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• W4283749878 abstract "HomeCirculation: Cardiovascular ImagingVol. 15, No. 8Cardiotoxicity of Aconite Poisoning Evaluated by Multimodalities Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessCase ReportPDF/EPUBCardiotoxicity of Aconite Poisoning Evaluated by Multimodalities Riku Arai, Nobuhiro Murata, Kosaku Kinoshita and Yasuo Okumura Riku AraiRiku Arai Division of Cardiology, Department of Medicine (R.A., N.M., Y.O.), Nihon University School of Medicine, Tokyo, Japan. Search for more papers by this author , Nobuhiro MurataNobuhiro Murata Correspondence to: Nobuhiro Murata, MD, Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchijomachi 30-1, Itabashi-ku, Tokyo 1738610. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0362-4268 Division of Cardiology, Department of Medicine (R.A., N.M., Y.O.), Nihon University School of Medicine, Tokyo, Japan. Search for more papers by this author , Kosaku KinoshitaKosaku Kinoshita https://orcid.org/0000-0002-9451-9027 Division of Emergency and Critical Care Medicine, Department of Acute Medicine (K.K.), Nihon University School of Medicine, Tokyo, Japan. Search for more papers by this author and Yasuo OkumuraYasuo Okumura https://orcid.org/0000-0002-2960-4241 Division of Cardiology, Department of Medicine (R.A., N.M., Y.O.), Nihon University School of Medicine, Tokyo, Japan. Search for more papers by this author Originally published30 Jun 2022https://doi.org/10.1161/CIRCIMAGING.122.014143Circulation: Cardiovascular Imaging. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: June 30, 2022: Ahead of Print A 27-year-old Japanese healthy female (height: 165.0 cm, weight: 56.4 kg) presented to the emergency department with nausea and impaired consciousness. She had attempted suicide by ingesting a natural ornamental aconite plant, including the flowers, leaves, stems, and roots, 2 hours before being transported to our hospital. Her blood pressure was 86/37 mm Hg, heart rate 92 bpm, respiratory rate 25/min, Glasgow Coma Scale E1V2M5, and body temperature 36.2 degrees. A blood gas analysis revealed an elevated lactate level of 3.3 mmol/L. The 12-lead ECG showed that the first 2 grouped beats were ventricular bigeminy, followed by escape capture bigeminy (Figure 1). Another ECG 30 minutes postadmission showed sinus rhythm with first-degree atrioventricular block and widespread concave ST-segment–elevation and PR depression present throughout the precordial (V3–V6) and limb leads (II, III, aVF) with reciprocal ST depression and PR elevation in aVR (Figure 2). Transthoracic echocardiography showed a preserved left ventricular function without left ventricular asynergy, valvular disease, or a pericardial effusion.Download figureDownload PowerPointFigure 1. The 12-lead ECG at presentation. The first 2 grouped beats are ventricular bigeminy with sinus rhythm and a premature ventricular contraction (PVC). After that, it becomes escape capture bigeminy with an atrioventricular (AV) junctional rhythm and PVCs, and the P waves exhibit AV dissociation.Download figureDownload PowerPointFigure 2. The 12-lead ECG 30 minutes after admission. The ECG shows normal sinus rhythm with first-degree atrioventricular block. Both PR segment depression and concave ST-segment elevation in leads II, III, aVF, and V3–6, and both PR segment elevation and ST-segment depression in aVR are noted.Given the medical history of aconite ingestion, and cardiotoxicity with neurological symptoms, we considered aconite poisoning was most likely and decided to perform a gastric lavage after tracheal intubation. On the monitored ECG, various arrhythmias were recorded within 24 hours postadmission (Figure S1), such as escape capture bigeminy, atrial escape beats (Figure S1A), ventricular bigeminy (Figure S1B), atrial ectopic beats followed by atrial fibrillation (Figure S1C), and parasystoles (Figure S1D and S1E). Landiolol was used under backup with temporary pacing to control both the ectopic beats and escape beats due to the aconite poisoning. Forty hours after ingesting the aconitine, those arrhythmias disappeared, and the atrioventricular conduction and ST-segment changes resumed normal conduction (Figure S2).The cardiac enzymes were within normal range on admission but increased thereafter and peaked 48 hours after the aconite ingestion (peak CK [creatine kinase]: 473 U/L, CK-MB: 15 U/L, troponin-I: 4.98 ng/mL). Coronary computed tomography angiography showed no significant epicardial coronary artery stenoses (Figure S3). Cardiac magnetic resonance imaging 5 days postadmission revealed the myocardial edema remained on the anterolateral left ventricular wall (Figure 3A, arrowheads) and part of the epicardium on T2-weighted imaging (Figure 3B, arrow) with late gadolinium enhancement (Figure 3C arrowheads, and Figure 3D arrow), which was consistent with perimyocarditis. Myocardial thallium-201 (201Tl) and iodine-123-BMIPP dual scintigraphy 