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(Circulation. 2000;102:2907.)
© 2000 American Heart Association, Inc.

Images in Cardiovascular Medicine

Malignant Ventricular Arrhythmias due to Aconitum napellus Seeds

M. Imazio, MD; R. Belli, MD; F. Pomari, MD; E. Cecchi, MD; A. Chinaglia, MD; G. Gaschino, MD; A. Ghisio, MD; R. Trinchero, MD; A. Brusca, MD

From Maria Vittoria Hospital Cardiology Department, Turin, Italy.

Correspondence to Massimo Imazio, MD, Cardiology Department, "Maria Vittoria" Hospital, via Cibrario 72, 10141 Torino, Italy. or cardomv{at}asl3.to.it

A 28-year-old man was admitted to the Emergency Department for syncope after several hours of violent vomiting and diarrhea. A few minutes after arrival, he complained of palpitations followed by a sudden loss of consciousness. An ECG showed a polymorphic ventricular tachycardia degenerating into ventricular fibrillation (Figure 1). Because of recurrent major ventricular arrhythmias, resuscitation was necessary for 1 hour. The patient was eventually admitted to the Coronary Care Unit. Physical examination, ECG (Figure 2), chest x-ray, echocardiogram, and routine blood chemistry were all normal. A history of a previous suicide attempt with rat poison was discovered, and a small bag of Aconitum napellus (wolfsbane, monkshood) seeds was found in the patient’s trousers. After several psychiatric assessments, the patient confessed to ingesting an unknown amount of these seeds for a suicidal purpose.

View larger version (115K): [in this window] [in a new window]   Figure 1. A, Polymorphic ventricular tachycardia recorded a few minutes after patient’s arrival. B, Coarse ventricular fibrillation.

View larger version (49K): [in this window] [in a new window]   Figure 2. Baseline ECG was normal after admission to Coronary Care Unit.

Aconitum napellus is a beautiful plant with blue or purple flowers (Figure 3). It can be found throughout the world, and it has long been known to be a poison.¹ The roots and seeds are freely sold on the herb market for treating musculoskeletal pain. They contain highly toxic C-19 diterpene and norditerpene alkaloids of aconitine, mesoaconitine, and the less toxic hypoaconitine; these compounds activate voltage-dependent Na⁺-channels in the heart and brain.^{2 3} The margin of safety between analgesic and toxic doses is very low. In the past, the plant was implicated in some cases of murder. Typical manifestations of poisoning are gastrointestinal, neurological, and cardiovascular, with malignant ventricular arrhythmias.⁴ Treatment is essentially supportive. No gross or histological cardiac abnormalities have been observed in the few autopsied cases.⁵ The problem of unregulated herb selling is now under discussion in the Italian Parliament. A new law will soon be passed to regulate herb selling.

View larger version (116K): [in this window] [in a new window]   Figure 3. Flowers of Aconitum napellus. The plant is found throughout the world.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

References

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2. Heubach JF, Schule A. Cardiac effects of lappaconitine and N-deacetyllappaconitine, two diterpenoid alkaloids from plants of the Aconitum and Delphinium species. Planta Med. 1998;64:22–26.[Medline] [Order article via Infotrieve]
   
3. Ameri A,. The effects of Aconitum alkaloids on the central nervous system. Prog Neurobiol. 1998;56:211–235.[Medline] [Order article via Infotrieve]
   
4. Tai YT, But PP, Young K, et al. Cardiotoxicity after accidental herb-induced aconite poisoning. Lancet. 1992;340:1254–1256.[Medline] [Order article via Infotrieve]
   
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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Imazio, M. Articles by Brusca, A. Search for Related Content PubMed PubMed Citation Articles by Imazio, M. Articles by Brusca, A. Related Collections CPR and emergency cardiac care Arrhythmias, clinical electrophysiology, drugs