Common Constipation Supplement Sends Woman to Cardiac ICU With Digoxin-Like Toxicity

A published case report in Annals of Internal Medicine Clinical Cases describes a 24-year-old woman who was admitted to the cardiac ICU after taking four pills of a supplement marketed as tejocote root to relieve constipation. Within 14 hours she developed confusion, nausea, vomiting, diarrhea, whole-body numbness, low blood pressure, and a dangerously slow heart rate — a clinical picture consistent with digoxin toxicity.

The underlying cause was not tejocote root itself, which has no established toxicity, but yellow oleander — a poisonous plant that contains cardiac glycosides similar to digoxin. Yellow oleander is commonly used to adulterate or outright replace tejocote in supplements sold online. A 2024 FDA warning flagged this exact substitution. Independent testing of 10 similar supplements found nine contained yellow oleander with likely no actual tejocote present.

Digoxin-like toxicity is notoriously difficult to diagnose. Key clinical signals include bradycardia, scooped ST segments on ECG, and hyperkalemia — all of which this patient exhibited. Her serum digoxin level appeared within normal therapeutic range on admission, which could mislead clinicians unfamiliar with cross-reactive cardiac glycosides from plant sources.

The patient was treated with 10 vials of digoxin-specific antibody fragments, a targeted antidote. Her blood pressure improved and potassium normalized, though she remained bradycardic during her ICU stay. The response to the antidote itself confirmed the diagnosis of cardiac glycoside poisoning.

For health-conscious supplement users, this case is a stark warning. The FDA does not require pre-market safety testing for dietary supplements, meaning toxic adulterants can reach consumers undetected. Clinicians are urged to consider cardiac glycoside poisoning in any patient presenting with bradycardia and GI symptoms after supplement use, and to treat promptly with digoxin-specific antibodies.