Oleander Poisoning

Nerium is a genus that contains only one species, Nerium oleander, which is widely present to Europe and Asia. The plant is a member of the Apocynaceae (dogbane family), one of the biggest plant groups.

Oleander is a tiny tree or shrub with long, thin, dark green leaves and vividly colourful, five-petaled blooms. The blooms can be solitary or double, and they are frequently grouped in clusters. Oleander is an excellent garden plant since it is a long-lived plant that thrives in a variety of circumstances. It is frequently grown for ornamental purposes, and numerous varieties are commercially available.

Nature

  • Oleander is one of the cardiac poisons.
  • They are glycosides and behave like digitalis.
  • Oleander is grown in gardens and on roadsides for the beauty of its flowers.
  • It has 2 varieties that is White Oleander and yellow oleander.
  • Shrub grows all over India and bears lanceolate leaves with white or pink flowers.
  • The leaves give clear thick juice.
  • All parts of plants are highly poisonous.
  • The various parts of the plant have been used as suicidal and homicidal poisons.

Botanical Name: Nerium odorum

Common Names:

Common oleander, white oleander, Kaner, Yellow oleander.

Family: Apocynaceae

Active Principles

  • Oleandrin (glycoside)
  • Nerin
  • Folinerin

Fatal Dose

  • 15 to 20 gm root
  • 5 to 15 leaves

Fatal Period

20 to 36 hours

Uses

  • Roots and leaves of the plant are used as medicine in cancer and ulcer treatment.
  • They are also believed to be effective against venereal diseases.
  • The bark in small doses is used as an antipyretic.
  • The roots and leaves are used both internally and through vagina to cause abortion.
  • It is also used as cattle poison.
  • Common oleander is a popular ornamental garden plants.

Administration

  • Oleander is administered in the form of pills.
  • It is mixed with food materials, sweets, soft drinks and liquors.
  • It is administered in the form of decoctions of its roots and leaves.
  • Oleander poisoning is often accidental when it is used as medicine to secure abortion.
  • Sometimes, it is used as suicidal poison.
  • Homicidal administration is rather rare.

Mechanism of Action

The glycosides have digoxin like action and inhibit sodiumpotassium ATPase.

Sign and Symptoms

  • Burning sensation in the mouth and throat.
  • Frothy salivation.
  • Vomiting
  • Diarrhoea
  • Abdominal pain
  • Dizziness
  • Jaw locking
  • Fainting
  • Death
  • Ventricular fibrillation
  • Delirium

The following are also seen:

GIT: Nausea, vomiting, diarrhoea. Numbness of tongue occurs sometimes.

CVS: Increased ectopy and conduction delay (bradycardia, supraventricular tachycardia with AV block), electrolyte imbalances (especially hyperkalaemia) and hypotension/ hypertension. Ventricular fibrillation is potentially lethal. Decreased QRS-T interval, T wave flattening/inversion, irregular ventricular rate, and increased PR interval, etc., have also been reported. Smoke from a burning oleander plant can cause dizziness, vomiting, and cardiac arrhythmias.

CNS: Delirium, lethargy, dizziness, drowsiness. Occasionally there may be seizures, and coma.

Treatment

► Gastric lavage with activated charcoal- Gastric lavage is of limited benefit in patients ingesting plant parts, particularly children, because of the size of the plant parts relative to the lavage tube. Also, the procedure may worsen bradycardia secondary to vagal stimulation. Whole gut lavage may be more useful in such situations.

► Atropine for AV block and sinus tachycardia- 1 mg IV; repeat in 3 to 5 minutes if asystolic cardiac arrest persists. 3 mg (0.04 mg/kg) IV is generally considered to be a fully vagolytic dose in most adults. Insertion of a pacemaker should be considered in those patients with severe bradycardia, and/ or slow ventricular rate due to second degree AV block who fail to respond to atropine (and/or phenytoin).

► Careful measurement of serum potassium is one of the most important laboratory tests to be done, since hyperkalaemia is quite common. The emergency management of lifethreatening hyperkalaemia (potassium levels greater than 6.5 mEq/L) includes IV bicarbonate, glucose, and insulin (administer 0.2 unit/kg of regular insulin with 200 to 400 mg/kg glucose). Concurrent administration of IV sodium bicarbonate (about 1 mEq/kg) is of additive value in rapidly lowering serum potassium levels.

► Symptomatic treatment.

► Digoxin-specific Fab fragment therapy- Treatment with Fab fragments should be considered in those severely intoxicated patients who fail to respond to immediately available conventional therapy

► IV fluids.

