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A case report of cardiotoxicity due to homeopathic drug overdose

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Aconite is one of the most toxic plants. Aconitine and related alkaloids found in the Aconitum species are highly toxic cardiotoxins and neurotoxins. Severe aconite poisoning can occur after accidental ingestion of the wild plant or consumption of an herbal decoction made from aconite roots. The toxic components of Aconitum as aconitine and related alkaloids cause cardiotoxicity, neurotoxicity and gastrointestinal toxicity through their actions on sodium channels. Cardiac manifestations include hypotension and ventricular tachyarrhythmias. Ventricular tachyarrhythmias and refractory cardiovascular collapse, such as in the case of this patient account for life-threatening toxicities in severe aconite poisoning. In general, vagal slowing is seen in 10 to 20% of fatal intoxications. If higher concentrations are present, supraventricular tachycardia, ventricular tachycardia, torsades de pointes, and other conduction disturbances may be seen. Ventricular fibrillation may be seen, and is often the cause of death. Available clinical evidence suggests that drugs like amiodarone and flecainide are reasonable first-line treatment.
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International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com Volume 3 Issue 4 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886
Received: 29th Aug 2014 Revised: 20th Sep 2014 Accepted: 29th Sep 2014
Case Report
A CASE REPORT OF CARDIOTOXICITY DUE TO HOMEOPATHIC DRUG OVERDOSE
MilindChandurkar1,Girish Patrike2, NitinChauhan2, SanketMulay2, Manoj Vethekar2, JaweedAkhtar2, Mallikarjun
Reddy2
1Professor and Head, 2PG Resident, Department of Medicine, Rural Medical College of PIMS (DU), Loni,
Ahmednagar, Maharashtra
*Corresponding author email: drmilindch@gmail.com
ABSTRACT
Aconite is one of the most toxic plants. Aconitine and related alkaloids found in the Aconitum species are highly
toxic cardiotoxins and neurotoxins. Severe aconite poisoning can occur after accidental ingestion of the wild plant
or consumption of an herbal decoction made from aconite roots. The toxic components of Aconitum as aconitine
and related alkaloids cause cardiotoxicity, neurotoxicity and gastrointestinal toxicity through their actions on
sodium channels. Cardiac manifestations include hypotension and ventricular tachyarrhythmias. Ventricular
tachyarrhythmias and refractory cardiovascular collapse, such as in the case of this patient account for life-
threatening toxicities in severe aconite poisoning. In general, vagal slowing is seen in 10 to 20% of fatal
intoxications. If higher concentrations are present, supraventricular tachycardia, ventricular tachycardia, torsades
de pointes, and other conduction disturbances may be seen. Ventricular fibrillation may be seen, and is often the
cause of death. Available clinical evidence suggests that drugs like amiodarone and flecainide are reasonable first-
line treatment.
Keywords: Aconite, cardiotoxicity, Neurotoxicity, Ventricular tachyarrythmias.
INTRODUCTION
Aconite has long been used in the traditional
medicine of Asia (India, China) Aconitum ferox
(Vatsanabha) is one of the deadliest poisons in
Ayurveda. It is categorized in Mahavishavarg in all
Ayurvedic texts1.In Asia most aconite poisoning
cases are related to the use of Aconitum rootstocks in
traditional medicine2.Extracts of the plant are also
used in homeopathy to decrease fever, as cardiac
depressant, and to treat neuralgia3. There were over
600 reported cases of poisoning in China alone up to
2006, and in Hong Kong It was estimated that 75% of
Chinese herbal medicine related hospital admissions
were related to aconite toxicity4. In this article we
report a case of aconite induced cardiotoxicity that
was managed in our hospital.
CASE REPORT
A35 yrs old female brought by relatives with
presenting complaints of nausea, epigastric pain and
severe vomiting since morning on the day of
admission.. She was referred from surgery OPD as
her pulse was rapid and irregularly irregular. Patient
advised medicine reference for tachycardia and
irregular pulse. On examination, Pulse was 150/min,
low volume, irregularly irregular. Blood pressure was
80 systolic mm of Hg. On auscultation S1, S2 heard.
