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Treatment of Toad Venom Poisoning With Digoxin-Specific Fab Fragments

  • R. Brubacher Jeffrey
    Correspondence
    Reprint requests: Dr. Jeffrey Brubacher, Dept of Emergency Medicine, Vancouver Hospital and Health Sciences Centre, 855 West 12th Avenue, Vancouver, BC, Canada V5Z 1M9
    Affiliations
    From the New York City Poison Control Center, New York City Department of Health

    Currently at the Vancouver Hospital and Health Sciences Centre, Vancouver, BC, Canada
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  • R. Ravikumar Padinjarekuttu
    Affiliations
    From the New York City Poison Control Center, New York City Department of Health

    the Bureau of Laboratories, New York City Department of Health
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  • Bania Theodore
    Affiliations
    From the New York City Poison Control Center, New York City Department of Health

    Currently at the Department of Emergency Medicine, Columbia Hospital Center, New York
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  • B. Heller Michael
    Affiliations
    From the New York City Poison Control Center, New York City Department of Health

    the Bureau of Laboratories, New York City Department of Health

    the Environmental Sciences Division, New York City Department of Health
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  • S. Hoffman Robert
    Affiliations
    From the New York City Poison Control Center, New York City Department of Health

    the Department of Emergency Medicine, Bellevue Hospital Center, New York
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      Toxicity from toad venom poisoning is similar to digoxin toxicity and carries a high mortality rate. We report on six previously healthy men who developed vomiting and bradycardia after ingesting a purported topical aphrodisiac. Each patient had positive apparent digoxin levels and the first four patients died of cardiac dysrhythmias. The last two patients recovered following treatment with digoxin Fab fragments. We analyzed samples of the purported aphrodisiac and found that it was identical to Chan Su, a Chinese medication made from toad venom. To our knowledge, this is the first reported use of digoxin Fab fragments to treat toad venom poisoning.

