Yew Causes Brugada ECG
2009; Lippincott Williams & Wilkins; Volume: 119; Issue: 13 Linguagem: Galês
10.1161/circulationaha.108.827147
ISSN1524-4539
AutoresChristian Veltmann, Martin Borggrefe, Rainer Schimpf, Christian Wolpert,
Tópico(s)Ion channel regulation and function
ResumoHomeCirculationVol. 119, No. 13Yew Causes Brugada ECG Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBYew Causes Brugada ECG Christian Veltmann, MD, Martin Borggrefe, MD, FESC, Rainer Schimpf, MD and Christian Wolpert, MD Christian VeltmannChristian Veltmann From the First Department of Medicine–Cardiology, University Hospital Mannheim, Mannheim, Germany. , Martin BorggrefeMartin Borggrefe From the First Department of Medicine–Cardiology, University Hospital Mannheim, Mannheim, Germany. , Rainer SchimpfRainer Schimpf From the First Department of Medicine–Cardiology, University Hospital Mannheim, Mannheim, Germany. and Christian WolpertChristian Wolpert From the First Department of Medicine–Cardiology, University Hospital Mannheim, Mannheim, Germany. Originally published7 Apr 2009https://doi.org/10.1161/CIRCULATIONAHA.108.827147Circulation. 2009;119:1836–1837A 52-year-old man presented to the emergency department with nausea, abdominal discomfort, and extreme fatigue after ingestion of ≈15 g of yew leaves 20 hours before admission. Physical examination revealed a blood pressure of 85/55 mm Hg and a regular heart rate of 190 bpm. The Glasgow coma scale was 15. Physical examination was otherwise unremarkable. Laboratory investigations showed a white blood cell count of 15×109/L and slightly elevated liver enzymes (alanine aminotransferase 63 U/L; aspartate aminotransferase 76 U/L). Stable monomorphic ventricular tachycardia was documented. Active charcoal was administered, and the patient was transferred to the intensive care unit. A lidocaine bolus of 50 mg was administered, and an infusion was started at a rate of 0.6 mg/kg per hour. After 10 minutes, the rate of ventricular tachycardia slowed to 150 bpm and converted to sinus rhythm. The ECG after termination of ventricular tachycardia revealed sinus rhythm at a rate of 71 bpm, first-degree atrioventricular block (PR 240 ms), significant prolongation of the QRS complex (150 ms) and right bundle-branch block. In addition, a coved-type Brugada ECG pattern with ST-segment elevation of 0.6 and 0.7 mV in leads V1 and V2, respectively, was identified. Serial 12-lead ECGs showed gradual regression of the ST-segment elevation (Figure). The ECG normalized within 26 hours. Because the Brugada phenotype had appeared after the yew leaf ingestion, an intravenous ajmaline challenge was performed 3 days later to exclude "true" Brugada syndrome. The ajmaline challenge was negative without any alteration of the ST segment. During follow-up of 1 year, the patient was asymptomatic. Download figureDownload PowerPointFigure. Precordial leads right after ventricular tachycardia termination (annotated as "0") and over the following 36 hours. The diagnostic coved-type ST elevations of Brugada syndrome in the right precordial leads gradually return back to normal. The paper speed is 50 mm/s.Yew (Taxus baccata) is a ubiquitous ornamental plant that is highly toxic.1 In most cases, ingestion leads to death from severe cardiac conduction defects, ventricular tachyarrhythmias, or electromechanical dissociation. The diagnosis of yew leaf intoxication is difficult if no anamnestic information is available because no specific symptoms occur. The treatment is mainly symptomatic. The prognosis of yew leaf intoxication depends on the amount of ingested yew tree constituents and on the cardiac involvement. The toxicity of Taxus baccata is based on pseudoalkaloids, which are found in all parts of the tree except for the red flesh of the berry. The major pseudoalkaloid, taxine B, accounts for 30% of the total taxine fraction. Taxine A only represents 1.8% of the taxine fraction.1 The proportion of taxol is very low at 0.01%. Taxine B and A mainly inhibit the cardiac calcium channel (ICa), but also the fast cardiac sodium channel (INa) in a dose-dependent manner. Taxol inhibits INa indirectly by enhancing tubulin polymerization causing a decrease of Nav1.5 expression, reduction of INa amplitude, and modification of the gating properties of the channel.2 Blockade of either INa or ICa causes the electrocardiographic phenotype of Brugada syndrome, an inherited primary electrical disease.3,4 For