Burning Desire
Want to know what candy can kill you? Though the flavor is so beloved, it was found in King Tut’s tomb. And might make camels less thirsty?
This is the Pick Your Poison Podcast. I’m Dr JP. ER doctor. Toxicologist, and unapologetic lover of all things poison. What animal can cause pain and toxicity without ever biting or stinging. And has been used as an aphrodisiac and even for murder?
Stay right here to find out.
This is an interactive story.
Survival isn't guaranteed.
What happens next depends on you. Will our patient live or die?
It's up to you and the choices you make.
Ready your clinical acumen and let's get started.
Today's episode starts in the car. You're on a road trip with three friends on a drive from Miami all the way down the spectacular Highway 1 to Key West, where are your staying for a few days of rest and recuperation. You pull into a gas station to use the bathroom. As you do a brown bug with yellow stripes hits the windshield, dropping onto the front of the car.
You use the bathroom while your friends get out to stretch their legs. When you come out a few minutes later, your friends are guzzling beers they bought from the store. You give them a minute to finish, then all get back into the car.
As you turn back onto the highway, a plastic takeout container slides along the dashboard With the beetle inside.
“Who did this, you ask? Why?”
You’re friends in the backseat are dying of laughter, saying they couldn't let it go because it's actually Spanish fly.
From the giggling no doubt they mean the aphrodisiac. “I thought those beetles were an iridescent green color,” you say.
Your friend shows you his phone where he's taken a picture of the beetle and asks Google to identify it. He's right. It is a type of blister beetle and they are the main Ingredient in Spanish fly.
“What about the pretty green ones,” you ask? Those are the ones you've always seen in toxicology textbooks. He googles again and says there are hundreds of types of blister beetles, the green one is found only in Europe and Asia.
Let's get right into question number one. Why are they called blister beetles?
They cause the skin to blister if you touch one.
They explode when threatened, causing burns.
There are carapace and blister scars off predators
The answer is A: If you touch one, they can cause your skin to blister.
After another hour of driving, you stop for lunch, enjoying tacos on the porch of a restaurant with expansive views of turquoise water and palm trees. You resist the urge to go for a swim, knowing you're just an hour or so away from your Airbnb. Since you've agreed to drive, your friends have several more beers. You finish paying the bill and are the last one to get back in the car.
Your friends, having now had multiple beers each, are loud and raucous but you put down the windows, crank up the music, let the wind blow through your hair, and enjoy drive.
Your friend in the front seat is rubbing his chest and saying something about burning but you can barely hear him over the music. The two in the back seat are laughing even louder no doubt thanks to too much alcohol.
Up front, your friend starts sweating. You ask if he wants the air conditioner on. He says no. The fresh air is better. He says he feels like he swallowed glass. Lunch was Mexican food. Maybe he's having acid reflux. You look over and frown. He's sweating profusely, with drops falling on the seat, even though the temperature outside is very comfortable.
Traffic starts to slow on the two-lane highway. It's Friday afternoon you're not the only people driving from Miami to Key West. The slowdown is no big deal. It's one of the most beautiful drives in the United States, if not the world. The scenery is spectacular and the only thing you have to do today is check into your Airbnb, so a little delay doesn’t matter.
A few minutes later you slam on the brakes, as traffic comes to a screeching halt. The plastic food container flies off the dashboard and into your lap.
It's empty; you're glad they let the poor insect free.
Your friend in the front seat starts throwing up. You would’ve assumed that this was car sickness except the car is not moving. You roll up the windows and put on the air conditioner to try to cool him down nevertheless sweat is pouring off him. He opens the door and leaves it open, vomiting out the side. You ask if he wants to pull off the road. He says, “Just get us to the Air BnB as soon as possible. I must have eaten something bad.”
“Anybody else feel sick,” you ask? You feel fine. Everybody else shakes their heads. You all shared most of the food at the restaurant so Food poisoning is unlikely. Maybe he got a little bit of a gastroenteritis ie a stomach virus before you left.
“It's burning; it's on fire,” he says, clutching his abdomen. Everyone’s vomited, you know the nasty taste and burning sensation from stomach acid but he keeps insisting it feels like he swallowed glass, kind of a strange description.
