© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.Background Taxus baccata, also known as English yew, is a poison that causes cardiac arrhythmias and can result in death from cardiogenic shock.Case summary A 49-year-old gentleman was admitted following yew ingestion with suicidal intent. He was bradycardic at 30 b.p.m. and hypotensive on arrival. Electrocardiography revealed complete heart block with broad complex ventricular escape rate of 30 b.p.m. Bedside echocardiography revealed severe global impairment of right and left ventricular systolic function. Urgent temporary transvenous pacing was instituted, and the patient was considered for veno-arterial extracorporeal membrane oxygenation. Unfortunately, he deteriorated rapidly and cardiorespiratory arrest ensued, and despite prolonged in-hospital resuscitation, the patient died. Post-mortem examination revealed small needle-shaped plant leaves together with seeds found in the stomach. Ante mortem serum sample analysis sent to the Royal Botanical Gardens and revealed the presence of taxine Type B alkaloids in the patient’s blood.Discussion Yew poisoning is a rare occurrence, and there is currently no effective antidote. Treatment involves supportive management, comprising prolonged effective cardiopulmonary resuscitation, pacing, and mechanical cardiac support. This case illustrates the importance of prompt recognition of yew poisoning, alongside early consideration of pacing and mechanical cardiac support. Due to the rarity of this cause of heart block, and since patients may not always volunteer a history of yew ingestion, yew poisoning is something that physicians should be aware of and this should be considered in the differential diagnosis in patients with unexpected heart block. Serum analysis for taxine alkaloids can be used to confirm the diagnosis.Peer reviewe

Chan, Mark

G, Natasha

Gorog, Diana

Gue, Ying X.

European Heart Journal - Case Reports

English

Background Taxus baccata, also known as English yew, is a poison that causes cardiac arrhythmias and can result in death from cardiogenic shock.Case summary A 49-year-old gentleman was admitted following yew ingestion with suicidal intent. He was bradycardic at 30 b.p.m. and hypotensive on arrival. Electrocardiography revealed complete heart block with broad complex ventricular escape rate of 30 b.p.m. Bedside echocardiography revealed severe global impairment of right and left ventricular systolic function. Urgent temporary transvenous pacing was instituted, and the patient was considered for veno-arterial extracorporeal membrane oxygenation. Unfortunately, he deteriorated rapidly and cardiorespiratory arrest ensued, and despite prolonged in-hospital resuscitation, the patient died. Post-mortem examination revealed small needle-shaped plant leaves together with seeds found in the stomach. Ante mortem serum sample analysis sent to the Royal Botanical Gardens and revealed the presence of taxine Type B alkaloids in the patient’s blood.Discussion Yew poisoning is a rare occurrence, and there is currently no effective antidote. Treatment involves supportive management, comprising prolonged effective cardiopulmonary resuscitation, pacing, and mechanical cardiac support. This case illustrates the importance of prompt recognition of yew poisoning, alongside early consideration of pacing and mechanical cardiac support. Due to the rarity of this cause of heart block, and since patients may not always volunteer a history of yew ingestion, yew poisoning is something that physicians should be aware of and this should be considered in the differential diagnosis in patients with unexpected heart block. Serum analysis for taxine alkaloids can be used to confirm the diagnosis

