The Full Story
Bongkrekic acid is a little-known toxin and source of food poisoning that is produced by the bacterium Burkholderia gladioli. These bacteria flourish in the presence of warm temperatures and fungal organisms—conditions that are commonly encountered in the process of food fermentation. Bongkrekic acid is not destroyed by cooking; it is odorless and tasteless, making it difficult to detect in contaminated foods. Most cases of bongkrekic acid poisoning have occurred after the consumption of locally produced fermented foods in China, Indonesia, and Mozambique. Bongkrekic acid poisoning has been reported after consumption of fermented noodles, corn flour, and beer in these regions. Tempe bongkrek, a traditional fermented presscake produced in Indonesia, has been responsible for thousands of cases of bongkrekic acid poisoning, many of which were fatal. Tempe bongkrek is now banned in much of Indonesia, although illegal production still occurs.
The toxic effects of bongkrekic acid are related to its effects on mitochondria. Mitochondria are small bodies within cells that generate energy for our bodies; bongkrekic acid interferes with cellular energy production, which results in cell damage and death. The initial symptoms of bongkrekic acid poisoning can include fatigue, dizziness, stomachache, vomiting, diarrhea, and sweating. Both high blood sugar (hyperglycemia) and low blood sugar (hypoglycemia) can occur. Severe cases may result in liver failure, kidney injury, and coma. Mortality rates range from 40 to 100%. Death from multiple organ failure can occur within a day after the initial signs and symptoms.
There is no safe dose of bongkrekic acid; doses as low as 1 mg have been fatal to humans. Because bongkrekic acid is a food-borne toxin, it is impossible to estimate how much of the poison is present in a contaminated product.
There is no antidote for bongkrekic acid poisoning. Treatment involves supportive care in a hospital, and many cases will require treatment in an intensive care unit. The best way to prevent this poisoning is to avoid consumption of fermented food products. While fermented foods often have tell-tale characteristics of spoilage such as a bad taste, foul odor, or discoloration, the absence of these features does not rule out bongkrekic acid contamination. Fermented foods might be treated with preservatives that can mask evidence of spoilage. In 2018, a family of seven in China became ill after eating wet rice noodles that were later found to be contaminated with bongkrekic acid. The noodles, which had been treated with preservatives, did not exhibit any signs of spoilage; two family members and the family dog (which was fed some of the leftover noodles) died.
Bongkrekic acid is not a common poison in the US, and you are most likely to be exposed to this dangerous toxin when traveling abroad. Avoidance of fermented foods, including presscake, wet rice noodles, and locally brewed alcohol can reduce your exposure to this dangerous poison.
If someone has been exposed to bongkrekic acid, please log on to the webPOISONCONTROL® online tool for guidance or call Poison Control at 1-800-222-1222. Whether you log on or call, expert assistance is available 24 hours a day.
Kelly Johnson-Arbor, MD
Medical Toxicology Physician
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