Nerium oleander L.
| 1. NAME |
| 1.1 Scientific name |
| 1.2 Family |
| 1.3 Common name(s) and synonyms |
| 2. SUMMARY |
| 2.1 Main risks and target organs |
| 2.2 Summary of clinical effects |
| 2.3 Diagnosis |
| 2.4 First-aid measures and management principles |
| 2.5 Poisonous parts |
| 2.6 Main Toxins |
| 3. CHARACTERISTICS |
| 3.1 Description of the plant |
| 3.1.1 Special identification features |
| 3.1.2 Habitat |
| 3.1.3 Distribution |
| 3.2 Poisonous parts of the plant |
| 3.3 The toxin(s) |
| 3.3.1 Name(s) |
| 3.3.2 Description, chemical structure, stability |
| 3.3.3 Other physico-chemical characteristics |
| 3.4 Other chemical contents of the plant |
| 4. USES/CIRCUMSTANCES OF POISONING |
| 4.1 Uses |
| 4.1.1 Uses |
| 4.1.2 Description |
| 4.2 High risk circumstances |
| 4.3 High risk geographical areas |
| 5. ROUTES OF EXPOSURE |
| 5.1 Oral |
| 5.2 Inhalation |
| 5.3 Dermal |
| 5.4 Eye |
| 5.5 Parenteral |
| 5.6 Others |
| 6. KINETICS |
| 6.1 Absorption by route of exposure |
| 6.2 Distribution by route of exposure |
| 6.3 Biological half-life by route of exposure |
| 6.4 Metabolism |
| 6.5 Elimination and excretion |
| 7. TOXINOLOGY |
| 7.1 Mode of Action |
| 7.2 Toxicity |
| 7.2.1 Human data |
| 7.2.1.1 Adults |
| 7.2.1.2 Children |
| 7.2.2 Relevant animal data |
| 7.2.3 Relevant in vitro data |
| 7.3 Carcinogenicity |
| 7.4 Teratogenicity |
| 7.5 Mutagenicity |
| 7.6 Interactions |
| 8. TOXICOLOGICAL ANALYSES AND BIOMEDICAL INVESTIGATIONS |
| 8.1 Material sampling plan |
| 8.1.1 Sampling and specimen collection |
| 8.1.1.1 Toxicological analyses |
| 8.1.1.2 Biomedical analyses |
| 8.1.1.3 Arterial blood gas analysis |
| 8.1.1.4 Haematological analyses |
| 8.1.1.5 Other (unspecified) analyses |
| 8.1.2 Storage of laboratory samples and specimens |
| 8.1.2.1 Toxicological analyses |
| 8.1.2.2 Biomedical analyses |
| 8.1.2.3 Arterial blood gas analysis |
| 8.1.2.4 Haematological analyses |
| 8.1.2.5 Other (unspecified) analyses |
| 8.1.3 Transport of laboratory samples and specimens |
| 8.1.3.1 Toxicological analyses |
| 8.1.3.2 Biochemical analyses |
| 8.1.3.3 Arterial blood gas analysis |
| 8.1.3.4 Haematological analyses |
| 8.1.3.5 Other (unspecified) analyses |
| 8.2 Toxicological Analyses and their Interpretation |
| 8.2.1 Tests on toxic ingredient(s) of material |
| 8.2.1.1 Simple Qualitative Test(s) |
| 8.2.1.2 Advanced Qualitative Confirmation Test(s) |
| 8.2.1.3 Simple Quantitative Method(s) |
| 8.2.1.4 Advanced Quantitative Method(s) |
| 8.2.2 Tests for biological specimens |
| 8.2.2.1 Simple Qualitative Test(s) |
| 8.2.2.2 Advanced Qualitative Confirmation Test(s) |
| 8.2.2.3 Simple Quantitative Method(s) |
| 8.2.2.4 Advanced Quantitative Method(s) |
| 8.2.2.5 Other Dedicated Method(s) |
| 8.2.3 Interpretation of toxicological analyses |
| 8.3 Biomedical investigations and their interpretation |
| 8.3.1 Biochemical analysis |
| 8.3.1.1 Blood, plasma or serum |
| 8.3.1.2 Urine |
| 8.3.1.3 Other fluids |
| 8.3.2 Arterial blood gas analyses |
| 8.3.3 Haematological analyses |
| 8.3.4 Interpretation of biomedical investigations |
| 8.4 Other biomedical (diagnostic) investigations and their interpretation |
| 8.5 Overall interpretation of all toxicological analyses and toxicological investigations |
| 9. CLINICAL EFFECTS |
| 9.1 Acute poisoning |
| 9.1.1 Ingestion |
| 9.1.2 Inhalation |
| 9.1.3 Skin exposure |
| 9.1.4 Eye contact |
| 9.1.5 Parenteral exposure |
| 9.1.6 Other |
| 9.2 Chronic poisoning |
| 9.2.1 Ingestion |
| 9.2.2 Inhalation |
| 9.2.3 Skin exposure |
| 9.2.4 Eye contact |
| 9.2.5 Parenteral Exposure |
| 9.2.6 Other |
| 9.3 Course, prognosis, cause of death |
| 9.4 Systematic description of clinical effects |
| 9.4.1 Cardiovascular |
| 9.4.2 Respiratory |
| 9.4.3 Neurological |
| 9.4.3.1 Central nervous system (CNS) |
| 9.4.3.2 Peripheral nervous system |
| 9.4.3.3 Autonomic nervous system |
| 9.4.3.4 Skeletal and smooth muscle |
| 9.4.4 Gastrointestinal |
| 9.4.5 Hepatic |
| 9.4.6 Urinary |
| 9.4.6.1 Renal |
| 9.4.6.2 Other |
| 9.4.7 Endocrine and reproductive systems |
| 9.4.8 Dermatological |
| 9.4.9 Eye, ear, nose, throat: local effects |
| 9.4.10 Haematological |
| 9.4.11 Immunological |
| 9.4.12 Metabolic |
| 9.4.12.1 Acid-base disturbances |
| 9.4.12.2 Fluid and electrolyte disturbances |
| 9.4.12.3 Others |
| 9.4.13 Allergic reactions |
| 9.4.14 Other clinical effects |
| 9.4.15 Special risks |
| 9.5 Other |
| 9.6 Summary |
| 10. MANAGEMENT |
| 10.1 General principles |
| 10.2 Life supportive procedures and symptomatic/specific treatment |
| 10.3 Decontamination |
| 10.4 Enhanced elimination |
| 10.5 Antidote/antitoxin treatment |
| 10.5.1 Adults |
| 10.5.2 Children |
| 10.6 Management discussion |
| 11. ILLUSTRATIVE CASES |
| 11.1 Case reports from the literature |
| 12. ADDITIONAL INFORMATION |
| 12.1 Specific preventative measures |
| 12.2 Other |
| 13. REFERENCES |
| 14. AUTHOR(S), DATES(S) REVIEWER(S), (INCLUDING UPDATES), COMPLETE ADDRESS(ES): |
NERIUM OLEANDER
International Programme on Chemical Safety
Poisons Information Monograph 366
Plant
1. NAME
1.1 Scientific name
Nerium oleander L.
