Article

Does mad honey poisoning require hospital admission?

Original Contribution

Does Mad honey poisoning require hospital admission?

Abdulkadir Gunduz MDa,?, Emine Sayin Merice MDb, Ahmet Baydin MDc,

Murat Topbas MDd, Hukum Uzun MDe, Suleyman Turedi MDa, Asim Kalkan MDa

aDepartment of Emergency Medicine, Karadeniz Technical University Faculty of Medicine, 61080 Trabzon, Turkey

bOrdu General Hospital, 52200 Ordu, Turkey

cDepartment of Emergency Medicine, Ondokuz Mayis University Faculty of Medicine, 55139 Samsun, Turkey dDepartment of Public Health, Karadeniz Technical University Faculty of Medicine, 61080 Trabzon, Turkey eRize General Hospital, 53100 Rize, Turkey

Received 14 November 2007; revised 12 March 2008; accepted 13 March 2008

Abstract

Background: The aim of this study was to describe current patterns of monitoring and treatment of mad honey intoxication to make recommendations for a more standardized approach to care of patients with mad honey poisoning.

Methods: Patients presenting to emergency departments because of honey poisoning between January and October 2007. Age, length of stay in the emergency department, pulse rate, and systolic and diastolic blood pressure are cited as mean +- SD.

Results: Forty-seven cases presenting to the 3 health institutions during 2007 were investigated. It was determined that patients had ingested “mad” honey between 0.5 and 9 hours (mean +- SD, 2.8 +- 1.8 hours) before presentation. Patients’ pulse rates were 30 to 77/min (mean +- SD, 46.6 +- 12.1/min), and systolic blood pressure ranged from 50 to 140 mm Hg (mean +- SD, 46.6 +- 12.1 mm Hg). Patient rhythms on arrival were determined as 37 (7.7%) Sinus bradycardia, 6 (12.8%) nodal rhythm, 3 (6.4%) normal sinus rhythm, and 1 (2.1%) complete atrioventricular block. Lengths of stay in hospital were 3.6 +- 2.2 hours in the first university hospital, 22.2 +- 3.8 hours in the second university hospital, and 3.4 +- 1.7 hours in the state hospital. A 0.5 to 2 mg of atropine was given to all patients.

Conclusions: Our study did not reveal any difference in complications or mortality between patients cared for with brief emergency department observation when compared with patients cared for with 1 day inpatient observation.

(C) 2009

Introduction

Mad honey poisoning is common in the Eastern Black Sea region of Turkey, particularly in the summer. Honeys obtained from the flowers of Rhododendron ponticum and

* Correspondence author. Acil Tip AD, Karadeniz Teknik Universitesi Tip Fakultesi Hastanesi, Trabzon, 61080, Turkey. Tel.: +90 0462 377 5715;

fax: +90 0462 325 12 46.

E-mail address: [email protected] (A. Gunduz).

Rhododendron luteum are the cause of such poisoning [1]. These plants are abundant in the forests of the region. Patients typically exhibit dizziness, sweating, inability to stand, and ataxia. This type of poisoning has been known to the people of the Black Sea Region for hundreds of years [2]. Many times, such patients are observed at home and treated with rest and observation. However, a significant number of patients present to the emergency department and are monitored, treated, and discharged from community hospital emergency departments. It is rare for patients to be

0735-6757/$ – see front matter (C) 2009 doi:10.1016/j.ajem.2008.03.021

Mad honey poisoning

2.4. Measurements

425

Fig. 1 Duration of hospitalization of patients with mad honey poisoning by province.

transferred to tertiary care university hospitals. Because there is limited information in the literature regarding the management of these patients, every health institution implements its own monitoring, treatment, and follow-up protocol. Some studies on this subject have reported admitting patients to Coronary intensive care units [3,4]. However 1 case report involving a series of 8 patients stated that lengthy admission was unnecessary [5]. The aim of this study was to determine the lengths of stay of patients presenting to the region’s 3 main health institutions with initial findings of mad honey poisoning. Also, outcomes for the different Treatment protocols are compared.

