Death from cardiac glycoside "pong-pong" following use as weight-loss supplement purchased on Internet.

Cerbera odollam or "pong-pong" tree contains cardiac glycosides similar to digoxin, oleander and yellow oleander. Cerbera odollam is a common method of suicide in South East Asia and has also been used as a weight loss supplement. We present a case of a 33-year-old female presenting with lethargy, vomiting, bradycardia, severe hyperkalemia of 8.9 mEq/L, slow atrial fibrillation followed by cardiovascular collapse following the ingestion of "pong-pong", the kernel of Cerbera odollam, as a weight loss supplement. Despite the administration of a total of nine vials of digoxin-specific Fab the patient could not be resuscitated. Clinicians should be aware of natural cardiac glycosides being uses as weight-loss agents and consider acute cardiac glycoside poisoning in patients with hyperkalemia, abnormal cardiovascular signs, symptoms and abnormal ECG findings.