University of Hertfordshire Research Archive

...Fatal heart block from intentional yew tree(Taxus baccata) ingestion: a case reportNatasha G. 1†, Mark Chan 1†, Ying X. Gue 1,2, and Diana A. Gorog 1,2,3*1Department of Cardiology, Lister Hospital, East and North Hertfordshire NHS Trust, Coreys Mill Lane, Stevenage SG1 4AB, UK; 2Department of Postgraduate Medicine, Universityof Hertfordshire, Hatfield, Hertfordshire AL10 9AB, UK; and 3Faculty of Medicine, National Heart & Lung Institute, Imperial College, Dovehouse Street, London SW3 6LY, UKReceived 14 July 2019; first decision 15 August 2019; accepted 21 November 2019Background Taxus baccata, also known as English yew, is a poison that causes cardiac arrhythmias and can result in death fromcardiogenic shock....................................................................................................................................................................................................Case summary A 49-year-old gentleman was admitted following yew ingestion with suicidal intent. He was bradycardic at 30 b.p.m.and hypotensive on arrival. Electrocardiography revealed complete heart block with broad complex ventricular es-cape rate of 30 b.p.m. Bedside echocardiography revealed severe global impairment of right and left ventricular sys-tolic function. Urgent temporary transvenous pacing was instituted, and the patient was considered for veno-arterialextracorporeal membrane oxygenation. Unfortunately, he deteriorated rapidly and cardiorespiratory arrest ensued,and despite prolonged in-hospital resuscitation, the patient died. Post-mortem examination revealed small needle-shaped plant leaves together with seeds found in the stomach. Ante mortem serum sample analysis sent to theRoyal Botanical Gardens and revealed the presence of taxine Type B alkaloids in the patient’s blood....................................................................................................................................................................................................Discussion Yew poisoning is a rare occurrence, and there is currently no effective antidote. Treatment involves supportivemanagement, comprising prolonged effective cardiopulmonary resuscitation, pacing, and mechanical cardiac sup-port. This case illustrates the importance of prompt recognition of yew poisoning, alongside early consideration ofpacing and mechanical cardiac support. Due to the rarity of this cause of heart block, and since patients may not al-ways volunteer a history of yew ingestion, yew poisoning is something that physicians should be aware of and thisshould be considered in the differential diagnosis in patients with unexpected heart block. Serum analysis for taxinealkaloids can be used to confirm the diagnosis.! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !Keywords Yew • Taxus baccata • Taxine alkaloids • Poisoning • Complete heart block • Case reportLearning points• Yew poisoning is a rare cause of complete heart block, which can lead to cardiogenic shock and death, with no effective antidote.• Treatment is supportive and includes temporary pacing and mechanical support.• We advocate early transfer to tertiary centres with extracorporeal membrane oxygenation facilities, given the low success rate of pacing incases of yew poisoning.* Corresponding author. Tel: !44 1707247512, Email: d.gorog@imperial.ac.uk† The first two authors contributed equally to the study.Handling Editor: Ross HunterPeer-reviewers: Debrabrata Bera and Rami Riziq Yousef AbumuaileqCompliance Editor: Rahul MukherjeeSupplementary Material Editor: Vishal Shahil MehtaVC The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), whichpermits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contactjournals.permissions@oup.com† The first two authors contributed equally to the study.† The first two authors contributed equally to the study.European Heart Journal - Case Reports CASE REPORTdoi:10.1093/ehjcr/ytz226 Arrhythmias/electrophysiologyDownloaded from https://academic.oup.com/ehjcr/advance-article-abstract/doi/10.1093/ehjcr/ytz226/5686032 by guest on 27 December 2019..........................................................................................................................................................................IntroductionTaxus baccata, also known as English yew, is an evergreen conifer thatis traditionally used in ornamental sculpture and woodwork. It is in-expensive and widely available in Europe and Asia. Throughout his-tory, yew tree species have been implicated in human and animalpoisoning.1 All parts of the yew tree, except for the red aril, containtaxine alkaloids.1 