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Toxicology Rounds

Just When You Thought It Was Safe to Go Back to the Boulangerie

Gussow, Leon MD

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Emergency Medicine News: May 2006 - Volume 28 - Issue 5 - p 9
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    The New York Times story dated Aug. 28, 1951, was headlined, “3 Die, Many Stricken by Madness from Poison in Bread in France.” It reported an outbreak of mass hallucinations in Pont-Saint-Esprit, a small town within sight of Mont Ventoux on the border between the regions of Provence and Languedoc. It was an occurrence so bizarre and frightening that it could have been the plot of a particularly gruesome and farfetched horror movie.

    In an accompanying United Press International dispatch, the mayor of Pont-Saint-Esprit, Albert Hebrard, described what he had witnessed. “I have seen healthy men and women suddenly become terrorized, ripping their bed sheets, hiding themselves beneath their blankets to escape hallucinations,” he said. “Charles Pommier, whom I have known for years, barricaded his doors and armed himself with a gun. He said he was ready to shoot the monster that was pursuing him.

    “Jacques Punch, 32, hurled himself out of a window of the second floor of his house. He shouted he was escaping from fire,” the mayor continued. “Gabriel Veladiere tried to throw himself into the Rhone. Before he was stopped by his friends, he screamed over and over, ‘I am dead and my head is made of copper, and I have snakes in my stomach and they are burning me.’”

    John G. Fuller's 1968 book, The Day of St. Anthony's Fire, about the episode in Pont-Saint-Esprit gives more details about the victims, both human and animal, of the mass intoxication. An inconsolable 5-year-girl shrieked, “Mama! Mama! The tigers! They are going to eat me! Mama, I am going to die! There is blood dripping from the ceiling!”

    One woman was convinced, against all evidence, that her children were being butchered and made into sausages. Cats wailed in agony. Dogs crunched on rocks and stripped the bark off trees until their teeth fell out.

    There were ultimately more than 200 victims with at least four fatalities. Doctors examining the victims in Pont-Saint-Esprit noted that the illness often started with severe gastrointestinal symptoms. Many patients presented with bradycardia, hypothermia, chills, mydriasis, cold extremities, and diminished peripheral pulses. Some developed tetanus-like spasms and peripheral gangrene.

    Finding the Culprit

    But what had caused the modern-day plague that engulfed this single obscure French village? It soon became clear that all the victims had eaten bread made by a specific baker, M. Roche Briand. Some contended that the bread had been poisoned with mercury, but the renal effects characteristic of acute mercury exposure were absent. Some blamed arsenic, but all tests were negative. Others suspected botulism, staphylococcal food poisoning, antimony, bismuth, thallium, and mescaline.

    Table
    Table:
    Symptoms of Epidemic Ergotism
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    Finally, the solution was announced by forensic chemists from the police department. “We have identified a vegetable alkaloid having the toxic and biological characteristics of ergot,” they proclaimed. Ergot! The flour used in M. Briand's boulangerie had been contaminated with Claviceps purpurea, a fungus that attacks wet rye and replaces the natural grain with curved, dark-purple projections called sclerotia. This fungus produces a mixture of biologically active chemicals so varied and complex it has been called a veritable treasure house of pharmacology. In addition to more than 20 distinct ergot alkaloids, the sclerotia of C. purpurea contain histamine, tyramine, serotonin, acetylcholine, and sterols.

    This biological witch's brew produces complex and dramatic effects. Some ergot alkaloids are potent direct vasoconstrictors. Others have strong oxytocic effects on the uterus, and have been used to hasten childbirth or reduce postpartum bleeding. Ergot alkaloids also are alpha-adrenergic blockers and central sympatholytics. They produce vomiting by stimulating the emetic chemoreceptor region of the brainstem. Because the common structure on which all the ergot alkaloids are built is lysergic acid, they can be powerful hallucinogens.

    Outbreaks of epidemic ergotism were recorded at least as far back as 857 when the German text Annales Xantenses reported, “A great plague of swollen blisters consumed the people by a loathsome rot so that their limbs were loosened and fell off before death.” Even more remotely, the author of the Assyrian Tablets in 600 B.C. commented on the “noxious pustules on the ear of grain.” The most recent major outbreak took place in Ethiopia in 1978.

    Epidemic ergotism occurs in two major forms: gangrenous and convulsive. (See table.) In gangrenous ergotism, vasoconstriction predominates, and victims present with blisters and ischemic pulseless limbs that can progress to frank (usually dry) gangrene, mummification, and autoamputation. Because of the burning ischemic pain and blackened gangrenous skin that results, this variant has been called lefeu sacre, or St. Anthony's Fire. Convulsive ergotism does not produce true seizures with loss of consciousness, but rather dystonia with writhing, tremors, and muscle spasm. This may be related to interference by some ergot alkaloids with dopamine activity. Although an epidemic can show a mixture of both forms of ergotism, usually one form predominates. The reasons for this are unclear, but may be related to underlying nutritional deficiencies among the victims or to the chemical makeup of the specific specimen of C. purpurea involved.

    Most recently reported cases of ergotism have involved isolated instances of overdose with ergotamine (Cafergot) prescribed for migraine. These have presented with vascular ischemia involving the mesenteric, renal, carotid, retinal, or coronary arteries as well as the peripheral vessels. Treatment includes discontinuing the causative medication and maintaining adequate hydration. Low-molecular-weight dextran, heparin, and vasodilators have all been used, but it is not clear in which clinical situations they might provide benefit.

    John G. Fuller's 1968 book about the outbreak in Pont-Saint-Esprit, The Day of St. Anthony's Fire (Macmillan), is out of print but still available from Amazon.com and Abebooks.com. Mary Kilbourne Matossian's Poisons of the Past: Molds, Epidemics, and History (Yale) also contains useful information, although her theory that ergotism was responsible for the Salem witch trials has been hotly contested.

    © 2006 Lippincott Williams & Wilkins, Inc.