A 46-year-old woman presented to the emergency room with acute onset of nausea, vomiting and prostration. She appeared ill and was poorly responsive to verbal stimuli. Physical examination showed a systolic blood pressure of 60 mmHg and a pulse of 40 bpm. ECG was notable for slight ST-elevations in the inferior leads. Right ventricular myocardial infarction with cardiogenic shock and bradycardia was suspected. Supportive therapy with catecholamines was initiated and an emergency coronary angiography was arranged. However, laboratory results showed normal troponin levels and a subsequent echocardiogram showed the absence of abnormal wall motion. Thorough history taking with the spouse revealed that the patient had consumed Turkish honey approximately 1 h before the symptoms began. The patient made a full recovery within 24 h with only supportive therapy. In retrospect, the clinical presentation was highly indicative of poisoning with grayanotoxins from the rhododendron plant, which contaminate some types of honey in the Black Sea area. A pollen analysis confirmed the presence of rhododendron in a honey sample. Historically this poisoning is referred to as mad honey disease. The ST-elevations in the ECG were a sign of early repolarization, a non-pathological finding.
Learning points: ST-elevation in the inferior leads of an ECG in the context of hypotension and bradycardia does not always indicate right myocardial infarction.In the proper context, intoxication with grayanotoxins should be included in the differential diagnosis of hypotension and bradycardia.Study of diseases occurring in the past in a particular region offers the physician the chance to make a diagnosis otherwise missed.
Keywords: Mad honey; poisoning with grayanotoxins; right ventricular myocardial infarction.