1.2 Family
Apocynaceae
1.3 Common name(s) and synonyms
Adelfa (Puerto Rico, Spain);
Alheli Extranjero (Puerto Rico); Baladre
(Catalunya-Spain); Espirradeira (Brazil);
Flor de Sao Jose (Brazil);
Laurel de jardín (Argentina Uruguay);
Laurel rosa
(Argentina, Uruguay); Laurier rose (France);
Loandro (Brazil); Loureiro rosa (Brazil);
Oleana (Hawaii); Oleander (Brazil, UK, USA);
Oliwa (Hawaii); Rosa Francesa (Cuba);
Rosa Laurel (Mexico);
Rose bay (UK).
2. SUMMARY
2.1 Main risks and target organs
N. oleander ingestion causes both cardiac and
gastrointestinal signs and symptoms. The main toxic
principles are the glycosides, which induce cardiac
arrhythmia and eventually death.
2.2 Summary of clinical effects
The clinical picture usually starts with
gastrointestinal signs: nausea, vomiting, abdominal pain and
diarrhoea. Later, cardiovascular and neurological symptoms
can occur. Sinus bradycardia or different degrees of
atrioventricular (AV) block are the most frequent cardiac
features. In severe cases, ectopic beats occur which may be
followed by ventricular tachycardia and fibrillation. The
main neurological symptoms are: tremor, drowsiness and
ataxia. Hypotension and unconsciousness may also occur.
Seizures have been described.
2.3 Diagnosis
Diagnosis is based on the clinical features (malaise,
vomiting, abdominal pain, bradycardia, dizziness),
electrocardiographic changes and glycosides investigated by
digoxin immunoassay. The triad of gastrointestinal distress,
circumoral erythema and cardiac dysrhythmia should alert to
the possibility of N. oleander poisoning.
A plant specimen or parts obtained from gastric lavage or
vomiting should be collected for botanical identification.
N. oleander can be recognized by microscopic examination of
its epidermis, where stoma cells are typical.
2.4 First-aid measures and management principles
Treatment should aim at:
-gut decontamination by means of emesis or lavage;
-correction of electrolyte imbalance;
-correction of severe bradycardia with atropine or electrical
pacing
-corrections of ventricular dysrhythmias;
-administration of digoxin-specific Fab antibodies could be
considered if available.
2.5 Poisonous parts
All parts of this plant, including the sap, either
fresh, dried or boiled, are toxic. A single leaf intensively
chewed has been reported to be lethal.
2.6 Main Toxins
The main poisonous principles are cardiac glycosides.
The one most studied is oleandrin, but there are more than
ten other glycosides whose chemical structure is well known:
5 ß-cardenolides, such as oleandrine; 5 a-cardenolides, such
as uzangenin-type; oleandrigenin (16-Acetylgitoxigenin) (ol).
The "ol" being: oleandroside (oleandrin); glucose
(glucosyloleandrin); gentiobioside (gentiobiosyl oleandrin);
diginoside (nerigoside); digitoxigenin (digitalose/diginose);
oleagenine - oleasides (A,E) (diginose, gentiobiose-
diginose). Adyregenin is a compound with no cardiac
effect.
3. CHARACTERISTICS
3.1 Description of the plant
3.1.1 Special identification features
N. oleander is an evergreen shrub reaching
four metres in height. Leaves are 10 to 22 cm long,
narrow, untoothed and short-stalked, dark or grey-
green in colour. Some cultivars have leaves
variegated with white or yellow. All leaves have a
prominent mid rib, are "leathery" in texture and
usually arise in groups of three from the stem. The
plant produces terminal flower heads, usually pink or
white, however, 400 cultivars have been bred and these
display a wide variety of different flower colour:
deep to pale pink, lilac, carmine, purple, salmon,
apricot, copper, orange and white (Huxley, 1992).
Each flower is about 5 cm in diameter and five-
petalled. The throat of each flower is fringed with
long petal-like projections. Occasionally double
flowers are encountered amongst cultivars. The fruit
consists of a long narrow capsule 10 to 12 cm long and
6 to 8 mm in diameter; they open to disperse fluffy
seeds. Fruiting is uncommon in cultivated plants.
The plant exudes a thick white sap when a twig or
branch is broken or cut (Font-Quer, 1974; Schvartsman,
1979; Lampe & McCann, 1985; Pearn, 1987).
3.1.2 Habitat
Where the species grows in the wild (i.e. in
the Mediterranean), it occurs along watercourses,
gravely places and damp ravines. It is widely
cultivated particularly in warm temperate and
subtropical regions where it grows outdoors in parks,
gardens and along road sides. Elsewhere, where the
plant is not frost-tolerant (e.g. in central and
western Europe), it may be grown as a conservatory or
patio plant.
3.1.3 Distribution
N. oleander is cultivated worldwide as an
ornamental plant; it is native only in the
Mediterranean region (Kingsbury, 1964; Hardin & Arena,
1974).
3.2 Poisonous parts of the plant
The whole plant, including the sap, is toxic.
3.3 The toxin(s)
3.3.1 Name(s)
Oleandrin, a glycoside, is the main toxin. Its
chemical name is 16b-acetoxy-3b-[(2,6 dideoxy-3-0-
methyl-a2-L-arabino-hexopyranosyl) oxy]-14-hydroxy-5ß,
14ß-card-20(22)-enolide (Reynolds, 1989).
