Wild Mistake: A Deadly Foraging Mystery

A harmless-looking plant gathered for a wilderness dinner. An ancient remedy for madness associated with Heracles. And a flower carrying the same kind of cardiac poison found in toxic toads.

Your patient. Your diagnosis. Your decision.

An interactive wilderness and emergency medicine case involving mistaken foraging, plant poisoning, vomiting, dangerous heart rhythms, persistent symptoms, and ancient Greek medicine.

Transcript

This is the Pick Your Poison Podcast. I’m Dr JP. ER doctor. Toxicologist, and unapologetic lover of all things poison. Wanna know what ancient remedy was a byword for treating madness in ancient Greece and was used to treat Heracles after he murdered his wife and children. And what flower contains the same toxin as poisonous toads? Listen to find out.

 Stay right here to find out.

This is an interactive story. 

Survival isn't guaranteed. 

Will our patient live or die? 

It's up to you and the choices you make. 

So lace up your hiking boots and let's get started

Today’s episode starts on a hike.

It’s one of the first warm days of spring. You’re out with two friends—serious outdoors types, who keep saying things like “this is an easy hike” as the trail winds relentlessly uphill.

Against your better judgement, They’ve convinced you not just to hike… but to camp overnight.

You stick to the trail, conserving energy, promising yourself it'll be worth it for the beautiful view from the top. Your friends keep detouring into the woods, foraging for ingredients for dinner. So far they've gathered hen of the woods mushrooms and wild carrots.

One of them suddenly crouches, brushing dirt aside.
 “Hey—come look at this.”

He pulls up a bright green sprout.

“Ramps,” the other says. They add it to the pile. They gather pine needles, and unsuccessfully try to find acorns.

An hour later you reach the end of the trail, admire the gorgeous view. You don't linger long because at this point all you can think about is dinner.  

Back at the campsite You fire up the campfire. Your friends prepare dinner, excited with their wholesome, all-natural bounty. 

One friend, a passionate photographer, arranges the fresh ingredients in the cast iron pot takes photographs and uploads them to his social media. They put the pine needles in a small pot a boiling water to make pine needle tea. After a few minutes the air is filled a woodsy Christmas tree smell. In a larger pan they add olive oil, salt, pepper, and chili powder to the mushrooms, carrots, and ramps. The delicious smell of mushrooms fills the campsite. 

They pull out some tortillas, fill it with vegetables, and offer you a wrap. You politely decline. To their horror you pull hot dogs out of your backpack. You stick it one on a tree branch and roast it over the fire. 

The hot dogs are ultra-processed and unhealthy, but most importantly, not foraged. Everyone enjoys their meal, which they wash down with a beer. You rummage in your backpack, pulling out marshmallows, chocolate, and graham crackers for s'mores. They enjoy the s'mores as much as you do and you joke about their lack of objection to the ultra-processed marshmallows. 

The fire burns low.

The forest goes quiet.

They turn in for the night.

You're wide awake thanks to the night shifts you've been working. You admire the stars then, open a book you've been trying to read for the past month, and enjoy the peacefulness of the outdoors.

The quiet atmosphere is broken, interrupted by groaning. Before you can ask if she's okay, your friend vomits on the ground just outside the tent flaps. She groans again, crawls out holding her stomach and lies on the ground in a fetal position, saying "I really don't feel good." Your other friend comes out of his tent, saying "Yeah I don't feel so great either."

"What's the matter?" you ask. He vomits next to the fire. You dig around in the first aid kit you always carry, relieved to find anti-nausea medicine. You give each a dose of ondansetron ie Zofran to put under their tongues.

It's been less than an hour since dinner but you say “Let's pack up and go.” You're staying in a state park, fortunately is not far from civilization, but still a good 30 or 45 minutes from your homes, not to mention the nearest hospital. Both friends are experienced campers, climbers, and outdoors persons. They both immediately say, "No. One says,” I’ll be fine with the nausea medicine.” And the other,” It's just a little stomach upset."