You hear the spatter of vomit on the pavement, as he vomits again. The smell is making the bile rise in your own throat. You look over to see a large amount of red blood. Hmmm.
The cars ahead, as far as you can see, haven't moved at all.
Vomiting up blood is not a super uncommon complaint. Anybody who vomits a lot can get irritation in their esophagus, followed by a little bit of red blood but this looks like a lot more than that.
Question number two. Which of the following is a risk factor for gastrointestinal bleeding?
A. Alcohol
B. Ibuprofen (i.e. Motrin)
C. Steroids (i.e. prednisone)
D. blood thinners.
E. All of the above.
The answer is E, all of the above. Alcohol is a risk factor for gastric ulcers and gastritis, as I'm sure you know. Your friends have been drinking copiously since landing in Miami but it's not acute alcohol intoxication that typically causes this but rather chronic alcohol exposure and alcohol use disorders. You know your friend doesn't have that.
“Have you been taking blood thinners,” you ask.
He shakes his head no as he wipes his mouth with a napkin someone else passes him.
“A lot of ibuprofen (i.e. Motrin)?”
“No,” he says again. “I don't understand why. Everything is burning so bad.”
The traffic is at an absolute standstill. You haven't moved even an inch. The bright red blood hadn't looked like irritation to begin with but he has several more episodes of vomiting up bright red blood, confirming your suspicion that this is something a lot more serious.
Now you're sweating yourself. True gastrointestinal bleeding is life-threatening and a real emergency. You're stuck basically in the middle of the ocean in a huge traffic jam.
Your friends in the back seat tell you the nearest hospital is in Key West, just a few miles ahead.
“Key West might as well be in a different state under the current circumstances,” you say.
After another minute someone says, "Behind us there's a hospital we passed.”
“How far?” you ask.
“About an hour.”
You're not sure what to do. Turn back, drive another hour and hope your friend is ok. Or cross your fingers, stay the course and hope that the traffic lightens up ahead. It's a tough decision.
Your friend says he doesn't want to go back, so you agree to stay here for now. Fifteen minutes later he gets out of the car and goes behind the bushes to urinate. When he gets back in he says, "There's blood in my urine."
This is getting weirder. If he was taking an anticoagulant, sure. Sometimes anticoagulants interact with other medicines or foods increasing their effects and causing bleeding from several locations. But he's an otherwise healthy twenty-nine-year-old man suddenly bleeding from several directions at one time. And why does he keep saying it feels like he swallowed glass?
You reach over and say, “Can I check your pulse?”
He extends his wrist. You check your watch and clock his heart rate at 120 beats per minute.
This is not good, not at all. The fast heart rate suggests he's losing enough blood that his heart is trying to compensate by beating faster. He says he feels dizzy, which is also not a great sign. You consider calling an ambulance but it's doubtful they'll get here quickly blocked by all this traffic.
You decide to go back to the hospital you previously passed. You're considering how to turn the car around when fortunately the traffic starts to move ahead. Moving slowly but at least moving, you inch past a truck rolled over onto its roof. Finally the road opens up, allowing you to race to the emergency department.
Of course normally you wouldn't be the doctor but this is fiction so it's up to you to figure out what's happened to your friend. The nurses hook him up to the monitor and get him undressed. His temperature is normal at 98.6 or 37°F. His heart rate is, as previously noted, fast with a heart rate of 120 and his blood pressure is on the low side at 105/65. respiratory rate is 18 and oxygen saturation is 100% on room air.
On physical exam he's awake and talking normally. His heart and lungs are otherwise normal. Pressing on his abdomen he has diffuse tenderness. His neurological exam is normal as is his muscle strength.
Whenever someone's having gastrointestinal bleeding we do a rectal exam ie a finger in the bottom to see if the bleeding is coming from both ends. Of course you'd never do a rectal exam on a friend but this is fiction and he consents. As you pull your finger out there's red on the fingertip of your glove.
GI bleeds, are extremely common in the emergency department. Our job is to stabilize the patient. We start with two large IVs so we can rapidly infuse IV fluid. You ordered two liters of fluid as well as lab work, including a complete blood count, coagulation studies and a type and screen, in case he needs a blood transfusion.
