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Endgames Case Review

A tropical electrocardiogram wave

BMJ 2022; 376 doi: (Published 19 January 2022) Cite this as: BMJ 2022;376:e065769
  1. Simon Findlay, cardio-oncology clinical research fellow1,
  2. Katharine Nelson, consultant2,
  3. Ian Logan, consultant3
  1. 1Northern Institute for Cancer Research, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
  2. 2Department of Cardiology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne
  3. 3Department of Nephrology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne
  1. Correspondence to: S Findlay simon.findlay1{at}

A man in his 70s on holiday from Ghana presented to the emergency department with a one week history of lethargy. On arrival he was bradycardic (heart rate 20 beats/min) and hypotensive (88/55 mm Hg).

He had a history of cardiac failure (left ventricular ejection fraction 35%), atrial fibrillation, chronic kidney disease stage G3aA3, hypertension, and stroke.

Over the past six months his daily dietary intake had comprised a large proportion of tropical fruits (including mangoes, bananas, and pineapples) and two litres of fresh orange juice. He was taking amlodipine 10 mg daily, allopurinol 100 mg daily, atorvastatin 20 mg daily, bumetanide 2 mg twice a day, carvedilol 6.25 mg twice a day, quinine sulphate 200 mg every night, ramipril 2.5 mg daily, spironolactone 25 mg daily, and warfarin.

Table 1 shows the results of electrocardiography (fig 1), ultrasonography, and key laboratory tests on admission to the emergency department.

View this table:
Table 1

Laboratory …

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