Taxine B is the most potent alkaloid with respect totoxicity.1 Taxines cause dose-dependent blockade of calcium and so-dium channels, resulting in pronounced QRS prolongation, decreasedmyocardial contractility, and prolonged atrioventricular conductiontime. Minimum lethal doses are reported to range from 0.6 to 1.3 gyew leaves/kg body weight, and intoxication is known to be resistantto standard treatments with no effective antidote.1We present the case of a fatal intentional ingestion of various yewtree constituents and the experience gained from a cardiologyperspective.TimelineCase presentationA well-built 49-year-old gentleman with a history of depression wasbrought in by the ambulance following intentional ingestion of yewtree leaves and seeds ("50 g) as a suicide attempt. The patient alsoreported consuming yew tree oil the previous day with no effect. Onassessment by the ambulance crew, he was found to be profoundlybradycardic, with a heart rate of 38 b.p.m. and hypotensive withblood pressure (BP) of 79/47 mmHg. Prior to arrival at the hospital,he was treated with bolus intravenous saline challenges and intraven-ous boluses of 600 lg of atropine, totalling 1800lg.On admission, the patient was drowsy but coherent and respon-sive to questions. He admitted to taking yew tree oil and seeds withsuicidal intent at 09.30 that morning. He was on sertraline for depres-sion, which was first diagnosed 20 years ago. On examination, he wasprofoundly bradycardic with a heart rate of 30 b.p.m. and hypoten-sive with BP of 70/50 mm Hg. His cardiorespiratory, abdominal, andneurological examinations were otherwise unremarkable. The elec-trocardiogram (ECG) (Figure 1) revealed complete heart block withvery broad QRS complex. The patient’s clinical presentation wasquickly recognized to be due to yew poisoning after consulting theUK National Poisoning Information Service’s (NPIS) online database,TOXBASEVR . He was then transferred as an emergency to the cardiaccatheterization laboratory for temporary pacing wire insertion. Thepatient was paced at 100 b.p.m. with increasing output due to diffi-culty in capture, but even with adequate pacing capture, the VP didnot respond. Eventually, there was failure of electrical capture.Bedside echocardiography revealed severe global biventricularimpairment of right and left ventricular systolic function. The systolicBP continued to fall to 50 mmHg, and asystole ensued. Cardiopul-monary resuscitation (CPR) was commenced in accordance with theUK Resuscitation Council’s Advance Life Support guidelines and thepatient was intubated and ventilated.Treatment with 50 mL sodium bicarbonate 8.4%, 10 mL 10% cal-cium gluconate, and 1 mg of adrenaline was administered within thefirst cycle of CPR. The local extracorporeal membrane oxygenation(ECMO) life support team was contacted and the patient provisional-ly accepted for transfer. Continuous CPR with the LUCASVR chestcompression system was initiated an hour into the arrest, in prepar-ation for transfer to the ECMO unit. The patient’s rhythm hithertohad predominantly shown pulseless electrical activity (PEA) and asys-tole on rhythm checks. There were three documented ventriculartachycardia episodes requiring defibrillation. There were intermittentepisodes of return of spontaneous circulation, with a BP of 140/90 mmHg, but each time this was followed by PEA or asystole.Despite prolonged resuscitation period of 1 h and 50 min, serial ar-terial blood gases continued to deteriorate, with progressive mixedmetabolic and respiratory acidosis, Type 2 respiratory failure, a risinglactate and hyperglycaemia (Table 1). This reflects the patient’s criticalcondition owing to inadequate cardiac output despite persistent re-suscitation efforts. After prolonged resuscitation, the patient died 3 hand 12 min post-admission.Post-mortem examination revealed small needle-shaped plantleaves together with seeds found in the stomach. Ante mortemserum sample analysis sent to the Royal Botanical Gardens andrevealed the presence of taxine Type B alkaloids in the patient’s6 h prior toadmissionDeliberate ingestion of approximately 50 g ofyew leaves and seeds.30 min prior toadmissionEmergency response by emergency medicalservices—treatment with bolus intravenoussaline challenges and doses of 600 lg of atro-pine totalling 1800 lg with no effect on brady-cardia and hypotension.Transferred to hospital by ambulance.Admission tohospitalProfoundly bradycardic with complete heartblock and hypotension.35 min post-admissionEchocardiography showed severe global rightand left ventricular impairment.Emergency temporary pacing wire insertion inthe cardiac catheterization laboratory.1 h 20 