After two liters of IV fluid, his heart rate improves to the 110s. His systolic blood pressure improves also to 110. However bright red blood is now coming out of his rectum and he continues to urinate blood.
Questions 3. Does he meet a blood transfusion?
A: yes
B: no
The answer is no. If someone's bleeding to death, if they've been shot for example, we don't wait for the lab work to go ahead with a transfusion. The blood helps to resuscitate the patient. In most cases, however, we wait for the red blood cell count because this directs the decision. Our usual cut-off is to transfuse if the hemoglobin is below 7 mg/dL.
His red cell count comes back at 9, low and a little worrisome but not in the life-threatening range and not meeting transfusion criteria right now. His coagulation studies are normal.
What causes bleeding? We think about problems with blood clotting. Low platelets are one reason the blood doesn't clot but his platelets are normal. In the past we've discussed problems with the coagulation pathway after ingestion of things like rat poison, but his studies (i.e. his PT/IR and PTT) are normal. Congenital problems like hemophilia cause bleeding but he's never had any problems before, so this isn't likely. DIC or disseminated intravascular coagulation is a widespread bleeding issue that happens with multi-system organ failure like sepsis, trauma, or obstetric emergencies. Did he suddenly develop multi-system organ failure in the last few hours? No.
Of course this is a toxicology not a hematology podcast so let's talk about toxins causing bleeding. Anticoagulants are at the top of every list. Things like aspirin, coumadin or warfarin, modern anticoagulants we call DOACs like dabigatran ie Pradaxa and rivaroxaban. He’s not taking any of these.
We’ve talked in the past about superwarfarins in rodenticides. Did somebody put something into his food? Possible but that should affect the PT and INR, which are normal here so again it doesn't exactly fit.
Snake venom is a great one for causing bleeding. We are in Florida with tons of venomous snakes but he didn't mention a snake bite.
Drugs of abuse, like cocaine and heroin, can induce DIC. It takes time to develop and he'd have a lot of other symptoms of drug use. Not likely since you've been with him for the past eight hours
Is there any other way to put this together? As I said GI bleeding is not uncommon, due to stomach ulcers, gastritis, or colon cancer. It's also not uncommon to have blood in the urine, due to things like Kidney stones and urinary tract infections. But the two together, aside from bleeding disorders and anticoagulants, don't really go together.
You call the gastroenterologist. You can almost hear her frown as she says, "He's bleeding in his urine too?"
She agrees to come assess him, but says she's doubtful she'll find the source on colonoscopy or endoscopy, since multiple different organ systems are involved. It's hard to disagree with her. Confused, you look through your friend’s chart again. He has denied any past medical history. He isn't taking any medicines, over-the-counter medicines or supplements. He's had a few beers today of course but denies tobacco, regular alcohol use or illicit drugs.
There's a fly buzzing lethargically around the emergency department. It lands on your head; you swat it off as you click through his labs. Flies are harmless, obviously, but I’m really grossed out by them in the emergency department, seems excessively dirty. The fly reminds you of the yellow striped beetle in the car and suddenly you become suspicious about the cause of your friends’ symptoms.
Question: 4 and time to pick your poison. Is this?
Bombardier beetle
Blister beetle
Scorpion beetles
Anwer: B. This is blister beetle toxicity. Bombardier beetles blow out toxic compounds, causing irritation especially if it gets into the eye, but not systemic toxicity. Scorpion beetles are really interesting. They have a stinger on each antenna and if stung, you get a painful local reaction like with a scorpion. They don't seem to cause systemic toxicity either.
Blister beetles are so named because if you touch one it pumps out a toxin causing blistering and irritation of the skin. The Latin name of one species reflects this, Lytta vesicatoria. Meaning vesicant, the medical word for a blistering agent. Another vesicant is sulfur mustard. Obviously our friend is not suffering from blistered skin or eye irritation.
What if you ingest a blister beetle or eat a Spanish fly preparation made for topical use? Essentially it causes blistering and irritation internally throughout your body, including your gastrointestinal and urinary tracts. Exactly what your friend has. The bleeding is a reflection of the internal blistering and irritation.
There was a blister beetle in your car. The question is, where is it now?
