ECG for physicians: a potentially fatal case of mistaken identity

Comfrey herbal remedy causing second-degree heart block: do not be outfoxed by digitalis

A previously well woman aged 63 years presents to the emergency department with vomiting, palpitations and 3 presyncopal episodes. She had no previous medical or cardiac history, with the patient stating that she tried a herbal remedy of boiled comfrey leaves for insomnia 18 hours before arrival to the department. Her ECG showed multiple abnormalities, including bradycardia, second-degree atrioventricular node block, Mobitz Type 2, a shortened QT interval, downsloping ST depression and presence of U waves. After viewing the images of comfrey and foxglove, it highlighted the possibility of mistaken ingestion of Digitalis, containing the organic forms of cardiac glycosides, such as digoxin and digitoxin. Raised serum digoxin levels confirmed this. The patient was haemodynamically stable, and given digoxin-binding antibodies. After 5 days of cardiac monitoring, her ECG returned to normal rhythm, and she was discharged home.

Bitter pill to swallow: a case of accidental poisoning with digitalis purpurea

While digitoxicity secondary to therapeutic use is frequent, due to its distinctive appearance and unpleasant taste accidental ingestion of digitalis purpurea (foxglove) is uncommon. This report relates the case of two previously healthy individuals who inadvertently consumed significant quantities of digitalis in its plant form. Both men presented in first-degree atrioventricular block and had digoxin levels of 4.9 μg/litre, but were otherwise stable and made unremarkable recoveries with repeated dose activated charcoal.