Persistent Nausea and Vomiting Due to Digoxin Toxicity

Author: V. Dimov, M.D.

A 66 yo CF came to the ED with nausea and vomiting for two months. She had been admitted to an OSH a week ago for nausea and vomiting and an EGD was negative. She vomited on average two to three times per day - typically a couple of hours after eating a meal. The emesis was yellow and watery.

Medications
Fosamax, Novolog, Lantus, Furosemide, Digitek 0.25mg daily,
Citalopram, Amiodarone, Diovan, Vytorin, Coumadin, Iron tablets, Aspirin

PMH
CHF, DM Type II, Atrial Fibrillation, Cardiomyopathy, Anemia, Osteoporosis, Osteoarthritis, Sleep apnea

Physical examination
VSS
Chest: CTA (B)
CVS: Clear S1S2
Abdomen: Soft, NT, ND, +BS
Extremities: no c/c/e
Neurologic: awake and alert, normal speech
Psychiatric: normal affect, conversant, appropriate

What is the most likely diagnosis?
Diabetic gastroparesis

Anything else?
Digoxin toxicity

What tests would you order?
CBC
CMP
Digoxin level
KUB, CXR
UA
EKG

What happened?
ECG showed a LBBB (not new, compared to previous EKGs) and first degree AVB, HR 64 bpm.

Laboratory results were unremarkable. Digoxin level was pending.

What happened next?
Digoxin level came back as 5.0 ng/mL. Repeated levels were 5.2 and 5.6 respectively.

The patient became bradycardic and was transferred to MICU where digoxin-specific Fab fragments were administered. Potassium levels was monitored and was in the range of 3.9-4.5 mEq/L.

Digoxin level decreased and patient was transferred to a regular medical floor. Nausea and vomiting resolved and she was discharged home.


Figure 1. Digoxin levels in toxicity and response to treatment with digoxin-specific Fab fragments.

Final diagnosis
Digoxin intoxication

What did we learn from this case?
The indications for administration of digoxin-specific Fab fragments are:

- Hemodynamic instability
- Life-threatening arrhythmias
- Severe bradycardia
- A potassium level above 5 mEq/L in the setting of acute overdose, regardless of clinical status or electrocardiographic findings
- Plasma digoxin concentration above 10 ng/mL, regardless of clinical status or electrocardiographic findings.
- Presence of a digoxin-toxic rhythm in the setting of an elevated digoxin level.

References
Digitalis Toxicity. eMedicine, 2006.
Toxicity, Digitalis. eMedicine, 2006.

Created: 09/13/2007
Updated: 09/13/2007