You don't love the idea of being in the wilderness, even if it's not exactly Death Valley, with people who don't feel well. They're teachers and reassure you that a lot of kids have been sick with stomach viruses and assume they just caught it at an unfortunate time. 

But…They don't get better. Your friend is still curled up on the ground. Every time she tries to sit up, she turns pale and starts sweating, like she's going to pass out. You put your fingers on your wrist to check her pulse, It’s in the 50s. That's low but you don't know what her resting heart rate is. She's a runner and it might be pretty low at baseline. It's been about 30 minutes since she took the Zofran so you give her a bottle of water. She takes a few sips and promptly vomits it up.

The other guy isn't doing much better. You check his pulse. It's the same in the 50s. Unlike her he's not an athlete and probably has a normal resting heart rate in the 70s-80s.

Question number 1. What’s the next step?

1. Leave now
2. Give more antinausea medicine
3. Look for rose hips to make tea
4. Look for a willow tree

The answer is A. It's not, in my opinion, safe to continue camping. If you said B, "Give more anti-nausea medicine," you're certainly not wrong. Your friends can't keep anything down so tea is certainly not helpful and willow bark contains aspirin but that's not going to help here either.

A basic stomach virus is still at the top of the list. But the low heart rates are weird. Usually people with stomach viruses have normal or fast heart rates if they become dehydrated so it's not entirely clear what's going on. You decide enough is enough, and at the very least you need to go back home. This time when you tell them everyone is leaving, rather than ask, they don't object. 

They're still throwing up. You tell them to leave the tents and camping gear, you'll come back and get it tomorrow. It takes some effort to get them in the car. Both are dizzy and worse with standing. They half walk, and you half drag them, one at a time and get them in. Both have a drop in the heart rates, with both of their pulses in the 40s when standing.

You punch one friend’s address into the GPS with a plan to get them home and into bed so they can rest and recover. As you hit the outskirts of civilization, your friend in the front seat seems kind of sleepy. Her breathing doesn't look right. It's not exactly a medical assessment but it's hard to see what's happening, in the dark, while driving. 

Change of plans.

You veer off at the next exit, heading for the emergency department instead. This is fiction so of course you are the doctor.

Your female friend looks worse out of the two of them so you start with her. She's 38 years old. She doesn't have any significant past medical history and doesn't take any medicines or over-the-counter medicines. The nurses check our vital signs, noting the following: temperature 98.6 or 37°C, Heart rate 45, Blood pressure 85/55, Respiratory rate 7, Oxygen saturation 100% on room air. 

On exam she seems tired, not her usual energetic self, but she’s answering questions appropriately. Her pupils are equal, round, and reactive to light. Her heart and lungs are clear. She doesn't have any abdominal tenderness and she has good muscle strength. Essentially she has a slow heart rate, low blood pressure, and a mildly low respiratory rate.

You order more nausea medicine as well as IV fluids to help the low blood pressure, then move to your male friend. He's 36 years old with a history of seizures history and is taking lamotrigine, an anti-epileptic medicine. His vital signs are as follows: temperature in the 98.6 or 37°C., heart rate is 50, blood pressure is 90/60, respiratory rate is 10 and oxygen saturation is 100% on room air.

His physical exam, other than the low heart rate and blood pressure, is similarly unremarkable. Again, you order nausea medicine and IV fluids.

Okay so what is happening here? Is this a stomach virus? Nausea and vomiting? Yes but a low heart rate and a low respiratory rate? That's pretty unusual with a stomach virus. The breathing should be normal and as I said, if anything, you expect a rapid heart rate from dehydration. We have talked before about a vagal response during vomiting that can slow the heart rate down but it would be weird for it to happen in two people at the same time.

I'm doubting a stomach virus at this point.

What could it be? we know it started rapidly. Both were completely fine, having had way less difficulty with the uphill hike than you. I don't know about your friends but when I was in college I knew a lot of people who liked to camp so they could do drugs.