3.3.2 Description, chemical structure, stability
Oleandrin:
CAS number: 465-16-7
Structural formula: C32H48O9
Molecular weight: 576.7
Structural name: oleandrin
3.3.3 Other physico-chemical characteristics
Oleandrin forms colourless, odourless, acicular
crystals which are very bitter (Shaw & Pearn, 1979).
The concentration of oleandrin in the plant tissues is
approximately 0.08% (Schvartsman, 1979).
Solubility: insoluble in water; it has little
resistance to light but it is heat-stable (Pearn,
1987; Reynolds, 1989).
3.4 Other chemical contents of the plant
N. oleander contains at least 2% cardiac glycosides.
Rosagenin may be extracted from the bark and has a
strychnine-like action. Several flavones (0.5%) and volatile
oils (unimportant amount), as well as rubber, fats, sugars
and hydrocyanic acid, can be isolated from its leaves
(Schvartsman, 1979; Shaw & Pearn, 1979; Pearn, 1987).
4. USES/CIRCUMSTANCES OF POISONING
4.1 Uses
4.1.1 Uses
Miscellaneous pharmaceutical product
Other therapeutic preparation
4.1.2 Description
Preparations containing the active principles
were used formerly as rodenticides, insecticides, and
as remedies for indigestion, fever, ringworm, malaria,
leprosy, venereal diseases and as abortifacients.
Therapeutic use of oleander glycosides as cardiac
drugs were assessed and documented in the 1930s (Shaw
& Pearn, 1979; Osterloh et al., 1982). The USSR
pharmacopoeia contains an oleandrin solution (solutio
Neriolini) and oleandrin tablets, and oleandrin
solution (oleandrin 22 mg, alcohol 74 mL, distilled
water to 100 mL). This contains 7 to 9 'frog units'
per mL (1 mg oleandrin = 34 to 44 frog units).
Oleandrin tablets each contain 100 mg of the active
principle (Reynolds, 1989).
4.2 High risk circumstances
The high risk circumstances of exposure are: children
playing with the ornamental shrub (tasting, chewing,
ingesting portions of the plant), and inappropriate medicinal
use of plant infusion. Intentional poisoning by ingestion of
plant infusions has been reported.
4.3 High risk geographical areas
Although the plant is native to the Mediterranean basin,
it has been introduced as an ornamental shrub in many
tropical and subtropical countries (Mahin et al., 1984). The
plant is common in Australia and southern Africa and
ingestion of plant parts is one of the major causes of
childhood admission to hospital (Shaw & Pearn, 1979).
5. ROUTES OF EXPOSURE
5.1 Oral
Parts of the plant can be ingested accidentally or in
suicide attempts (Jouglard et al., 1973; Pronczuk & Laborde,
1988). Extracts or herbal teas made of N. oleander have
been ingested for suicidal or medicinal purposes (Haynes et
al., 1985; Blum & Rieders, 1987). Ingestion of water
contaminated with N. oleander leaves (from a flower bowl),
meat cooked or stirred with the stems, and honey made by bees
visiting the flowers have produced toxic effects (Hardin &
Arena, 1974).
5.2 Inhalation
Smoke from burning N. oleander may be toxic (Hardin &
Arena, 1974; Shaw & Pearn, 1979).
5.3 Dermal
No data available.
5.4 Eye
No data available.
5.5 Parenteral
No data available.
5.6 Others
A fatal case, following rectal and oral administration of
N. oleander extract, has been described (Blum & Rieders,
1987).
6. KINETICS
6.1 Absorption by route of exposure
Oleandrin is well absorbed orally (Schvartsman, 1979).
6.2 Distribution by route of exposure
Wide body distribution is expected: high concentrations
of oleandrin have been measured in blood, liver, heart, lung,
brain, spleen and kidney in a fatal case of N. oleander
extract poisoning (Blum & Rieders, 1987).
6.3 Biological half-life by route of exposure
No data available.
6.4 Metabolism
No data available.
6.5 Elimination and excretion
Oleandrin is eliminated very slowly from the body (one
to two weeks) (Shaw & Pearn, 1979).
7. TOXINOLOGY
7.1 Mode of Action
The cardiac effects of the glycosides are due to direct
cardiotoxicity and an indirect effect via the vagal nerve.
The direct effect is due to the inhibition of the Na-K
ATP-ase pump (sodium-potassium adenosine triphosphatase
enzyme system). This specific action increases intracellular
sodium ion and serum potassium concentrations. The sodium
influx lowers the membrane potential threshold, increasing
excitability. The chronotropic effect is primarily central,
mediated by an increase of vagal tone which decreases the
rate of sinoatrial node depolarization (Osterloh et al.,
1982).
7.2 Toxicity
7.2.1 Human data
7.2.1.1 Adults
Between 7 to 20, or a "handful", of
the leaves have been ingested by adult
patients who were intoxicated but recovered
completely; the dose of oleandrin in this
sample is not known (Pronczuk & Laborde,
1988; Shumaik et al., 1988).
7.2.1.2 Children
A single leaf may be lethal to a
child (Shaw & Pearn, 1979).
7.2.2 Relevant animal data
One leaf of N. oleander may be sufficient to
kill a sheep (Shaw & Pearn, 1979). The lethal dose of
N. oleander leaves reported for several animal
species is about 0.5 mg/kg. Animals poisoned by
eating the plant often develop bloody diarrhoea, due
to a direct effect on the gastrointestinal tract. The
bitter and astringent taste of the plant's leaves
means that all but starving creatures are likely to be
exposed. (Szabuniewicz et al., 1971; Pearn, 1987).
7.2.3 Relevant in vitro data
No data available.
7.3 Carcinogenicity
No data available.
7.4 Teratogenicity
No data available.
7.5 Mutagenicity
No data available.
7.6 Interactions
Pre-medication with digoxin or other cardiac glycosides
may increase the severity of poisonings. The well-known
interaction between digoxin and quinidine (increasing digoxin
levels) should be considered.
8. TOXICOLOGICAL ANALYSES AND BIOMEDICAL INVESTIGATIONS
8.1 Material sampling plan
8.1.1 Sampling and specimen collection
8.1.1.1 Toxicological analyses
Suspect material, scene residues,
vomited or washed out gastric contents should
be collected for analysis, as well as
preparations containing N. oleander.
Plasma samples should be taken for the
digoxin immunoassay.
