Bongkrekic Acid Poisoning Associated with Burkholderia gladioli: A Systematic Review

Bongkrekic acid (BKA) poisoning is a rare but highly lethal foodborne illness caused by the mitochondrial toxin produced by Burkholderia gladioli pv. cocovenenans. Historically concentrated in Indonesia and China, recent outbreaks in Africa and North America underscore its global public health relevance. A comprehensive literature search was conducted in PubMed and China National Knowledge Infrastructure, supplemented by manual searches. A total of 91 studies were included. Outbreaks are mainly linked to traditional fermented foods such as tempe bongkrek, rice noodles, and corn products, with case fatality rates ranging from 30% to 100%. BKA irreversibly inhibits adenine nucleotide translocase, leading to profound mitochondrial dysfunction and multiorgan failure. Clinically, poisoning progresses rapidly from gastrointestinal symptoms to severe hepatic, renal, and neurological damage. Liquid chromatography-tandem mass spectrometry remains the gold standard for confirmation, while immunoassays and molecular tools provide rapid screening in outbreak settings. Despite advances in detection and mechanistic understanding, prevention is hindered by the toxin's heat stability and its association with traditional food practices. Enhanced surveillance, point-of-care diagnostics, and targeted public education in high-risk regions are urgently needed.