 Could this be a drug of abuse? Well it doesn't really fit with the typical toxidrome. Certainly the slow breathing can go along with an opioid but she's awake and her main complaint is vomiting, which doesn't fit. Sympathomimetics would cause a rapid heart rate and high blood pressure. Hallucinogens can cause significant nausea and vomiting but neither of them is hallucinating. It doesn't fit and as far as you know neither of them does drugs anyway.

That brings us, of course, to every toxicologist's worry: foraged ingredients and the reason you brought hot dogs. You yourself do not have even a twinge of nausea, forget vomiting and a low heart rate. 

You're probably shouting it right now, “what about the mushrooms?”

Excellent question. You don't need me to tell you. There are tons of different poisonous mushrooms, causing a lot of different symptoms. Could this be Amanita phalloides, the death cap mushroom? That fortunately we can rule out because the symptoms wouldn't start for at least six hours after exposure except for the one exception of Amanita smithiana in the Pacific Northwest. 

Plenty of mushrooms can cause nausea and vomiting, from just mild gastrointestinal upset that passes in a few hours. There are some mushrooms which, interestingly, cause toxicity when taken in combination with alcohol. Your friends did each have one beer with dinner. Could it be one of those?

No, and I'm doubtful this is a toxic mushroom at all. Why? They ate hen of the woods mushrooms, also called maitake mushrooms. These are the flat mushrooms that kind of look like a shelf. They are pretty difficult to misidentify or mistake for poisonous varieties. While I don't recommend eating any foraged mushrooms, given the risks, these are pretty low risk. 

If you listened to the Last Supper episode, you might have some questions so let me clarify. Amanita phylloides, the death cap mushrooms, can be confused for matsutake mushrooms. The hen of the woods mushrooms are called maitake mushrooms. And just for the sake of being thorough there are some mushrooms which cause bradycardia via anticholinergic toxicity but these are single-stemmed mushrooms and not shelf-style mushrooms, like the hen of the woods. Bottom line, I don't think it's the mushrooms.

What about the wild carrots? We talked about what wild carrots can be mistaken for in a prior episode the hazardous hike. question number 2. is it?

1. Belladonna
2. Poison Hemlock.
3. Wolfsbane

Wild carrots have been mistaken for both poison hemlock and water hemlock. I'm sure you know this is toxic, used to kill Socrates. Could this be hemlock toxicity? On set it is fairly rapid. Water Hemlock Causes a slow heart rate and low blood pressure but one of the big manifestations of toxicity is seizures so it doesn't entirely fit. Poison hemlock causes nicotinic toxicity like nicotine or tobacco poisoning, resulting in weakness, paralysis, and ultimately respiratory failure. We can exclude poison hemlock. Water hemlock isn't entirely excluded but I'm doubtful wild carrots are the culprit.

 What about the tea? Tons of people have been poisoned intentionally or unintentionally by toxic tea. What can go wrong with pine needle tea? Most pine needles are non-toxic to humans, there is one serious exception. That's if the pine needles come from the yew tree. Were there yew trees in the area where you were hiking? You have no idea. 

What happens? Yew trees contain compounds causing sodium channel blockade resulting in both fast and slow heart rates. It causes the classic EKG finding from sodium channel blockade: a wide QRS. It can result in cardiac arrest and death. Yew trees are where taxol, the potent chemotherapeutic agent, is derived from. 

What about the wild ramps? Wild ramps basically look like green sprouts and they are another thing I wouldn't eat if they had been foraged because they can be easily mistaken for other green leaves, especially in the spring when many plants are sprouting. What's been mistaken for wild ramps? Lily of the Valley is one. Hellebore is another, specifically the false Hellebore plant. A caveat here: I'm talking about what can can be mistaken when foraging for American plants. Of course this can vary widely across different countries and continents. 

Anyway, these are really potent toxins and not ones you love to be applied to potential causes of your close friend's symptoms.

