Illustrative Case: a 48-year-old man with chief complaint of dizziness. Additional complaints include perioral paresthesias, nausea, vomiting, generalized fatigue, and a possible syncopal episode. He seems confused and cannot add much history, but his family states that he may have ingested something he purchased from the internet.
Initial vitals include HR 33, BP 80/65, Oxygen saturation 98% on RA, temperature 36.7.
What is your differential diagnosis?
One of the most challenging differentials in toxicology is the hypotension and bradycardic patient. Common considerations include:
Beta blockers
Calcium channel blockers
Clonidine
Digoxin
Botanicals
What are your next steps?
A patient with these vital signs should immediately be placed on a cardiac monitor, and ideally with pacer pads. The team should place two large bore IVs, pulse oximeter, and draw labs for analysis. The airway should be rapidly assessed. Atropine and pressors should be readily available. An ECG should be obtained immediately. An accucheck should be obtained, and if glucose is elevated in this non-diabetic patient , it could be a clue to a calcium channel blocker ingestion. A digoxin concentration should be obtained.
What is the differential for botanicals that can lead to this toxic syndrome?
Oleander, Foxglove, Lily of the Valley, Digitalis, Squill, Bufotoxin and many other plants and natural substances contain cardiac glycosides.
What did this patient order?
Grayanotoxin and cardiac glycosides
“Mad Honey” is honey contaminated with grayanotoxin produced by bees which feed on the nectar of plants containing grayanotoxin, primarily in the ericaceae family, including Rhododendron and Kalmia (Mountain Laurel) species. Rhododendron and mountain laurel are common plants, ubiquitous in the Western US, and contaminated honey has been found in Canada. Mad honey is mainly produced in Turkey and Nepal, where it is often consumed for supposed health benefits or for recreational purposes. Products marketed as “Mad Honey” are freely available for purchase online.
What did this patient order?
Grayanotoxin and cardiac glycosides
“Mad Honey” is honey contaminated with grayanotoxin produced by bees which feed on the nectar of plants containing grayanotoxin, primarily in the ericaceae family, including Rhododendron and Kalmia (Mountain Laurel) species. Rhododendron and mountain laurel are common plants, ubiquitous in the Western US, and contaminated honey has been found in Canada. Mad honey is mainly produced in Turkey and Nepal, where it is often consumed for supposed health benefits or for recreational purposes. Products marketed as “Mad Honey” are freely available for purchase online.
Symptoms of grayanotoxin poisoning usually occur within 3 hours of ingestion. Common symptoms include nausea and vomiting, sweating, and dizziness. Like the cardiac glycosides, clinical signs of grayanotoxin toxicity include hypotension and bradycardia. Gastrointestinal symptoms are similar, including nausea, vomiting, and less commonly, diarrhea. Additional but less common symptoms include diplopia, blurred vision, and salivation through an unknown mechanism. Atrial fibrillation, asystole, and MI have been documented but are not the norm.
Treatment of grayanotoxin poisoning consists of usual supportive care, including activated-charcoal, and IV fluids or pressors for blood pressure support. Pacing and atropine have also been successfully used for bradycardia.
Written by:
Dr. Kathleen Rowland, MD
Emergency Medicine, PGY-3
Cook County Health
Reviewed by:
Dr. Steven Aks, DO
Toxikon Consortium Director
Cook County Health
References:
Cagali KE, Tufekcioglu O, Sen N, et al: Atrioventricular block induced by mad-honey intoxication: Confirmation by pollen analysis. Tex Heart Inst J 2009;36:342-4.
DF Yeih, FT Chiang, SKS Huang. Successful treatment of aconitine induced life threatening ventricular tachyarrhythmia with amiodarone. Heart 2000;84:e8
emcrit.org/toxhound/ff-plant-sodium-channel-openers
Goldfrank’s Toxicologic Emergencies
Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Brooks DE, Dibert KW, Rivers LJ, Pham NPT, Ryan ML. 2019 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 37th Annual Report. Clin Toxicol (Phila). 2020 Dec;58(12):1360-1541. PubMed PMID: 33305966.
Gunduz A, Turedi S, Russell RM, et al: Clincal review of grayanotoxin/mad honey poisoning past and present. Clin Toxicol 2009;46:437-442.
Jansen SA, Kleerekooper I, Hofman ZL, Kappen IF, Stary-Weinzinger A, van der Heyden MA. Grayanotoxin poisoning: 'mad honey disease' and beyond. Cardiovasc Toxicol. 2012;12(3):208-215. doi:10.1007/s12012-012-9162-2