Morphology and anatomy:
Specimens of the leaves, flowers and branches
should be collected for botanical and
pharmacognostical identification. Suspect
material and plant portions found in vomit or
scene residues should be taken for the
macroscopic and microscopic analysis.
8.1.1.2 Biomedical analyses
Blood and urine should be collected
for routine biochemical analysis. Serum
samples should be taken for measurements of
the serum potassium concentration.
8.1.1.3 Arterial blood gas analysis
Blood should be collected for
arterial blood gas analysis in unconscious
patients.
8.1.1.4 Haematological analyses
Blood should be collected for
routine haematological analyses.
8.1.1.5 Other (unspecified) analyses
No data available.
8.1.2 Storage of laboratory samples and specimens
8.1.2.1 Toxicological analyses
Biological samples should be stored
at 4°C in a refrigerator. For macroscopic
and microscopic analysis fresh plant material
should be kept between sheets of newspaper.
Dried plant material should be protected from
moisture.
Plant portions found in vomit or scene
residues have to be stored in clean bottles
or sealed plastic bags.
8.1.2.2 Biomedical analyses
Biological samples should be stores
at 4°C in a refrigerator.
8.1.2.3 Arterial blood gas analysis
Storage is not possible.
8.1.2.4 Haematological analyses
Samples should be stored at 4°C in a
refrigerator.
8.1.2.5 Other (unspecified) analyses
No data available.
8.1.3 Transport of laboratory samples and specimens
8.1.3.1 Toxicological analyses
No special requirements.
For macroscopic and microscopic analysis:
no special requirements.
8.1.3.2 Biochemical analyses
No special requirements.
8.1.3.3 Arterial blood gas analysis
Transport to the laboratory
immediately.
8.1.3.4 Haematological analyses
No special requirements.
8.1.3.5 Other (unspecified) analyses
No data available.
8.2 Toxicological Analyses and their Interpretation
8.2.1 Tests on toxic ingredient(s) of material
8.2.1.1 Simple Qualitative Test(s)
A. Identification of the plant
parts (additional to 3.1.1)
The powdered leaves are characteristically a
light yellow green in colour and taste
bitter.
Anatomical:
The lower surface of the leaf has
characteristic abaxial grooves containing
(single-cell hair) and vimicelled trichomes.
The cells of the mesophyllum contain calcium
oxalate crystals (35 µm).
B. Identification of toxic, active
ingredients in plant or preparation
(i) Specific reaction:
- Principle of test (or method):
In general cardenolides form with aromatic
nitro compounds in alkaline solution (e.g.
Kedde-reagent) typical and very specific re,
violet-red or blue-violet products
(Meisenheimer adducts).
- Sampling: plant parts, (preferably leaves,
flowers, fruit).
- Chemicals and reagents
Chemicals:
* dioxane
* dichloromethane (methylene chloride)
* 3,5-dinitro benzoic (C2H4N2O6)
* ethanol
* methanol
* 2 N NaOH (8,4 g NaOH dissolved in 100 mL
water)
* oleandrine
* oleander glycoside mixture -1 for TLC-
comparison
Reagents:
* Keddle-reagent: dissolve 3 g of 3,5-
dinitro benzoic acid in ethanol.
Take 5 mL and mix with 5 mL of a 2 N NaOH
directly before use.
Equipment:
* round bottle flask, 50 mL
* pipettes 0.1 mL and 0.5 mL
* test tubes
* filter-paper or silica gel plate
(5 × 5 cm)
* Extrelut R- column (20 mL, Nr. 11737 Merck
AG, D-6100
* Darmstadt
- Test sample (or specimen) preparation
* Extract 1 g of material (suspect material,
scene residues) with 20 mL methanol 50%
for 15 minutes under reflux on a water
bath.
* Filtrate and evaporate the extract to a
volume of 10 mL.
* Apply the extract on an ExtrelutR- column
and wait for 20 minutes.
* Extract the retain material with 60 mL of
dioxan-methanol-dichloromethane
[8+1+1].
* Collect the extract and evaporate to 10
mL.
Reference compound
Dissolve 10 mg of oleandrine in 10 mL
ethanol
Dissolve 10 mg of the "Oleander glycoside
mixture" in 10 mL ethanol.
- Procedure:
* Spot 100 µL of the extract on a filter-paper
or on a silica gel plate [5 × 5 cm]
* Add 5 drops of the Keddle-reagent
* An immediate blue, red or violet-blue
colour indicates the presence of
cardenolides (Colour vanish).
Analytical calibration procedure and
calculation of results not necessary.
Quality control
Carry out a blank test by taking 100 µL of
water instead of the sample.
Carry out a positive control test by
taking 100 µL of a cardenolide solution
such as oleandrin in ethanol.
- Specificity
A specific reaction with the lactone ring of
the cardenolide-molecule. Cardenolides
respond with a blue, red or violet- blue
colour reaction.
- Analytical performance: detection limit
3 µg of a cardenolide.
- Analytical assessment of the result: a
positive result indicates the presence of a
cardenolide.
- Medical interpretation of the result:
consider the possibility of ingestion of
cardenolides.
(ii) Thin Layer Chromatography
- Principle of test:
TLC separation of the Oleander cardenolide
mixture, (Wagner & Bladt, 1995), detection in
UV-254 and detection of the cardenolide zones
with Kedde-reagent.
- Sampling: 1 to 2 g of the suspect material
or residue.
- Chemicals and reagents
Chemicals:
* chloroform
* dioxane
* dichloromethane (methylene chloride)
* 3,5-dinitro benzoic acid
* thyl acetate
* methanol
* 2 M sodium hydroxide (8,4 g NaOH dissolved
in 100 mL water)
* sulfuric acid (conc.)
* water
* TLC-Silicagel 60 F 254 plates (with
fluorescence marker) (e.g. Merck
Darmstadt, Roth D 7500 Karlsruhe Nr.
2-8867 and 2-8864)
* oleandrine
* oleander glycoside mixture -1 for TLC-
comparison
Reagents:
* Keddle-reagent: dissolve 3 g of 3,5-
dinitro benzoic acid
* in ethanol.
* Take 5 mL and mix with 5 mL of a 2 M NaOH
directly
* before spraying.
