Multiple cardiac arrhythmias in a previously healthy child: a case of accidental digitalis intoxication?

Area of Science:

• Pediatric Cardiology
• Clinical Toxicology
• Emergency Medicine

Background:

• Digoxin toxicity is a significant concern in pediatric patients, often presenting with cardiac arrhythmias.
• Accidental or intentional ingestion can lead to severe clinical manifestations requiring prompt diagnosis and management.

Observation:

• A 3-year-old child presented with emesis and bradycardia (40-60 bpm).
• Initial ECG revealed complete atrioventricular block with a junctional escape rhythm, progressing to atrial flutter/fibrillation.
• Despite negative initial toxicology screens, a digoxin level of 2.9 ng/mL was confirmed 20 hours post-presentation.

Findings:

• Digoxin toxicity manifested as multiple, complex arrhythmias in a pediatric patient.
• The presentation mimicked other conditions, delaying diagnosis despite clinical suspicion.
• Intravenous atropine temporarily accelerated the junctional rhythm, but sinus rhythm with prolonged PR interval eventually resumed.

Implications:

• This case highlights the diverse cardiac manifestations of pediatric digoxin toxicity.
• Clinicians should maintain a high index of suspicion for digoxin toxicity in children with unexplained emesis, altered consciousness, and bradyarrhythmias.
• Difficulties in diagnosis underscore the importance of considering occult ingestions, even when denied by caregivers.