Susumber berries: Unexpected cause of cholinergic poisoning

A 65-year-old Jamaican man with no significant medical conditions was brought to the emergency room (ER) after he had suddenly developed abdominal pain, profuse vomiting, and subsequent blurred vision, dysarthria, bilateral hand weakness, and unsteady gait. His initial vital signs and general physical examination were normal. His neurologic examination was significant for widely coarse opsoclonus; severe labial, lingual, and palatal dysarthria; distal weakness of his bilateral wrist extensors (4/5), interossei (4−/5), and opposition (4−/5); dysmetria; presence of Woltman sign, or delayed deep tendon reflexes; and severe gait ataxia. Upon speaking to his wife, who was also in the ER for abdominal pain, we discovered that she too had opsoclonus, dysarthria, bilateral hand weakness, dysmetria, and the presence of Woltman sign, though all to a lesser degree. She revealed that the prior evening, they had eaten an “authentic Jamaican dinner,” consisting of codfish, ackee, and frozen, uncooked susumber berries, which she had imported from Jamaica 3 weeks earlier and later frozen. He had consumed more of the susumber berries than she. As he was more severely affected, immediate MRI of the brain to assess for any acute brainstem pathology was performed, but it was normal. After measurement of vital capacities, his being 0.9 L and hers being 1.2 L, both were admitted to the medical intensive care unit for supportive care. The following day, despite being bradycardic to the 40s, her general and neurologic examinations were completely normal. Her husband had minimal L wrist extension weakness (4+/5), with resolution of the other signs and symptoms. Their creatine kinases and transaminases had risen dramatically but responded to aggressive medical management. As they recovered well, an EMG/NCS was not performed. They were discharged home on day 3 of the hospitalization.