You march back toward the room.
“Where is the blister beetle?” you ask yanking the curtain back.
One of your friends says,” Ummm”
"Well you know, it's just an insect." The other friend says
"I ate it," the patient says.
You close your eyes for a minute and take a deep breath, reminding yourself that you're a doctor so you have to behave in a professional manner, rather than shout at the top of your lungs, "Why in the hell would you do something so stupid?"
Instead you ask in what you hope is a calm tone of voice: “Why did you eat the insect? The extremely toxic insect?”
“It was a dare," he says with a smile as if that explains everything. You silently promise yourself never to go anywhere with these friends again, not even to a coffee shop.
“Explain please,” you say.
Well after we googled it and found out it was Spanish fly, we dared him to eat it to see what would happen.”
“It worked,” he says.
At your confused look He gestures to his groin and you notice tenting in the sheet.
You put your head in your hands. “Has it been worth it, you ask” Now that you're about to bleed to death?”
“What do you mean "bleed to death"? You probably never heard of Spanish fly since it's an aphrodisiac. For men,” he says raising an eyebrow. “I ate it on a dare, thinking it would be hilarious if it worked.”
Oh it's working,” you say. “I don't mean just the erection. It's what's causing the pain and the bleeding.”
A shocked look crosses his face. "What do you mean?"
“Cantharidin is the active ingredient in the Spanish fly. It's a vesicant, which means it makes things blister. I can tell it's working because it's causing blistering inside your gastrointestinal and genital urinary tracts. That’s why they are bleeding.”
Occasionally children eat blister beetles, causing toxicity and several patients have mistaken the instructions for Spanish fly and, rather than rubbing it topically, have ingested it.
His eyes widen as a shocked expression crosses his face. “Am I going to die? because of a bug?”
“You googled everything else. Why didn’t you google the side effects before eating eat it?” you snap.
You Take a deep breath. Remind yourself again that you're the medical professional here.
“People have died from this. In fact they have been murdered with Spanish fly. But, we have modern medicine on our side, hopefully you'll be okay.”
You have a long conversation with the gastroenterologist and the hospitalist doctors, agreeing, colonoscopy and endoscopy are likely low yield.
Is there an antidote for this? No. Care is supportive including IV fluids, pain medicine, and blood transfusions if necessary. Cantharidin is the name of the toxin produced by the blister beetles to defend themselves, its what causes toxicity. Symptoms usually last for less than 24 hours. Cantharidin is metabolized pretty quickly, hopefully your friend will be okay by tomorrow.
He spends that night, the first day of vacation, in the hospital but by the next day his pain and vomiting have improved and he has just a trace amount of blood in his urine. His kidney function (i.e. his creatinine) bumped up slightly but the hospitalist agrees to let him go if he continues to drink a lot of fluids and have his it rechecked as an outpatient the following day.
You make it to the beach for a day before you have to return home. Your friends jokingly challenge each other to eat a jellyfish. The jellyfish in Florida sting but aren't usually life-threatening. You roll your eyes and go back to your book, promising yourself for the hundredth time never to go on vacation with these people again.
Fortunately, your friend recovers with no sequelae, his kidneys improve, and the bleeding stops. This is a fictional case as are all our cases. But it is based on real poisonings.
Let's talk more about Spanish fly. First of all, I'm sure you're wondering why people use this toxic ingredient as an aphrodisiac. Well it's meant to be applied topically (i.e. rubbed on rather than ingested). The idea is if you rub it on, it causes mild irritation, thus increasing blood flow to the groin, thus its aphrodisiac effects. Female partners of men who have applied Spanish Fly sometimes have vaginal irritation and can even get vaginal bleeding. But if used topically the side effects are generally mild. In the U.S. Spanish fly is easy to find in bodegas and gas stations but you never know what you're getting. Often times doesn't actually contain Cantharidin and could be anything.
Blister beetles are extremely common worldwide. There are more than 200 types in the U.S. alone. Even brushing the bugs can cause cantharidin to get onto your skin, causing burning and blistering. Often times it's seen in skin folds like in the elbows or armpits. the rash can take a day or so to develop. If you see one be extremely careful to wash your hands because if you rub cantharidin in your eye it can cause extreme eye irritation.
