A case report of cardiac glycoside-like intoxication following reported exposure to tejocote

Background

Crataegus mexicana, or tejocote, has been traditionally used to treat various ailments across many Latin American countries. Several hawthorn species have shown a positive inotropic effect similar to digitalis. Recently, tejocote root has been touted as a popular slimming agent. The FDA has issued warnings regarding adulterated over-the-counter tejocote root preparations that have been found to be substituted with yellow oleander. This case describes a reported tejocote root intoxication resulting in ventricular tachycardia, gastrointestinal distress, and a falsely positive digoxin assay.

Case report

A 57-year-old male-to-female transgender patient presented to the ED complaining of persistent nausea and vomiting. The patient reported consuming two pills of tejocote daily for the past month as a weight loss supplement and denied any other medications. Initial vitals showed a blood pressure of 96/48 mmHg, a pulse of 65 beats per minute, and a normal temperature, respiratory rate, and oxygen saturation. Chemistry showed an elevated potassium level of 5.7 mmol/L and a white blood cell count (WBC) of 13.85 ×10^9/L. An electrocardiogram revealed a pattern often seen with chronic cardiac glycoside use (i.e., scooping of the ST segment, the so-call “Salvador Dali sign”), so a digoxin level was obtained and shown to be elevated at 0.17 ng/mL. A service was consulted, and the patient was admitted for observation. During her hospitalization, she developed a transient episode of non-sustained ventricular tachycardia accompanied by hypoxemia while being treated with albuterol. Over the following days, electrolytes normalized, and the patient was ultimately discharged.

Conclusion

Consumption of over-the-counter tejocote root preparations may cause toxicities similar to cardiac glycosides. Components of purported tejocote root preparations may cross-react with commercial digoxin assays, leading to falsely elevated levels. Recently, FDA has issued warnings regarding the adulteration of these preparations with yellow oleander. Clinicians need to be aware of over-the-counter tejocote root preparations and their potential for toxicity.