the first time, we could demonstrate the effect of combined sodium and calcium channel blockade caused by yew leaf intoxication. Fish et al have demonstrated via in vitro experiments that blocking both sodium and calcium channels unmasks the Brugada ECG more effectively than single-channel block alone.5 In the present patient, blockade of INa alone by ajmaline was not able to induce the Brugada phenotype.Yew leaf intoxication leads to a new form of acquired Brugada syndrome. The underlying mechanisms of cardiac tachyarrhythmias and heart failure after yew leaf ingestion have been discussed, and we have drawn attention to the severity of deliberate or accidental intoxication resulting from the ingestion of this common ornamental plant.DisclosuresNone.FootnotesCorrespondence to Christian Veltmann, MD, First Department of Medicine, University Hospital Mannheim, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany. E-mail [email protected]References1 Wilson CR, Sauer J, Hooser SB. Taxines: a review of the mechanism and toxicity of yew (Taxus spp.) alkaloids. Toxicon. 2001; 39: 175–185.CrossrefMedlineGoogle Scholar2 Veldkamp MW, Casini S, Demirayak I, Chatyan H, Remme CA, Tan HL. Tubulin polymerization affects cardiac sodium channel function: involvement of the beta-subunit. Heart Rhythm. 2008; 5: S210. Abstract.Google Scholar3 Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, Gussak I, LeMarec H, Nademanee K, Perez Riera AR, Shimizu W, Schulze-Bahr E, Tan H, Wilde A. Brugada syndrome: report of the second consensus conference. Circulation. 2005; 111: 659–670.LinkGoogle Scholar4 Antzelevitch C, Pollevick GD, Cordeiro JM, Casis O, Sanguinetti MC, Aizawa Y, Guerchicoff A, Pfeiffer R, Oliva A, Wollnik B, Gelber P, Bonaros EP Jr, Burashnikov E, Wu Y, Sargent JD, Schickel S, Oberheiden R, Bhatia A, Hsu LF, Haïssaguerre M, Schimpf R, Borggrefe M, Wolpert C. Loss-of-function mutations in the cardiac calcium channel underlie a new clinical entity characterized by ST-segment elevation, short QT intervals, and sudden cardiac death. Circulation. 2007; 115: 442–449.LinkGoogle Scholar5 Fish JM, Antzelevitch C. Role of sodium and calcium channel block in unmasking the Brugada syndrome. Heart Rhythm. 2004; 1: 210–217.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Alarfaj M and Goswami A (2021) Cardiotoxicity in yew berry poisoning, The American Journal of Emergency Medicine, 10.1016/j.ajem.2021.05.043, 50, (812.e1-812.e4), Online publication date: 1-Dec-2021. Zoltani C (2018) Cardiovascular Toxicity Veterinary Toxicology, 10.1016/B978-0-12-811410-0.00014-3, (227-238), . Zutter A, Hauri K, Evers K, Uhde S, Fassl J, Reuthebuch O, Berset A, Kühne M and Donner B (2017) "Chaotic Arrhythmia" During Successful Resuscitation After Ingestion of Yew (Taxus baccata) Needles, Pediatric Emergency Care, 10.1097/PEC.0000000000001196, Publish Ahead of Print, Online publication date: 6-Jun-2017. Senthilkumaran S, Meenakshisundaram R and Thirumalaikolundusubramanian P (2015) Plant Toxins and the Heart Heart and Toxins, 10.1016/B978-0-12-416595-3.00005-0, (151-174), . Lassnig E, Heibl C, Punzengruber C and Eber B (2013) ECG of a "dying heart" in a young woman — A case of yew poisoning, International Journal of Cardiology, 10.1016/j.ijcard.2013.03.106, 167:3, (e71-e73), Online publication date: 1-Aug-2013. Jambeih R, Shaheen W, Li V and Shaheen M (2012) ST-segment elevation and ventricular tachycardia after ingestion of a common ornamental plant—a case report, Indian Heart Journal, 10.1016/S0019-4832(12)60066-2, 64:2, (211-213), Online publication date: 1-Mar-2012. Casini S, Tan H, Demirayak I, Remme C, Amin A, Scicluna B, Chatyan H, Ruijter J, Bezzina C, van Ginneken A and Veldkamp M (2009) Tubulin polymerization modifies cardiac sodium channel expression and gating, Cardiovascular Research, 10.1093/cvr/cvp352, 85:4, (691-700), Online publication date: 1-Mar-2010., Online publication date: 1-Mar-2010. Fabiani A, Dal Bo E, Di Bella S, Gabrielli M, Bologna A, Albert U and Sanson G (2021) Pica (Allotriophagy): An Underestimated Risk Factor for Severe Leptospirosis (Weil's Diseases)? Report of a Leptospira Septic Shock Successfully Managed with ECMO, Infectious Disease Reports, 10.3390/idr13030058, 13:3, (619-626) April 7, 2009Vol 119, Issue 13 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.108.827147PMID: 19349337 Originally publishedApril 7, 2009 PDF download Advertisement SubjectsArrhythmias
Referência(s)