a fatal case of suicide fruit ingestion in singapore by cerbera cardiac glycoside intoxication: case report and review of literatures

Case presentation: we present a case of lethal glycoside toxicity from cerbera fruit ingestion. despite the patient’s asymptomatic presentation, life threatening clinical features such as hyperkalaemia, hypotension and arrhythmia occurred later. treatments for cardiac glycoside toxicity were instituted: activated charcoal (ac), atropine, hyperkalaemia management, digoxin immune fab (digifab) and intravenous lipid emulsion (ile). advanced cardiac life support (acls) was instituted with automated chest compression device. the patient died despite prolonged of resuscitation effort. cerbera glycoside toxicity warrants serious consideration in view of rare presentation and unpredictable nature of toxicology. discussion: we highlight the prevalence of cerbera species in asia-pacific and present the similarities of cardiac glycosides pharmacology. early recognition of ingestion and cardiac monitoring are particularly important. in this case, patient deteriorated despite normal serum digoxin level. this poses significant diagnostic and prognostic challenge. as the evidence of cerbera glycoside poisoning treatment options is lacking, we take this opportunity to examine treatment options in assumption of similar pharmacology among cardiac glycoside family. we present in-dept discussion on digoxin antidote, multidose-activated charcoal (mdac), ile to reduce of serum free glycoside. electrical and pharmacology treatment for arrhythmia were explored. we propose ecmo should always be considered for cardiac toxicity in anticipation of treatment failure. conclusion: cerbera glycoside poisoning should be treated with utmost caution as the fruit is easily accessible and highly toxic. close cardiac monitoring is a must due to high mortality risk. digifab should be instituted as guided by toxicologist. patients should be transferred to ecmo centre for observation in all cases due to the unpredictable nature of toxin. further investigation of treatment is awaited.