- Email: [email protected]
Honey intoxication and the Bezold–Jarisch reflex
Letters to the Editor
251
Honey intoxication and the Bezold–Jarisch reflex Philipp Eller ⁎, Kathrin Hochegger Department of Internal Medicine, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria Received 29 December 2008; accepted 30 December 2008 Available online 26 January 2009
Keywords: Bezold–Jarisch reflex; Heart block; Honey intoxication
In their recently published article, Weiss and coworkers describe a case of a second degree heart block due to honey intoxication in a Turkish patient in Vienna [1]. This was not the first report in the European Union, as we have recently documented a similar case with a complete atrioventricular heart block and an idiotypic ventricular escape rhythm after honey poisoning in Western Austria [2]. Food poisoning with grayanotoxin-contaminated honey mainly occurs in Turkey [3], but also in California [4], and Korea [5]. Weiss et al. and our report point out, that honey intoxications are no more limited to the native habitat of Rhododendron ponticum on the Anatolian Plateau, as Turkish immigrants have brought their nutrition habits and its complications to Central Europe [1,2]. The nectar of Rhododendron ponticum and Rhododendron luteum contains grayanotoxin, which is a neurotoxin and binds to voltage-gated sodium channels in their open state, thus prolonging their depolarisation [6,7]. The stimulation of the unmyelinated afferent cardiac branches of the vagus nerve leads to a tonic inhibition of central vasomotor centres with a reduced sympathetic output and a reduced peripheral vascular resistance [8,9]. Thereby, grayanotoxin triggers the cardioinhibitory Bezold–Jarisch reflex leading to bradycardia, continued hypotension, and peripheral vasodilatation [3,8]. The original description of this cardiovascular reflex was given by Albert von Bezold and Adolf Jarisch [10], who used veratridine instead of grayanotoxin. Both toxins bind to the same neurotoxin receptor site 2 on voltage-gated sodium channels and activate them [6]. Recognition of the Bezold–Jarisch reflex is important for the management of patients. In honey intoxications, bradycardia and atrioventricular block are pharmacologically induced and are not symptoms of a structural heart disease. ⁎ Corresponding author. Tel.: +43 512 504 81396; fax: +43 512 504 25608. E-mail address: [email protected] (P. Eller).
0167-5273/$ - see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.12.206
Therefore, the Bezold–Jarisch reflex is readily responsive to the antidote atropine regardless of which toxin (grayanotoxin or veratridin) triggers this cardioinhibitory reflex by activating the afferent vagus nerve. Thus, there is no need for electric pacing in honey intoxications. The authors of this manuscript certify that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [11]. References [1] Weiss TW, Smetana P, Nurnberg M, Huber K. The honey man— Second degree heart block after honey intoxication. Int J Cardiol 2010;142:e6–7. [2] Eller P, Hochegger K, Tancevski I, Pechlaner C, Patsch JR. Sweet heart block. Circulation 2008;118:319. [3] Yilmaz O, Eser M, Sahiner A, Altintop L, Yesildag O. Hypotension, bradycardia and syncope caused by honey poisoning. Resuscitation 2006;68:405–8. [4] Lampe KF. Rhododendrons, mountain laurel, and mad honey. Jama 1988;259:2009. [5] Choo YK, Kang HY, Lim SH. Cardiac problems in mad-honey intoxication. Circ J 2008;72:1210–1. [6] Catterall WA, Goldin AL, Waxman SG. International Union of Pharmacology. XLVII. Nomenclature and structure–function relationships of voltage-gated sodium channels. Pharmacol Rev 2008;57:397–409. [7] Maejima H, Kinoshita E, Seyama I, Yamaoka K. Distinct sites regulating grayanotoxin binding and unbinding to D4S6 of Na(v)1.4 sodium channel as revealed by improved estimation of toxin sensitivity. J Biol Chem 2003;278:9464–71. [8] Campagna JA, Carter C. Clinical relevance of the Bezold–Jarisch reflex. Anesthesiology 2003;98:1250–60. [9] Onat F, Yegen BC, Lawrence R, Oktay A, Oktay S. Site of action of grayanotoxins in mad honey in rats. J Appl Toxicol 1991;11:199–201. [10] Jarisch A, Henze C. Ueber Blutdrucksenkung durch chemische Erregung depressorischer Nerven. Naunyn-Schmiedebergs Arch Pharmakol Exp Pathol 1937;187:706–30. [11] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.