No cardiac murmur. ECG suggestive of Bidirectional
DOI: 10.5958/2319-5886.2014.00057.5
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Chandurkar et al., Int J Med Res Health Sci. 2014;3(4):1072-1075
ventricular tachycardia(Fig 2). 2DECHO screening
done in OPD there was normal. Patient admitted in
Intensive care unit. Emergency cardioversion was
done with 360 J for ventricular tachycardia but it
didn’t revert. Inj. Amidarone 300 mg. iv. bolus was
given and sinus rhythm was achieved(Fig 3). patient
was then put oni.v.Amidarone1gm infusion for 24
hrs. Hypotension responded to fluid therapy and
supportive care. However, patient had intractable
vomiting for 3 days, which was treated with inj
Ondansetron 4 mg and i.v. fluids for dehydration.
Detailed history given by patient suggestive of
consumption of Mother Tincture (Aconite Radice
Preparation) about two teaspoonful for pain abdomen
and gall stones, and followed by above symptoms
after 1-2 hour of consumption. (Bottle presented by
the patient)(Fig 1b) prescribed by homeopathic
doctor. The patient was not advised regarding
frequency, quantity and dilution of the drug.
Patient responded to intravenous antiarrhythmic drug
(Inj. Amidarone). But intermittent multiple
ventricular ectopics were observed till next day. Fluid
resuscitation was done and hemodynamic stability
maintained with supportive care.
Fig 1: a) Aconitum Plant b) Mother Tincture
presented by Patient
Fig 2: ECG on admission suggestive of Bi-
directional ventricular tachycardia
Fig 3: ECG on discharge Normal Sinus Rhythm
Other routine laboratory investigations (LFT, RFT,
and Chest X-Ray) are within normal limit. Patient
treated successfully and discharged on 5th day.
DISCUSSION
Homeopathy has a holistic approach to healing, with
as its central tenet that “like cures like”. Established
in 1796 by the German physician Samuel Christian
Hahnemann, it treats patients with heavily diluted
preparations of substances which in their undiluted
form are thought to cause effects similar to the
symptoms presented. Homeopathic medicines are in
general considered to be safe when administered
appropriately, toxicological aspects should not be
neglected, especially when using lower dilutions of
unsafe starting material5.
Aconite is a well known toxic plant of the genus
Aconitum in the Ranunculaceae family. Aconite
related alkaloids such as aconitines, benzoylaconines
and aconines, and the aconitines (aconitine,
hypaconitine, jesaconitine and mesaconitine) are the
causative agents of Aconite poisoning6.Aconitum
alkaloids are the active ingredients and the source of
toxicity. The amount and type of aconitum alkaloids
are the main factors determining the severity of
intoxication. For the same plant, the level of active
ingredient is affected by the time of harvest and
method of processing. The tuberous roots of genus
Aconitum are commonly applied for various diseases.
These tubers of Aconitum are used in the herbal
medicines only after processing7. Soaking and boiling
during processing or decoction preparation will
hydrolyze aconite alkaloids into less toxic and non-
toxic derivatives8,9. The detoxification induced a
change in the structure of aconitine making it less
cardio-toxic10. However, the use of a larger than
recommended dose and inadequate processing
increases the risk of poisoning.
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Chandurkar et al., Int J Med Res Health Sci. 2014;3(4):1072-1075
Typical manifestations of poisoning are
gastrointestinal, neurological, and cardiovascular,
with malignant ventriculararrhythmias11. The
neurological features could be sensory symptoms like
tingling or numbness or motor like weakness in one
or all limbs. The cardiovascular manifestations are
chest pain, shock and palpitations due to various
ventricular and supraventricular tachycardias. The
gastrointestinal features are similar to any other toxin
like nausea, vomiting, pain in abdomen and
diarrhoea. Death occurs usually due to refractory
ventricular tachycardia or ventricular asystole. The
reported overall in-hospital mortality is 5.5%.
Aconitine can also cause BiVentricular
Tachycardia12.
The toxic effects on heart and nervous system of
aconitine and similar alkaloids are due to action on
voltage sensitive sodium channels of above tissues.