* Solvent system for TLC: ethylacetate-
methanol-water
[81+11+8]
* Reference compounds:
Dissolve 10 mg of oleandrine in 10 mL
ethanol
Dissolve 10 mg of lanatoside C in 10 mL
ethanol
Dissolve 10 mg of the "Oleander glycoside
mixture" in 10 mL ethanol.
- Equipment:
* round bottle flask 50 mL
* TLC tank
* UV lamp (254 nm)
* fume cupboard
* spray apparatus
- Test sample (or specimen) preparation
* Extract 1 g of material (suspect material,
scene residues) with 20 mL methanol (50%)
for 15 minutes under reflux on a water
bath.
* Filtrate and evaporate the extract to a
volume of 10 mL.
* Apply the extract on an Extrelut20-
column and wait for minutes.
* Extract the retained material with 60 mL
of dioxanmethanol- dichloro methane
[8+1+1].
* Collect the extract and evaporate to
10 mL.
* Reference compounds
Dissolve 10 mg of oleandrine in 10 mL
ethanol
Dissolve 10 mg of lanatoside C in 10 mL
ethanol
Dissolve 10 mg of the "Oleander glycoside
mixture" in 10 mL ethanol.
- Procedure:
* Apply 20 µL of each cardenolide reference
solution to the TLC plate along the
baseline.
* Apply 20 µL and 40 µL of the test sample
preparation to the TLC plate along the
baseline.
* Prepare the TLC tank with the solvent
mixture.
* Place the prepared TLC plate in the tank
and allow to run for 12 cm
* Take the TLC plate out and allow to dry.
* Detection
Place the plate under UV lamp (UV-254 nm)
to visualize the spots and mark with a
pencil. Cardenolides show weak
fluorescence quenching. Spray the TLC
with Kedde-reagent and immediately blue,
violet-blue and red-violet spots indicate
the presence of cardenolides. Plant
extracts show 8-10 Kedde-positive zones in
the R-range 0.1 - 0.9.
Another re-agent used may be conc.
Sulfuric acid (unspecified reaction).
Mostly red to red-brown spots indicate the
presence of cardenolides. Plant extracts
show at least 8-10 red zones in the
R-range 0.1-0.9.
Calculate the Rf-values of the zones and
compare the Rf-values with the reference
compound and the Rf-values of the
cardenolid compounds given in table 2.
Analytical calibration procedure and
calculation or results is not applicable.
- Quality control:
Carry out positive control test by taking
20 µL of a cardenolide solution such as
oleandrine in ethanol.
Compare the TLC-fingerprint of an
authentic N. oleander cardiac
glycosides-extract.
- Specificity:
A specific reaction with the lactone ring
of the cardenolide-structure.
Cardenolides respond with blue, red or
violet-blue colour.
- Analytical performance: detection limit
3 µg of a cardenolide.
- Analytical assessment of the result: a
positive result indicates the presence of
a cardenolide.
- Medical interpretation of the result:
consider the possibility of ingestion of
cardenolides.
8.2.1.2 Advanced Qualitative Confirmation Test(s)
With the HPLC-method a cardenolide
profile of oleander glycosides in plant
extracts or oleander-preparations can be
achieved. The analysis is performed on a RP-
18 column by gradient elution (acetonitrile-
water) and detection in UV-220 nm. (Tittel &
Wagner, 1981).
Depending on habitat, distribution and time
of harvest, the cardenolide content in leaves
of different origin shows marked differences
in the distribution of the major
glycosides.
8.2.1.3 Simple Quantitative Method(s)
- Principle of test: The purified
cardenolide fraction of suspect material or
scene residue, is measured after addition of
Kedde-reagent at its absorption maximum
(540 nm).
- Sampling: 2 g plant material, suspect
material, scene residue, stomach content
- Chemicals and reagents: chemicals
(analytical grade)
* 3,5-dinitro benzoic acid (C2H4N2O6)
* ethanol
* methanol
2 N NaOH (8,4 g of a NaOH are dissolved in
100 mL of water)
* water (distilled)
* Aluminium oxide (Al2O3) acidic
Reagents:
* Kedde-reagent:
Dissolve 3 g of 3,5-dinitro benzoic acid in
ethanol
Take 5 mL and mix with 5 mL of a 2 N NaOH
directly before spraying.
Equipment:
flasks: 5 mL and 20 mL
volumetric flasks: 25 mL and 50 mL
pipettes: 1,2,3,4 mL
chromatographic column [15 mm diameter,
200 mm length]
with tap and glass filter (medium porosity
grade)
timer: 2 minutes
spectrophotometer visible
glass cuvettes (1 cm path length)
- Test sample (or specimen) preparation:
- Weigh a precise amount of powdered
plant material (2 g).
- add 35 mL of mixture of 24 mL ethanol
+ 36 mL water.
- heat for 20 minutes under reflux.
- filtrate after cooling through
filter-paper.
- wash with residue twice with 5 mL
portions of the ethanol-
water mixture (24+36).
- combine the filtrates and add the
ethanol-water mixture to mark in a
volumetric flask 50 mL.
Preparation of the column:
- 4.2 g Al2O3 and 20 mL water are shaken
in a flask for approximately 5 minutes.
- after standing for 5 minutes the
supernatant water is discarded.
- wash four times the Al2O3-material with
50 mL portions of ethanol.
- discard the ethanol.
add 50 mL of ethanol, shake well and transfer
the Al2O3 material into the column.
wait for 15 minutes, then add 10 mL ethanol.
-open the tap and discard the ethanol till
approximately 1/2 cm above the column
material (Al3O2). Close the tap.
Procedure:
- apply exactly 2 mL of the filtrate to the
column.
- eluate 4 times with O.5 mL ethanol and
finally with 16 mL ethanol.
- collect the cardenolide containing
fractions in a volumetric flask and make up
to 25 mL volume with ethanol and 4 mL Kedde-
reagent in a flask as blank (solution).
- take exactly 4 mL of the cardenolide
fraction and add 4 mL Kedde-reagent, mix
thoroughly.
- transfer into the glass cuvette.
- read the absorbence of the test solution
exactly 2 minutes (with timer) after addition
of the reagent against the blank at 540 nm as
the coloration is time-dependent!
- Analytical calibration procedure and
calculation or results:
- calibrate with four standards of a solution
of 10 mg oleandrine 100 mL ethanol.
- take 1/2/3/4 mL and add each time 4 mL of
the Kedde-reagent.
