Accidental digitoxin intoxication: an interplay between laboratory and clinical medicine |
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| Authors: | Luigi M Castello Sophie Negro Francesca Santi Isabella Zanotti Matteo Vidali Marco Bagnati Giorgio Bellomo Gian Carlo Avanzi |
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| Institution: | 1.Medicina e Chirurgia d’Accettazione e d’Urgenza, Azienda Ospedaliero-Universitaria Maggiore della Carità, Scuola di Specializzazione in Medicina d’Emergenza-Urgenza, Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, Novara, Italy;2.Laboratorio Ricerche Chimico-Cliniche, Azienda Ospedaliero-Universitaria Maggiore della Carità, Dipartimento di Scienze della Salute, Università del Piemonte Orientale, Novara, Italy |
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| Abstract: | Introduction:Two Italian adults arrived at the Emergency Department referring diarrhea, nausea and vomiting for 4 days; weakness, fatigue and visual hallucinations were also complained of. Patients reported the ingestion of some leaves of a plant, which they supposed to be “donkey ears”, a week before. Physical examination showed hypotension and bradycardia and ECG examination disclosed sinus rhythm and repolarization abnormalities (scooping of the ST-T complex) in both patients and a 2:1 AV block in the man.Materials and methods:Digoxin concentration was evaluated twice for each patient (at the admission and after 4 hours) by the automated immunoassay system ADVIA Centaur®. Digitoxin concentration was evaluated by liquid chromatography-mass spectrometry (LC-MS/MS).Results:Despite clinical picture was suggestive of digitalis intoxication, digoxin levels were undetectable. Due to the more severe clinical picture, the male patient was treated with anti-digoxin antibodies (Digifab®) achieving a good clinical improvement and remission of the AV block within two hours. Initial diagnosis was confirmed by LC-MS/MS showing high digitoxin concentrations, but digoxin was undetectable. Patients remained stable and 48 hours later were discharged from the hospital.Conclusion:Whereas digoxin determination frequently relies on monoclonal antibodies which do not cross-react to digitoxin, polyclonal antibodies constituting Digifab® recognize a large spectrum of cardiac glycosides, including digitoxin. This report emphasizes the primary role of the clinical approach to patients in the emergency setting and how an active communication and a continuous sharing of professional experiences between Laboratory and Clinicians ensure an early and correct diagnosis. |
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| Keywords: | digitalis glycosides/poisoning digitoxin digoxin antibodies Fab fragments digitoxin/toxicity digitoxin/analysis |
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