Aconitine binds to the open state of the voltage-
sensitive sodium channel and inhibits its inactivation.
Aconitine will induce arrhythmias after the fiber has
been completely repolarised. This arrhythmia is
generally facilitated in the presence of high Cat +
solution, yet the aconitine-induced arrhythmia occurs
even in the presence of low Ca++ solutions. Thus
intracellular Na+ loading plays an important role in
the aconitine-induced delayed afterdepolarization and
transient inward currents in low Ca++ solution. The
consequent prolonged inward current of the sodium
channel leads to intracellular accumulation of Na+
and activates the NaCa exchanger, causing Ca2+
overload and delayed afterdepolarization. Several
reports suggest that delayed after depolarization has
an important role in triggering and
maintainingBiVentricular Tachycardia12.
Management of aconite poisoning is supportive,
including immediate attention to the vital functions
and close monitoring of blood pressure and cardiac
rhythm. Extensive vomiting and diarrhoeamayrequire
that fluid and electrolytes be monitored and replaced
as necessary. Inotropic therapy is required if
hypotension persists. Ventricular arrythmias caused
by aconite toxicity are refractory to both electrical
and chemical cardioversion. In such cases it is
important to maintain basic life support and early use
of cardiopulmonary bypass. Antiarrythmics like
Amiodarone and Flecainide are reasonable first-line
drugs as per presently available evidence.13
CONCLUSION
This case report emphasises the importance that there
may be many more cases of acute aconite toxicity
which must be going unnoticed due to consumption
of toxin in inappropriate dilution, form or as herbal
drug. Homoeopathy is the method of treating an
ailment caused by injurious toxic substances with the
same or similar substances given in an extremely
diluted form. It is absolutely essential that the poison
of the like thereof be diluted to the extent that it
causes no harm to the body. One should advise
patients regarding quantity and dilution of the drug
while prescribing homeopathic medication.
Detailed history, clinical examination, early
management of ventricular tachycardia and
supportive intensive care management in case of
aconite induced cardiotoxicity help to treat patients
successfully.
Acknowledgement: The Authors do not report any
conflict of interest regarding this work.
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... "Lurida terribiles miscent aconita novercae" (translation in English: "terrible stepmothers mix up ghastly pale wolf's bane"), the terrible warning of Publius Ovidius Naso Aconitine is one of the main secondary metabolites of Aconitum sp. and is well known in Chinese traditional medicine, but not exclusively, for being used for the preparation of herbal remedies to prevent or cure various human diseases or metabolic disorders involved in the pathogenesis of these conditions [6]. In traditional medicinal practices, the lateral roots/rhizomes of Aconitum sp., which are processed to a significantly reduced toxicity, are most commonly used for their analgesic properties and specific effects on the heart system, heart rate and blood pressure [7][8][9][10][11][12][13]. In alternative homeopathic treatments, a number of formulations containing aconites, such as Qili-Qiangxin capsules, used in Shenfu injections are indicated in the treatment of heart failure [14,15]. ...
... Despite the fact that both synergistic Aconitine is one of the main secondary metabolites of Aconitum sp. and is well known in Chinese traditional medicine, but not exclusively, for being used for the preparation of herbal remedies to prevent or cure various human diseases or metabolic disorders involved in the pathogenesis of these conditions [6]. In traditional medicinal practices, the lateral roots/rhizomes of Aconitum sp., which are processed to a significantly reduced toxicity, are most commonly used for their analgesic properties and specific effects on the heart system, heart rate and blood pressure [7][8][9][10][11][12][13]. In alternative homeopathic treatments, a number of formulations containing aconites, such as Qili-Qiangxin capsules, used in Shenfu injections are indicated in the treatment of heart failure [14,15]. ...
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AconitumFerox): From VishaTo Amrita
  • Anjali Sheokand
  • U K Anitasharma
  • Gothechavatsanabha
Anjali Sheokand, AnitaSharma UK. GothechaVatsanabha (AconitumFerox): From VishaTo Amrita. International Journal OfAyurvedic And Herbal Medicine. 2012;2(3):423-26