Methods

Study design

All patients presenting to emergency departments with mad honey poisoning between January and October 2007 were enrolled in this observational study. The diagnosis of mad honey poisoning was based on a history of ingestion of unprocessed locally obtained honey and typical signs of dizziness, ataxia, bradydysrhythmias, diaphoresis, and hypotension.

Study setting and population

The study was performed at 2 university hospitals each with 20000 annual emergency department visits and 1 state hospital with more than 100000 emergency department visits yearly.

Study protocol

Physicians at the 3 emergency departments of hospitals located in the Black Sea coast (northeast of Turkey) completed the forms given to them.

Patients’ ages and sex, time of honey ingestion, pulse rate on admission to the emergency department, whether the patient had been admitted to intensive care, and whether Temporary pacemakers had been fitted were all recorded. The duration of emergency department stay was evaluated separately for each hospital (Fig. 1). The distribution of patients with a pulse rate below 60/min and those with diastolic blood pressure below 90 mm Hg on presentation to the emergency department was also examined (Fig. 2). Posttreatment follow-up was performed at cardiology out- patient clinics. If a patient did not follow up as recom- mended, the patient was contacted by telephone to determine if there was morbidity or mortality.

2.5. Data analysis

Data were entered using a form prepared by the researchers that was completed during initial presentation and at the time of patient discharge. Age, length of stay in the emergency department, pulse rate, and systolic and diastolic blood pressure are reported as mean +- SD. Quantitative data are given as percentages.

Results

Forty-seven patients presented to the 3 health institutions during 2007. They were all enrolled in this study.

Twenty-one cases presented to the regional hospital in the province of Ordu, 14 in Trabzon, and 12 in Samsun. Forty (85%) were men, and 7 (15%) were women. They were aged between 19 and 79 years (mean +- SD, 56.3 +- 12.2 years) and presented to the emergency department between 0.5 and 9 hours (mean +- SD, 2.8 +- 1.8 hours) after ingesting honey. Thirty-one patients (67.4%) were poisoned after consuming 1 spoonful of honey, 4 (8.5%) after 2 spoonfuls, 5 (10.6%)

Fig. 2 Pulse rate distribution at time of admission.

426 A. Gunduz et al.

Fig. 3 Systolic pressure distribution at time of presentation.

after 3 spoonfuls, 4 (8.5%) after 4 spoonfuls, and 3 (6.3%) after more than 4 spoonfuls. Patients’ pulse rates were 30 to 77/min (mean +- SD, 46.6 +- 12.1/min); systolic blood pressure, 50 to 140 mm Hg (mean +- SD, 79.8.6 +- 19.4 mm Hg); and diastolic blood pressure, 20 to 100 mm Hg (mean +- SD, 51.6 +- 15.2 mm Hg) (Fig. 3). One patient (2.1%) was fitted with a temporary pacemaker, admitted to coronary intensive care, and monitored for 24 hours. Patient rhythms on arrival were as follows: 37 (78.7%) sinus bradycardia, 6 (12.8%) nodal rhythm, 3 (6.4%) normal sinus rhythm, and 1 (2.1%) complete atrioventricular (AV) block. length of hospitalization was 3.6 +- 2.2 hours in the first university hospital, 22.2 +- 3.8 hours in the second, and 3.7 +- 1.7 hours in the state hospital. Because of protocols of the second university’s hospital, the patients were observed for at least 18 hours without regard to the patients’ clinical condition. Our data showed no mortality or complications related to mad honey poisoning in patients discharged from the hospital or the emergency department with 100% follow- up of patients either in person or by telephone.

Discussion

Locally produced honey is widely consumed in the Black Sea region. In general, beekeepers sell their own unprocessed honey in local or regional markets. This honey is a natural, unprocessed, and unregulated product. They reach the consumer directly, with no intermediate processing. When rhododendrons bloom in May and June, beekeepers take their hives to higher altitudes where these flowers are plentiful. It is during that season that mad honey is produced from valleys where rhododendron flowers are abundant. Fewer cases of mad honey poisoning are seen in years in which there is high rainfall in May and June, because of the honey having a lower toxic content. It is interesting that no cases of honey poisoning have been reported from North America, Europe, or the Far East, which have similar plant cover [6]. Local producers know which valley and which

season will produce toxic honey. They will generally warn the consumer at the time of sale. However, known toxic honey is also frequently used in the region as an Alternative medicine. It is believed to promote general health and is also used for gastric pain, bowel disorders, and hypertension and as a pain reliever [5,7]. Its popularity as an alternative medical treatment also increases the manufacture and consumption of mad honey.

