Authors: Dr Shobhit Swarup

Abstract

Cerebera odollam, commonly known as the pong‑pong or suicide tree, contains potent cardiac glycosides capable of inducing life‑threatening arrhythmias and hyperkalemia. Intentional ingestion is well‑documented in parts of South and Southeast Asia. Despite the biochemical similarity of its toxins to digoxin, evidence guiding optimal medical management remains limited. This case report highlights a severe presentation of C. odollam toxicity and describes the critical role of early recognition, management of hyperkalemia, and timely administration of anti‑digoxin immune Fab.

A 56‑year‑old woman presented to the Emergency Department with vomiting, dizziness, and lethargy following intentional ingestion of pong‑pong seeds obtained from a local park. Initial vital signs were stable, and point‑of‑care ultrasound revealed normal cardiac activity. Laboratory findings demonstrated acute kidney injury (creatinine 110 µmol/L), severe hyperkalemia (6.8 mmol/L), elevated lactate (3.5 mmol/L), and a measurable digoxin level of 0.7 ng/L. Electrocardiography showed abnormalities consistent with hyperkalemia and cardiac glycoside toxicity.

Hyperkalemia protocol was initiated with intravenous dextrose‑insulin therapy. Activated charcoal and antiemetics were administered, followed by an initial four vials of Digibind®. Due to worsening hyperkalemia, the patient was transferred to the intensive care unit for continuous renal replacement therapy (CRRT), and additional vials of anti‑digoxin immune Fab were arranged. She subsequently developed transient ventricular standstill lasting five seconds, requiring Advanced Cardiac Life Support interventions and temporary transvenous pacing. CRRT was discontinued once potassium levels stabilized, and a total of 12 vials of Digibind® were administered.

The patient showed steady improvement and was transferred to the general ward by day three, with psychiatric review completed prior to discharge planning.

This case underscores the potentially fatal consequences of C. odollam ingestion and the importance of rapid identification and treatment. Prompt reversal of hyperkalemia, avoidance of calcium administration, use of anti‑digoxin immune Fab, and readiness to manage brady‑ and tachyarrhythmias are critical to improving survival outcomes. Clinicians in endemic regions should maintain a high index of suspicion for pong‑pong toxicity in compatible presentations.

Keywords: Toxicology, Pong Pong, cardiac glycoside, digoxin immune fab