A bongkrekic acid incident in Taiwan, and a proposed nomogram for determining clinical severity

Bongkrekic acid is a rare but highly lethal cause of food poisoning. We report a 33-person incident in Taiwan linked to its exposure.

A retrospective analysis was conducted after the incident. Whole blood and stool samples were tested using quadrupole time-of-flight and triple quadrupole mass spectrometry. Patients were classified into two groups. Group 1, comprising self-limited and outpatient cases, and Group 2, comprising hospitalized and fatal cases. An arbitrary nomogram was developed to differentiate between these two groups.

Between March 19 and 24, 2024, 33 people (aged 10-66) developed symptoms after eating flat rice noodles at a restaurant which began a median of six hours post-ingestion. Three patients experienced transient symptoms that resolved without medical assistance (self-limited, Group 1), 20 patients had symptoms which resolved in an outpatient setting (outpatient, Group 1), four patients were admitted to the hospital (hospitalized, Group 2), and recovered under conservative treatment. Six patients developed acute liver failure and circulatory failure, resulting in death (fatal, Group 2). All Group 2 patients had whole blood bongkrekic acid concentrations above a reference line (a linear line connecting 100.00 ng/mL on day two to 10.00 ng/mL on the tenth day post-ingestion).

The incident was difficult to detect due to patients visiting various facilities across time and location. Whole blood bongkrekic acid concentrations were positively correlated with disease severity. Concentrations above the defined reference line were associated with worse outcomes, suggesting the nomogram could guide hospitalization decisions. In mass food poisoning investigations, non-invasive stool collection may serve as a reliable screening tool for bongkrekic acid exposure.

Though rare, bongkrekic acid poisoning can cause severe illness and death. Clinicians should suspect it in patients presenting with gastrointestinal symptoms and acute liver injury.