From Cultural Delicacy to Emergency: Managing Rare Mad Honey Poisoning in Rural Eastern Nepal

Background: Mad honey poisoning results from ingestion of honey containing grayanotoxins, derived primarily from Rhododendron species found in the Himalayas of Nepal and other regions. While traditionally valued for its medicinal and cultural significance, mad honey can cause serious toxicity. Case Presentation: A 50-year-old man from rural eastern Nepal presented with multiple episodes of vomiting, hypotension (BP 70/50 mm Hg), and bradycardia (52 bpm) approximately 1.5 hours after consuming 50 ml of wild honey. He had no prior medical conditions. Clinical Findings and Diagnosis: The patient was conscious and oriented but hypotensive and bradycardic. ECG showed sinus bradycardia, and laboratory tests revealed a slight elevation in PT/INR, serum creatinine, and alkaline phosphatase. Diagnosis was clinical, based on history and characteristic signs, as grayanotoxin assays are not available locally. Management and Outcome: Supportive care with intravenous fluids stabilized his blood pressure. A single dose of intramuscular epinephrine (0.5 mg) corrected bradycardia and hypotension. Additional medication included hydrocortisone, ondansetron, and ranitidine. Continuous cardiac monitoring was maintained. Symptoms resolved within 24 hours, and he was discharged with advice to avoid mad honey in the future. Follow-up in two weeks showed full recovery. Conclusion: Mad honey poisoning, though rare, presents with distinct gastrointestinal and cardiovascular manifestations resulting from grayanotoxin’s effect on sodium channels and vagal tone. Early recognition and supportive management lead to favorable outcomes. Given the cultural importance of mad honey in Nepal, culturally sensitive public health education and improved clinical awareness are essential to minimize morbidity associated with this toxic exposure.