min post-admissionFailing to capture with temporary pacing wiredespite good lead position. Cardiac arrest inthe cardiac catheterization laboratory.Cardiopulmonary resuscitation commenced,patient intubated, and ventilated.1 h 35 min post-admissionVenoarterial-extracorporeal membrane oxy-genation discussed with tertiary centre, butpatient too unstable to be transported anddeteriorating rapidly.2 h 30 min post-admissionAt 1 h 50 min of resuscitation, blood gas read-ings continued deteriorating.Resuscitation was deemed futile.Time of death 3 h 12 min post-admission.3 days post-admissionPost-mortem revealed stomach contents ofneedle-shaped leaves and seeds. Ante mor-tem serum analysis revealed presence of tax-ine Type B alkaloids.2 N.G. et al.Downloaded from https://academic.oup.com/ehjcr/advance-article-abstract/doi/10.1093/ehjcr/ytz226/5686032 by guest on 27 December 2019.....................................................................blood. Given the history, serum analysis and post-mortem findings,the cause of death was deemed to be due to yew (leaves, oil, andseed) poisoning.DiscussionTaxine alkaloids are the active constituents in yew plants that causecardiotoxicity.1 These alkaloids are present in all parts of the plant,apart from the fleshy red part of the plant, the aril.2 Our patientingested an equivalent of around 0.7–0.8 g/kg of yew tree leaves,seed, and oil. According to Wilson et al.,1 the lethal oral dose of yewleaves in humans range from 0.6 to 1.3 g yew leaves/kg body weight.Yew tree poisoning has a high mortality rate, but remains a rare oc-currence, with only a handful of case reports in the literature.3–14Cardiotoxicity occurs via the blockade of sodium and calciumchannels in cardiac myocytes, leading to atrioventricular block, evi-denced by prolonged PR and QRS intervals on the ECG.1 The clinicalseverity is dependent on quantity, type and route of exposure, andwhether the seed was chewed or only swallowed.2 Clinical signs andsymptoms usually occur within 3–4 h following ingestion, and includedizziness, pupillary dilation, nausea and vomiting, abdominal pain,muscle weakness, and seizures.1,2 Patients may present with an initialtachycardia, however, can progress rapidly to bradycardia, cardiacstandstill, and death secondary to cardiogenic shock. Presently, thereis no effective antidote, and management of yew poisoning is largelysupportive, including activated charcoal, fluid resuscitation, electro-lyte replacement, inotropic support, and prolonged CPR in light ofthe long duration of cardiotoxicity of taxines.2,14Temporary transvenous pacemaker insertion or external pacingshould be considered, although electrical capture may be challenging,and was unsuccessful in the majority of the yew tree poisoningcases.2,5 The UK NPIS do not advocate gastric decontamination asthe benefit is unclear.2 Although not licensed for this purpose,digoxin-specific fragment antigen-binding (Fab) has been shown to bebeneficial if administered early.2,5 Other adjuncts include the use oflidocaine and lipid emulsion.2 Mechanical cardiac support, includingvenoarterial-ECMO or an intra-aortic balloon pump may be consid-ered if other measures have failed, and if there is life-threateninghaemodynamic instability.2,14Given the prevalence of yew trees in Europe and publicized con-tent on the internet as a method of suicide,15 yew poisoning is easilyaccessible. As such, this highlights the importance of early recognitionof yew poisoning, anticipation of cardiac arrhythmias, and promptmanagement with supportive treatment, prolonged CPR and consid-eration of electrical and mechanical cardiac support. On hindsight,Figure 1 Electrocardiogram on admission revealing complete heart block with broadened, bizarre, and sinusoidal QRS appearance.Fatal heart block from intentional yew tree ingestion 3Downloaded from https://academic.oup.com/ehjcr/advance-article-abstract/doi/10.1093/ehjcr/ytz226/5686032 by guest on 27 December 2019..........................................................................................................we advocate early transfer to tertiary centres with ECMO facilities,given the low success rate of pacing in cases of yew poisoning.Although it is reassuring that these cases remain a rarity, such casesshould be recorded nationally, to improve the understanding andmanagement through pooled data.Lead author biographyDr Natasha G. is an academic foun-dation doctor at CambridgeUniversity Hospitals NHS trust. Shegraduated from University CollegeLondon medical school and receiveda 1st class honours and Dean’s Listnomination for her intercalated BScin medical science with surgicalsciences.Supplementary materialSupplementary