Severe acute hemolytic anemia following Nerium oleander poisoning: A case report

Background Nerium oleander poisoning is classically characterized by cardiotoxicity and gastrointestinal symptoms resulting from exposure to cardioactive glycosides. Severe acute hemolytic anemia is an uncommon and poorly characterized manifestation of oleander intoxication, and evidence supporting a causal relationship remains limited. Case report We report the case of a 54-year-old woman who intentionally ingested blended raw Nerium oleander leaves and branches with water. Initial presentation was characterized by transient sinus bradycardia (40 beats/min), without atrioventricular conduction abnormalities or malignant dysrhythmias. Following consultation with the Poison Control Center, the patient underwent whole bowel irrigation and subsequently received one vial of digoxin-specific antibody fragments. Despite limited transient cardiac involvement, she developed severe acute hemolytic anemia, with hemoglobin decreasing from 14.7 g/dL to a nadir of 8.1 g/dL, requiring transfusion of two units of packed red blood cells. Laboratory findings demonstrated indirect hyperbilirubinemia, elevated lactate dehydrogenase, markedly reduced haptoglobin, reticulocytosis, and peripheral blood smear abnormalities. Direct antiglobulin testing and glucose-6-phosphate dehydrogenase deficiency screening were negative. Plasma and urinary oleandrin concentrations confirmed systemic exposure. Hematologic parameters progressively normalized, and hemoglobin reached 14.5 g/dL at 35-day follow-up. Why Should an Emergency Physician Be Aware of This? Although gastrointestinal and cardiac manifestations remain the hallmark of Nerium oleander poisoning, emergency physicians should recognize that severe acute hemolytic anemia may occur as an uncommon complication. Prompt recognition, exclusion of alternative causes, and close hematologic monitoring may facilitate timely supportive management, including transfusion when clinically indicated.