Lily of the Valley, and other Convalleria plants, can cause digoxin-like toxicity with nausea, vomiting, and a slow heart rate. That could fit here. I'd send it a digoxin level for cross reactivity causing a false positive dig level though it's not a definitive test for sure. A low potassium might be a sign of Lily of the Valley toxicity. 

You order an EKG and labs on both patients. Your female friend has complete heart block, meaning none of the impulses conducted into her heart are getting through and her ventricles are beating slowly on their own. You tell the nurse to apply the external pacemaker pads as a precaution, you can turn it on if her heart rate gets lower or if she becomes more symptomatic. Your male friend has sinus bradycardia, not concerning at this point. You're relieved that both have a narrow QRS and neither EKG shows signs of sodium channel toxicity, making yew poisoning less likely. 

How do we figure out what's poison them? Well unfortunately, not knowing a common scenario in the emergency department. So what do we do? 

First supportive care; in this case nausea medicine and IV fluids. Atropine, a medicine we've talked about before that can raise your heart rate, is worth considering. I'd order a dose for your female friend with the heart block to see if it helps but I don't think the male friend with sinus bradycardia needs it right now. After a milligram of atropine her heart rate does come up to the high 50s.

Is there an antidote for any of these plants? There isn't. After supportive care we treat based on symptoms, more nausea medicine, more atropine, external pacemaker if the heart rate became severely bradycardic. If this is something like U toxicity or a digoxin-like toxicity that might develop ventricular tachycardia or ventricular fibrillation, we would treat that according to standard ACLS protocols, with shocks, epinephrine, et cetera.

Thinking back to when they were cooking, You do have a guess as to which of these might be the toxin. Which of the following senses might give you a clue as to what happened? Question 3.

1. Taste
2. Touch
3. Smell
4. Sound

The answer is C. smell. You remember the delicious smell of the mushrooms and the Christmas tree smell of the tea. 

What you didn't smell? 

Onions. 

A classic way to identify the difference between ramps versus the look-alike plants of Helleborus and Lily of the Valley is a strong onion smell. Now I wouldn't stake my health on this, but if the onion smell is missing, those green leaves probably aren't ramps. It should have been easy to smell especially when cooked over the campfire. 

You continue close observation and, much to your relief, over the next hour your friend's conditions don’t deteriorate. They still report nausea though the anti-emetics are helping and their heart rates are still slow but both are awake and talking and thus far without evidence of dangerous arrhythmias.

An hour later your friend is well enough to text the photos of the plants he took prior to cooking to a friend who's a botanist. He calls you into the room, showing the text he got back. The botanist thinks the wild ramps were not ramps at all but False hellebore.

He says, "Am I going to die?"

You probably heard of hellebore a classic poisonous plant, associated with witches and necromancy. In its early stages of sprouting the green leaves are easily mistaken for ramps. Both have big flat green leaves. The difference, however, The False hellebore has beautiful lines called pleats on the leaves. 

Let me give you a little tip here for plant identification. I've said many times before I'm a toxicologist, not a mycologist or a botanist. I'm better at treating the patient than identifying the plant that poisoned them. But I do have a nice trick to help if you take a picture on your phone, on iPhones at least, there is a little symbol at the bottom, the letter I with some stars. If you tap this, it'll try to identify the plant and give you some information. It's far from 100% and I certainly wouldn't eat anything I identified this way but it can be a useful tool for helpful information. 

Is your friend gonna die? What does Hellebore do? Well first let's talk about what it is because I find the entire taxonomy, and even toxicology, extremely confusing. The reason for this is because there are a number of different types of plants that are called Hellebore plants. Just to name a few there are: real Hellebores, False Hellebores, black Hellebores. Most of them have really, really beautiful flowers and all them have been used as both toxins and medicines since ancient times. 