Grayanotoxin found in rhododendron flower pollen and nectar is the toxic agent. Grayanotoxins are diterpenes, which are polyhydroxylated cyclic hydrocarbons, containing no nitrogen [6], They are found in the nectar, pollen, and other plant parts and products in a number of members of the family Ericaceae, such as Rhododendron luteum [6,8].

Grayanotoxins have a toxic cellular effect on the sodium channel. The work of a number of researchers was summarized by Maejima et al [9], who stated that grayanotoxins act in 3 ways on the voltage-dependent sodium channel. First, the grayanotoxin binds to the voltage- dependent sodium channel in its open state. Second, the modified sodium channel is unable to inactivate. Third, the activation potential of the modified sodium channel is shifted in the direction of hyperpolarization.

The amount of honey needed to produce toxicity is quite small. The average amount of ingested honey in 1 report was

13.45 +- 5.39 g (range, 5-30 g). Symptoms began 1.5 to 3 hours after ingesting the honey [4]. Poisoning in our cases was generally observed to have occurred after the ingestion of 1 spoonful (15 g).

In untreated cases of severe intoxication, the worst signs and symptoms last about 24 hours. By the end of that time, the patient is alert, and vital signs are normal. Complete recovery may take several more days [10-12]. The exact duration of symptoms is largely undocumented, although 1 researcher was able to safely discharge mild cases of mad honey poisoning after 2 to 6 hours of cardiac monitoring [5]. There are no detailed studies of the duration of individual signs and symptoms in severe mad honey poisoning in the modern medical literature. The duration of signs and symptoms in this study is similar to that of a previous report. [5]. Whereas patients were discharged in less than 5 hours in 2 of the health institutions, in the third hospital, patients were generally monitored in emergency department for 18 to 24 hours under the protocols of the hospital without independence of the patients’ clinical conditions. In the same hospital, 1 patient diagnosed with complete AV block was admitted to intensive care and monitored for 1 day.

cardiac dysrhythmias were reported in the 10 different series and case reports [3-5,13-19]; either a nonspecific bradyarrhythmia or a sinus bradycardia were reported in approximately 75% of cases. heart blocks of varying degrees were present in 25% of patients. Nodal rhythms were observed in 11% of patients, whereas 8.7% of patients had a Complete heart block, and 2.9% had a second-degree heart block. One patient was asystolic (1.45%). Another patient was reported as having Wolff-Parkinson-White syndrome,

Mad honey poisoning 427

which is most likely unrelated to the intoxication. Sinus bradycardia was determined in 37 (78.7%) of the cases in this study, nodal rhythm in 6 (12.8%), normal sinus rhythm in 3 (6.4%), and complete AV block in 1 (2.1%). Dysrhythmia, the most frequently encountered sinus bradycardia in both our studies and previously reported studies, emerges as the rhythm most requiring intensive care in AV block.

Although the symptoms and signs of honey poisoning can be alarming and, sometimes, life threatening, supportive care with electrocardiographic monitoring, normal saline infu- sion, and intravenous atropine is usually sufficient to ensure recovery [4,5,19]. A temporary pacemaker may be needed in patients who have third-degree heart block [5]. The cases in this study returned to a normal rhythm with sufficient fluid support and the administration of between 0.5 and 2 mg of atropine. In those rare cases when atropine and intravenous saline are not adequate, advanced cardiac life support bradyarrhythmia protocols should be considered.

In conclusion, mad honey poisoning is largely unreported beyond Turkey’s Black Sea coast, where it is frequently encountered. There are major differences between health centers’ treatment and monitoring protocols. Our results suggest that 6-hour monitoring was sufficient for stable emergency department patients. However, because of the small number of patients involved in this study further studies would be useful to corroborate our findings.

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