Novel methods of self-poisoning: repeated cardenolide poisoning after accessing Cerbera odollam seeds via the internet

Cerbera odollam: A Case Report of Attempted Suicide by Pong Pong

Cerbera odollam, commonly referred to as the "suicide tree" or "pong pong," produces highly toxic seeds that are used for suicidal and homicidal purposes. It is important that western physicians be aware of the symptoms associated with these seeds and how to diagnose and treat them.

Prime eligible poisons: identification of extremely hazardous substances available on Amazon.com®

Background: Widespread use of the Internet has increased availability of numerous products. Multiple published cases highlight that toxic xenobiotics are available for purchase online. Most cases describe purchase from the deep web. We sought to identify extremely hazardous substances available from an online retailer.Methods: Over a 10-month period, the online retailer Amazon.com^® was searched for each of the products listed by the Environmental Protection Agency's "List of Extremely Hazardous Substances." Product names, availability on Amazon Prime^®, need for a business account, price, and quantity were collated.Results: We identified 79/340 (23.2%) of these substances were available on Amazon.com^®. Almost one-third of the available substances were eligible for Amazon Prime^®. Approximately one-third of the products were available in an amount that could be toxic by purchasing a single unit (31/79). Of these 31 products, only four required a business account, 18 were eligible for Amazon Prime^®, and nine were neither eligible for Prime nor required a business account. Notable products include sodium azide, acrylamide, mercuric acetate, and hydrazine.Conclusions: The ease of purchase and ready availability of such highly toxic substances is concerning. Online retailers like Amazon.com^® should consult with toxicologists or other qualified experts and governmental agencies to identify which products should be removed or restricted to business accounts.

Cerbera odollam toxicity: A review

Cerbera odollam is a plant species of the Apocynaceae family. It is often dubbed the 'suicide tree' due to its strong cardiotoxic effects, which make it a suitable means to attempt suicide. The plant grows in wet areas in South India, Madagascar, and Southeast Asia; and its common names include Pong-Pong and Othalanga. The poison rich part of the plant is the kernel which is present at the core of its fruit. The bioactive toxin in the plant is cerberin, which is a cardiac glycoside of the cardenolide class. Cerberin has a mechanism of action similar to digoxin; hence, Cerbera odollam toxicity manifests similar to acute digoxin poisoning. Ingestion of its kernel causes nausea, vomiting, hyperkalemia, thrombocytopenia, and ECG abnormalities. Exposure to high doses of Cerbera odollam carries the highest risk of mortality. Initial management includes supportive therapy and administration of atropine followed by temporary pacemaker insertion. Administration of digoxin immune Fab may be considered in severe cases, although efficacy is variable and data limited to isolated case reports.

Study on Clinical Profile and Predictors of Mortality in Cerbera odollam Poisoning

Context:

Cerbera odollam is a tree native to South Asia. It belongs to the poisonous Apocynaceae family. Deliberate self-harm with fruit of this plant is a major clinical problem in the developing world. Ingestion of C. odollam kernels is the cause of deaths in more than half of Kerala's plant poisoning deaths. The data on clinical features and complications of C. odollam poisoning are sparse, apart from a few case reports and limited studies.

Aims:

The present study was done to find the mode of presentation, complications, need for cardiac pacing, inhospital mortality, and the predictors of mortality in patients with C. odollam poisoning.

Settings and Design:

This was a retrospective study conducted in the department of general medicine in a tertiary care center in Alappuzha district, Kerala. The study period was for 1 year from January 1, 2016, to December 31, 2016.

Subjects and Methods:

All the patients admitted with a history of ingestion of odollam during the study period were included in the study. Data were collected from case records. The study was approved by the institutional ethics committee and research committee (IEC/TDMCA/EC3.dated29/11/201).

Statistical Analysis Used:

The data were analyzed using SPSS 16 for Windows (SPSS Inc., Chicago, IL, USA).

Results:

In this study, 102 patients were identified with C. odollam poisoning, and the mortality rate was 16.7%. Electrocardiogram (ECG) changes were common in our patients, and we observed different types of heart block in the same ECG itself. Ingestion of more than two kernels of odollam, late presentation to hospital, vomiting, bradycardia, hypotension, hyperkalemia, and more severe ECG changes were associated with significantly higher mortality in this study.

Conclusions:

C. odollam poisoning is a common method of deliberate self-harm in Kerala. It carries a high mortality rate, and the predictors of mortality include vomiting, bradycardia, hypotension, hyperkalemia, and the presence of severe ECG changes.