Login | Users Online: 1515  
Home Print this page Email this page Small font sizeDefault font sizeIncrease font size   
Home | About us | Editorial board | Search | Ahead of print | Current Issue | Archives | Submit article | Instructions | Subscribe | Advertise | Contact us

Table of Contents
Year : 2010  |  Volume : 11  |  Issue : 3  |  Page : 115-116  

Acute cardiac toxicity of Nerium oleander/indicum poisoning (Kaner) poisoning

Department of Medicine Jawarhar Lal Nehru Medical College, Ajmer - 305 001, Rajasthan, India

Date of Web Publication22-Feb-2011

Correspondence Address:
Ibraheem Khan
VPO- Samraya, Weir, Bharatpur, Rajasthan - 321 408
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1995-705X.76803

Rights and Permissions

We present a case of oleander leaf extract poisoning manifested by vomiting, lightheadedness, and heart block. Practicing physicians should understand the potential lethal properties of oleander and its availability throughout the world.

Keywords: AV block, cardiac glycosides, Nerium oleander

How to cite this article:
Khan I, Kant C, Sanwaria A, Meena L. Acute cardiac toxicity of Nerium oleander/indicum poisoning (Kaner) poisoning. Heart Views 2010;11:115-6

How to cite this URL:
Khan I, Kant C, Sanwaria A, Meena L. Acute cardiac toxicity of Nerium oleander/indicum poisoning (Kaner) poisoning. Heart Views [serial online] 2010 [cited 2023 Dec 9];11:115-6. Available from: https://www.heartviews.org/text.asp?2010/11/3/115/76803

   Introduction Top

Kaner (Nerium oleander/indicum) is an ornamental shrub or small, densely branched tree, 1 to 10 m tall in the Dogbane family Apocynaceae. Leaves are in pairs of three or whorled, very green, leathery, narrowly elliptic to linear entire. Flowers grow in clusters in terminal branches, each 2.5 to 5 cm, funnel-shaped with five lobes, fragrant, various colors from pink to red, white, peach, and yellow. [1]

The common oleander is one of most poisonous plants that have been shown to contain nondigitalis cardiac glycosides. Oleander is an idiom for plants of the N. oleander L, N. indicum, and Nerium odorum species. Common names include soland, lorier bol, rosebay, and rose laurel and kaner. [2]

The oleander is most prevalent, and alluring flowers make it a particular hazard for accidental ingestion. [2] The plant also has shown toxicologic importance for accidents when used in folk medicines, when adults unknowingly eat parts of the plant, or food that has come into contact with the plant, such as hot-dog sticks, and in homicides or suicides. Also, as our case illustrates, toxicities are not limited to temperate climates. [3]

All parts of the oleander plant contain cardiac glycosides, including the roots and the smoke produced from burning, as heat does not inactivate the glycosides. The toxic component are the two potent cardiac glycosides, oleanderin and neriine, which can be isolated from all parts of the plant, Both are very similar to the toxin of Foxglove. [4] Both have positive inotropic, negative chronotropic, and cross reactivity. This includes direct glycoside poisoning of the sodium-potassium pump of the heart and increased vagotonia. Most symptoms from oleander poisoning are cardiac and gastrointestinal in nature and appear four hours after the ingestion. [5]

We report a case of intentional oleander ingestion.

   Case Report Top

A 21-year-old female was admitted in the emergency room with vomiting and lightheadedness 15 hours after ingestion of common oleander aqueous leaf extract (10-20 leaves). She had been advised to take the extract in order to conceive a baby.

The patient was a non-smoker and non-alcoholic. She had no drugs allergy and was mentally sound. On initial examination, the blood pressure was 122/80 mmHg with irregular pulse of 46/min. She was looking toxic due to excessive vomiting. Other general physical parameters were normal. Her chest and lungs were clear to auscultation and percussion. Cardiovascular examination revealed an irregular rhythm with soft S1and normal audible S2 over the cardiac apex.

