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After a New Jersey toddler experienced a serious heart complication found to be due to consumption of a weight loss supplement purchased by the child's mother, testing revealed that the product, which was supposed to contain tejocote root, actually contained the potentially highly toxic yellow oleander, CDC researchers reported.

In September 2022, an emergency physician contacted the New Jersey Poison Information and Education System (NJPIES) about a 23-month-old child who had consumed Eva Nutrition Mexican Tejocote Root, marketed as a weight loss supplement, and developed nausea and vomiting, reported Noah Berland, MD, of the NJPIES and Rutgers New Jersey Medical School in Newark, and colleagues.

The child experienced age-specific bradycardia (heart rate of 90 bpm versus a normal range of 98-135 bpm) and was hypotensive (blood pressure 71/60 mm Hg), they noted in the .

ECG results showed sinus bradycardia, frequent premature ventricular complexes, and scooped ST segments consistent with cardenolide toxicity. A serum digoxin assay showed a level of 0.5 ng/L, "which NJPIES interpreted as being attributable to cross-reactivity with a nondigoxin cardiac glycoside," Berland and team wrote.

Despite FDA regulations, "misbranded dietary supplements are frequently found to contain potentially dangerous substances," they noted, adding that yellow oleander contains the cardenolide thevetin B, "which has the same clinical effects as other cardenolides, such as digoxin, and can be highly toxic."

"For public health officials, this is concerning because these supplements contain a highly toxic substance and are readily available from multiple retailers," they wrote.

The child received treatment with 40 mg of digoxin-specific antibody fragments (FAB; a digoxin overdose antidote), and ECG results and blood pressure normalized. A repeat ECG 12 hours later again showed evidence of cardenolide toxicity, so the patient received a second dose of FAB, and ECG results returned to normal.

In December, NJPIES purchased 10 products labeled as tejocote root and marketed as weight loss supplements online, and sent them to a laboratory in Oregon that specializes in the analysis of chemical constituents found in dietary supplements. The lab used ultra-high-pressure liquid chromatography-accurate mass-time of flight mass spectrometry analysis to compare the purchased supplements with tejocote root that was procured and authenticated by an ethnobotanist.

Nine of the 10 products were found to actually contain yellow oleander, with no evidence of tejocote root.

Just last week, the FDA expanded a consumer warning about in certain botanical weight loss products.

"Clinicians need to be aware that persons with signs and symptoms of cardiac glycoside exposure might have been exposed to products labeled as tejocote, Nuez de la India, or other supplements marketed for weight loss and might benefit from treatment with a similar approach to that used in cases of nondigoxin cardiac glycoside exposures," Berland and colleagues wrote. "Persons who are exposed to yellow oleander with evidence of toxicity might have a positive serum digoxin result on immune assays caused by cross-reactivity and might respond to FAB, as did the patient in this report."

"However, higher doses of FAB might be required for the reversal of yellow oleander toxicity than that typically used in cases of digoxin toxicity," they added.

Serum digoxin assays are not reliable for detection of thevetin B and cardiac glycosides other than digoxin, they explained, noting that "laboratory-reported digoxin levels do not accurately reflect serum levels of other cardiac glycosides."

"Future prevention efforts need to include reporting products such as these to FDA and alerting retailers who might be unknowingly selling these hazardous products," Berland and team concluded. "Clinicians will need to ask persons seeking care with evidence of cardiac glycoside toxicity about the use of weight loss supplements and consider FAB for treatment."

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