PMC6906804_01
(a) Two fresh leaves belonging to a plant responsible for the intoxication. Samples were deposited at the Poison Centre of Niguarda Hospital, Milan, Italy. The leaves were subjected to macro and microscopic analyses suitable for the identification by a botanist. Then, the leaves were dried and used for phytochemical analyses. (b) Plant during flowering.
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The Poison Control Centre of Niguarda Hospital (Milan, Italy) was consulted, and a sample consisting of two fresh leaves was sent to the aforementioned centre for the botanical identification (Figure 1(a)). The typical purple tubular flowers confirmed that it was a plant belonging to the Digitalis genus (Figure 1(b)).
(a) Telemetry recordings showing sinus rhythm with a single episode of advanced AV block (two consecutive P waves not followed by a QRS complex:arrows) followed by second-degree AV block episode. Note diffuse ST segment depression with down-up sloping typical of digitalis intoxication. (b) Telemetry recordings showing bigeminal ventricular ectopic beats and a run of accelerated idioventricular rhythm (8 beats at 72 bpm). Reduction of the intoxication signs.
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Two days after admission, a single episode of advanced AV block (two consecutive P waves not followed by a QRS complex) was recorded by telemetry, followed by a second-degree AV block episode (Figure 2(a)). On the fourth day, a single run of accelerated idioventricular rhythm (8 beats at 72 bpm) was detected (Figure 2(b)).
Graphical representation of potassium and digoxin serum levels measured in the study patient from day 0 up to day 12.
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SR with occasional episodes of sinoatrial block and a slow regression of the VR intoxication signs. Serum digoxinemia were still considered toxic (2.4 mug/L) on day 12 (Figure 3).
Plasma analysis by LC-MS. (a) Plasma profile with peak (A) corresponding to a glycoside unidentified; (b) authentic standard of gitoxin, which allowed to identify the compound in plasma sample; (c) fragmentation of gitoxin with typical fragment at 743 m/z; and (d) fragmentation of unknown compound with a fragment at 779 m/z.
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As shown in Figure 4, plasma contained traces of gitoxin identified in comparison to the authentic peak (b) whereas digitoxin and digoxin were not detectable.