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Alternative Cures,
Unexpected Complications
Submitted by Rais Vohra MD
Department of Emergency Medicine
California Poison Control System
In the hierarchy of medical evidence, the case series occupies
a lowly position, couched as it is between the anecdotal case
report and the more credible investigative methods such as
controlled trials. Still, case series offer valuable insights about
new conditions or hazards, and help us generate hypotheses
about what precisely to study and explore more in depth.
With that perspective, I share three cases that highlight
a common type of toxicologic hazard – the availability of
unregulated or alternative remedies that patients may be
obtaining “under the counter.”
The first patient was
a three-year-old boy who
accidentally ingested a
weight loss supplement
marketed in Spanish as
a “fat burning almond”
containing a natural ingredient. The child developed vomiting and
lethargy at home, and
in the emergency department was found to have
bradycardia with a pulse in the 50s as well as mild hyperkalemia. After intravenous hydration and observation he improved, but still required an admission for observation.
The substance in the dietary supplement was identified as
seeds of a highly toxic plant called yellow oleander (Thevetia
peruviana), a tree commonly found in Asia and South
America that contains the cardiac glycosides that resemble
digoxin.
Almendara quema grasa, a dieting aid processed in Mexico,
prompted 4 separate calls made to our state’s poison control
system in the last year. This product is typically packaged
as a “fat-burning almond” (“Almendra Quema Grasa” is
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the brand name of one product) or Indian Nut (“Nuez de la
India”).
The cluster of cases, all from different hospitals in the
southern California region, allowed poison center investigators working with analytical labs to determine the origin and
hazards associated with this dieting practice. Unfortunately, the surreptitions marketing of this product makes it very
difficult to intercept distribution. Anecdotal online reports
indicate that this product is derived from the seeds of yellow
oleander (Thevetia peruviana), a plant native to Mexico, and
now established also in Florida, Hawaii, and South Asia. T
peruviana contains cardiac glycosides (thevetin a and b, peruvoside, and neriifolin), which like digoxin poison the sodium/potassium ATP-ase in the cardiac and nervous tissues.
Indeed, this child’s digoxin level was detectable (0.5 ng/
mL). Like digoxin itself, yellow oleander can cause fatalities
by inducing cardiac irritability and refractory bradycardia.
Vomiting is a frequent side effect as well, which compounds
bradycardia by augmenting the effects of the vagus on the
heart. The antidote for this poison is high doses of antidigoxin antibody, often required in higher doses than those
for digoxin toxicity because the binding of the antibody is
not as exact as with digoxin.
The child’s mother had purchased the seeds from a local
vendor, and internet websites provide ample instructions on
how to take these seeds – the appropriate daily dose is 1/32 of
a seed, a tiny sliver of the nut-like object. This is, for lack of a
better term, a wise dose, since only two or three whole seeds
of this plant can be fatal to an adult.
The second patient is a 35-year-old woman with systemic
inflammatory response syndrome (SIRS), triggered by a violent gastroenteritis. She developed signs of distress rapidly, and became dehydrated shortly after her diarrhea began.
She tried to tough it out at home, but when a high fever
spiked and she noted blood, she presented for medical attention. She said her symptoms began a day after she had taken
some capsules called “Vibora de Cascabel” (rattlesnake pills),
which are gelatin capsules containing dehydrated, powderized snake-meat. This agent is advocated for numerous ailments, and sold as vitamin supplements in our local swap
meets like the “Cherry Avenue Auction,” where the picture
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Tox Tidbits
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of these Viboras was taken. The patient’s husband, incidentally, took
the capsules as well and
suffered no ill effects (he
was a more long-term
user), but she was diagnosed with an infection
from an unusual bacteria encountered in reptiles, (Salmonella arizonae) and required antibiotic therapy for about a week
before being discharged home.
Last patient: A 61-yearold woman suffered a myocardial
infarction, and although her left heart catherterization
revealed normal coronary arteries, she was found to have
depressed ejection fraction (30 percent) with a catecholamineinduced (Tsakotsubo-type) cardiomyopathy. She recovered
well enough to be discharged to home.
She was convinced by well meaning relatives that her
heart would benefit from more oxygen, who further suggested
that she take a solution that would provide just that – food
grade hydrogen peroxide. Unfortunately she ingested the
concentrated 35 percent solution (the actual used beer bottle
is shown where it was being stored) without diluting it. By
comparison, household peroxide that is available in most
drug stores has a concentration of three percent, and even
that product has been associated with complications after
ingestion. As soon she drank a gulp, she gasped and began
to vomit. She returned to the hospital after a terrible night
with hematemesis, severe abdominal pain and chest burning,
headache and generalized weakness. She was visibly pale and
severely distressed but her neurologic exam showed no focal
deficits except a mild facial droop.
Numerous websites actually promote the use of “peroxide
hyperoxygenation therapy” for a variety of chronic
illnesses. The peroxide, in concentrated form, has a twofold mechanism of toxicity: it is locally corrosive to the
gastrointestinal mucosa, and once in the blood stream it can
dissociate into oxygen bubbles in a reaction enhanced by the
enzyme catalase: 2 [H2O2] > 2[H2O] + O2 (gas). A lot of
oxygen can be liberated – it estimated that just 1 mouthful (30
cc) of concentrated hydrogen peroxide releases 3.5 LITERS
of oxygen gas. The real problem with all this oxygen is that
the blood cannot contain it in the dissolved form – and gas
bubbles precipitate as emboli all over the body. This process
resembles air emboli that are released after certain invasive
procedures, or nitrogen bubble formation causing “the
bends” in a scuba diver who comes to the seawater’s surface
too fast. In all of these situations, the advocated treatment is
hyperbaric oxygen therapy (HBO), where a patient is placed
in a compressive-air chamber that can be
pressurized to three atmostpheres of oxygen
(e.g. three times the air pressure that we
experience at sea level). Small case series and
animal models suggest that this “barometric
compression” treatment helps to squeeze
the air bubbles into a much smaller size,
and sometimes back into the solution
of the bloodstream, thus minimizing
embolic damage to the brain and other
tissues.
Given her recent MI and her severe
distress and possible facial droop, this
patient received two HBO treatments
over two days in one of our medical
center’s HBO chambers. After the
second treatment she felt markedly improved and her
strength returned. Interestingly, the patient’s MRI showed
scattered hyperintensities in numerous foci of ischemia, as
shown in these images.
There are many reasons why patients seek out alternative,
herbal or complementary treatments that are scientifically
unsound and possibly even harmful. Compounding the
public’s perceptions and demands, the availability of
hazardous regimens in the commercial sphere is a constant
challenge for the Food and Drug Administration and related
regulatory agencies: it seems that when one dangerous,
surreptitiously distributed agent is taken off the market or
wanes in popularity, another one is ready to assume its place
in the constant demand for miracle cures.
Ironically, we began with discussing the hierarchy of
medical literature, and the limitations of case series as a source
of reliable medical knowledge. As I look back at these cases, I
note that all the patients or relatives involved in these stories
got their information from others who vouched for the safety
and efficacy of these treatments., perhaps with testimonials
or anecdotes of success. In brief, by basing their decisions on
stories they heard from their friends, relatives, and online
contacts, they were ultimately relying on a perilous source of
medical knowledge – the lowly case series.
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