Electrocardiogram revealed inverted P wave in inferior lead and prolonged PR interval (.28 s), with varying degree AV blocks and normal QRS duration [Figure 1] and [Figure 2].
Figure 1: Electrocardiogram shows intermittent AV block 15 hours after the ingestion

Click here to view
Figure 2: Electrocardiogram in lead II (Top) shows first degree AV block with inverted P wave and prolonged PR interval .28 sec and in lead V2 intermittent 2:1 AV block 15 hours after the ingestion. First degree AV block after .6 mg iv atropine administration in lead II (Middle). First degree AV block Type I Second-Degree AV block with atypical wenckebach periodicity with junctional rhythm after .6 mg iv atropine administration in lead II (Bottom)

Click here to view

The patient was given .6 mg of intravenous atropine sulfate which did not resolve her bradycardia, but other symptoms were improved.

Next day, the patient was given intravenous atropine sulfate. 6 mg twice a day and tablet orciprenaline 10 mg three times a day.

After three days, the patient was discharged on request, with sinus node dysfunction and varying degree AV blocks [Figure 2] but asymptomatic.

   Discussion Top

Most of the plants, including foxglove and oleander, have been identified as containing cardiac glycosides and these are oleandrin, oleandroside, nerioside, digitoxigenin, thevetin, and thevetoxin. [3] The cardiac glycosides in oleander produce more gastrointestinal effects than those in digoxin, and the symptoms range from nausea and vomiting to cramping and bloody diarrhea. Also, it causes irritation to the mucosal membranes, resulting in burning around the mouth and increased salivation. Confusion, dizziness, drowsiness, weakness, visual disturbances, and mydriasis are central nervous system manifestations of toxicity. [4]

The most serious side effects of oleander poisoning are cardiac abnormalities, including various ventricular dysrhythmias, tachyarrhythmias, bradycardia, and heart block. [2] Electrocardiography often reveals an increased PR interval, a decreased QRS-T interval, and T wave flattening or inversion. It is thought that these clinical manifestations are the result of both increased vagotonia and direct cardiac glycoside toxicity. [3]

The treatment of oleander poisoning is empirically based on the treatment of digitalis-glycoside toxicity and consists of supporting the patient hemodynamically. This may include administering atropine for severe bradycardia; using phenytoin or lidocaine hydrochloride to control dysrhythmias; placing a temporary venous pacemaker; or electrical counter shock and administering digoxin-specific Fab antibody fragments (Digibind). [4]

Other treatment methods are aimed at removing the toxic substance from the stomach by emesis. Special concern must be given to a patient with bradycardia before emesis is induced because of the possibility of a vagal reaction and worsening of the bradycardia. Unabsorbed glycosides may be bound to some extent, depending on the particular glycoside, by various binding agents in the gut. These agents theoretically should be more effective in absorbing less polar glycosides, such as digitoxin, than the more polar glycosides like digoxin (for example, cholestyramine resin and colestipol). The use of these agents is not thought to have substantial value in the treatment of advanced toxicity, and they were not used in our patient. [6] Activated charcoal has been shown to be useful in preventing further absorption of the cardiac glycosides by interruption of the enterohepatic circulation of the glycoside, but it was not used in our patient because she was brought after 15 hours of ingestion of the toxin and due to the unknown status about the enterohepatic circulation of oleander's glycosides. [6]

   Conclusion Top

It is interesting that oleander poisoning can be fatal with relatively small amounts ingested. Osterloh and associates calculated the lethal oleander leaf dose of their patient to be approximately 4 gm. [3] Practicing physicians should understand the potential lethal properties of oleander and its availability throughout the world.

   References Top

1.Frohne DP, Fander HJ. A colour Atlass of poisonous plants. London: Wolfe Publishing LTD; 1984. p. 190.  Back to cited text no. 1
2.Ansford AJ, Morris H. Fatal oleander poisoning. Med J Aust 1981;1:360-1.  Back to cited text no. 2
3.Osterloh J, Herold S, Pond S. Oleander interference in the digoxin radioimmunoassay in a fatal ingestion. JAMA 1982;247:1596-7.  Back to cited text no. 3
4.Shumaik GM, Wu AW, Ping AC. Oleander poisoning: Treatment with digoxin- specific Fab antibody fragments. Ann Emerg Med 1988;17:732-5.  Back to cited text no. 4
5.Behcet Al, Yarbil P, Dogan M, Kabul S, Yildirm C. A case of non-fatal oleander poisoning BMJ Case Reports. 2010.  Back to cited text no. 5
6.McEvoy GK, Litvak K, Mendham NA. Drug Information 88. In: Bethesda MD, editors. American Hospital Formulary Service. America: American Society of Hospital Pharmacists; 1988. p. 764-71.  Back to cited text no. 6