It's the green iridescent beetles that are associated with Spanish fly as I said before. If you learn nothing else from this podcast, I hope you learn that. Brightly colored is a warning sign from Mother Nature. Don't eat the red berries, don't touch the bright frogs, and don't touch the brightly colored beetles either.
Beetles make cantharidin internally. In the presence of danger they close their breathing pores, causing pressure to build up inside their body until fluid is pushed out through the knees. It is also a love potion for the beetles. As adults, only males make cantharidin.
Question number five: Which body part is the cantharidin released from?
Wings
Outer shell
Mouth
Knees
The answer is D, the knees. During mating, they squeeze it out of their knees into a sticky ball, which they put on their head for the female to sniff. After mating, she smears the cantharidin over her eggs to keep predators away.
Interestingly enough it's not just the beetles using Cantharidin to keep away predators. Birds use it as well. Nuthatches nest in holes in trees and are often in competition with squirrels. The birds will grab a blister beetle in their beak and rub it around the entrance to their nest as a squirrel Repellent. Pretty ingenious.
In the past, like many toxins, cantharidin was used as medicine for things like urinary tract infections, pneumonia, and arthritis. I have to say, Seems like a case where the medicine might be worse than the disease. That said we still do use it in modern times, topically only, for wart removal and for treatment of a rash called molluscum contagiosum.
There are some really interesting cases of toxicity associated with Spanish fly. I mentioned murder. This is an interesting but terrible case from the 1950s in London. A man decided he wanted to attract the attention of a co-worker not interested in his advances as he was a married man. The man snuck into the company warehouse, took some cantharidin, and ejected it into chocolates known as Coconut Ice. He himself did not have a scientific background but he had been warned by a chemist earlier in the day that cantharidin was poisonous. He then gave the poisonous chocolates to two women, both of whom horrifically died. He was convicted of manslaughter, though he served only five years in prison.
Even as far back as the 1700s, cantharidin was used for nefarious purposes. In 1739 an English woman was charged with murder for killing a man with cantharidin in his coffee. Though she was acquitted after it couldn't be determined whether he'd taken it himself, possibly to treat syphilis. The Marquis de Sade was imprisoned for poisoning sex workers with Spanish fly in 1772.
There's another interesting case from Nigeria in 1869. Some French army officers presented to a medical doctor, complaining of dizziness, nausea, and weakness. All were noted to have persistent erections. They hadn't taken any aphrodisiacs or eaten any beetles but being Frenchmen they had eaten frogs. The doctor went down to the stream where the frogs came from, noticing the frogs were eating green iridescent beetles.
And because I know you want to know, is there any evidence to support using cantharidin as an aphrodisiac? There is no scientific evidence to support this, though I would never discount the power of suggestion. Wait did I just hear you say what about the erections in our patient and the Frenchman? Priaprism can happen in men following ingestion but I'm sorry to tell you this: results from vascular inflammation and irritation, i.e. from toxicity rather than physiological arousal. One source had this hilarious line. “This toxic response has been mistakenly interpreted as aphrodisiac activity throughout history.”
And this is kind of a cool question: Were blister beetles responsible for one of the biblical plagues in Egypt? Blister beetles are attracted to lights and can descend on inhabited areas in huge swarms. Anybody who brushes against the Beatles can develop blisters as we mentioned earlier. Thousands of people can be injured during the swarm and some communities have even required temporary evacuation.
Some research has suggested that blister beetles were responsible for the third and fourth plagues. The plagues of gnats and flies, after their population exploded in the Nile Delta. Further extrapolating that the outbreak of blisters days later was the sixth plague. As I said the skin blistering can be delayed by a day or two after exposure to the Beatles. I don't know if it's true but it's certainly an interesting theory.
The last question in today's podcast: Blister beetles can be a significant issue for farm animals, causing toxicity and even death if they are eaten. Sometimes they can contaminate hay. So the last question is, which type of animal is most sensitive to blister beetle poisoning? Eating less than half of a blister beetle is enough to be fatal to this animal.
A. sheep
B. cows
C. horses.
D. goats.
Follow the Twitter and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else.
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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.