Antiarrhythmics (e.g. lignocaine) : Lignocaine is useful in the management of ventricular tachy-arrhythmias, PVCs, and bigeminy.

Haemodialysis: Haemodialysis is ineffective in removing cardiac glycosides, but may assist in restoring serum potassium to normal levels.

Post-Mortem Finding

  • Seeds and leaf fragments are often found even in putrefied bodies.
  • Gastrointestinal track may be found congested.
  • Petechial hemorrhages over heart are seen.

Yellow Oleander

Botanical Name – Cerbera thevetia, Thevetia peruviana, T.neriifolia.

Common Name – Bastard oleander, Exile oleander, Be-still tree, Lucky nut, Tiger apple.

Nature

  • This plant resembles common oleander but have large bell-shaped yellow color flowers.
  • The plant bears fruits, which are diamond to globular in shape and 4 to 5 cm in length.
  • The fruits are initially greenish in colour but turns yellow and then black when becomes ripe.
  • The fruit contains a single nut, which is elongated triangular with deep groove along the edge.
  • Each nut contains 5 pale yellow seeds.
  • Milky juice (sap) exudes from all parts of plant.

Toxic Part of Plant

All parts but seed and root are more toxic.

Active Principles

  • Cerberin
  • Nerifolin
  • Peruvoside
  • Ruvoside
  • Thevetin A and B

Fatal Dose

  • 8 to 10 seeds
  • 15 to 20 gm of root
  • 5 to 10 leaves

Fatal Period

2 to 3 hours if powdered root taken.

Sign and Symptoms

  • The milky juice (sap) if applied to skin may cause inflammation to human beings.
  • Numbness in mouth and tongue.
  • Vomiting
  • Diarrhea
  • Headache
  • Giddiness
  • Loss of muscle power
  • Tachycardia
  • Cardiogenic shock
  • Jaundice
  • Renal failure

Treatment

► Gastric lavage with multiple dose activated charcoals is said to be effective since charcoal binds glycoside in the gut lumen and promotes their elimination.

► Bradyarrhythmias are treated with intravenous boluses of atropine and intravenous infusion of isoprenaline.

► Temporary cardiac pacing.

► Administration of antidigoxin Fab fragment is considered as effective but expensive and not widely available.

Post-Mortem Findings

  • Congestion of organs
  • Subendocardial and perivascular hemorrhage with focal myocardial edema.

White Oleander

Common Name- Nerium odorum

Nature

  • This plant is commonly known as white or sweet scented oleander.
  • Its white or pink flower is commonly given as offerings in temples.
  • All parts of this plant are poisonous.
  • The leaves, bark and flowers of this plant are used in treatment of skin diseases, wounds, snake bite and gynaecological conditions

Active Principle: Nefrin

Fatal Dose

  • 15 to 20 gm root
  • 5 to 15 leaves

Fatal Period

20 to 36 hours

Sign and Symptoms

  • Burning sensation in the mouth and throat.
  • Frothy salivation.
  • Vomiting
  • Diarrhoea
  • Abdominal pain
  • Dizziness

Forensic Examination and Detection

● On warming with sulphuric acid or phosphoric acid for some time at 100 degree celcius gives pink colour which indicate oleander.

● Ether extract gives crimson colour with sulphuric acid and ferric sulphate also indicated oleander.

● Ether extract when injected into a frog produces convulsion which also indicates oleander poisonings.

Other Instruments

  • Thin-layer chromatography
  • Fluorescence spectrophotometry can also be used to identify oleander glycosides.
  • Reverse-phase HPLC and HPLC/MS are more specific.
  • Because oleander-derived cardiac glycosides are crossreactive with the frequently used radio-immunoassays for digoxin, an elevated level may help confirm suspicion of oleander poisoning.

Toxicological Materials

  • Vomitus
  • Purges
  • Faeces
  • Urine
  • Blood
  • Stomach contents
  • Intestines.

Medico Legal Importance

● Accidental poisoning from its use in traditional medicine. Accidental death occurs due to consumption of folk medicine containing oleander.

● Suicidal ingestion of decoction prepared from leaves or root is fairly common in rural areas.

● Homicidal cases are rare, but have been reported.

● Root used for causing abortion.

● Cattle poison has been also reported.

● Common oleander resist decomposition and burning, thus can be detected from decomposed bodies or ash.

References

  • Dr. K.S. Narayan Reddy. The essential of forensic medicine and toxicology.34th edition.
  • VV Pillay. Modern medical toxicology.4th edition.
  • R.K.Sharma. Concise textbook of forensic medicine and toxicology. 3rd edition.
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