragment administration for the treatment of yew intoxication.
Cardiotoxicity of yew
2015, Cor et Vasa
The Common Yew (Taxus baccata) is an ornamental tree. The taxine alkaloids contained in yew berries, needles or bark are poisonous. The lethal dose for an adult is reported to be 50 g of yew needles. Patients who ingest a lethal dose frequently die due to cardiogenic shock, in spite of resuscitation efforts. Although no specific therapy exists, in some patients the asystole phase can be overcome by instituting extracorporeal membrane oxygen therapy (ECMO). Therapeutic procedures reported in the literature are only referred to in published case reports and it is not self-evident whether they have been effective or whether the patient had ingested a non-lethal dose of the toxins. In our case report, we describe lethal intoxication by common yew needles in a suicide attempt and summarize the treatment options referred to in literature.
Plant Toxins and the Heart
2015, Heart and Toxins
Nature has endowed medicinal and nonmedicinal values to plants. Humans use plants for both purposes. Some plants have toxic substances that may affect one or more organs or systems. Plant toxicology began in view of significant poisoning of livestock. Often, the difference between a therapeutic and a toxic level is slight, and patients can easily develop an adverse reaction to a plant, plant material, or preparation from a plant. In this chapter, the cardiotoxic effects of some of the plants that are not used routinely in medical practice are described. In addition, classification of cardiotoxins; mechanisms of action; influencing factors for toxins; clinical problems; community, administrative, and preventive aspects; and future directives are explained.
Eight cases of fatal and non-fatal poisoning with Taxus baccata
2013, Forensic Science International
This paper describes two fatalities, three non-fatal intentional and three accidental oral ingestions of yew (Taxus baccata) leaves. In all cases the post-mortem external examinations showed no signs of violence. Internal examinations revealed small green, needle-like particles on the tongue, in the esophagus and in the stomach. Yew leaves were also identified in the stomach contents, whereas Taxus leaves were cut into small pieces and then ingested in one case.
The analytical method used was based on a liquid–liquid-extraction under alkaline conditions followed by LC–MS/MS analysis (QTRAP 5500). Chromatographic separation was achieved by HPLC on a Kinetex C18 2.6u (100 × 3) mm. The analytical method allows the simultaneous identification and quantification of the commercially available yew alkaloids taxoids (m/z): paclitaxel (854.2 → 105.0/286.1), 10-deacetyltaxol (10-DAT: 812.2 → 105.0/286.1), baccatin III (BAC III: 604.0 → 105.0/327.0), 10-deacetylbaccatin III (10-DAB III: 562.1 → 105.0/327.0), cephalomannine [taxol B] (562.1 → 105.0/327.0) and of 3,5-dimethoxyphenol (3,5-DMP: 155.0 → 111.9/122.9) also encompassing the qualitative analysis of the alkaloidal diterpenoids (Q1 → 194.0/107.0); reference mass spectra obtained from a yew leaves extract: monoacetyltaxine (MAT: 568.4), taxine B (584.2), monohydroxydiacetyltaxine (MHDAT: 626.4), triacetyltaxine (TAT: 652.4), monohydroxytriacetyltaxine (MHTAT: 668.4).
In both fatalities, paclitaxel, 10-DAT and cephalomannine were not identified in urine, cardiac and femoral blood but all taxoids and 3,5-DMP were present in stomach content and excreted into the bile. In urine, highest 3,5-DMP concentration was 7500 μg/L and 23,000 μg/L after enzymatic hydrolysis, respectively.
In intentional and accidental poisonings, when electrocardiogram (ECG) examinations revealed ventricular tachycardia and/or prolonged QRS intervals, taxines were identified in plasma/serum, even after the ingestion of a few number of yew leaves, when 3,5-dimethoxyphenol was not even found. According to the data from one near-fatal intentional poisoning, elimination half-life of MAT, TAXIN B, MHDAT and MHTAT in serum was calculated with 11–13 h and taxines were detected up to t = +122 h post-ingestion of approximately two handfuls of yew leaves.

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: This work was partially supported by contributions from the National Center for Health Services Research, Zoll Medical Instruments Incorporated, the Asmund Laerdal Acute Medicine Foundation, and the Physio-Control Corporation.

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Case reportNear-fatal yew berry intoxication treated with external cardiac pacing and digoxin-specific FAB antibody fragments

Ann Emerg Med

Ann Emerg Med

Lancet

J Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Med

J Am Coll Cardiol

Ann Emerg Med

Am Heart J

Plant Toxicity and Dermatitis

Human Poisonings From Native and Cultivated Plants

Poisonous plants

Naturally occurring cardiac glycosides

Med J Aust

Lethal intoxication with leaves of the yew tree (Taxus baccata)

Arch Toxicol

Case report
Near-fatal yew berry intoxication treated with external cardiac pacing and digoxin-specific FAB antibody fragments