Abstract Title Beautiful, sweet-smelling, and poisoning: A rare case of Lily of the Valley intoxication

Background We are presenting a Lily Of The Valley (Convallaria Majalis) poisoning case that we encountered in our clinic. This is a rare intoxication; few cases have been reported in the literature, mainly for accidental ingestion.

Case Presentation A 34-year-old Female with a PMH of anemia and anxiety presented at our FM Clinic complaining of nausea, multiple episodes of NBNB vomiting, dizziness, and weakness. Symptoms started two hours before her presentation to the clinic. The patient said she was hiking in upstate New York and picked up two stalks of an unknown plant. The morning of her presentation she mixed the plant with breakfast and ingested it along with her boyfriend. After one hour, she started feeling numbness in her tongue and thereafter started the nausea followed by vomiting six times. Her boyfriend also presented the same symptoms. The patient denied smoking, alcohol intake, or recreational drug use. On arrival at the clinic, her vital signs were T 97.8, HR 62 bpm, BP 77/49 mmHg, RR 18, SpO2 100% on RA. The cardiovascular system was remarkable for severe hypotension and sinus bradycardia. The Poison Control Center was contacted and confirmed from the description and picture identification that the plant was likely the Lily of the Valley. The patient was transferred to the ED, and her boyfriend was also contacted to come. ECG done showed normal sinus rhythm. Labs were remarkable for hypoglycemia (FS 57). CBC with neutrophilia 82.6%, VBG: pH 7.30. Digoxin levels <0.2. The drug screen was negative. The patient was on the cardiac monitor for two hours, had no more episodes of emesis, and was no longer nauseous or dizzy. Repeat a set of Vitals: T 98.8, HR 55 BP 95/54 mmHg, MAP 62, SpO2 94% on RA. She left against medical advice.

Discussion Convallaria majalis (Lily of the Valley) is one of the world's most poisonous plants. Cases of human poisoning are rare. The principal component of glycosides is convallatoxin. Manifestations of this poisoning are similar to those seen in digitalis intoxication in the elderly: digestive disorders, bradycardia, imbalance in the BP, and arrhythmias. The toxicity mechanisms are identical to those of digitalis. The patient presented in this case had bradycardia and severe hypotension, but because her partner was also presenting the same symptoms, it brought the suspicion of an intoxication.