- measure each solution exactly after
2 minutes at 540 nm against the blank.
- construct a calibration function.
- compare the absorbence of the test solution
with the calibration function.
- alculate the oleandrin amount as:
a × 1562.5
% = ----------
e × (100-t)
a = mg oleandrin found in the calibration
function
e = sample material in analytical solution
t = loss of liquid (%)
(t = weigh a precise amount of powdered plant
material (1 g) and heat: at 110°C till the
material has a constant weight: the
difference in weight indicates the loss of
liquid of the material).
- Quality control:
It is important that test and reference
solution are measured exactly after 2 minutes
after adding the Kedde-reagent (coloration is
time dependent!).
- Specificity: the method is generally
applicable for cardenolides. The total
cardenolides are calculated as oleandrine.
- Analytical performance
Mean coefficient of variation 6%. Detection
limit is 1 µg of cardenolide.
- Analytical assessment of the result
Consider the presence of cardenolides.
- Medical interpretation of the result
Consider the possibility of ingestion of
cardenolides.
8.2.1.4 Advanced Quantitative Method(s)
Methods for toxic, active
ingredients. With the HPLC-method of
external standard a quantitative estimation
of the oleander glycosides can be achieved.
The analysis is performed on a RP-18 column
isocratic and by gradient elution
(acetonitrile-water) and detection in UV-220
nm. (Tittel & Wagner, 1981).
column µ-Bondapak .. C-18 (300 × 4 mm
ID)
flow 2 mL/minutes
detection 220 nm
solvent acetonitrile-water (40+60)
isocratic
oleandrin Rt 12.5 minutes
adynerin Rt 14 minutes
Quantitative estimation of glycosides other
than oleandrine and adynerine is possible by
linear gradient elution (20 to 50%
acetonitrile in 45 minutes).
8.2.2 Tests for biological specimens
8.2.2.1 Simple Qualitative Test(s)
8.2.2.2 Advanced Qualitative Confirmation Test(s)
8.2.2.3 Simple Quantitative Method(s)
8.2.2.4 Advanced Quantitative Method(s)
8.2.2.5 Other Dedicated Method(s)
8.2.3 Interpretation of toxicological analyses
8.3 Biomedical investigations and their interpretation
8.3.1 Biochemical analysis
8.3.1.1 Blood, plasma or serum
"Basic analyses"
"Dedicated analyses"
"Optional analyses"
8.3.1.2 Urine
"Basic analyses"
"Dedicated analyses"
"Optional analyses"
8.3.1.3 Other fluids
8.3.2 Arterial blood gas analyses
8.3.3 Haematological analyses
"Basic analyses"
"Dedicated analyses"
"Optional analyses"
8.3.4 Interpretation of biomedical investigations
8.4 Other biomedical (diagnostic) investigations and their
interpretation
8.5 Overall interpretation of all toxicological analyses and
toxicological investigations
Sample collection
Plant specimens should be collected for botanical
identification if possible. They should be transported
between two newspaper sheets (preferably the leaves and
flowers). Plant portions found in vomit should be stored in
a plastic bag.
Biomedical analysis
ECG is valuable for diagnosis, prognosis and treatment since
cardiac effects similar to digitalis glycosides may occur
(Goldfrank et al., 1994). The serum potassium concentration
should be measured because of its prognostic importance.
Toxicological/toxinological analysis
Plasma samples should be taken for digoxin immunoassay.
In a mild case of N. oleander poisoning the apparent
digoxin level was 1.5 ng/mL (Shumaik et al., 1988). In a
fatal case of N. oleander poisoning "digoxin" level was 5.8
mcg/l. A cross reactivity between oleander glycosides was
demonstrated in a radioimmunoassay. Using this method, 5.8
mcg/l of digoxin corresponds to 580 mcg/l of total cardiac
glycoside concentration (Osterloh et al., 1982). Cheung et
al. (1984) found radioimmunoassay to be a rapid and
convenient method to confirm N. oleander poisoning, but the
apparent "digoxin" concentration was not proportional to the
cardiac glycoside concentration.
Test for active ingredient
Immunoassay is a rapid and convenient method for confirming
ingestion of N. oleander. The competitive immunoassay
method allows rapid screening of suspected specimens. This
method is also useful for confirming the presence of cardiac
glycosides in serum (Radford et al., 1986). Cross reactivity
has been demonstrated between the cardiac glycosides in
N. oleander and the digoxin radioimmunoassay (Osterloh et
al., 1982; Haynes et al., 1985). Oleandrin can be detected
by thin layer chromatography, with location by fluorescence
and chromogenically by means of p-anisaldehyde.
Quantification can be performed by fluorescence
spectrophotometry with excitation at 355 nm and fluorescence
scanning from 340 to 580 nm (Blum & Rieders, 1987).
Test for biological sample
Parts of the plant can be confirmed by microscopic
examination of the epidermis, where stoma cells are
typical.
Biochemical investigations
Serum electrolytes should be monitored, with special
attention to potassium. Serum urea and creatinine should be
measured in severe cases.
Interpretation
The most important biochemical measurement is the serum
potassium concentration. It has prognostic significance,
since the elevated potassium facilitates cardiac arrhythmias.
Digoxin radioimmunoassay may help to confirm poisoning.
9. CLINICAL EFFECTS
9.1 Acute poisoning
9.1.1 Ingestion
The clinical effects are mainly cardiac and
gastrointestinal, resulting in a clinical picture
similar to that of digoxin poisoning, including
nausea, vomiting, salivation, colic and diarrhoea
(Hardin & Arena, 1974). Parts of the plant may be
recognized in the vomit. Bloody diarrhoea has been
described (Shaw & Pearn, 1979). Circumoral erythema
has been described as a typical sign (Lewin et al.,
1986).
Sinus bradycardia is the most frequent cardiovascular
sign, and it may progress to atrioventricular block
(AV) and asystole. Ventricular arrhythmias, premature
ventricular beats, ventricular tachycardia and
ventricular fibrillation can occur in severe cases
(Osterloh et al., 1982).
The triad of gastrointestinal distress, circumoral
erythema and cardiac dysrhythmias in a child or adult
should alert to the possibility of poisoning by
N. oleander (Lewin et al., 1986).
Central nervous system effects occur frequently and
include ataxia, drowsiness, mydriasis, muscular
tremors, seizures and coma (Shaw & Pearn, 1979; Lewin,
1980).