12 days postadmission were normal (Figure S4), which could deny the possibility of vasospastic angina. Each viral paired serum antibody test was negative for viral perimyocarditis. Quantitative analyses of the initial blood and urine aconitine and related alkaloids were performed by liquid chromatography–tandem mass spectrometry. The blood and urine aconitine levels were 0.6 μg/mL and 27 μg/mL, mesaconitine 0.8 μg/mL and 41 μg/mL, hypaconitine 3 μg/mL and 58 μg/mL, and jesaconitine 720 μg/mL and 13 000 μg/mL, respectively. The patient was finally diagnosed with cardiotoxicity and perimyocarditis due to aconitine poisoning. She became asymptomatic 48 hours after the aconite ingestion and was discharged on day 13.Download figureDownload PowerPointFigure 3. Cardiac magnetic resonance imaging 5 days after admission. It reveals the myocardial edema remained on the anterolateral left ventricular wall (A, arrowheads) and a part of the epicardium on the T2-weighted imaging (B, arrow) with subendocardial late gadolinium enhancement (C, arrowheads and D, arrow).The Aconitum species, wild aconite plants, contain aconitine, mesaconitine, hypaconitine, jesaconitine, and other aconitium alkaloids, which are known cardiotoxins and neurotoxins.1 The cardiotoxicity includes hypotension, chest pain, bradycardia, sinus tachycardia, ventricular ectopy, and ventricular fibrillation. The mechanisms of that cardiotoxicity are due to their actions on the voltage-sensitive sodium channels of the myocardium. Aconitine binds with a high affinity to the open state of voltage-sensitive sodium channels at site 2, which causes a persistent activation of the sodium channels and induces arrhythmias due to triggered activity. Hypotension and bradycardia are due to activation of the ventromedial nucleus of the hypothalamus.2Lin et al3 reported a case of myocarditis due to aconite poisoning revealed by Tc-99 m-PYP scintigraphy; however, there was limited data evaluating cardiotoxicity with other modalities. Iodine-123-BMIPP imaging evaluates the metabolism of fatty acids in the myocardium, and is also useful in estimating recent myocardial ischemia within a week of occurrence. Combined myocardial 201Tl and iodine-123-BMIPP imaging can differentiate vasospastic angina from other chest pain syndromes. Briefly, the decreased iodine-123-BMIPP uptake but normal perfusion in the correspondent coronary artery territory identified by 201Tl imaging is caused by a delayed metabolic recovery after the recovery of perfusion, suggesting vasospastic angina. The diagnostic sensitivity of BMIPP imaging for vasospastic angina is 72.5%.4 Her heart had a normal uptake of both Tl and BMIPP, which could deny the possibility of vasospastic angina. In our case, we evaluated the cardiotoxicity including arrhythmias and perimyocarditis using multimodalities.Article InformationAcknowledgmentsThe authors would like to thank Dr Koichi Nagashima for the interpretation of the ECG, and Dr Nami Sawada, Dr Shingo Ihara, Dr Tsukasa Kuwana, Dr Katsunori Fukumoto, Dr Masaki Monden, Dr Keisuke Kojima, Dr Korehito Iida, Dr Akimasa Yamada, and Dr Daisuke Fukamachi for their critical care of this patient. The authors also thank John Martin for his help with the English editing.Sources of FundingNone.Supplemental MaterialFigures S1–S4Disclosures None.FootnotesSupplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.122.014143.For Sources of Funding and Disclosures, see page 618.Correspondence to: Nobuhiro Murata, MD, Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Oyaguchijomachi 30-1, Itabashi-ku, Tokyo 1738610. Email murata.nobuhiro@nihon-u.ac.jpReferences1. Niitsu H, Fujita Y, Fujita S, Kumagai R, Takamiya M, Aoki Y, Dewa K. Distribution of Aconitum alkaloids in autopsy cases of aconite poisoning.Forensic Sci Int. 2013; 227:111–117. doi: 10.1016/j.forsciint.2012.10.021CrossrefMedlineGoogle Scholar2. Chan TY. Aconite poisoning.Clin Toxicol (Phila). 2009; 47:279–285. doi: 10.1080/15563650902904407CrossrefMedlineGoogle Scholar3. Lin CC, Phua DH, Deng JF, Yang CC. Aconitine intoxication mimicking acute myocardial infarction.Hum Exp Toxicol. 2011; 30:782–785. doi: 10.1177/0960327110385960CrossrefMedlineGoogle Scholar4. Sueda S. Clinical usefulness of myocardial scintigraphy in patients with vasospastic angina.J Cardiol. 2020; 75:494–499. doi: 10.1016/j.jjcc.2019.10.003CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Mou X, Zhang A, He T, Chen R, Zhou F, Yeung T, Wang C, Tang C, Lu X, Li L and Fan X (2023) Organoid models for Chinese herbal medicine studies, Acta Materia Medica, 10.15212/AMM-2022-0047, 2:1 August 2022Vol 15, Issue 8 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.122.014143PMID: 35770651 Originally publishedJune 30, 2022 Keywordsblood gas analysiscardiotoxicitysuicide, attemptedblood pressureaconitumPDF download Advertisement SubjectsMagnetic Resonance Imaging (MRI)" @default.
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