Oleander (Nerium oleander) poisoning mimics which class of drug toxicity, and what is the most useful forensic confirmatory test?

• A Tricyclic antidepressant toxicity; confirmed by urine immunoassay for TCAs
• B Calcium channel blocker toxicity; confirmed by serum calcium measurement
• C Digitalis glycoside toxicity; confirmed by cross-reacting digoxin immunoassay or HPLC-MS for oleandrin ✓
• D Beta-blocker toxicity; confirmed by propranolol levels on GC-MS

Explanation

Oleandrin and neriine (cardiac glycosides in Nerium oleander) have the same mechanism as digoxin — inhibition of Na+/K+-ATPase, causing increased intracellular calcium, bradyarrhythmias, and heart block. Clinically and on ECG, oleander toxicity is indistinguishable from digoxin poisoning, and many immunoassay digoxin tests cross-react with oleandrin, giving a falsely positive digoxin level. Confirmatory analysis uses HPLC-MS to identify oleandrin specifically. This cross-reactivity has medicolegal significance in differentiating accidental from intentional poisoning.

Reference: The Essentials of Forensic Medicine and Toxicology (Narayan Reddy), 34th ed.

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Written and medically reviewed by the StethoPrep medical team.