251
Honey intoxication and the Bezold–Jarisch reflex Philipp Eller ⁎, Kathrin Hochegger Department of Internal Medicine, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria Received 29 December 2008; accepted 30 December 2008 Available online 26 January 2009
Keywords: Bezold–Jarisch reflex; Heart block; Honey intoxication
In their recently published article, Weiss and coworkers describe a case of a second degree heart block due to honey intoxication in a Turkish patient in Vienna [1]. This was not the first report in the European Union, as we have recently documented a similar case with a complete atrioventricular heart block and an idiotypic ventricular escape rhythm after honey poisoning in Western Austria [2]. Food poisoning with grayanotoxin-contaminated honey mainly occurs in Turkey [3], but also in California [4], and Korea [5]. Weiss et al. and our report point out, that honey intoxications are no more limited to the native habitat of Rhododendron ponticum on the Anatolian Plateau, as Turkish immigrants have brought their nutrition habits and its complications to Central Europe [1,2]. The nectar of Rhododendron ponticum and Rhododendron luteum contains grayanotoxin, which is a neurotoxin and binds to voltage-gated sodium channels in their open state, thus prolonging their depolarisation [6,7]. The stimulation of the unmyelinated afferent cardiac branches of the vagus nerve leads to a tonic inhibition of central vasomotor centres with a reduced sympathetic output and a reduced peripheral vascular resistance [8,9]. Thereby, grayanotoxin triggers the cardioinhibitory Bezold–Jarisch reflex leading to bradycardia, continued hypotension, and peripheral vasodilatation [3,8]. The original description of this cardiovascular reflex was given by Albert von Bezold and Adolf Jarisch [10], who used veratridine instead of grayanotoxin. Both toxins bind to the same neurotoxin receptor site 2 on voltage-gated sodium channels and activate them [6]. Recognition of the Bezold–Jarisch reflex is important for the management of patients. In honey intoxications, bradycardia and atrioventricular block are pharmacologically induced and are not symptoms of a structural heart disease. ⁎ Corresponding author. Tel.: +43 512 504 81396; fax: +43 512 504 25608. E-mail address: [email protected] (P. Eller).
0167-5273/$ - see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.12.206
Therefore, the Bezold–Jarisch reflex is readily responsive to the antidote atropine regardless of which toxin (grayanotoxin or veratridin) triggers this cardioinhibitory reflex by activating the afferent vagus nerve. Thus, there is no need for electric pacing in honey intoxications. The authors of this manuscript certify that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [11]. References [1] Weiss TW, Smetana P, Nurnberg M, Huber K. The honey man— Second degree heart block after honey intoxication. Int J Cardiol 2010;142:e6–7. [2] Eller P, Hochegger K, Tancevski I, Pechlaner C, Patsch JR. Sweet heart block. Circulation 2008;118:319. [3] Yilmaz O, Eser M, Sahiner A, Altintop L, Yesildag O. Hypotension, bradycardia and syncope caused by honey poisoning. Resuscitation 2006;68:405–8. [4] Lampe KF. Rhododendrons, mountain laurel, and mad honey. Jama 1988;259:2009. [5] Choo YK, Kang HY, Lim SH. Cardiac problems in mad-honey intoxication. Circ J 2008;72:1210–1. [6] Catterall WA, Goldin AL, Waxman SG. International Union of Pharmacology. XLVII. Nomenclature and structure–function relationships of voltage-gated sodium channels. Pharmacol Rev 2008;57:397–409. [7] Maejima H, Kinoshita E, Seyama I, Yamaoka K. Distinct sites regulating grayanotoxin binding and unbinding to D4S6 of Na(v)1.4 sodium channel as revealed by improved estimation of toxin sensitivity. J Biol Chem 2003;278:9464–71. [8] Campagna JA, Carter C. Clinical relevance of the Bezold–Jarisch reflex. Anesthesiology 2003;98:1250–60. [9] Onat F, Yegen BC, Lawrence R, Oktay A, Oktay S. Site of action of grayanotoxins in mad honey in rats. J Appl Toxicol 1991;11:199–201. [10] Jarisch A, Henze C. Ueber Blutdrucksenkung durch chemische Erregung depressorischer Nerven. Naunyn-Schmiedebergs Arch Pharmakol Exp Pathol 1937;187:706–30. [11] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.