9.1.2 Inhalation
Inhalation of smoke from burning the plant may
cause poisoning.
9.1.3 Skin exposure
Sap contains an unidentified irritant of the
mucous membranes of the mouth and intestine (NCPCC,
1979).
9.1.4 Eye contact
Severe eye irritation can be caused by the sap
(NCPCC, 1979).
9.1.5 Parenteral exposure
No data available.
9.1.6 Other
A fatal case of rectal and oral administration of
N. oleander extract has been described (Blum &
Rieders, 1987).
9.2 Chronic poisoning
9.2.1 Ingestion
Chronic poisoning has not been described, even
in patients treated with Oleandrin extracts.
9.2.2 Inhalation
No data available.
9.2.3 Skin exposure
No data available.
9.2.4 Eye contact
No data available.
9.2.5 Parenteral Exposure
No data available.
9.2.6 Other
No data available.
9.3 Course, prognosis, cause of death
Patients with cardiovascular illness, those who ingest
more than 0.5 mg/kg of N. oleander leaves and/or those who
arrive late to hospital are at highest risk. Serum potassium
concentrations are of prognostic importance, as in digoxin
intoxication (Goldfrank et al., 1994). The presence of
hyperkalaemia in the initial stage of intoxication worsens
the prognosis. Deaths from ingestion of N. oleander occur
due to dysrhythmias (Lewin et al., 1986).
9.4 Systematic description of clinical effects
9.4.1 Cardiovascular
ECG changes include sinus bradycardia, varying
levels of atrioventricular block, ventricular
arrythmias and finally ventricular fibrillation, which
is the usual cause of death.
9.4.2 Respiratory
No effects have been described either in acute
or chronic poisoning.
9.4.3 Neurological
9.4.3.1 Central nervous system (CNS)
Ataxia, drowsiness, mydriasis,
seizures and coma.
9.4.3.2 Peripheral nervous system
No effects have been described either
in acute or chronic poisoning.
9.4.3.3 Autonomic nervous system
Mydriasis, pallor, hypersalivation
and other autonomic effects have been
described.
9.4.3.4 Skeletal and smooth muscle
Muscle tremor may occur after acute
poisoning.
9.4.4 Gastrointestinal
Nausea, vomiting, colic and diarrhoea are
characteristic of acute poisoning.
9.4.5 Hepatic
No data available.
9.4.6 Urinary
9.4.6.1 Renal
No data available.
9.4.6.2 Other
No data available.
9.4.7 Endocrine and reproductive systems
No data available.
9.4.8 Dermatological
Irritant circumoral erythema has been described
as a typical sign.
Sap contains an unidentified allergen which produces
dermatitis
(NCPCC, 1979).
9.4.9 Eye, ear, nose, throat: local effects
Local effects: the sap irritates the eyes and
the mucous membranes of the mouth and intestine
(Pearn, 1987).
9.4.10 Haematological
No data available.
9.4.11 Immunological
No data available.
9.4.12 Metabolic
No data available.
9.4.12.1 Acid-base disturbances
No data available.
9.4.12.2 Fluid and electrolyte disturbances
Hyperkalaemia may be detected in
acute poisoning. Gastrointestinal fluid loss
often leads to dehydration and hypovolaemic
shock.
9.4.12.3 Others
No data available.
9.4.13 Allergic reactions
Sap contains an unidentified allergen which
produces dermatitis (NCPCC, 1979).
9.4.14 Other clinical effects
No data available.
9.4.15 Special risks
Pregnancy: Although N. oleander has been
ingested as an abortifacient, abortion has not been
reported after acute poisoning (Spevak & Soc, 1975).
N. oleander poisoning in a cow during the second
half of pregnancy did not produce abortion (Mahin et
al., 1984).
Breast feeding: no data available.
Enzyme deficiencies: no data available.
9.5 Other
No data available.
9.6 Summary
10. MANAGEMENT
10.1 General principles
Even asymptomatic patients should be admitted for
observation, decontamination and cardiovascular monitoring.
Repeated electrocardiograms or continuous ECG monitoring are
necessary.
The triad of gastrointestinal distress, circumoral erythema,
and cardiac dysrrhythmias in a child or adult should alert
the clinician to the possibility of poisoning due to
N. oleander; the serum concentration of digoxin level
should be measured. A positive result in a patient who is
not taking the cardiac glycosides suggests ingestion of a
digitalis-like substance (Lewin et al., 1986).
Treatment should aim at gut decontamination by means
of emesis or lavage; correction of electrolyte imbalance; and
correction of severe dysrthymias (Kunkel, 1983).
10.2 Life supportive procedures and symptomatic/specific treatment
Management depends on the occurrence of cardiac
effects. Bradycardia may require atropine or electrical
pacing (Kunkel, 1983).
Ventricular arrhythmias could be treated with phenytoin or
lignocaine. Phenytoin should be infused intravenously slowly
in doses of 3.5 to 5.0 mg/kg, at a rate not greater than 50
mg/minute to repeat once if necessary. Lignocaine may be
administered at a dose of 1 mg/kg as a slow intravenous bolus
followed by continuous infusion of 2 to 4 mg/minute
(adult).
Treatment of hyperkalaemia should aim at lowering the serum
potassium level with insulin, glucose, sodium bicarbonate and
ion-exchange resins. Haemoperfusion may be considered in
severe cases. Calcium chloride is contraindicated (Goldfrank
et al., 1994).
10.3 Decontamination
Emesis or gastric lavage are indicated at an early
stage if the patient has not vomited copiously or if no
contraindications exist. It should be followed by the
administration of activated charcoal and, possibly, a
cathartic. The indication and value of decontamination
procedures will depend on the time elapsed since ingestion
(Pronczuk & Laborde, 1988; Goldfrank et al., 1994).
10.4 Enhanced elimination
Forced diuresis, haemoperfusion and haemodialysis are
not effective in increasing digoxin elimination (Goldfrank et
al., 1994). The same criteria can be applied to other
cardiac glycosides of similar chemical structure.
10.5 Antidote/antitoxin treatment
10.5.1 Adults
Digoxin-specific Fab antibody fragments have been
used successfully in an adult patient intoxicated with
N. oleander (Shumaik et al., 1988).
Although not available for routine use in all
countries even for digoxin poisoning, Fab fragments
are a possibility to consider when N. oleander
poisoning is unresponsive to conventional treatment.