In medieval times hellebore was used to treat demonic possession, madness, and seizures. As with much from history it can be difficult to sort out specifically which plants are being referred to. Many times the plants were divided into black hellebore, which is the traditional hellebore species, and white hellebore, often false Hellebore. I have to share with you this quote which made me laugh from a 1653 Pharmacopeia “the root of white Hellebore, or Sneezwort, being grated and up the nose, causeth Sneezing, kills Rats, and Mice, being mixed with their meat: it is but a scurvy, churlish Medicine; being taken inwardly, and therefore better let alone than used;

True hellebores are in the Hellebore family. The word is derived from the Greek words helein-“to kill” and bora “food”. In the case of our patients what's been confused for ramps is the False hellebore. These are in a genus called Veratrum, specifically Veratrum viridae.

What's the difference? Why does it matter? Well true Hellebore plants contain cardiac glycosides, digoxin like compounds We associate with foxglove. But Interestingly hellebores contain bufadienole hellebrin, A bufadenolide, similar to the digoxin-like substance found in poisonous toads.

Conversely, Veratrum toxins in false hellebores, like veratradine and similar compounds, bind to sodium channels, causing repetitive firing. This means that normal impulses can't be conducted, resulting in bradycardia and hypotension due to overstimulation of the vagus nerve. The medical word for this is the Bezold-Jerisch reflex. It's a triad of bradycardia, hypotension, and slow breathing. 

Question 4. What other types of problems can cause a Bezold-Jarisch reflex?

1. Heart attack
2. Drowning
3. Spinal cord injury

Answer: is a heart attack can also cause it, it's essentially a reflexive response to noxious stimuli in the heart.

Do you think false hellebores or true hellebores are more toxic? Actually I guessed this one wrong. I'd have guessed the digoxin-like compounds in the true hellebores caused more toxicity, like we see with foxglove. But in reality patients who ingest true hellebores can have some symptoms of nausea and vomiting and mild bradycardia but rarely develop significant toxicity. The Veratrum toxins in the false hellebores seem to cause more serious toxicity, nevertheless Most patients recover in 24 hours. There are only a few reports of death. In one case two people were found dead with Veratrum seeds in their stomach, and there are a few reports from China of death after Veratrum exposure. 

Over the next two hours your friend's symptoms disappear. The nausea and vomiting go away and their heart rates improve back to normal. Fortunately they're discharged with no sequelae. Despite what happened, they are already planning their next camping trip. You sincerely hope there's no foraging involved in this one and recommend they bring hot dogs instead. This is a fictional case, as are all our cases to protect the innocent, but it is based on real poisonings.

In ancient times, hellebore was thought to be a cure for madness. There are so many stories about this that Hellebore became a byword for insanity. One famous story is about Heracles who, In a fit of madness murdered his wife and children. Seeking a cure he was treated with hellebore by a healer in Antikyra. The city became so famous for having the highest quality Hellebore that telling someone to "go to Antikyra” meant saying they were crazy and needed help. 

Hippocrates said, “those who are mad should be treated with Hellebore” and Roman poet Juvenal in the first century jokingly said, “The whole world needs a dose of hellebore.” a sentiment surprisingly relevant in modern times. Tho please don't take Hellebore. It's been used on poison arrows and there are reports of Greeks poisoning the water supply during wars with this plant.

There is evidence of Veratrum use in medicine from literally around the world and across time, from Chinese traditional medicine, in Russian, ancient Greece, Iran, and Native Americans in the United States. The problem is it has a very narrow therapeutic window, meaning it works but the toxicity is so high you might kill the patient in the process. It was used in modern medicine to treat high blood pressure but was never approved as a drug because it had too many side effects. 

Not surprisingly false hellebore causes severe poisoning in in animals including sheep and cows. In pregnant sheep it causes significant congenital deformities. 

Last question in today’s podcast. If we have any Vets listening, I'll bet this is an easy one. What is the description of the congenital deformity that occurs if Hellebore is eaten early in the pregnancy?

1. Cyclops calves
2. Monkey-faced lambs
3. Twisted spine deformity
4. Split-stomach piglets

Follow the X and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else. 

Thanks for listening. It helps if you subscribe, leave reviews and/or tell your friends. Transcripts are available at pickpoison.com. 

  While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Until next time, take care and stay safe.