  [Figure 1], [Figure 2]

This article has been cited by
1 A toxic shrub turned therapeutic: The dichotomy of Nerium oleander bioactivities
Rajat Sharma, Swati Singh, Nisha Tewari, Priyankar Dey
Toxicon. 2023; 224: 107047
[Pubmed] | [DOI]
2 Oleandrin: A Systematic Review of its Natural Sources, Structural Properties, Detection Methods, Pharmacokinetics and Toxicology
Jinxiao Zhai, Xiaoru Dong, Fenglian Yan, Hongsong Guo, Jinling Yang
Frontiers in Pharmacology. 2022; 13
[Pubmed] | [DOI]
3 Methods of Studying Ultraweak Photon Emissions from Biological Objects. II. Methods Based on Biological Detection
I. V. Volodyaev, L. V. Beloussov, I. I. Kontsevaya, A. E. Naumova, E. V. Naumova
Biophysics. 2021; 66(6): 920
[Pubmed] | [DOI]
4 Ethnobotanical biocultural diversity by rural communities in the Cuatrociénegas Valley, Coahuila; Mexico
Eduardo Estrada-Castillón,José Ángel Villarreal-Quintanilla,Juan Antonio Encina-Domínguez,Enrique Jurado-Ybarra,Luis Gerardo Cuéllar-Rodríguez,Patricio Garza-Zambrano,José Ramón Arévalo-Sierra,César Martín Cantú-Ayala,Wibke Himmelsbach,María Magdalena Salinas-Rodríguez,Tania Vianney Gutiérrez-Santillán
Journal of Ethnobiology and Ethnomedicine. 2021; 17(1)
[Pubmed] | [DOI]
5 DNA-damage and cell cycle arrest initiated anti-cancer potency of super tiny carbon dots on MCF7 cell line
Sinem Simsek,Ayça Aktas Süküroglu,Derya Yetkin,Belma Özbek,Dilek Battal,Rükan Genç
Scientific Reports. 2020; 10(1)
[Pubmed] | [DOI]
6 A comprehensive review of cardiotoxic effects of selected plants
Akbar Anaeigoudari,Nahid Azdaki,Mohammad Reza Khazdair
Toxin Reviews. 2020; : 1
[Pubmed] | [DOI]
7 Tossicologia del Nerium Oleander: rassegna storica
Giuliano Dallæolio
La Rivista Italiana della Medicina di Laboratorio. 2020; 15(4)
[Pubmed] | [DOI]
8 Toxicity effects of Nerium oleander, basic and clinical evidence: A comprehensive review
T Farkhondeh,M Kianmehr,T Kazemi,S Samarghandian,MR Khazdair
Human & Experimental Toxicology. 2020; 39(6): 773
[Pubmed] | [DOI]
9 Comparative Cardiotoxicity of Low Doses of Digoxin, Ouabain, and Oleandrin
Ana F. M. Botelho,Ana L. S. Miranda,Thalita G. Freitas,Paula F. Milani,Tatiane Barreto,Jáder S. Cruz,Marília M. Melo
Cardiovascular Toxicology. 2020; 20(6): 539
[Pubmed] | [DOI]
10 The pharmaco-toxicological conundrum of oleander: Potential role of gut microbiome
Priyankar Dey
Biomedicine & Pharmacotherapy. 2020; 129: 110422
[Pubmed] | [DOI]
11 An unusual case of AV block
Carla Paolini,Giacomo Mugnai,Mirko Zanatta,Cosimo Perrone,Patrizia Dovigo,Vito Cianci,Claudio Bilato
Journal of Electrocardiology. 2020; 59: 17
[Pubmed] | [DOI]
12 Add oleander to your list of corrosives
Omer Taskin,Fuat Belli,Ayca Acikalin,Nezihat Rana Disel
Turkish Journal of Emergency Medicine. 2019; 19(3): 115
[Pubmed] | [DOI]
13 A Probable Fatal Case of Oleander (Nerium oleander) Poisoning on a Cattle Farm: A New Method of Detection and Quantification of the Oleandrin Toxin in Rumen
