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Detectable Digoxin Concentrations in 3 Patients with Ramps Misadventure

      Allium tricoccum (commonly known as “ramps”) is an edible plant known for its strong garlic-like odor and onion flavor. Unfortunately, A tricoccum mimics such as Lily of the Valley (Convallaria majalis) and False Hellebore (Veratrum viride) can lead to foraging errors and subsequent patient harm/toxicity. We describe 3 adults who foraged and ate what they believed were A tricoccum and then subsequently became symptomatic with detectable digoxin concentrations. A 41-y-old woman, 41-y-old man, and a 31-y-old man presented to the emergency department after ingesting an unknown plant that was believed to be A tricoccum. On arrival to the emergency department, the patients were hypotensive and bradycardic. They had detectable digoxin concentrations ranging from 0.08 ng·mL-1 to 0.13 ng·mL-1. One patient received 20 vials of digoxin antibody fragments. All 3 patients recovered without complication. Laboratory analysis of plant specimen was positive for cyclopamine, a teratogenic alkaloid found in Veratrum californicum. A tricoccum foraging errors can be a source of morbidity given their similarity in appearance to plants like C majalis and V viride. C majalis causes a detectable digoxin concentration via its cardiac steroid compound (convallatoxin) that is similar to digoxin. V viride contains alkaloid compounds (such as veratridine) that can cross react with digoxin assays and lead to a falsely elevated digoxin concentration. Clinicians should be prompted to think about ingestion of C majalis or Veratrum spp. when patients present with bradycardia, gastrointestinal symptoms, and detectable digoxin concentrations after plant ingestion and/or foraging for A tricoccum.

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      References

      1. Hamel P.B. Chiltoskey M.U. Cherokee Plants and Their Uses -- A 400 Year History. Herald Publishing Co., Sylva, NC1975: 52
      2. Densmore F. Uses of Plants by the Chippewa Indians, SI-BAE Annual Report #44. 1928; 296, 346. Available at: https://www.biodiversitylibrary.org/item/151430#page/11/mode/1up. Accessed April 20, 2022.

        • Bechtel L.K.
        • Lawrence D.T.
        • Haverstick D.
        • Powers J.S.
        • Wyatt S.A.
        • Croley T.
        • et al.
        Ingestion of false hellebore plants can cross-react with a digoxin clinical chemistry assay.
        Clin Toxicol (Phila). 2010; 48: 435-442
        • Anwar M.
        • Turner M.
        • Farrell N.
        • Zomlefer W.B.
        • McDougal O.M.
        • Morgan B.W.
        Hikers poisoned: Veratrum steroidal alkaloid toxicity following ingestion of foraged Veratrum parviflorum.
        Clin Toxicol (Phila). 2018; 56: 841-845
        • Jaffe A.M.
        • Gephardt D.
        • Courtemanche L.
        Poisoning due to ingestion of Veratrum viride (false hellebore).
        J Emerg Med. 1990; 8: 161-167