Toxicology/brief research report
Mad Honey Sex: Therapeutic Misadventures From an Ancient Biological Weapon

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Study objective

“Mad honey” poisoning occurs from ingestion of honey produced from grayanotoxin-containing nectar, often in the setting of use as an alternative medicine. This study is designed to assess the clinical effects, demographics, and rationale behind self-induced mad honey poisoning.

Methods

The study consisted of 2 components: a standardized chart review of the signs, symptoms, and treatment of patients with mad honey ingestion, treated in our emergency department between December 2002 and January 2008; and a cross-sectional survey of a convenience sample of beekeepers specializing in the production and distribution of mad honey.

Results

We identified 21 cases. Patients were overwhelmingly men (18/21) and older (mean [SD]), 55 [11] years. Local beekeepers (N=10) ranked sexual performance enhancement as the most common reason for therapeutic mad honey consumption in men aged 41 through 60 years. Symptoms began 1.0 hour (SD 0.6 hour) after ingestion and included dizziness, nausea, vomiting, and syncope. Abnormal vital signs included hypotension (mean arterial pressure 58 mm Hg [SD 13 mm Hg]) and bradycardia (mean 45 beats/min [SD 9 beats/min]). Seventeen patients had sinus bradycardia and 2 had junctional rhythm. Nine patients were treated with atropine; 1 patient received dopamine. All patients were discharged 18 to 48 hours after admission.

Conclusion

A dietary and travel history should be included in the assessment of middle-aged men presenting with bradycardia and hypotension. A mad honey therapeutic misadventure may be the cause rather than a primary cardiac, neurologic, or metabolic disorder.

Introduction

“Mad honey” is honey purposely derived from grayanotoxin-containing nectar of Rhododendron ponticum, a member of the Ericaceae family with particularly high concentrations of grayanotoxin. The ancient Greek general Xenophon published the first account of mad honey intoxication in 401 bc after his soldiers feasted on wild honeycombs in Asia Minor near the Black Sea.1 All of Xenophon's soldiers recovered. Three hundred years later, the Roman general Pompey was not so fortunate. In 67 bc, his men were deliberately poisoned with grayanotoxin-contaminated honey, and 3 Roman cohorts (1,440 soldiers) were slaughtered by enemy forces while intoxicated.2 The population of Roman citizens is estimated to be 1,250,000 during the time of Christ; the current population of the United States is more than 300,000,000. To place the massacre in a modern perspective, the same ratio of US military deaths would be approximately 345,600.

Along the Black Sea region of modern Turkey, mad honey is produced and marketed as an alternative medicine by beekeepers armed with a knowledge of local plant flora and familiar with the behaviors of native Caucasian honeybees.3

Grayanotoxin-containing plants are native to ecosystems throughout the world, including Japan, Nepal, Brazil, and parts of Europe.3, 4 There are a number of toxic species native to the United States. Of particular importance are R occidentale, R macrophyllum, and R albiflorum, species found in a wide swath of North American territory from British Columbia to Oregon and southern California.4 The majority of published cases of mad honey poisoning occur in Asia Minor.4 The popular use of mad honey for self-treatment of disease has resulted in a series of grayanotoxin-poisoned patients presenting to our emergency department (ED) of Gazi University Hospital, Ankara, Turkey.

The primary goal of this study was to describe the clinical and demographic features of adults poisoned by a mad honey therapeutic misadventure. A secondary goal was to formally assess and rank the clinical reasons behind mad honey self-treatment. We explored reasons why older men predominate in symptomatic mad honey ingestions. To our knowledge, this is the first formal investigation into the rationale behind traditional mad honey treatment after centuries of use and abuse of this ancient folk medicine.

Section snippets

Study Design

This study consisted of 2 components: a retrospective case review and a cross-sectional survey of a convenience sample of mad honey beekeepers.

Setting

The case series portion of the investigation was conducted at an urban university teaching hospital with 35,000-40,000 ED visits annually. The authors extracted clinical data from ED and inpatient medical records. The data collection methodology followed all ethical principles, as outlined in the Declaration of Helsinki.5

The survey portion was performed

Characteristics of Study Subjects

During the 6-year study period, 205,150 patients were treated in our ED. We identified 21 symptomatic patients who admitted to mad honey ingestion during the designated case review period. No patient had an alternative diagnosis. The average patient age (mean [SD]) was 55 (11) years (range 41 to 86 years) and most (85.7%) were men (Table 1). No pediatric patients presented with mad honey poisoning during the observation period. Virtually every patient presented with bradycardia and complaints

Limitations

This study contains limitations inherent to convenience sampling and retrospective case series. Investigators used memories of mad honey cases and searched medical records during the designated period. We cannot be completely certain that all mad honey cases were identified because manual searches of medical records are generally inefficient means of identifying records appropriate for study, and the ability to query computer-based databases evolved markedly during the study period. Thus, it is

Discussion

An overwhelming number of patients were men and middle aged. The preponderance of middle-aged men has been reported previously,9 but the reason for this has not been previously elucidated. In the largest mad honey case series to date, Yilmaz et al9 found that of 66 patients, 80.3% were men with an average age of 51 years (P<.001; Z test of proportions). Previous commentary on the male preponderance has observed that the uneven sex distribution of reported cases “was difficult to explain.”9

Mad

References (20)

  • A. Gunduz et al.

    Mad honey poisoning

    Am J Emerg Med

    (2006)
  • O. Yilmaz et al.

    Hypotension, bradycardia and syncope caused by honey poisoning

    Resuscitation

    (2006)
  • H. Yavuz et al.

    Honey poisoning in Turkey

    Lancet

    (1991)
  • XenophonThe Anabasis

  • StraboThe Geography of Strabo

    (1924)
  • F.Y. Onat et al.

    Mad honey poisoning in man and rat

    Rev Environ Health

    (1991)
  • K.F. Lampe

    Rhododendrons, mountain laurel, and mad honey

    JAMA

    (1988)
  • Declaration of Helsinki: ethical principles for medical research ınvolving human subjects

  • J. Prevas

    Xenophon's March Into the Lair of the Persian Lion

  • Erectile dysfunction

    N Engl J Med

    (2000)
There are more references available in the full text version of this article.

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Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.

Supervising editor: Richard C. Dart, MD, PhD.

Author contributions: AD, AK, and FB conceived the case series portion of the study. AD, GA, and NOD undertook data extraction of medical records. AD and HFG designed the survey portion of the investigation. AD and HFG drafted the article, and all authors contributed substantially to its revision. AD takes responsibility for the paper as a whole.

Reprints not available from the authors.

Publication date: Available online August 15, 2009.

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