Suna Rubini,Suna Rossi,Suna Mestria,Suna Odoardi,Suna Chendi,Suna Poli,Suna Merialdi,Suna Andreoli,Suna Frisoni,Suna Gaudio,Suna Baldisserotto,Suna Buso,Suna Manfredini,Suna Govoni,Suna Barbieri,Suna Centelleghe,Suna Corazzola,Suna Mazzariol,Suna Locatelli
Toxins. 2019; 11(8): 442
[Pubmed] | [DOI]
14 Study of troponin, creatine kinase biomarkers, and histopathological lesions in experimental Nerium oleander toxicity in rats and mice
Monireh Khordadmehr,Saeed Nazifi
Journal of Veterinary Research. 2018; 62(1): 97
[Pubmed] | [DOI]
15 Improved method for diagnosis of Nerium oleander poisoning in necropsy tissues
Ana F.M. Botelho,Fabiano A.S. Oliveira,Aparecida T.L. Fiúza,Heloísa P. Pedroza,Stephanie E.M.T. Branco,Felipe Pierezan,Marília M. Melo,Benito Soto-Blanco
Pesquisa Veterinária Brasileira. 2018; 38(5): 967
[Pubmed] | [DOI]
16 An evaluation for the standardization of the Allium cepa test as cytotoxicity and genotoxicity assay
Elena Bonciu,Peter Firbas,Carmem S. Fontanetti,Jiang Wusheng,Mehmet Cengiz Karaismailoglu,Donghua Liu,Felicia Menicucci,Dmitry S. Pesnya,Aurel Popescu,Anton V. Romanovsky,Silvia Schiff,Joanna Slusarczyk,Cleiton P. de Souza,Alka Srivastava,Anca Sutan,Alessio Papini
Caryologia. 2018; : 1
[Pubmed] | [DOI]
17 Successful use of digoxin-specific immune Fab in the treatment of severe Nerium oleander toxicosis in a dog
Amaris Pao-Franco,Tara N. Hammond,Linda K. Weatherton,Camille DeClementi,Scott D. Forney
Journal of Veterinary Emergency and Critical Care. 2017;
[Pubmed] | [DOI]
18 Hydroalcoholic extract from Nerium oleander L. (Apocynaceae) elicits arrhythmogenic activity
Ana Flávia Machado Botelho,Artur Santos-Miranda,Humberto Cavalcante Joca,Cláudio Roberto Scabelo Mattoso,Maira Souza de Oliveira,Felipe Pierezan,Jader Santos Cruz,Benito Soto-Blanco,Marília Martins Melo
Journal of Ethnopharmacology. 2017; 206: 170
[Pubmed] | [DOI]
19 Niosomes of Nerium oleander extracts: In vitro assessment of bioactive nanovesicular structures
Aybike Gunes,Emine Guler,Rabia Nur Un,Bilal Demir,F. Baris Barlas,Murat Yavuz,Hakan Coskunol,Suna Timur
Journal of Drug Delivery Science and Technology. 2017; 37: 158
[Pubmed] | [DOI]
20 Plant-derived cardiac glycosides: Role in heart ailments and cancer management
Seema Patel
Biomedicine & Pharmacotherapy. 2016; 84: 1036
[Pubmed] | [DOI]
21 Isolated Compounds and Cardiotonic Effect on the Isolated Rabbit Heart of Methanolic Flower Extract of Nerium oleander L.
Vung Nguyen Tien,Loi Vu Duc,Tung Bui Thanh
Research Journal of Phytochemistry. 2016; 10(1): 21
[Pubmed] | [DOI]
22 Yellow Oleander Poisoning in Children- A Report of Two Cases
Sravanthi K,Suneel Mundkur,Shrikiran Aroor,Sandeep Kumar,Harish Kashyap
Pediatric Oncall. 2014; 11(4)
[Pubmed] | [DOI]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Case Report
    Article Figures

 Article Access Statistics
    PDF Downloaded369    
    Comments [Add]    
    Cited by others 22    

Recommend this journal