04 July 2023

Death from drinking coconut water

"We describe the fatal course of a patient with initial symptoms of vomiting and nausea who developed symptoms of dystonia, encephalopathy, and coma. The cause of death was poisoning with 3-nitropropionic acid from coconut water spoiled with the fungus Arthrinium saccharicola...

Approximately 4.5 hours before admission, the patient had consumed coconut water directly from a coconut using a straw. Because the water had a foul taste, he swallowed only a small amount. Afterward, he opened the nut and described to his wife that the interior was slimy and looked rotten.

The coconut was preshaved, with visible endosperm (coconut meat) at the top for easy access to the carpels (holes) and the coconut water. A straw was included and used for puncturing the coconut at the time of consumption (Figure). Recommended storage was at 4°C–5°C in the refrigerator, but the coconut had been kept on the kitchen table for 1 month after purchase...

Approximately 24 hours after admission, a new computed tomography scan of the cerebrum showed severe edema, especially in the infratentorial region, with impending signs of brain herniation. The pupils were dilated, brainstem reflexes were absent, and the patient had no spontaneous respiration.

Fungi of the Arthrinium genus produce the lipophilic and highly toxic 3-nitropropionic acid (3-NPA), which is involved in the etiology of moldy sugar cane poisoning with severe encephalopathy. 3-NPA irreversibly binds to and inhibits succinate dehydrogenase in the mitochondria, thereby blocking the citric acid cycle and ATP generation in cells, which would explain the observed severe lactate acidosis."
More details at the National Library of Medicine, which I hope is not behind a paywall.  This case is frankly scary as hell.

This case was recently discussed at a Reddit thread which I have lost.  One of the recommendations there was not to drink blindly from a straw; decant the water/milk to a clear container, then open the coconut to examine the core.

14 comments:

  1. The problem was not drinking from a straw, it was drinking a liquid after it had sat on the counter for a month and then drinking from a straw.

    ReplyDelete
  2. I guess if you put the lime in the coconut and drink it all up, you should make sure you follow the storage directions for the coconut…

    Bicycle Rider

    ReplyDelete
  3. Nothing too scary about this other than the lax food safety the folks with the nut had taken.

    ReplyDelete
    Replies
    1. Scary to me as an intensive care physician for 30 years with a boatload of experience treating metabolic acidosis. Unlike "normal" lactic acidosis from hypoperfusion or ischemia, this case is occurring at the cellular level similar to cyanide intoxication but without AFAIK any intervention to reverse the process.

      Delete
    2. Don't get me wrong, I'm not being dismissive of the un-treatable, just saying that this one was easily preventable with what I believe to be basic food safety regimes.

      That said I'll toss out a question; how often do you clean the water dispenser nozzle on the refrigerator, with what, and what's possible to be growing there if/when you don't?

      Delete
    3. Perfectly fine to leave an "unmolested" coconut unrefrigerated. It was the preparation that caused the problem, or caused need for refrigeration, which was not understood by the victim, despite what may have been offered on the packaging (I'll assume they "shave" the coconut and then shrink-wrap it in plastic, with label). The man made an understandable mistake. Anyway, one person's "basic food safety" is another's neurosis. I've heard a lot of crazy stuff about food safety. I'd put cleaning the water nozzle in that category. In fact, there are also dangers in living in an overly sanitary/sterile environment--especially for children.

      Delete
  4. Welp, there goes my Almond Joys....

    ReplyDelete
  5. Love coconut "milk." Never even thought of using a straw. Punch a hole and drain into a glass. If the flavor is off (very rarely), discard. Never seen this; bad idea (said the Monday morning quarterback): "The coconut was preshaved, with visible endosperm (coconut meat) at the top for easy access to the carpels (holes) and the coconut water. "

    ReplyDelete
  6. Which is why you need to use fresh coconuts if you are going to use coconut water as an emergency IV fluid https://pubmed.ncbi.nlm.nih.gov/10674546/

    ReplyDelete
    Replies
    1. Woah - that is a totally new concept for me. Will check the refs. Tx, Marge.

      Delete
    2. You meant “whoa?” Woah is used in the UK

      BICYCLE RIDER

      Delete
  7. Here's a video dramatization of the case: https://www.youtube.com/watch?v=VZut_SZYybA

    ReplyDelete
  8. Not nearly as many as get killed by falling coconuts each year.

    ReplyDelete
  9. This is why the nose is an important player in eating or drinking. The straw prevented its participation.

    ReplyDelete