Detectable Digoxin Concentrations in 3 Patients with Ramps Misadventure

Area of Science:

• Toxicology
• Botany
• Emergency Medicine

Background:

• Allium tricoccum (ramps) is a wild edible plant with a distinct garlic-onion flavor.
• Misidentification of ramps with toxic look-alikes, such as Convallaria majalis (Lily of the Valley) and Veratrum species (False Hellebore), poses a significant risk.

Observation:

• Three adult patients presented with hypotension and bradycardia after consuming a plant mistaken for ramps.
• Detected digoxin concentrations in patients ranged from 0.08 to 0.13 ng/mL.
• Plant analysis confirmed the presence of cyclopamine, an alkaloid found in Veratrum species.

Findings:

• Convallaria majalis contains convallatoxin, a cardiac glycoside that can elevate digoxin levels.
• Veratrum species contain alkaloids like veratridine, which can cause false positives in digoxin assays.
• Ingestion of these toxic plants can mimic cardiac glycoside toxicity.

Implications:

• Clinicians should consider toxic plant ingestion, specifically Convallaria majalis or Veratrum species, in patients presenting with bradycardia, gastrointestinal issues, and elevated digoxin levels after foraging.
• Accurate plant identification is crucial to prevent severe toxicity and misdiagnosis in foraging-related incidents.
• Awareness of these plant mimics is essential for emergency departments managing potential poisonings.