Nerium Oleander L

17/11/2015 Nerium oleander L.(PIM 366)

http://www.inchem.org/documents/pims/plant/pim366.htm 1/31

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 Firstaid 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 physicochemical characteristics

3.4 Other chemical contents of the plant

4. USES/CIRCUMSTANCES OF POISONING

4.1 Uses

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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 halflife 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 Interactions8. TOXICOLOGICAL ANALYSES AND BIOMEDICALINVESTIGATIONS

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






8.1.3 Transport of laboratory samples and specimens


8.1.3.2 Biochemical 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







8.2.2.5 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 toxicologicalinvestigations

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 Acidbase 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


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.


Blood and urine should be collected for routine biochemical analysis. Serum samples should be taken for measurements of the serum potassium concentration.


Blood should be collected for arterial blood gas analysis in unconscious patients.


Blood should be collected for routine haematological analyses.


No data available.

8.1.2 Storage of laboratory samples and specimens


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.


Biological samples should be stores at 4°C in a refrigerator.


Storage is not possible.


Samples should be stored at 4°C in a refrigerator.


No data available.

8.1.3 Transport of laboratory samples and specimens




No special requirements. For macroscopic and microscopic analysis: no special requirements.

8.1.3.2 Biochemical analyses

No special requirements.


Transport to the laboratory immediately.


No special requirements.


No data available.

8.2 Toxicological Analyses and their Interpretation

8.2.1 Tests on toxic ingredient(s) of material


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

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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.


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.


‐ 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.


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





8.2.2.5 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


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

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: [email protected] Date: July 1997

See Also: Toxicological Abbreviations

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Nerium Oleander L

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