A Fatal Case of Suicide Fruit Ingestion in Singapore by Cerbera Cardiac Glycoside Intoxication: Case Report and Review of Literature

Case Presentation: We present a case of Cerbera fruit ingestion which highlight the knowledge gap in unusual glycoside poisoning. Despite the patient's asymptomatic presentation, life threatening clinical features such as hyperkalaemia, hypotension and arrhythmia occurred later. Treatments instituted were activated charcoal (AC), atropine, hyperkalaemia management, Digoxin Fab and intravenous lipid emulsion (ILE). Advanced Cardiac Life Support (ACLS) was instituted with automated chest compression device. The patient died despite prolonged of resuscitation effort. Cerbera glycoside toxicity warrants serious consideration in view of rare presentation and unpredictable nature of toxicology. Discussion: We highlight the prevalence of Cerbera species in Asia-Pacific and present the similarities of cardiac glycosides pharmacology. Early recognition of ingestion and cardiac monitoring are particularly important. In this case, we highlight the diagnostic and prognostic challenge as patient deteriorated despite normal serum digoxin level. As the evidence of Cerbera glycoside poisoning treatment options is lacking, we take this opportunity to examine treatment options assuming similar pharmacology among cardiac glycoside family. We argue for a case for use of Digoxin Fab which is the prevailing treatment for glycoside poisoning. Multi-dose-activated charcoal (MDAC) and ILE are postulated to have physiological basis given current evidence. Electrical and pharmacology treatment for arrhythmia were explored as there is limited evidence. We propose ECMO should always be considered for cardiac toxicity in anticipation of treatment failure as the novel therapy has shown great promise. Conclusion: Cerbera glycoside poisoning should be treated with utmost caution as the fruit is easily accessible and highly toxic. Close cardiac monitoring is a must due to high mortality risk. Digoxin Fab should be instituted as guided by toxicologist. Patients should be transferred to ECMO centre for observation in all cases due to the unpredictable nature of toxin. Further investigation of treatment is awaited.