10.5.2 Children
No data available.
10.6 Management discussion
The use of digoxin-specific Fab fragments deserves
further evaluation.
11. ILLUSTRATIVE CASES
11.1 Case reports from the literature
An elderly woman was found weak and vomiting and
developed a tonic seizure followed by cardiac arrest on
arrival at hospital. Despite continuous cardiopulmonary
resuscitation the patient died. The potassium level was 8.6
mEq/L and the apparent digoxin level was 5.8 mcg/L. Cross
reactivity between oleandrin and digoxin was calculated at
29,000:1 in the digoxin-radioimmunoassay (Osterloh et al.,
1982).
A 37-year-old man ingested a "handful" of N. oleander
leaves. Two hours later, he presented with bradycardia (30
to 45 bpm) with sinoatrial block and junctional escape. He
was treated with a single dose of five vials of digoxin-
specific Fab antibody fragment (Digibind). The pre-treatment
apparent digoxin level was 1.5 mcg/L. After treatment the
patient improved, with a sinus bradycardia (56 bpm), and
recovered uneventfully (Shumaik et al., 1988).
12. ADDITIONAL INFORMATION
12.1 Specific preventative measures
Prevent small children from playing with the plant and
ingesting parts of it.
12.2 Other
No data available.
13. REFERENCES
Arzneimittel Codex (DAC) ed. (1979). Monograph"Oleanderblätter".
Blum LM and Rieders F (1987) Oleandrin distribution in a fatality
from rectal and oral Nerium oleander extract administration.
J Anal Toxicol, 11(5): 219-221.
Cheung K, Hind J and Duffy P. (1989) Detection of poisoning by
plant-origin cardiac glycoside with the Abbott TDX analyzer. Clin
Chem, 35: 295-297.
Font-Quer P (1979) Plantas medicinales. Barcelona, Ed. Labor SA.
Goldfrank LR, Flomenbaum NE, Lewin NA, Weisman RS, Howland MA and
Hoffman RS eds (1994) Goldfrank's Toxicologic Emergencies, 5th ed.
Appleton-Century-Crofts, Norwalk.
Hardin JW and Arena JM (1974) Human poisoning from native and
cultivated plants, 2nd ed. Kingsport, Tennessee, Duke University
Press.
Haynes BE, Bessen HA and Wightman WD (1985) Oleander tea: herbal
draught of death. Ann Emerg Med, 14(4): 350-353.
Huxley A ed-in-chief (1992) The New Horticultural Society
dctionary of grdening, vol. 3. London, MacMillan.
Jouglard J, Deltour JF, Richardot R and Grinorian G (1973) Bilan
des intoxications aigues par les plantes signalés au centre
antipoisonings de Marseille. Lyon Med, 223(2): 186-187.
Kingsbury JM (1964) Poisonous plants of the United States and
Canada. Englewood Cliffs, NJ Prentice Hall.
Kunkel DB (1983) Poisonous Plants. In: Haddad LM and Winchester
JF eds. (1983) Clinical management of poisoning and drug
overdose. Philadelphia, Saunders, p 317.
Lampe KF and McCann MA (1985) AMA handbook of poisonous and
injurious plants. Chicago, Illinois, American Medical
Association.
Mahin L, Marzou A and Huart A (1984) A case report of Nerium
oleander poisoning in cattle. Vet Hum Toxicol, 26: 303-304.
NCPPC (National Clearinghouse for Poison Control Centers) (1979)
Nerium Oleander. 1979; 145 supp.
Osterloh J, Herold S and Pond S (1982) Oleander interference in
the digoxin radioimmunoassay in a fatal ingestion. JAMA, 247(11):
1596-1597.
Pearn J (1987) Oleander poisoning. In: Covacevich J, Davie P and
Pearn J eds (1987) Toxic plants & animals; a guide for Australia.
Brisbane, Queensland Museum, pp 37-49.
Pronczuk J and Laborde A (1988) Plantas silvestres y de cultivo:
riesgo de intoxicacion para el hombre. Montevideo, Universidad de
la Republica.
Radford DJ, Gillies AD, Hinds JA and Duffy P (1986) Naturally
occurring cardiac glycosides. Med J Aust, 144: 540-554.
Reynolds JEF ed (1989) Martindale: the extra pharmacopoeia, 29th
ed. London, The Pharmaceutical Press.
Shaw D and Pearn J (1979) Oleander poisoning. Med J Aust,
2: 267-269.
Shumaik JM, Wu AW and Ping AC (1988) Oleander poisoning:
treatment with digoxin-specific Fab antibody fragments. Ann Emerg
Med, 17(7): 732-735.
Spevak L and Soc M (1975) Two cases of poisoning by tea from
Oleander leaves. Arch Hig Rada Toksicol, 26: 147-50.
Schvartsman S (1979) Plantas venenosas. Sarvier Sao Paulo.
Szabuniewicz M, Mc Crady JD and Camp BJ (1971) Treatment of
experimentally induced oleander poisoning. Arch Int Pharmacodyn
Ther, 189: 12-21.
Tittel G and Wagner H (1981) Qualitative und quantatitve Analyse
von Herzglykosiddrogen durch HPLC-Verfahren. Planta Med,
43: 252-262.
Wagner H and Bladt S (1995) Plant drug analysis, 2nd ed. Berlin,
Springer.
14. AUTHOR(S), DATES(S) REVIEWER(S), (INCLUDING UPDATES), COMPLETE
ADDRESS(ES):
Author: Dr A. Laborde
CIAT 7° piso
Hospital de Clinicas
Av. Italia s/n
Montevideo
Uruguay
Tel: 598-2-804000
Fax: 598-2-470300
Date: November 1989
Peer review: Singapore, November 1989
Peer review of Section 8: Algiers, Algeria, November 1992
General edit and botanical review:
Christine Leon
Medical Toxicology Unit
Guy's & St Thomas Hospital Trust
c/o Royal Botanic Gardens, Kew
Richmond
Surrey
TW9 3AB
United Kingdom
Tel: +44 (0) 181 332 5702
Fax: +44 (0) 181 332 5768
e-mail: c.leon@rbgkew.org.uk
Date: July 1997