A 33-year-old male, working in a grocery store presented to emergency room with a history of generalized weakness and breathlessness of class II over a period of two days. There was no history of fever, chest pain, palpitation, syncope or any known allergic disorders. He was a teetotaler and was not under any medications. His medical history otherwise was not significant. On examination, he was found to be conscious, well oriented, moderately built, and well nourished. There was no pallor, pedal edema or any clinical evidence of hypo or hyperthyroidism. He had a pulse rate of 48/min (irregular), BP: 80/60mm of Hg, and respiratory rate of 13/min. He was afebrile and his oxygen saturation on room air was 98%. Auscultation revealed normal heart sounds, no murmur or gallop but his heartbeat was regularly irregular. The lungs were clear. His abdomen and central nervous examinations were normal.
A provisional diagnosis of fatigue for evaluation was made. His capillary blood glucose level was 146 mg/dl and ECG showed bradycardia with Mobitz II block. Since there was symptomatic bradycardia, a trial of 2 mg of atropine was given intravenously and there was no response. He was started on dopamine 5 microgram/kg/min titrated upwards to 10 microgram/kg/min. He was admitted to the intensive care unit for further management. His hematological and biochemical values including thyroid profile, calcium, magnesium, and electrolytes were within normal limits. His Troponin-T, RPR [Rapid Plasma Reagin] test, and HIV status were negative. As he had isolated electrocardiographic features of Mobitz type II block without any demonstrable cause, he was subjected for echocardiogram, which was normal. The cardiologist opined for urgent pacing, but the patient refused. However, with the consent of the patient, his right internal jugular vein was canulated with 14G venflon so as to facilitate emergency transvenous insertion of pacemaker.
He was managed with oral orciprenaline and atropine (sos). Dopamine was slowly tapered and stopped within 36 hours. As the patient was symptomatically improving, a diagnosis of idiopathic second-degree type II A V block was considered. While on re-evaluation of the case, a non-specific penile ulcer was noticed. On careful interrogation, the patient admitted of suffering from penile ulcer for which he applied a native medicine paste on alternative days for a week as advised by a native medical practitioner of his village. The last application of the medication was 24 hours before presenting to our emergency room. He denied any extramarital relationship. Hence, the native medical practitioner was contacted in person to know more about the paste.
On interaction with the native physician concerned, he explained that the paste was made of bark and leaves of yellow oleander plant, tulsi, tamarind, onion, and neem. He also admitted that he was treating all open wounds or ulcers presented to him with the same paste! With the benefit of doubt, the patient was started with multidose activated charcoal (MDAC) for a day. So, the final diagnosis at the time of discharge was drug induced A V block probably due to transcutaneous absorption of oleander. Our diagnosis was supported by normalization of rhythm within 2 days in the absence of offending drugs.
As this has raised the suspicion of transcutaneous absorption of naturally occurring cardiac glycoside (oleander), it was decided to contact the native practitioner and find out if any of his cutaneous ulcer cases were on treatment with similar paste at present. Three more cases with cutaneous ulcer on treatment with similar paste were evaluated at the practitioner's clinic, after obtaining informed consent as all of them refused hospitalization and modern medicines. They were followed up at their residence.