material is available at European Heart Journal - CaseReports online.Slide sets: A fully edited slide set detailing this case and suitable forlocal presentation is available online as Supplementary data.Consent: The author/s confirm that written consent for submis-sion and publication of this case report including image(s) andassociated text has been obtained from the patient in line withCOPE guidance.Conflict of interest: none declared.References1. Wilson CR, Sauer J, Hooser SB. Taxines: a review of the mechanism and toxicityof yew (Taxus spp.) alkaloids. Toxicon 2001;39:175–185.2. National Poisons Information Service [Internet]. https://www.toxbase.org/ (13December 2019).3. Baum C, Bohnen S, Sill B, Philipp S, Damerow H, Kluge S, Reichenspurner H,Blankenberg S, Soffker G, Barten MJ, Sydow K. Prolonged resuscitation and car-diogenic shock after intoxication with European yew (Taxus baccata): Completerecovery after intermittent mechanical circulatory support. Int J Cardiol 2015;181:176–178.4. Cummins RO, Haulman J, Quan L, Graves JR, Peterson D, Horan S. Near-fatalyew berry intoxication treated with external cardiac pacing and digoxin-specificFAB antibody fragments. Ann Emerg Med 1990;19:38–43.5. Farag M, Badowski D, Koschny R, Skopp G, Brcic A, Szabo GB. Extracorporeallife support and digoxin-specific Fab fragments for successful management ofTaxus baccata intoxication with low output and ventricular arrhythmia. Am JEmerg Med 2017;35:1987.e3–1987.e7.6. Lassnig E, Heibl C, Punzengruber C, Eber B. ECG of a “dying heart” in a youngwoman—a case of yew poisoning. Int J Cardiol 2013;167:e71–e73.7. Panzeri C, Bacis G, Ferri F, Rinaldi G, Persico A, Uberti F, Restani P.Extracorporeal life support in a severe Taxus baccata poisoning. Clin Toxicol (Phila)2010;48:463–465.8. Pierog J, Kane B, Kane K, Donovan JW. Management of isolated yew berry tox-icity with sodium bicarbonate: a case report in treatment efficacy. J Med Toxicol2009;5:84–89.9. Soumagne N, Chauvet S, Chatellier D, Robert R, Charriere JM, Menu P.Treatment of yew leaf intoxication with extracorporeal circulation. Am J EmergMed 2011;29:354 e5–e6.10. Thooft A, Goubella A, Fagnoul D, Taccone FS, Brimioulle S, Vincent JL, DeBacker D. Combination of veno-arterial extracorporeal membrane oxygenationand hypothermia for out-of-hospital cardiac arrest due to Taxus intoxication.CJEM 2014;16:504–507.11. Vali!s M, Ko!cı́ J, Tu!cek D, Lutonsk"y T, Kopová J, Barto"n P, Vy!sata O, Krajı́!ckováD, Korábe!cn"y J, Masopust J, Klzo L. Common yew intoxication: a case report.J Med Case Rep 2014;8:4.12. Van Ingen G, Visser R, Peltenburg H, Van Der Ark AM, Voortman M. Sudden un-expected death due to Taxus poisoning. A report of five cases, with review ofthe literature. Forensic Sci Int 1992;56:81–87.13. Willaert W, Claessens P, Vankelecom B, Vanderheyden M. Intoxication withTaxus baccata: cardiac arrhythmias following yew leaves ingestion. Pacing ClinElectrophysiol 2002;25(4 Pt 1):511–512.14. Zutter A, Hauri K, Evers KS, Uhde S, Fassl J, Reuthebuch OT, Berset A, KuhneM, Donner BC. “Chaotic arrhythmia” during successful resuscitation after inges-tion of yew (Taxus baccata) needles. Pediatr Emerg Care 2017;35:e223–e225.15. BBC. Ben Hines Died After Ingesting Yew Tree Poison. 2014. https://www.bbc.co.uk/news/uk-england-norfolk-26089688 (13 December 2019).....................................................................................................................................................................................................................Table 1 Serial arterial blood gas results during the admission reflecting biochemical deteriorationTime post-admission 20 min 1 h 30 min 2 h 5 min 2 h 30 min Normal rangespH 7.280 7.287 7.023 6.897 7.350–7.450pCO2 (kPa) 6.11 6.41 8.16 9.68 4.70–6.00pO2 (kPa) 2.98 1.98 8.35 8.26 10.70–14.60HCO3 (mmol/L) 21.0 22.5 15.6 13.8 23.0–30.0BE (mmol/L) -5.7 -4.5 -16.0 -20.3 -1 to !1Na (mmol/L) 140.6 141.4 142 138.8 133.0–146.0K (mmol/L) 3.96 4.05 4.22 3.35 3.50–5.30Ca (mmol/L) 1.19 1.33 1.25 1.31 1.15–1.33Cl (mmol/L) 105 106 101 107 95–108Glu (mmol/L) 9.4 8.9 20.7 22.3 3.5–6.0Lac (mmol/L) 4.30 4.17 11.76 11.37 1.00–1.80FiO2 (%) 60.0 20.0 100.0 100.0 21.0Bold values represent values outside the normal range.4 N.G. et al.Downloaded from https://academic.oup.com/ehjcr/advance-article-abstract/doi/10.1093/ehjcr/ytz226/5686032 by guest on 27 December 2019

Fatal heart block from intentional yew tree (Taxus baccata) ingestion: a case report

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Fatal heart block from intentional yew tree (Taxus baccata) ingestion: a case report

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