Correspondence

Herbal Aconite Tea and Refractory Ventricular Tachycardia

N Engl J Med 2005; 353:1532October 6, 2005

Article

To the Editor:

Recently, a patient presented to our emergency department with severe poisoning after ingesting an aconite-containing tea with therapeutic intent. Her course highlights the potentially great danger of ingesting such a preparation. The patient, a 66-year-old woman without known cardiac disease, obtained the herb for treatment of her osteoarthritis from a local herbalist, who instructed her to prepare it by making a tea. Approximately 90 minutes after ingestion of the tea, facial and extremity paresthesias developed, after which nausea, generalized weakness, and chest pressure rapidly developed. On arrival at our emergency department, she was found to have a hemodynamically compromising supraventricular tachycardia that was refractive to both administration of adenosine and electrical cardioversion. Subsequently, ventricular tachycardia developed; it had varying morphologic features (monomorphic, polymorphic, and bidirectional), was associated with periods of pulselessness, and was refractory to both electrical and various pharmacologic interventions. After approximately four hours, there was conversion to sinus rhythm, which continued until the patient was discharged as neurologically normal four days later.

The results of routine blood chemical tests were normal, the presence of digoxin was ruled out, and a myocardial perfusion scan was normal. A sample of the herb was determined on gas chromatography to contain aconitine. Aconitine binds with high affinity and causes persistent activation of sodium channels. It is one of various alkaloids responsible for the clinical effects of aconite.1 Aconitine is used in Chinese and Japanese medicine as an analgesic or antirheumatic agent and to treat neurologic indications, and it has a well-documented association with life-threatening ventricular dysrhythmias.2 Incorrect preparation and a narrow therapeutic index have been implicated in the toxic effects. The combination of paresthesias, muscle weakness, and ventricular tachycardia is typical in poisoning.3 There remains no consistently effective treatment, although class I antiarrhythmic drugs (particularly flecainide) and beta-blockers have decreased mortality in a rat model.4 Although reports of poisonings with aconite have been extremely rare in North America, this could change with the increasing popularity of herbal medicines.

Lisa Lowe, M.D.
Michael J. Matteucci, M.D.
Aaron B. Schneir, M.D.
University of California, San Diego, Medical Center, San Diego, CA 92103
aschneir@ucsd.edu

4 References

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Citing Articles (8)

Citing Articles

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   Ming-da WANG, Zhi-gang ZHANG. (2011) Successful management of electrical storm after acute myocardial infarction: a case report. Academic Journal of Second Military Medical University 31:1, 111-112
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   Antoine Strzelecki, Nicolas Pichon, Jean M. Gaulier, Jean B. Amiel, Pauline Champy, Marc Clavel. (2010) Acute Toxic Herbal Intake in a Suicide Attempt and Fatal Refractory Ventricular Arrhythmia. Basic & Clinical Pharmacology & Toxicology 107:2, 698-699
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   Ara Tachjian, Viqar Maria, Arshad Jahangir. (2010) Use of Herbal Products and Potential Interactions in Patients With Cardiovascular Diseases. Journal of the American College of Cardiology 55:6, 515-525
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   Philippe Gottignies, Tarek El Hor, Joseph Kengni Tameze, Anatol Basaula Lusinga, Jacques Devriendt, Philippe Lheureux, David De Bels. (2009) Successful treatment of monkshood (aconite napel) poisoning with magnesium sulfate. The American Journal of Emergency Medicine 27:6, 755.e1-755.e4
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   Sheng-Nan Wu, Bing-Shuo Chen, Ming-Wei Lin, Yen-Chin Liu. (2008) Contribution of slowly inactivating potassium current to delayed firing of action potentials in NG108-15 neuronal cells: Experimental and theoretical studies. Journal of Theoretical Biology 252:4, 711-721
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   Ming-Wei Lin, Ya-Jean Wang, Shiuh-Inn Liu, An-An Lin, Yi-Ching Lo, Sheng-Nan Wu. (2008) Characterization of aconitine-induced block of delayed rectifier K+ current in differentiated NG108-15 neuronal cells. Neuropharmacology 54:6, 912-923
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7. 7

   An A. Landeghem, Els A. Letter, Willy E. Lambert, Carlos H. Peteghem, Michel H. A. Piette. (2007) Aconitine involvement in an unusual homicide case. International Journal of Legal Medicine 121:3, 214-219
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8. 8

   Karta Purkh Singh Khalsa. (2007) Low Dose Herbs. Journal of Herbal Pharmacotherapy 7:1, 87-98
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