(1652) The Real Mad Hatter: A Case of Mad Honey Intoxication-Induced Bradycardia

Introduction: Physicians have faced the clinical dilemma of grayanotoxins since 401 BC. Grayanotoxins are found in honey from certain plant populations. “Mad Honey” is a commercially available product recently made popular by social media and celebrities due to its hallucinogenic effects. The public is relatively unaware of the multiple physiologic impacts of grayanotoxins. Grayanotoxins can cause a multitude of adverse effects including bradycardia, bradyarrhythmias, syncope, flushing, impaired consciousness and inability to stand. The grayanotoxins work through sodium ion channels and muscarinic receptors leading to the cardiac abnormalities. Here we present a case of a young male who ingested an entire jar of “Mad Honey.”

Description: A 39-year-old male with a past medical history of hypertension, hyperlipidemia, palpitations on metoprolol, who presented to the Emergency Department (ED) after ingesting an entire jar of “Mad Honey” (150 g). He consumed a teaspoon of “Mad Honey” a week prior without any effect. Around 30 minutes after ingesting the jar, he developed nausea and vomiting which progressed to multiple syncopal events, vision and speech impairment. Upon EMS arrival, he was bradycardic to the 20s and hypotensive. He was given IV atropine and externally paced until he was started on an epinephrine drip with improvement in his heart rate and blood pressure. In the ED, he was placed on norepinephrine with improvement in his hemodynamics and admitted to the critical care unit. He was transitioned back to epinephrine which was titrated off within 24 hours.

Discussion: There is no antidote or reversal agent for grayanotoxins currently available. The standard supportive care with vasopressors and tincture of time is the main option. This patient also had an underlying arrhythmia with metoprolol use which may have worsened his presentation. We chose to use epinephrine as a primary vasopressor given his symptoms and bradycardia for its beta agonist effects and previous minimal response to atropine. Ultimately, he was titrated off all pressors and discharged to home after 24 hours of ICU monitoring.