Yew Poisoning in Adolescents

Yew poisoning can result from the ingestion of yew needles and is a severe form of intoxication caused by the alkaloid taxine B. The yew (Taxus baccata) contains various alkaloids, of which taxine B is the main component, accounting for around 30%. It is rapidly absorbed by the digestive system and has a cardiotoxic effect, resulting in severe intractable cardiac arrhythmias which often require prolonged resuscitation or ECMO therapy (extracorporeal membrane oxygenation) and may be fatal (1, 2). In addition to poison elimination, the rapid application of digoxin-specific Fab antibody fragment (Fab) seems to be the currently most promising therapeutic approach (3, 4), given that the pro-arrhythmogenic effect of the toxins may be reduced by cross reaction of antibodies with the taxines (5).

Current problem

Poisonings and attempted suicides involving yew have risen continuously in Germany. While the number of cases reported to the poison control centers in 2019 was 229 (Munich) and 258 (Berlin), they rose to 397 (Munich) and 278 (Berlin) in 2023. According to information provided by these centers, between 4.5% (Munich) and 6.5% (Berlin) of these cases were taken with suicidal intent.

A significant reason for the rise are advertisements for this form of suicide posted on internet forums. The following cases from our pediatric cardiac intensive care units (ICUs) in Grosshadern (Munich), Frankfurt, and Ravensburg will be presented. None of the five adolescents presented had a known history of diseases, drug usage, or psychiatric diagnoses.

Case 1

An adolescent had prepared himself a smoothie and accidentally added yew needles to the mixture. Early symptoms of nausea, dizziness, and vomiting started to develop a few hours later, followed by ventricular tachycardia (VT) (180 beats/minute [min]) which persisted despite fractionated administration of 450 milligrams (mg) amiodarone, three cardioversions, and brief resuscitation. In the ICU his heart rate varied between 27 and 150 beats/min with reduced pump function. The administration of activated charcoal had no effect. The rhythm became more stable after intravenous (IV) application of 2 x 80 mg digoxin-specific Fab antibody fragments; an initial effect of narrowing QRS complexes was evident after 30 mins. A normal sinus rhythm was achieved after 12 hours (hrs.).

Case 2

An adolescent suffered a tonic-clonic seizure followed by cardiac arrest after ingesting yew with suicidal intent. Torsade de pointes tachycardia progressed to VT. A ROSC (return of spontaneous circulation) was achieved after administration of 300 mg amiodarone, 2 g magnesium, and six defibrillations, although VT with very wide QRS complexes (QRS 180 milliseconds [ms]) still persisted (Figure). A trial of lipid rescue, which was administered without knowledge of the possible cause of the intoxication, had only a short-term effect. Lipid rescue is the intravenous administration of a 20-percent lipid solution which mobilizes and binds highly lipophilic substances from tissues. The desired effect in yew poisoning is based on the lipophilic properties of alkaloids.

Figure

Typical rhythm disturbance with wide QRS complexes and variable heart rate

Heart stimulation was not possible, even after the implantation of an intracardiac pacemaker for bradycardia. Only after all the needles had been removed by gastroscopy and activated charcoal administered did the rhythm improve within 12 hours.

Case 3

An adolescent was found on a park bench with VT after ingesting yew with suicidal intent and was resuscitated. After administration of 300 mg amiodarone, 2 g magnesium, and two doses of adrenaline, a total of nine defibrillations were conducted until ROSC was achieved. Yew poisoning was assumed due to persistent VT. After the poisoning had been confirmed by gastroscopy, activated charcoal was administered and the toxins were eliminated. The electrocardiogram only appeared normal once digoxin-specific Fab antibody fragments (1 x 160 mg, then 160 mg over 8 hrs.) had been administered. Here too, initial changes to the QRS complexes were apparent within the first hour.

Case 4

An adolescent had drunk a highly concentrated brew of yew needles with suicidal intent. He asked for help of his own accord and was admitted as an inpatient in an alert and hemodynamically stable condition. Treatment with digoxin-specific Fab antibody fragments was initiated at a low dose, which did not succeed in preventing repeated VT requiring resuscitation. Despite lipid rescue, lidocaine, amiodarone, noradrenaline, adrenaline, and ECMO, it was only possible to achieve ROSC for short episodes. The adolescent died from refractory hypotension and multiple organ failure.

Case 5

An adolescent had ingested crushed yew needles with suicidal intent. He presented initially with dizziness, nausea, and abdominal pain associated with a tachycardic sinus rhythm with a prolonged QTc-interval of 460 ms in a hemodynamically stable condition. On admission to hospital, gastroscopy was immediately performed to eliminate the toxins, after which activated charcoal was administered. This confirmed that a large amount of yew had been ingested. Treatment with IV digoxin-specific Fab antibody fragments was also commenced immediately at an initial dose of 80 mg over 30 mins, followed by 30 mg/hr. The QTc time was reduced to 420 ms after 24 hrs. Cardiac arrythmia did not develop despite the large amount of yew and thus high dose of toxin.

Discussion

Nowadays, yew poisoning should always be considered when acute malignant ventricular arrhythmia develops in an adolescent that does not respond to medication or defibrillation.

Rapid identification and neutralization of the toxin is crucial; options include removal of the toxin by gastroscopy combined with the administration of activated charcoal. A large number of case reports have employed numerous drugs and interventions. A trial with lipid rescue may be attempted in view of the lipophilic properties of taxine B (2). The best option, however, appears to be treatment with digoxin-specific Fab antibody fragments (3, 4). Generally, treatment is based on the dose–effect principle—the initial dose is given repeatedly until clinical improvement is observed. A loading dose of 80 to 160 mg over 30 mins., followed by 160 mg or 30 mg/hr for the next 8 hrs., has been reported. A potential side effect would be an allergic reaction due to the fact that Fab-fragments are obtained from sheep, but this is irrelevant in an emergency situation. The dose for children also depends on the amount of poison ingested and the effect achieved, not on body weight.

The option of ECMO is not always available, especially for children, and has its limits as the reported cases show. ECMO is often associated with a good outcome (3).

Evelyn Bienenstein, Jens Böhmer, Nikolaus Haas

Department of Pediatric Cardiology and Pediatric Intensive Care, Munich University Hospital, LMU Munich; Ravensburg Pediatric Department, Oberschwabenklinik (Bienenstein) [e-mail]

Pediatric Department of Frankfurt Hoechst University Hospital; Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden (Böhmer)

Department of Pediatric Cardiology and Pediatric Intensive Care, Munich University Hospital, LMU Munich (Haas)

Acknowledgments

Our thanks go to the colleagues Dr. David Steindl at the Poison Hotline of the Charité – Berlin University of Medicine and to Dr. Tobias Zellner at the Poison Hotline of the Munich Technical University for providing the latest figures.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Manuscript received on 2 October 2024, revised version accepted on 10 February 2025.

Translated from the original German by Dr. Grahame Larkin.

Cite this as: Bienenstein E, Böhmer J, Haas N: Yew poisoning in adolescents. Dtsch Arztebl Int 2025; 122: 304–5. DOI: 10.3238/arztebl.m2025.0031

References

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