Total number and mortality rate of reported bongkrekic acid poisoning outbreaks by province, China, 2010-2020.
Recently a fourth individual has succumbed to bongkrekic acid poisoning following a food poisoning outbreak at Polam Kopitiam, a well-known Malaysian restaurant chain in Taipei, Taiwan. This incident occurred between April 19th and 23rd, affecting 35 individuals who had consumed kway teow, a type of flat noodle, from this establishment.
From 2010 to 2020, the China National Foodborne Disease Outbreak Surveillance System recorded 19 outbreaks of bongkrekic acid poisoning. These incidents resulted in 146 cases of illness, 139 hospitalizations, and 43 deaths, equating to a case-fatality rate of 29.5%.
On October 4, 2020, twelve individuals from five families shared meals at lunch and dinner. The following morning, all twelve had breakfast together before parting ways. Nine of these individuals later exhibited gastrointestinal symptoms such as nausea, vomiting, and abdominal pain after consuming a sour soup, a homemade specialty. Tragically, all nine succumbed to their symptoms. Investigations revealed that the corn used in the soup had been fermented in water for about a month a year earlier.
In 2018, a family in China experienced bongkrekic acid poisoning after consuming wet rice noodles that appeared unspoiled despite being contaminated. The incident tragically resulted in the deaths of two family members and their dog, which had also consumed the noodles.
On January 9, 2015, a severe outbreak occurred in a rural town in Mozambique, where more than 230 people fell ill and 75 died after consuming pombe, a traditional alcoholic drink. Initially suspected of being contaminated with crocodile bile, subsequent tests confirmed the presence of toxic levels of bongkrekic acid.
The earliest recorded case of bongkrekic acid poisoning dates back to 1895 in Java, Indonesia, following consumption of tempe Bongkrek, a traditional Indonesian fermented food.
Bongkrekic acid, a potent mitochondrial toxin produced by Burkholderia gladioli, poses significant risks in food fermentation processes, particularly in homemade products from regions like China and Indonesia. This toxin disrupts the mitochondrial adenine nucleotide translocase (ANT), essential for energy production within cells. Exposure to bongkrekic acid can lead to severe metabolic disturbances, organ failure, and death, with symptoms manifesting within 1-10 hours post-exposure. Despite its odourless and tasteless nature, making it hard to detect, the toxin has been linked to high mortality rates in past outbreaks, emphasising the critical need for awareness and preventive measures against such poisonings.
Many countries have implemented strict regulations regarding the production of fermented foods, including mandatory microbial testing and specific hygiene standards. Indonesia, for example, has banned the production and sale of tempe bongkrek, although enforcement remains challenging. Fermented foods are significant in many cultures due to their nutritional value and unique flavours. Understanding the cultural attachment to these practices is crucial for implementing effective health interventions. In many regions, traditional fermented foods are a cheap source of protein, making local populations reluctant to give up such practices despite the risks.
Bongkrekic acid poisoning can rapidly progress to severe symptoms and death, often within hours. Diagnosis involves patient history, symptom assessment, and laboratory tests to detect toxins. Treatment is supportive and symptomatic, including hydration, managing electrolyte imbalances, and supporting respiratory and cardiac function. Rapid medical intervention is crucial to improve survival chances.
Bongkrekic acid disrupts mitochondrial ANT, crucial for ATP synthesis, leading to a catastrophic decrease in cellular energy, affecting critical organs. Ongoing research focuses on preventing Burkholderia gladioli from producing bongkrekic acid and exploring potential inhibitors that could neutralise the toxin in contaminated foods.
The recurrent instances of bongkrekic acid poisoning underscore a critical public health challenge that transcends geographic and cultural boundaries. The recent outbreak in Taipei is a stark reminder of the dangers posed by improperly fermented foods and the stealthy nature of bongkrekic acid, which remains potent and undetectable in contaminated foods. As global cuisines become increasingly accessible across borders, the risk of such foodborne illnesses could potentially rise, making international cooperation and stringent food safety regulations more important than ever.
Ultimately, the fight against bongkrekic acid poisoning is not only about enhancing food safety but also about improving global health security. By fostering a better understanding of this toxin, enhancing surveillance and reporting systems, and promoting international collaboration, we can better protect communities worldwide from the devastating impacts of this and similar toxins.