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      REFERENCES

        • Chen KK
        • Kovarikova A.
        Pharmacology and toxicology of toad venom.
        J Pharmaceut Sci. 1967; 56: 1535-1541
        • Huang KC.
        • Chan Su.
        Huang KC The pharmacology of Chinese herbs. CRC Press, Boca Raton, Fla1993: 114-117
        • Morishita S
        • Shoji M
        • Oguni Y
        • et al.
        Pharmacological actions of ‘Kyushin,' a drug containing toad venom: cardiotonic and arrhythmogenic effects, and excitatory effect on respiration.
        Am J Chin Med. 1992; 20: 245-256
        • Yei CC
        • Deng JF.
        Toad or toad cake intoxication in Taiwan: report of four cases.
        J Formos Med Assoc. 1993; 92: S135-39
        • Hitt M
        • Ettinger DD.
        Toad toxicity.
        N Engl J Med. 1986; 314: 1517
      1. Anonymous. Family eats toad: one dies of poisoning: child is victim of strange food.
        Honolulu Star Bulletin. 1935; 18 (April): 1
        • Chem MS,
        • Ray CY
        • Wu D.
        Biologic intoxication due to digitalis-like substance after ingestion of cooked toad soup.
        Am J Cardiol. 1991; 67: 443-444
        • Licht LE.
        Death following possible ingestion of toad eggs.
        Toxicon. 1967; 5: 141-142
        • Lyttle T.
        Misuse and legend in the ‘toad licking phenomenon.
        Int J Addict. 1993; 28: 521-538
        • Hoch JH.
        A survey of cardiac glycosides and genins. University of South Carolina Press, Charleston1961
        • Bania T
        • Gruber P
        • Howland MA
        • et al.
        Rock Hard: a fatal plant aphrodisiac [abstract].
        Vet Hum Toxicol. 1993; 35: 328
        • Brubacher Jr.,
        • Hoffman RS
        • Bania T
        • et al.
        Deaths associated with a purported aphrodisiac—New York City, February 1993-May 1995.
        MMWR. 1995; 44: 853-855
        • de Smet PA
        • Rivier L.
        Intoxicating snuffs of the Venezuelan Piaroa Indians.
        J Psychoact Drugs. 1985; 17: 93-103
        • Yoshida S
        • Kamano Y
        • Sakai T.
        Studies on the surface anesthetic activity of bufadienolides isolated from Chan Su.
        Chem Pharm Bull. 1976; 24: 1714-1717
        • Fabing HD
        • Hawkins JR.
        Intravenous bufotenine injection in the human being.
        Science. 1956; 123: 886-887
        • Osterloh J
        • Herold S
        • Pond S.
        Oleander interference in the digoxin radioimmunoassay in a fatal ingestion.
        TAMA. 1982; 247: 1596-1597
        • Hastreiter AR
        • van der Horst RL
        • Chow-Tung E.
        Digitalis toxicity in infants and children.
        Pediatr Cardiol. 1984; 5: 131-148
        • Cheung K
        • Hinds JA
        • Duffy P.
        Detection of poisoning by plantorigin cardiac glycoside with the Abbot TDx analyzer.
        Clin Chem. 1989; 35: 295-297
        • Radford DJ
        • Cheung K
        • Urech R
        • et al.
        Immunologic detection of cardiac glycosides in plants.
        Aust Vet J. 1994; 71: 236-238
        • Haynes BE
        • Bessen HA
        • Wightman WD
        • et al.
        Oleander tea: herbal draught of death.
        Ann Emerg Med. 1985; 14: 350-353
        • Tuncok Y
        • Kozan O
        • Cavdar C
        • et al.
        Urginea maritima (Squill) toxicity.
        J Toxicol Clin Toxicol. 1995; 33: 83-86
        • Fushimi R
        • Koh T
        • Iyam S
        • et al.
        Digoxin-like immunoreactivity in Chinese medicine.
        Ther Drug Monitor. 1990; 12: 242-245
        • Koobatian TJ
        • Roberts JR.
        Falsely elevated serum digoxin levels secondary to endogenous digoxin-like immunoreactive substances.
        Acad Emerg Med. 1995; 2: 322-326
        • Valdes R
        • Graves SW
        • Brown BA
        • et al.
        Endogenous substances in newborn infants causing false positive digoxin measurements.
        J Pediatr. 1983; 102: 947-950
        • Kerkey SA
        • Poston L
        • Wolfe CD
        • et al.
        A longitudinal study of maternal digoxin-like immunoreactive substances in normotensive pregnancy and pregnancy induced hypertension.
        Am J Obstet Gynecol. 1990; 162: 783-787
        • Graves SW
        • Brown B
        • Valdes R.
        An endogenous digoxin-like substance in patients with renal impairment.
        Ann Intern Med. 1983; 99: 604-608
        • Shilo L
        • Adawi A
        • Solomon G
        • et al.
        Endogenous digoxin-like immunoreactivity in congestive heart failure.
        BMJ. 1987; 295: 415-416
        • Antman EM
        • Wenger TL
        • Butler VP
        • et al.
        Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific FAB antibody fragments.
        Circulation. 1990; 81: 1744-1752
        • Woolf AD
        • Wenger T
        • Smith TW
        • et al.
        The use of digoxin-specific FAB fragments for severe digitalis intoxication in children.
        N Engl J Med. 1992; 326: 1739-1744
        • Hess T
        • Stucki P
        • Barandum S
        • et al.
        Treatment of a case of lanatoside C intoxication with digoxin-specific F(ab)2 antibody fragments.
        Am Heart J. 1979; 98: 767-771
        • Bania T
        • Hoffman RS
        • Howland MA.
        Accidental Indian hemp (Apocyneacea cannabinum) cardiac glycoside toxicity [abstract].
        Vet Hum Toxicol. 1993; 35: 328
        • Safadi R
        • Levy I
        • Amitai Y
        • et al.
        Beneficial effect of digoxin-specific Fab antibody fragments in oleander intoxication.
        Arch Intern Med. 1995; 155: 2121-2125
        • Shumaik GM
        • Wu AW
        • Ping AC
        • et al.
        Oleander poisoning: treatment with digoxin-specific FAB antibody fragments.
        Ann Emerg Med. 1988; 17: 732-735
        • Rich SA
        • Libera JM
        • Locke RJ.
        Treatment of foxglove poisoning with digoxin-specific FAB fragments.
        Ann Emerg Med. 1993; 22: 1904-1907
        • Sabouraud A
        • Urtizberea M
        • Cano N
        • et al.
        Specific anti-digoxin Fab fragments: an available antidote for proscillarin and scilliroside poisoning?.
        Hum Exp Toxicol. 1990; 9: 191-193
        • Bagrov AY
        • Roukoyatkina NI
        • Fedorova OV
        • et al.
        Digitalis-like and vasoconstrictor effects of endogenous digoxin-like factors from the venom of Bufo marinus toad.
        Eur J Pharmacol. 1993; 234: 165-172
        • Banner W
        • Bach P
        • Burk B
        • et al.
        Influence of assay methods on serum concentrations of digoxin during FAB fragment treatment.
        J Toxicol Clin Toxicol. 1992; 30: 259-267
        • Rainey PM.
        Effects of digoxin immune FAB (ovine) on digoxin immunoassays.
        Am J Clin Pathol. 1989; 92: 779-786
        • Valdes R
        • Brown BA
        • Graves SW.
        Variable cross-reactivity of digoxin metabolites in digoxin immunoassays.
        Am J Clin Pathol. 1984; 82: 210-213
        • Palumbo NE
        • Perri S
        • Read BS.
        Experimental induction and treatment of toad venom poisoning in the dog.
        J Am Vet Med Assoc. 1975; 167: 1000-1005
        • Bismuth C
        • Gaultier M
        • Conso F
        • et al.
        Hyperkalemia in acute digitalis poisoning: prognostic significance and therapeutic implications.
        J Toxicol Clin Toxicol. 1973; 6: 153-162
        • Dally S
        • Alperovitch A
        • Lagier G
        • et al.
        Facteurs prognostiques de l'intoxication digitalique aigue.
        Nouv Presse Med. 1981; 10: 2257-2260
        • Ordog GJ
        • Benaron S
        • Bhasin V
        • et al.
        Serum digoxin levels and mortality in 5, 100 patients.
        Ann Emerg Med. 1987; 16: 32-39

      Uncited references

      1. Anonymous. “U. S. says 4 died in New York eating an alleged aphrodisiac.”.
        New York Times. 1995; 25 (Nov): 1
        • Nanji AA
        • Greenway DC.
        Falsely raised plasma digoxin concentrations in liver disease.
        BMJ. 1985; 290: 432-433

      Linked Article

      • Society and Toxicology: A Double Standard?: Or of Mice and Toads … (With Apologies to Mr. Steinbeck)
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