Discussion
Traditionally many people from Nepal and other parts of the world use
wild honey for medicinal purposes in gastritis, diabetes, hypertension,
common cold, wound healing, and sexual stimulant. In addition, it has
also been used recreationally; euphoric effects are seen in low doses
and with increasing doses, it can be hallucinogenic and potentially
fatal. The toxic effects of wild honey are due to grayanotoxin which is
found in different species of rhododendron transmitted by wild bees,
this condition is characterized as a mad honey disease. This toxin binds
voltage-gated sodium channel preventing its inactivation and causing
hyperpolarization which results in effects similar to cholinergic excess
[5].
The main complaints of wild honey poisoning are dizziness, bradycardia,
nausea, vomiting, and pre-syncope [2]. Although the exact amount of
honey required for poisoning is not known, but symptoms have been
reported after ingestion of 1 tablespoon of honey [6]. Symptoms have
been reported to occur 0.5-3 hours after ingestion [7]. In our case,
the patient experienced typical symptoms of dizziness, and vomiting 30
min after ingestion.
The diagnosis of wild honey poisoning is made clinically based on the
history of ingestion and clinical feature. There are no routine blood
tests available to measure grayanotoxin levels. Sinus bradycardia,
atrioventricular block, and nodal rhythms are usually reported on ECG
[8]. In addition, findings such as QT prolongation and
Wolff-Parkinson-White (WPW) syndrome have also been reported [8, 9].
In our case, the ECG did not show any significant arrhythmia but had
mild QT prolongation (QT interval= 480ms). The history of ingestion of
wild honey was the only significant finding that led to suspicion of
wild honey poisoning. Hence, wild honey poisoning should be suspected in
presence of a history of ingestion with unexplained hypotension by other
causes.
The toxic effects of poisoning usually last for 24 hours [10].
Treatment involves symptomatic management and observation. Hypotension
is treated with normal saline infusion and atropine is used in
bradycardia. Transvenous pacing and adrenaline infusion are required in
refractory cases (1). Our patient’s symptoms recovered in 24 hours.
However, during the course of observation patient became hypotensive
after initial stabilization. Subsequently, he required a nor-adrenaline
infusion to stabilize his blood pressure. In the rural context of Nepal
and other parts of the world, facilities to provide nor-adrenaline
infusion may not be available. The majority of cases resolve with fluid
resuscitation but the patient may deteriorate after initial
stabilization, which happened in our case. Therefore, observation and
close monitoring should be done in a setting where appropriate
intervention can be done.
Wild honey hunting has been a tradition in certain Himalayan parts of
Nepal. Moreover, it is also a source of income. Data regarding the toxic
components and safety value in these wild honey is not available
warranting further research.