Henry Kissinger once remarked that “power is the ultimate aphrodisiac,” but some individuals look for more straightforward ways to enhance sexual experience, often through nostrums on the internet or at local sex shops. Unfortunately, some of these products are quite dangerous.
It is difficult to imagine what foolhardy soul came up with the idea that ingesting blister beetle corpses — Spanish Fly — would work as an aphrodisiac. The medical use of blister beetles goes back to antiquity; Hippocrates (c. 460-c. 370 BC) prescribed beetles for edema and amenorrhea, and the death of the Roman poet and philosopher Lucretius was attributed to an overdose of a love potion thought to have been prepared from these beetles.
Spanish Fly consists of dried and powdered blister beetles, and more than 1000 different species of beetles have defensive secretions that can cause blisters, the most famous being Lytta vesicatoria (AKA Cantharis vesicatoria) a shiny green bug native to Southern Europe. L. vesicatoria secretes cantharidin, a small fat-soluble organic molecule that is a powerful irritant and vesicant.
Cantharidin is corrosive and acts as a cellular poison. The toxin is eliminated through the kidneys, causing lower urinary tract irritation and pelvic congestion that some apparently mistake for arousal. Priapism is a late development in cantharidin toxicity, often preceding death.
Erosion and Hemorrhage
Cantharidin produces widespread damage, and affects many organ systems. It irritates the upper gastrointestinal system, causing dysphagia, abdominal pain, nausea, and hematemesis. Erosion and hemorrhage can be seen throughout the entire upper GI tract in extreme cases.
Effects on the kidneys include glomerular damage and acute tubular necrosis. Renal congestion and edema create pressure on glomerular capillaries, impairing glomerular filtration and contributing to the oliguria that accompanies significant toxicity. Gross genitourinary hemorrhage can occur.
Products labeled Spanish Fly are available over-the-counter and online (including Rite Aid Pharmacy and Amazon) and most preparations contain no or only homeopathic amounts of cantharidin. Karras, et al., described four patients who presented after drinking Kool-Aid that reportedly had a peculiar taste. (Am J Emerg Med 1996;14:478.) Analysis of the liquid revealed that it contained 400 μg/mL cantharidin. Signs and symptoms exhibited in these cases included abdominal and flank pain, nausea and vomiting, dysuria, frequency, urgency, and hemoconcentration. All four recovered uneventfully with supportive care, and none reported feeling amorous during their clinical course.
The key factors in treating these patients include instituting pain control, administering antiemetics, and maintaining adequate hydration. Visualizing the inferior vena cava using the TUSH exam will help guide fluid administration. (EMN 2016;38:1; http://bit.ly/2auJ0yM.) It makes sense to withhold activated charcoal: Mild cases won't benefit and more severe ones may require endoscopy to evaluate corrosive damage. Cantharidin is tightly bound to proteins, and hemodialysis will not significantly accelerate elimination. Areas of external contamination should be irrigated with copious amounts of water.
No specific antidote exists, and deaths are rare, though they have been reported after ingestion of cantharidin. Fatalities have usually been attributed to direct cardiac toxicity, hemorrhage, and hypovolemia.
The New York City Department of Health and Mental Hygiene issued an alert last November about an illegal aphrodisiac after a 39-year-old man died after ingesting the product Piedra China. This substance was being sold surreptitiously in adult stores, smoke shops, and other outlets. Its small, dark brown chunks were to be applied topically to the male genitals, presumably because its local anesthetic property would delay ejaculation. Similar products were also sold as Jamaican Stone, Love Stone, Hard Rock, and Rock Hard.
Piedra China and analogous products contain bufadienolides, a mixture of chemicals found in the venom produced by the parotid glands of various species of Bufo toads. These chemicals include several hallucinogenic tryptamines and cardioactive steroids with digitalis-like properties. These cardiotoxins can kill victims who ingest the topical preparation.
The Centers for Disease Control and Prevention also reported five cases, four of them fatal, of toxicity after ingestion of topical aphrodisiacs made from toad venom. (MMWR 1995;44:853.) These cases were also from New York City, and presentation was quite similar to that seen with digoxin poisoning. Symptoms started with gastrointestinal manifestations such as nausea, vomiting, and abdominal pain. Bradycardia and hypotension were common. Some patients had hyperkalemia, a poor prognostic sign in acute digoxin toxicity. Conduction blocks, atrial fibrillation, ventricular tachycardia, ventricular fibrillation, and asystole were also seen.
All patients in that report had measurable levels of digoxin. An important point: The cardioactive steroids in toad venom have digoxin-like actions, but they are not digoxin. They do partially cross-react with laboratory tests that measure digoxin levels. Although a measurable digoxin concentration confirms the presence of a cardiac glycoside, the quantitative level has no prognostic value.
Successful management of cardiac glycoside toxicity requires good supportive care. Hemodynamically significant bradycardia can be treated with atropine; definitive treatment involves administering digoxin-specific antibody fragments. The authors of the report on the New York City cases noted that the New York City Poison Control Center recommended “empiric administration of large quantities of Digibind (10 vials) to symptomatic patients.”
The take-home point is to consider toxicity from cardioactive steroids if a patient presents with unexplained bradycardia or hypotension, especially if the individual is an otherwise healthy young man with hyperkalemia. If indicated, consider empirical administration of Digibind. Remember also that certain plants contain digoxin-like glycosides, including foxglove, lily of the valley, oleander, and red squill.Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.