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.