Mad honey (wild honey) poisoning: clinical case series from Nepal

Mad honey is commonly used for hypertension, and coronary artery disease, and as a sexual stimulant. Patients with mad honey poisoning present with dizziness, nausea, syncope, blurred vision, bradycardia, and hypotension with ECG findings of sinus bradycardia, complete AV block, and ST elevation. Here, the authors report five cases admitted to our tertiary care center following the consumption of mad honey. The amount of ingestion of honey varies from 1 to 2 teaspoons (~10-20 ml). Most of the cases presented with chief complaints of nausea, dizziness, and vomiting, and all the cases had hypotension and bradycardia. Two cases were admitted to the ward and three of them were admitted to the ICU for further management. They were managed with intravenous fluid, injection atropine along with adjunctive vasopressor and oxygen whenever necessary. Mad honey contains grayanotoxin extracted from the nectar of Rhododendron species. This honey contains grayanotoxin, which binds to sodium channels in its open state causing hyperpolarization of the sodium channel predominantly causing gastrointestinal, neurological, and respiratory symptoms. Intravenous fluids and injection atropine are the mainstays of management in an ICU setup. Some also may require vasopressors. Mad honey poisoning is rare, and limited cases have been reported in Nepal. Physicians should consider mad honey poisoning in cases with ingestion history and clinical symptoms, as it may be a clinical diagnosis due to limited lab tests for grayanotoxin intoxication. Supportive management still forms the cornerstone for its management after diagnosis.